Failure to Administer Mealtime Insulin as Ordered Resulting in Elevated Medication Error Rate
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 medication errors out of 25 opportunities, resulting in an 8% error rate. The errors occurred during a medication pass on the 200 and 300 halls, where Nurse #1, a temporary agency nurse, was responsible for all blood sugar checks and insulin administration. Breakfast meal trays for the 200 Hall were scheduled to be delivered at 7:30 AM and 7:40 AM, but insulin doses were observed being administered later, and not in accordance with physician orders specifying administration before meals. For Resident #29, who had diabetes, diabetic retinopathy, and long-term insulin use, physician orders directed administration of 10 units of Humalog insulin subcutaneously before meals, to be held if blood sugar was less than 100, along with a separate sliding-scale Humalog order before meals and at bedtime. During the observed medication pass at 9:15 AM, Nurse #1 obtained a blood sugar of 295 and administered a total of 14 units of Humalog (10 units scheduled plus 4 units sliding scale) when the resident’s breakfast tray was not present in the room. Resident #29 later reported that the insulin was administered after she finished her morning meal. The Nurse Practitioner, Physician, and DON each stated that insulin was expected to be administered prior to meals and in accordance with physician orders. For Resident #82, who had diabetes, chronic kidney disease, and long-term use of hypoglycemic drugs, a physician order directed sliding-scale Humalog insulin to be given subcutaneously before meals and at bedtime based on specific blood sugar ranges. During the same medication pass at 9:25 AM, Nurse #1 obtained a blood sugar of 256 and administered 4 units of Humalog insulin when the resident’s breakfast tray was not in the room. Resident #82 reported that nurses usually obtained his blood sugar before meals but that he typically received insulin after he finished eating, and on the observed date he ate breakfast and then received insulin afterward, later than usual. Nurse #1 stated she was unfamiliar with which residents required blood glucose monitoring or insulin, which caused delays and failure to administer insulin according to the physician’s orders.
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