Insulin Administered to Non-Diabetic Resident Due to Misidentification
Penalty
Summary
The deficiency involves the facility’s failure to prevent a significant medication error when insulin was administered to a resident who was not diabetic. The resident had severe cognitive impairment, was non-ambulatory, and required maximum assistance with mobility, with documented diagnoses including non-Alzheimer’s dementia, traumatic brain injury, and heart disease. The resident’s care plan addressed risks such as pressure ulcer development and falls but contained no interventions related to diabetes management or care. On the evening of the incident, an LPN assisted a CNA in putting the resident to bed. The CNA was told by another CNA that the resident being assisted was a different resident, and that CNA went into the room and confirmed the incorrect identity. Relying on this information, the LPN performed a finger-stick blood glucose test, obtained a reading of 142, and administered 20 units of Insulin Glargine, a long-acting insulin, under the assumption that the resident was the diabetic resident. After the insulin was given, the LPN sought further verification with a certified medication technician and discovered that the residents had been placed in the wrong beds, and insulin had been administered to the wrong resident. The resident who received the insulin was not diabetic and subsequently experienced a drop in blood sugar, was transferred to the hospital, and was diagnosed with hypoglycemia and acute metabolic encephalopathy due to accidental insulin administration. Interviews revealed that the LPN had attempted to confirm the resident’s identity with two CNAs and the resident, but the resident was unable to self-identify, and the CNAs had incorrectly identified the resident. The LPN also used a CNA’s tablet to compare the resident’s picture in the EMR, in a setting where residents did not wear identifying armbands, there were no names on doors unless chosen by residents, and there was no policy on how often or by whom resident photos in the EMR should be updated.
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