Medication Error: Insulin Administered Instead of Tuberculin Solution
Penalty
Summary
The facility failed to administer medications safely and as prescribed for one resident when a nurse gave Humalog, a fast-acting insulin, instead of tuberculin solution. Facility policy on administering medications, revised April 17, 2024, requires that medications be administered in a safe and timely manner as prescribed, that staff verify the right medication, dose, time, and method before administration, and that the nurse contact the physician or medical director if a dosage is believed to be inappropriate or a medication has potential adverse consequences. For this resident, the nurse did not follow these verification steps and administered Humalog insulin despite there being no physician order for Humalog in the resident’s record. The resident involved had multiple medical diagnoses, including metabolic encephalopathy, hypertension, hyperlipidemia, paroxysmal atrial fibrillation, and neurocognitive disorder with Lewy bodies, and had been admitted on December 31, 2025. Progress notes documented that in the early morning of January 1, 2026, a nurse notified the RN supervisor that the resident had received insulin, and new orders were received to monitor blood sugars. A medication error report documented that the resident was given Humalog instead of tuberculin solution, and review of the physician’s orders confirmed there was no order for Humalog. In an interview, the DON confirmed that the resident received Humalog insulin in error instead of tuberculin solution on that date.
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