Medication Administration Errors and Improper Insulin Practices
Penalty
Summary
The deficiency involves failure to administer medications as ordered and to maintain an acceptable medication error rate, resulting in 8 errors out of 25 opportunities (32%) for two residents. For one resident, an LPN prepared and administered multiple morning oral medications, including Hydralazine, Potassium Chloride, Torsemide, and Oxybutynin, significantly later than the scheduled 9:00 AM time, with actual administration occurring between 11:38 AM and 11:41 AM. The same resident’s lispro insulin vial was not in its original box, was not properly labeled with a dispensed or opened date, and bore a handwritten date next to the expiration/discard date; the LPN administered 2 units of lispro insulin from this vial. The resident’s blood pressure readings taken shortly thereafter were elevated, and the LPN administered Metoprolol Tartrate at 12:00 PM. The pharmacist later stated that Hydralazine should be spaced approximately 6–8 hours apart and Metoprolol Tartrate 10–12 hours apart, and that administering these medications too close to the next scheduled dose could increase medication effects, while late doses could result in elevated heart rate and blood pressure as the medication’s effects diminish. For another resident, the LPN stated that the resident’s blood glucose was 49 and that the resident was out of insulin. The LPN withdrew 2 units of Novolog and 10 units of Lantus from another resident’s insulin vials and administered them to this resident, despite acknowledging she had been taught not to borrow medications. The LPN also stated she was behind on 8:00 AM medications, including this resident’s insulin, and that the resident had eaten breakfast around 7:00 AM without having blood glucose checked or morning insulin administered beforehand. The medication administration record showed that Lantus 10 units subcutaneously daily at 8:00 AM was actually given at 10:52 AM, and Novolog per sliding scale scheduled for 8:00 AM was given at 10:48 AM. The Novolog prescribing information indicates it is a rapid-acting insulin that should be administered within 5–10 minutes of a meal, and adverse reactions include hypoglycemia.
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