Failure to Administer Insulin as Ordered Results in Significant Medication Errors
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically related to the administration of insulin for four out of eight residents reviewed. Facility policy required medications to be administered according to physician orders, manufacturer specifications, and professional standards. However, documentation showed that insulin was not administered as ordered for multiple residents with type 2 diabetes and other comorbidities such as hypertension and cerebrovascular disease. In several cases, blood sugar checks were either not performed as ordered or, when performed, were not followed by the required insulin coverage prior to meals. For example, one resident did not receive sliding scale insulin coverage before breakfast despite a blood sugar check, and another did not have a blood sugar reading obtained, resulting in no insulin being given. A review of staff documentation and interviews confirmed that the responsible RN did not administer insulin coverage after obtaining blood sugar readings for four residents. The Nursing Home Administrator, DON, and Assistant DON acknowledged that insulin administration was not consistently managed under the facility's medication administration policy, leading to these significant medication errors. The findings were supported by clinical record reviews, staff statements, and direct confirmation from facility leadership.