Significant Insulin Medication Error and Delayed Response to Hypoglycemia
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors related to insulin administration. The resident, who had type 1 diabetes mellitus and a history of low blood glucose levels, had physician’s orders for Lantus (insulin glargine) 29 units subcutaneously at bedtime and Humalog (lispro) insulin per sliding scale at 6:00 a.m., 11:00 a.m., and 4:00 p.m. On the evening in question, the RN responsible for medication administration drew up and administered 29 units of Humalog, a rapid-acting insulin, instead of the ordered 29 units of Lantus, a long-acting insulin, at the resident’s bedtime medication pass. After discovering that the wrong insulin had been given, the RN informed the resident of the error and then administered the Lantus insulin that had originally been ordered, without first consulting the resident’s physician. The RN documented that the resident was instructed to check her own blood glucose every 20–30 minutes and report the results, and she was encouraged to eat sugar-rich foods. The RN did not perform or document a full nursing assessment, including serial blood glucose checks performed by staff, vital signs, or evaluation of the resident’s cognitive or physical status, despite the known medication error and the resident’s history of low blood sugars. The RN notified the DON and called the on-call physician service but did not immediately send the resident to the emergency room as directed by the DON and as required by facility protocol for a significant insulin error and hypoglycemia. Instead, the RN waited approximately four and a half hours before arranging EMS transport, during which time the resident’s blood glucose fluctuated and dropped to 54 mg/dL, with no documented staff monitoring of vital signs or continuous assessment. EMS ultimately found the resident in a hypoglycemic state with a blood glucose of 42 mg/dL and provided oral glucose before transporting her to the hospital, where she was monitored and treated for recurrent hypoglycemia related to the excessive and incorrect insulin administration. Facility investigation and staff interviews confirmed that the RN failed to follow medication administration standards, physician orders, and the facility’s Management of Hypoglycemia policy. The investigation documented that there was no record of ongoing blood glucose monitoring by staff, no documentation of vital signs such as heart rate and blood pressure, and no timely implementation of emergency measures following the insulin overdose. The medical director later stated she was not notified at the time of the error and that, given the excessive amount of incorrect insulin, the resident could be at cardiac and neurologic risk, underscoring the seriousness of the medication error and the lack of appropriate clinical response by facility staff at the time of the incident.
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