F0760

D

Significant Insulin Administration Error Due to Failure to Verify Medication Type

Borger, Texas 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 a nurse administered the wrong type of insulin. The resident was an older female with multiple diagnoses, including Type 2 diabetes, dementia, Parkinson’s disease, pancreatic disease, malnutrition, hypothyroidism, hypertension, and atherosclerotic heart disease. Her MDS showed she was cognitively interviewable and independent with ADLs. Her care plan for diabetes included administration of diabetes medications as ordered and monitoring for side effects and effectiveness. Physician orders specified two long-acting insulin glargine (Lantus) regimens—one pen injector dose in the evening and one vial dose in the morning—and a short-acting insulin aspart (Flasp) pen on a sliding scale three times daily.

On the day of the incident, the LVN assigned to the resident went to the medication cart after already taking the resident’s vital signs. The resident typically received insulin via a pen and preferred it at a certain time. The LVN reported that she was looking for two insulin pens for the resident, as she had seen two pens previously, but on this occasion found only one pen in the cart. She then located a vial of insulin, which she believed to be the long-acting insulin needed at that time. Instead of using facility-provided drug reference materials or consulting the DON, ADON, or a more experienced nurse, she used an external AI tool (ChatGPT) to verify the insulin type and admitted she did not read the full response. Based on this incomplete external check, she proceeded to administer the insulin.

After administering the insulin, the LVN went on to give insulin to another resident and then realized that the insulin she had given the first resident was actually the short-acting insulin, not the long-acting insulin ordered for that time. This error resulted in the resident receiving 45 units of short-acting insulin instead of the prescribed long-acting insulin. The LVN then checked the resident’s blood glucose, which was 200, and rechecked it 10 minutes later, finding it at 145. The resident recalled receiving insulin via a regular syringe instead of her usual pen and later learned she had received the wrong insulin. The facility’s written policy required staff to familiarize themselves with medications using facility drug references, to verify the type of insulin and dosage, and to read the label three times and check it against the MAR and the order, as well as to follow the five rights of medication administration. The events described show that these established procedures were not followed, leading to a significant medication error and the resident’s transfer to the hospital for observation after an insulin overdose.

The nurse practitioner reported being informed that the nurse was out of long-acting insulin and had used an internet search to determine if another insulin was equivalent, then administered 45 units of short-acting insulin in error. The NP emphasized that this was a very serious situation and stated that a nurse should not use internet searches to make nursing judgments but should instead consult the DON or ADON. The NP indicated that the resident’s blood sugars remained within a normal range for her and did not drop below 120. The resident expressed discomfort with new or PRN nurses and stated she trusted the older nurses who had been at the facility longer, and she was glad that someone was following up on the incident because she believed it should never have happened.