F0760

D

Failure to Properly Administer Insulin and Provide Ordered Rifaximin Therapy

Lakeport, California Survey Completed on 03-13-2026

Penalty

No penalty information released

Summary

Licensed nurses failed to ensure residents were free from significant medication errors related to insulin administration and critical medication omissions. During a medication pass observation, one nurse administered 20 units of glargine via an insulin pen to a resident’s abdomen but removed the pen immediately after injection without maintaining the needle in place for the required duration per manufacturer instructions. In a separate observation, another nurse administered 4 units of lispro via an insulin pen to a different resident’s abdomen and withdrew the pen after only 5 seconds, despite being aware this was earlier than required. The DON acknowledged that insulin pens require a specific hold time on the skin to ensure the full dose is delivered and that this topic had been covered in a prior in‑service by the pharmacy consultant, who had instructed staff that long‑acting insulins require at least a 10‑second hold and short‑acting insulins at least 6 seconds.

A third resident, admitted with alcoholic cirrhosis and portal hypertension, had a physician’s order for rifaximin 550 mg by mouth twice daily for prophylaxis of hepatic encephalopathy. Review of the MAR showed multiple entries coded as “medication not available,” with 15 missed doses in one month and an additional 14 missed doses in the following month, along with seven doses incorrectly documented as administered despite the medication not being supplied by the pharmacy since an earlier date. The resident reported that staff had stopped giving his liver medication about a month earlier because it was too expensive and stated he was receiving other liver medications that were only part of his full treatment. He also reported feeling that his ammonia level was rising and that he was feeling “weird” and falling asleep at abnormal times during the day.

Further record review showed no nursing progress notes indicating that the physician or DON had been notified about the repeated unavailability and omission of rifaximin, despite the facility’s policy defining omission of an ordered drug as a medication error and requiring prompt provider notification of significant errors. The DON later confirmed that there were no notes documenting MD notification, that the seven doses marked as given on the MAR were documented in error, and that a total of 36 doses of rifaximin had been missed. The physician stated that the resident was on the maximum dose of lactulose and that there was nothing more that could be done to stop the decline without rifaximin, emphasizing the necessity of that medication.