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Based on record review and interview, the faciliy failed to ensure a correct dose of insulin was administered to a patient. This affected one (Patient #2) of ten patients reviewed.

Findings include:

Record review revealed Patient #2 was admitted on 02/11/24 with seizure like activity. Patient #2 had a past medical history of diabetes, gastroesophageal reflux, hypertension, hyperthyroidism, and subdural hematoma. Patient #2 was discharged on 02/14/24.

Review of Patient #2's blood glucose levels revealed they fluctuated during her hospital stay. On 02/11/24 at 4:30 P.M. on admission, her blood sugar was 86 grams per deciliter (g/dL). On 02/11/24 at 10:00 P.M., her blood sugar was 103 g/dL; 02/12/24 at 6:24 A.M., 167 g/dL; 02/12/24 at 11:35 A.M., 221 g/dL; 02/12/24 at 4:00 PM, Patient #2 refused a blood sugar check; 02/12/24 at 10:13 P.M., 64 g/dL; 02/13/24 at 6:37 A.M., 117 g/dL; 02/13/24 at 11:00 A.M., 317 g/dL; 02/13/24 at 4:10 P.M., 42 g/dL; 02/13/24 at 9:54 P.M., 134 g/dL; 02/14/24 at 5:51 A.M., 111 g/dL; 02/14/24 at 11:23 A.M., 294 g/dL; and 02/14/24 at 3:36 P.M. prior to discharge, 110 g/dL.

Review of physician's order dated 02/11/24 revealed an order for Lantus (long-acting insulin) 10 units daily. Review of the medication administration record revealed Patient #2 received this daily during her stay.

Review of physician's order dated 02/11/24 revealed an order for Humalog (short acting insulin) per the sliding scale before meals and at bedtime. The sliding scale revealed if blood sugar was 0-20; 0 units of insulin; 201 to 250, three units; 251 to 350, five units; 351 to 400, seven units; and if blood sugar is greater than 400 the physician must be notified.

Review of Patient #2's blood glucose monitoring revealed on 02/13/24 at 11:00 AM, her blood sugar was 317 g/dL. Review of the medication administration record for Patient #2 revealed on 02/13/24 at 11:56 A.M. documented Patient #2 received nine units of Humalog (fast acting) insulin. The order was for five units of Humalog insulin for a blood sugar between 251 and 300.

During an interview on 04/02/24 at 8:27 A.M., Staff E, an RN, stated the nursing students informed him Patient #2 had a blood sugar of 317 and they administered nine units of Humalog insulin. Staff E reported he did not go and confirm Patient #2's sliding scale and this was right before lunch. He did not realize a medication error was ever made.

Review of the facility policy titled "Medication Administration", effective June 2023, revealed prior to administration of any medication the nurse must verify patient identification, medication name, does, route, frequency, rate of administration, and compatibility.