F0759

D

Medication Administration Errors with Insulin and Pantoprazole

Dublin, Ohio Survey Completed on 01-26-2026

Penalty

No penalty information released

Summary

The deficiency involves a failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 25 observed medication administration opportunities, resulting in a 12% error rate. One resident with chronic kidney disease and aftercare for joint replacement had a physician order for pantoprazole 40 mg packet to be dissolved in 5 milliliters of apple juice and given once daily. During observation, a Certified Medication Aide (CMA) poured the pantoprazole packet into a cup of water and administered it, rather than using apple juice as ordered and as required by FDA instructions for pantoprazole delayed-release oral suspension. The Executive Director confirmed that the electronic MAR did not specify administration in apple juice or applesauce, and FDA guidance indicated pantoprazole granules must be given only in apple juice or applesauce due to pH requirements and specific preparation instructions.

Another resident, admitted and readmitted with diagnoses including metabolic encephalopathy and type 2 diabetes, had a care plan addressing potential for unmanaged blood sugar and an order for Lantus insulin 18 units twice daily. During observation, an RN drew up Lantus in an insulin syringe, and when asked to verify the dose, the syringe’s black stopper was at the 20-unit mark. The RN initially asserted that the surveyor was looking at the wrong side of the syringe and claimed that one side showed 1-unit increments and the other 2-unit increments, stating she had drawn up 18 units. Upon further questioning, the RN rechecked the syringe and adjusted the plunger to the 18-unit mark. The DON later verified that the insulin syringe was marked in 1-unit increments on both sides, confirming that the RN had initially prepared an incorrect dose.

A third resident with a fracture of the left femur and type 2 diabetes had a care plan for altered endocrine function and an order for Humalog insulin 19 units before every meal. During observation, the CMA removed a new Humalog KwikPen from the medication cart, dialed it directly to 19 units, and prepared to administer it. When the surveyor asked whether the pen needed to be primed, the CMA stated she did not understand the question and again indicated she did not know what priming was before entering the resident’s room to administer the insulin. Manufacturer instructions for the Humalog KwikPen specified that the pen must be primed before each injection by selecting 2 units, holding the pen needle-up, tapping to collect air bubbles, and pushing the dose knob until zero appears, to ensure proper function and accurate dosing. These events occurred despite facility policies and the medication aide job description requiring staff to follow medication labels, verify orders, and administer medications in accordance with established nursing standards, facility policies, and state requirements.