F0842

D

Failure to Document Insulin Medication Error Resulting in Incomplete Medical Record

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 complete and accurate medical record for one resident when a medication error was not documented in accordance with facility policy. The resident had a history of 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 11:00 p.m. with an insulin pen labeled with another resident’s name and placed it on the bedside tray table. The resident recognized that the insulin pen did not belong to her, informed the LVN, and took a photo of the pen showing a male resident’s first and last name. The LVN then left the room with the incorrect insulin pen and returned with the correct insulin pen labeled with the resident’s name, after which the resident received her insulin injection. The resident stated she felt stressed after discovering the medication error.

In a subsequent interview, the LVN acknowledged that she had separated an expired insulin pen belonging to another resident from the medication cart container and placed it on top of the cart, then also placed the resident’s insulin pen on the same side of the cart while preparing medications. The LVN stated she mistakenly grabbed the other resident’s insulin pen from the top of the cart and brought it into the resident’s room, and that the resident identified the wrong name on the pen before administration. The LVN admitted she did not document this medication error and only reported it verbally to her RN supervisor. Review of the resident’s electronic medical record showed no nursing progress notes documenting a medication error or incident on that date. The DON and nursing staff stated that standard practice and facility policies require documentation of medication errors or incidents in the resident’s clinical record, including a factual description of the error and events, incidents, or accidents involving the resident. The failure to document the medication error resulted in an incomplete medical record for the resident on that date.

Interviews with other nursing staff confirmed that insulin pens are labeled by pharmacy with resident names, that nurses are expected to verify the “five rights” (right patient, drug, dose, route, and time) when preparing and administering medications, and that medication errors must be documented in the clinical record. The facility’s policies on Charting and Documentation and on Adverse Consequences and Medication Errors require that events, incidents, or accidents involving the resident, and any medication errors, be documented in the resident’s medical record, including a factual description of the error. Despite these requirements, no documentation of the incident involving the wrong insulin pen was found in the resident’s record.