Significant Insulin Administration Error Involving Wrong Insulin Type and Dose
Penalty
Summary
The deficiency involves the facility’s failure to prevent a significant medication error for one cognitively intact resident with insulin‑dependent diabetes, anxiety, and depression. The resident’s daughter had submitted a complaint to the state alleging that insulin was not administered according to physician orders. Review of the resident’s records showed that the resident was hospitalized and not present in the facility at the time of survey. During interviews, the resident’s daughter and son both reported that the resident had been transferred to the hospital after receiving a large dose of fast‑acting insulin instead of the prescribed long‑acting insulin. The DON acknowledged that the resident had a medication error. Further review of the medical record and facility documentation confirmed that the resident was administered 52 units of Novolog (short‑acting insulin) instead of the ordered long‑acting insulin, constituting wrong medication and wrong strength/quantity. A nurse involved in the incident reported that the fast‑acting insulin was given in error in place of the long‑acting insulin and that this was reported to the DON. A nurse progress note documented that the resident returned from the emergency department with EMS, with EMS reporting that the resident’s blood glucose never dropped below 100 and the event was uneventful. A physician note documented that staff reported the resident had been transferred to the emergency department after mis‑administration of 52 units of short‑acting insulin. During a later observation, the resident was seen in bed, non‑verbal and non‑responsive to questions, with her son at the bedside and hospice services in place.
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