F0760

D

Insulin Pen Labeled for Another Resident Brought to Bedside

Sherman Oaks, California Survey Completed on 03-19-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when an LVN brought an insulin pen labeled for a different resident to the bedside. The affected resident had type 2 diabetes mellitus, morbid obesity, and essential hypertension, and required varying levels of assistance with activities of daily living. The resident had physician orders for Insulin Glargine 60 units at bedtime, to be held if blood sugar was less than 100, and Insulin Lispro per sliding scale before meals and at bedtime.

On the evening in question, the resident reported that an LVN entered the room around 11 p.m. with an insulin pen that had a male resident’s name on the label and placed it on the bedside tray table. The resident, who was oriented and knowledgeable about her medications, read the name on the pen, recognized it did not belong to her, and informed the LVN. The resident took a photo of the insulin pen, which showed a male first and last name corresponding to another resident. The resident stated that after pointing out the error, the LVN left the room with the incorrect pen and later returned with an insulin pen labeled with the correct name, after which the insulin injection was administered. The resident reported feeling stressed after discovering the medication error.

In a subsequent interview, the LVN explained that while preparing medications at the cart outside the resident’s room, she removed an expired insulin pen that did not belong to the resident and placed it on top of the cart to address later. She then removed the correct resident’s insulin pen from the container and also placed it on the same side of the cart. While gathering the rest of the resident’s medications, she inadvertently picked up the other resident’s insulin pen from the top of the cart and brought it into the room, stating she had not yet read the name on the pen when the resident noticed the error. The DON and another LVN described the standard process for medication administration, including verifying the “five rights” and preparing medications for only one resident at a time, and facility policies required checking the medication label three times to ensure the right resident, medication, dose, time, and route. The incident occurred when these procedures were not followed, resulting in the wrong resident’s insulin pen being brought to the bedside and observed by the resident.