Failure to Administer Ordered Insulin Due to Medication Access and Documentation Errors
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate dispensing and administration of medications for a resident with multiple diagnoses, including type 2 diabetes mellitus. Upon admission, the resident had a physician's order for Lantus (insulin glargine) to be administered subcutaneously at bedtime. Although the medication was documented as given on the Medication Administration Record (MAR), the assigned LVN did not actually administer the insulin on the first night of admission. The LVN stated she assumed the medication had not arrived from the pharmacy and inadvertently documented its administration when she only intended to record the completion of blood glucose monitoring (accuchecks). The resident later reported not receiving her insulin on the first night but had no noticeable effects and continued to receive her medication on subsequent nights. The facility's Director of Nursing Services confirmed that Lantus was available in the emergency medication kit and should have been administered as ordered. The LVN did not access the e-kit to obtain the medication, despite its availability and the presence of a physician order. Facility policy required medications to be administered accurately and timely as ordered by the physician.