Resident Sent to Hospital after Staff Administers Wrong Dosage
A newly admitted resident was sent to the hospital after Palm Garden of Pinellas did not ensure insulin orders were clarified. This mistake caused the resident to receive the wrong dosage, and his blood sugar reached a dangerous level that caused him to be hospitalized. The facility was also cited for not properly administering insulin.
The resident in this citation was newly admitted with specific medication orders from the hospital. The orders stated the resident should receive 0.3 milliliters of insulin twice a day. When this facility receives an insulin order that is in anything other than “units,” they are required to call the doctor right away for clarification, no matter the time of day or night. This is because milliliters and units are not the same, so the measurement provided by the hospital needed to be converted to units.
The nurse who received the insulin orders from the hospital told the Advanced Registered Nurse Practitioner (ARNP) that the resident should receive 3 milliliters. The ANRP acknowledged this dosage and also agreed to check the resident’s blood sugar to see if the insulin needed adjusted. The investigator of this citation, however, found that the insulin order for the resident was written for 3 units, not 3 milliliters. For two days, the resident’s blood sugar levels went up and down because he was receiving the wrong dosage. Having consistent, accurate dosages is essential for patients with diabetes. One small mistake can drastically change the health of a resident.
On the second day of receiving the wrong dosage of insulin, the resident’s blood sugar spiked to above 500. The resident’s wife, who was very upset, called the nurses’ station and emergency medical services was called after. The resident left the facility shortly after on a stretcher.
The investigator of this citation began interviewing members of the facility to determine how such a big discrepancy was missed in the resident’s medication orders. The investigator tried to contact the ARNP who originally verified the medication order in milliliters, but she could not be reached. The investigator then contacted the attending physician, who was covering for the ARNP while she was away. He also didn’t comment on the order for the medication, stating he was driving and didn’t have access to the resident’s record.
The Director of Nursing (DON) told the interviewer that all nurses are taught to give insulin in units, not milliliters. However, another interview with a staff member revealed that he had never been educated on insulin orders. Normally, he just verifies the order with the doctor. The lack of training was confirmed when the investigator reviewed the documents for a training session. There were no signatures of training on insulin orders, meaning there was no confirmed documentation that the staff in the facility received proper education on dosage and administration of insulin. Nursing home residents and their family members count of the facility’s staff to know and comply with medication policies that keep residents safe and in good health. When they do not, they break their promise to keep your loved one safe from harm.
Further investigation found that a staff member in this facility did not administer insulin properly. When insulin is administered, the needle must be “primed.” This means you remove the air from the needle and cartridge that may have collected. If a needle is not primed before each injection, a resident could get too much or too little insulin. When a staff member went to administer insulin, she did not prime the needle.
An interview with the Consultant Pharmacist revealed that she believed insulin pens “don’t need to be primed every time.” As far as she had read, she didn’t believe priming was a requirement. The Director of Nursing also did not know priming was required. The investigator followed up with the Consultant Pharmacist again, who said that when she looked up the type of insulin pen they used for the resident, the instructions said the pen needs to be primed with 2 units every time a needle is changed. The Consultant stated that insulin pens are “more of an education issue. Nurses need to be more educated.” She said the instructions for priming were also not written clearly in the manufacturer’s own literature. According to the Consultant, “it does not make a significant difference in the dose they are getting” when the needle is not primed. The investigator reviewed the manufacturer’s instructions and noted that it included a step for “prime your pen.”
When a loved one is placed in a nursing home, you expect the facility to treat your loved one with care and also follow their own procedures and policies. It is especially important when giving medication to a resident that they depend on to have a good quality of life. When critical errors occur in nursing homes that affect residents, they feel less confident in the facility’s ability to care for them properly. Nursing homes must always work hard to abide by their policies to ensure the safety of all residents.
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