Failure to Administer Insulin as Ordered and Incorrect PRN Morphine Dose
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors related to insulin administration and morphine dosing. The resident had multiple diagnoses, including diabetes, severe protein-calorie malnutrition, and a need for assistance with personal care. The resident’s diabetic care plan, revised 1/22/26, directed staff to provide timely notification to the physician for any change in condition, and a physician’s order dated 2/2/26 specified a sliding scale regimen for Insulin Aspart Injection Solution 100 units/mL based on blood glucose ranges, including instructions to give 6 units and notify the provider if the blood sugar was greater than 351. Review of the MAR from 2/2/26 to 3/18/26 showed no documented insulin administrations or blood sugar checks on multiple evening shifts (2/2, 2/8, 2/9, 2/12, 2/15, 2/23, 2/27, 3/5, 3/6, 3/12, 3/15, and 3/16). The DON confirmed that the insulin administration record contained multiple blanks and that there was documentation of blood sugar readings but no documentation of insulin doses administered. The facility also failed to follow physician orders for PRN morphine for the same resident. The resident’s record contained two morphine orders: Morphine Sulfate 15 mg, 0.5 tablet by mouth every 1 hour PRN for pain/dyspnea, and Morphine Sulfate 15 mg, 15 mg by mouth three times a day for pain. A nursing progress note dated 3/4/26 documented that the resident was given the wrong dose of PRN morphine. A medication error report from 3/4/26 at 3:15 AM recorded that a licensed nurse administered a full 15 mg tablet instead of the ordered half tablet for the PRN dose. The error was identified when the resident asked whether a whole or half tablet had been given and stated that only half should have been administered. The licensed nurse verified the order and acknowledged that a medication error had occurred, and the DON later confirmed the occurrence of this error.
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