Missed Insulin Doses Due to Transcription and MAR/TAR Workflow Errors
Penalty
Summary
The deficiency involves a failure to accurately transcribe and administer an ordered insulin medication for one resident. The resident had multiple medical diagnoses, including diabetes mellitus due to an underlying condition with diabetic amyotrophy, acute kidney failure, COPD, and hyperkalemia. Clinical discharge instructions directed administration of insulin glargine 30 units subcutaneously every 24 hours, and the facility’s physician order and MAR reflected an active order for insulin glargine 30 units subcutaneously once daily starting the day after admission. The MAR entries for several consecutive days showed a chart code indicating documentation in nurses’ notes rather than actual administration of the insulin. Progress notes documented that a CMA repeatedly noted the insulin glargine order and reported it to the nurse each morning, stating they did not administer insulin and only informed the nurse when such medications appeared on the MAR. The CMA also stated they did not inform anyone else and did not think the resident received the medication. An LPN reported that they administered medications listed on the TAR and that CMAs administered medications on the MAR, and acknowledged they did not review the MAR when giving medications, which led to the insulin being missed because it was listed on the MAR instead of the TAR. The ADON confirmed that the insulin order had been placed on the MAR rather than the TAR and that the resident had missed doses of insulin as a result of this transcription and administration process failure.
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