F0760

G

Significant Medication Errors Involving Insulin and Antiepileptic Management

Kalamazoo, Michigan Survey Completed on 02-24-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure residents were free from significant medication errors, specifically related to insulin administration for a resident with type 2 diabetes and antiepileptic medications for a resident with epilepsy. For the diabetic resident, the care plan identified a risk for blood sugar fluctuations and directed staff to administer medications as ordered, monitor blood glucose, follow hypoglycemia protocols, and report abnormal values to the physician. The resident’s insulin regimen was changed to include long-acting insulin at bedtime and scheduled short-acting insulin with meals plus a sliding scale. After this change, the resident experienced a first documented episode of severe hypoglycemia, during which an LPN found the resident non‑responsive with a critically low blood glucose and administered glucagon per protocol. The progress note for this event did not document that a provider was notified, and the medical director later confirmed he had not been made aware of this episode, nor had the insulin orders been reviewed or adjusted afterward.

On a subsequent date, the same resident experienced another severe hypoglycemic episode. A CNA reported the resident felt hot, and when the LPN assessed the resident, she was diaphoretic and unresponsive with a blood glucose of 29. Multiple glucagon injections and oral glucose were administered with assistance from other nurses and a nurse practitioner, and the resident was ultimately sent to the hospital. Hospital records documented that the resident had been receiving 10 units of long‑acting insulin at night and 2 units of insulin with meals, and noted that hypoglycemia could be due to an insulin dosing error or accurate dosing in a patient not eating adequately. Review of the resident’s orders and MAR showed that the short‑acting insulin lispro was ordered as 7 units with meals plus a sliding scale, and that on the day of the second hypoglycemic event, the LPN administered 7 units of lispro at 10:32 a.m. for a blood glucose of 140 and then again at 1:05 p.m., giving 7 units plus 2 units per sliding scale for a blood glucose of 177. The LPN later acknowledged she was behind on medications, gave the morning and lunch insulin doses 2.5 hours apart, did not know whether the resident had eaten breakfast or lunch or how much was consumed, and did not realize the doses were so close together. The DON confirmed the insulin doses were given late and that nurses were expected to administer insulin with meals, check blood glucose before eating, and assess intake, while the medical director, PA, and pharmacist all stated they would be concerned about lispro being given 2.5 hours apart without knowledge of food intake.

The second resident had a diagnosis of epilepsy and a care plan goal to remain free from injury related to seizure activity, with interventions including administering medications as ordered and monitoring for effectiveness and side effects. MAR review showed that this resident missed multiple doses of Keppra and valproic acid over several days, including missed morning doses of Keppra and multiple missed doses of valproic acid on consecutive days. Progress notes documented that the resident refused morning medications on one day, that the nurse reapproached and the resident took only part of the medications, and that the resident’s family member expressed concern about lethargy, abnormal responsiveness, and the possibility of seizure, requesting hospital evaluation. The resident was sent to the hospital and returned with an increased Keppra dose, but subsequent notes indicated ongoing lethargy, refusal of meals, and refusal of medications. The resident later had seizure activity at the facility, and days afterward, staff documented that the resident had been unable to swallow food and medications for several days and that valproic acid was not given for this reason, leading to a provider notification and transfer to the emergency department.

Hospital records for this resident described a history of TBI, epilepsy, and nonverbal status, with presentation for failure to thrive and significant dysphagia over 24–48 hours, during which the resident was unable to take medicines or oral intake. The family reported being told that oral antiepileptic medications drooled out of the resident’s mouth and could not be swallowed, and that the last seizure a few days prior was believed to be due to inability to take oral medications. The hospitalization summary noted status epilepticus and an acute ischemic infarction, and the attending physician stated that due to dysphagia the resident frequently missed antiepileptic doses, making breakthrough seizures unsurprising. Interviews with facility staff revealed that the LPN caring for the resident on one of the key days could not recall whether the provider was notified about missed Keppra and valproic acid doses, and the unit manager acknowledged she did not further investigate family concerns and confirmed multiple missed doses without documentation of provider notification. Another LPN reported being told by a CNA that the resident had been having swallowing issues and missing medications for days before she assessed the resident, notified the provider, and arranged hospital transfer. The DON and PA both stated that nurses were expected to notify providers whenever medications were missed or there was a change in condition, and review of records showed no documentation that providers were notified of the repeated missed antiepileptic doses due to dysphagia.

Facility policies on medication administration required medications to be given as prescribed, within one hour before or after scheduled times, with before/after meal orders followed as written, and required explanatory notes and notification of the DON and physician when two doses of a medication were refused or withheld. The change in condition policy required that sudden or serious changes in condition be communicated to the physician with a request for prompt evaluation, and that all nursing actions be documented in progress notes. In both residents’ cases, the documented findings show that medications were not administered in accordance with physician orders and facility policy, that critical changes in condition and missed doses were not consistently communicated to providers, and that documentation of provider notification was lacking despite repeated episodes of hypoglycemia and missed antiepileptic doses associated with dysphagia and seizure activity.