F0760

D

Insulin Administered to Wrong Resident Due to Failure to Verify Identity

Pembroke, North Carolina Survey Completed on 01-20-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when insulin was administered without a corresponding order. A cognitively intact resident admitted with influenza and pneumonia, and without a diagnosis of diabetes, had active physician orders for oxygen, albuterol, digoxin, and metoprolol, but no orders for insulin. The resident’s electronic MAR for the month showed no insulin orders. Despite this, the resident received 10 units of insulin lispro during a medication pass.

On the day of the incident, a nurse working on the medication cart administered 10 units of lispro insulin to this resident instead of to the intended resident who shared the same last name. The nurse reported being distracted and acknowledged that she failed to adequately verify the correct resident before administering the medication. The resident questioned the injection, stating she was not diabetic and did not take insulin, after being told it was her evening insulin. The unit manager later confirmed that the nurse had given insulin to the wrong resident.

Interviews with the DON, pharmacist, medical director, and administrator confirmed that the resident had no insulin order and that the insulin was given in error due to failure to verify the right resident. The DON and administrator both stated it was their expectation that the nurse verify the right resident, right medication, right dose, and right route prior to administration, which did not occur in this case. The pharmacist and medical director confirmed that the insulin administration was unintended for this resident and that it occurred because the nurse confused two residents with the same last name during the medication pass.