Insulin Administered Without Order Due to Resident Misidentification
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, specifically the administration of insulin without a physician’s order. The resident was an older male with Parkinson’s disease, dysphagia, muscle weakness, difficulty walking, metabolic encephalopathy, emphysema, COPD, GERD, hyperlipidemia, and a contracted right wrist, and was PEG-tube dependent for nutrition and medications. His admission MDS and care plan did not identify diabetes or insulin dependence, and his active physician orders did not include any insulin. Instead, his orders included medications such as laxatives, carbidopa-levodopa, entacapone, ibuprofen, ondansetron, acetaminophen, cetirizine, esomeprazole, and ipratropium-albuterol, all to be administered via PEG tube or other specified routes. Despite the absence of an insulin order, the resident received approximately 0.5 units of insulin. The RN involved reported that he had been employed at the facility for three days and that he failed to correctly match the resident’s face with the intended recipient of the insulin, confusing the resident with his roommate who required insulin. This error occurred around the scheduled medication time in the morning. The facility’s own medication administration policy required staff to review the MAR to identify the medication to be administered and to compare the medication source with the MAR to verify the resident name, medication name, form, dose, route, and time, as well as to adhere to resident rights, but this verification process was not followed. The incident was discovered after the resident’s family, using video camera surveillance, observed that the resident had been given insulin despite having no such order. Documentation showed a blood glucose value of 132 mg/dL at the time of the event, and the complaint/grievance report confirmed that the wrong medication had been administered. Interviews with facility leadership and clinical staff confirmed that the resident was normally given medications through his PEG tube, that there were no active insulin orders, and that the RN acknowledged failing to verify the resident’s identity before administering the insulin. The facility’s resident rights policy stated that residents have the right to receive services and items included in the plan of care, which in this case did not include insulin therapy.
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