Wrong Insulin Type Administered Due to Storage and Verification Failure
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received the correct type of insulin as ordered. The resident had physician orders for Lantus 40 units at bedtime and Novolog per sliding scale three times daily with meals. During an evening medication pass, an LPN administered Novolog instead of the ordered bedtime Lantus dose. The LPN reported that the medication bag was labeled as Lantus, but the insulin pen inside was actually Novolog, and both types of insulin had been stored together in the same bag. After administering the dose, the LPN noticed the pen color was incorrect and recognized that the wrong insulin had been given. Following the administration error, the LPN immediately notified the DON, and the resident was assessed and had blood sugar rechecked. The nurse practitioner and the resident’s power of attorney were notified, and the resident was sent to the emergency room. Progress notes document that the resident was transferred for evaluation and treatment related to blood glucose and later returned with stable vital signs and a blood sugar of 137. The hospital after-visit summary lists a diagnosis of accidental or unintentional insulin overdose with hypoglycemia, and notes that the resident’s point-of-care glucose was checked multiple times in the emergency room and that the resident received education on signs and symptoms of hypoglycemia before being discharged back to the facility.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.