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Based on interview and record review, the facility failed to ensure that insulin was administered in accordance with the orders of the physician responsible for the patient's care when RN 1 administered one unit of insulin to Patient 1 instead of two units as ordered by the physician.

Findings:

A review of Patient 1's record on 9/22/10 at 10:50 a.m. showed a physician's order for regular insulin subcutaneously every six hours. The order indicated the nursing staff were to follow the facility's Insulin Scale 1 protocol to determine the amount of insulin to be administered based on the patient's blood glucose.

Patient 1's Critical Care Flow Sheet dated 9/21/10 indicated that RN 1 administered 1 unit of insulin to Patient 1 at 11 a.m. for a blood glucose of 206. The facility's Insulin Scale 1 was reviewed and indicated that for a blood glucose of 201 to 250, the patient should receive 2 units of insulin.

On 9/22/10 at 11:45 a.m., Patient 1's record was reviewed with the director of post acute services. She stated "That's a med (medication) error." She acknowledged that Patient 1 should have received two units of insulin for a blood glucose of 206.



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