Medication Error Rate Exceeded 5% During Insulin Administration
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 2 errors out of 34 opportunities, resulting in a 5.8% error rate. For one resident with type 2 diabetes mellitus and multiple comorbidities, the care plan included administration of insulin as ordered. The physician’s order specified Lantus 18 units subcutaneously in the morning. During a morning medication pass, an LPN administered the resident’s eye drops and oral medications but held the ordered Lantus dose, despite the resident not refusing the injection and there being no parameters in the order to hold it. The LPN later confirmed she did not contact the provider and that the resident’s blood sugar that morning was 97, and facility policy required contacting the prescriber if a dosage was believed to be inappropriate or excessive. For a second resident with type 2 diabetes mellitus and other diagnoses including dementia, depression, and chronic kidney disease, the care plan identified risk for hyper/hypoglycemia with an intervention to administer medications as ordered. The physician’s order specified Lantus SoloStar 10 units subcutaneously in the morning. During observation of a medication pass, an RN prepared the Lantus pen by attaching a needle and dialing the dose to 10 units but administered the injection without priming the pen. In interview, the RN stated she checked the pen for air bubbles but did not know any other way of priming it. The manufacturer’s instructions for the Lantus SoloStar pen require performing a safety test before each injection, including selecting 2 units, removing caps, holding the pen needle-up, tapping to move air bubbles, and pressing the injection button to ensure insulin comes out and the dose window returns to 0. These observed deviations from ordered insulin administration and manufacturer instructions contributed to the calculated medication error rate above 5%.
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