Unprescribed Insulin Administration to Non-Diabetic Resident
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors when nursing staff administered insulin that was not prescribed. The resident, who had diagnoses including multiple sclerosis, late-onset Alzheimer's disease, essential hypertension, and hypertensive heart disease with heart failure, was documented on the MDS as moderately cognitively impaired and not receiving insulin. A nursing progress note recorded that the resident was given 15 mg of glargine Lantus, a long-acting insulin, even though there was no prescription for insulin. At the time of this administration, the resident’s blood sugar was 109 mg/dl. Subsequent documentation by the NP confirmed that the resident was not diabetic and had mistakenly received 15 units of Lantus. The NP note indicated that vitals were assessed and the resident’s glucose was 107 mg/dl following the error. The DON later verified in interview that the resident had received insulin when it was not prescribed. The facility’s medication administration policy required that medications be administered safely, timely, and as prescribed, and that staff verify resident identity before administration using methods such as checking the identification band, photograph, or confirming identity with other personnel. This incident was identified incidentally during a complaint investigation.
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