**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that the resident was free from any significant medication errors for (Resident #1) of 5 residents reviewed. This facility failed to administer insulin medication for (Resident #1) according to the doctor's order. Resident #1 was administered a long- acting insulin (released over time), the resident should have been administered short acting insulin (taken daily before meals). This failure could place residents at risk of jeopardizing their health by not receiving medications as ordered. The noncompliance was identified as PNC (Past non-compliance). The non-compliance began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before the survey began. Findings Include: Review of Resident #1 face sheet undated reflected, a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 was admitted with a diagnosis of Type 2 Diabetes mellitus without complications, Parkinson's Disease (disorder of the central nervous system that affects movement), heart failure, mild cognitive impairment, acute kidney failure, and elevated blood pressure. Review of Resident #1 quarterly MDS assessment dated [DATE] revealed, he has a BIMS score of 12 indicating mild cognitive impairment. Review of Resident #1 care plan dated [DATE], reflected the following: The resident will be free from any symptoms or signs of hypoglycemia (Low blood glucose level) and the resident will have no complications related to diabetes. Interventions reflected Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Review of LVN A, progress note dated [DATE], reflected the following: This nurse was getting supplies to check blood sugar and checked insulin pens. Resident has 2 insulin pens. This nurse set both pens on top of cart. I checked order and resident's name to be on the pens. When grabbing supplies to take to resident's room this nurse grabbed the wrong insulin pen and administered Humalog instead of Tresiba which is a routine medication he receives in the morning. When this nurse noticed she gave the wrong insulin pen this nurse immediately notified charge nurse of what had happened and charge nurse gave orange juice while this nurse called Doctor [NAME]. Doctor [NAME] ordered this nurse to check blood sugar every 15 minutes for 2 hours. This nurse checked blood sugar before giving insulin and blood sugar was 86. After giving insulin, eating cookies, drinking orange juice with sugar, and milk resident blood sugar was checked and blood sugar reading was 88. Doctor [NAME] was notified of blood sugar and ordered dextrose 5% via IV and resident refused. Doctor [NAME] also ordered this nurse to give resident Glucogon shot. Doctor [NAME] also ordered for this nurse to send resident to the hospital. Review of the Facility investigation dated [DATE], reflected Resident # 1 was administered 34 units of Humalog 100units/nL- sliding unit, but should have been administered Tresiba 100 unit /mL (34 units) which is given daily. The investigation reflected, Resident # 1 was given milk, cookies, orange juice, and a glugon shot. The report indicated that Resident # 1 was stable, and did not have symptoms of hypoglycemia at the time of his discharge to the hospital. Resident # 1 was sent to the hospital for IV glucose and observation, the report reflected that Resident # 1 did not have any adverse- affects from the medication error. The investigation reflected, that LVN A was immediately removed from the floor, confirmed findings (that this was a significant medication error), the nursing staff were in-served on long acting and fast acting insulin and insulin administration. The report reflected that LVN A, would be doing vitals signs only under the supervision of the DON until further notice. Review of the MAR, revealed, Resident #1 had orders for the following diabetic medications: 1. Medication Order date- [DATE]- Tresiba Solution 100 UNIT/ML (Insulin Degludec) Inject 34 unit subcutaneously one time a day related to Type 2 Diabetes Mellitus. Long- acting 2. Medication order date - [DATE]-Humalog KwikPen Solution Pen-injector 100 UNIT/ML (Insulin Lispro (1 Unit Dial)) Inject subcutaneously one time a day related to Type 2 Diabetes Mellitus. Short-acting Review of medical records dated [DATE], EMS (emergency medical service) arrived at 8:44 am - per hospital records Resident #1 arrived at the hospital at 8:52 am. Resident #1 was admitted to the hospital and treated for hypoglycemia (Low BGL). Resident #1 remained in the hospital for IV of D5W (saline with glucose/sugar) treatment and monitoring. Resident #1 was discharged back to the facility at 12:48 pm on [DATE]. Per hospital records the residents blood glucose levels remained stable with the lowest reading at 79 (normal 70-110). Interview on [DATE] at 3:45pm with Resident #1, revealed he is not able to recall any of the events that took place. He stated he was in this facility because in [DATE] he had a diabetic black -out. Resident # 1 stated that he did take insulin, however, was not able to recall the recent incident. During a phone interview on [DATE] at 10:00am with LVN A, stated she was scheduled to work the 6am to 2pm shift on [DATE]. She stated approximately 8:32am she was getting Resident #1 medication ready and took out both insulin pens. She stated as she was checking the MAR to ensure she had the correct medication; she turned and grabbed the wrong pen and administered the resident the wrong medication. She stated she gave Resident #1; 34 units of Humalog KwikPen Solution Pen-injector 100 UNIT/ML (Insulin Lispro (1 Unit Dial). Inject subcutaneously one time a day related to Type 2 Diabetes Mellitus. She stated she should have been given the Tresiba Solution 100 UNIT/ML (Insulin Degludec) Inject 34 unit subcutaneously one time a day related to Type 2 Diabetes Mellitus. She stated that she immediately notified the charge nurse of her mistake. During an interview on [DATE] at 10:50am with the DON, she stated she a call from the charge nurse on duty that day [DATE] regarding the medication error and immediately came to the facility. DON stated the resident was administered the wrong medication and the wrong dosage of medication. She stated LVN A, gave the Resident # 1, 34 units via IV of Humalog Solution 100 UNIT/ML (Insulin Lispro (1 Unit Dial)) Inject subcutaneously one time a day related to Type 2 Diabetes mellitus, she stated the resident should have been given Tresiba Solution Pen/Injec 100 UNIT/ML (Insulin Degludec) Inject 34 unit subcutaneously one time a day related to Type 2 Diabetes Mellitus. She further stated by giving the resident this medication the resident could have died due to low (BGL). The DON stated all new staff are trained with a tenured nurse before going out on the floor. She stated all nursing staff are trained on medication administration. During a phone interview on [DATE] at 3:30pm with Pharmacist, revealed that giving a resident the wrong dosage of the Humalog 100 unit/nl sliding scale could have different effects. He stated it could cause nausea, dizziness, confusion, could cause the person blood sugar levels to drop and send the person into Hyperglycemia. He stated if the person was given the Glucagon shot (given if a person has had an over- dose of this medication) the resident must have been having an adverse effect. During a phone interview on [DATE] at 3:50pm with PCP, revealed the resident should have been given the long- acting insulin which is the Tresiba Solution 100 UNIT/ML (Insulin Degludec), instead of the short-acting Humalog KwikPen Solution Pen-injector 100 UNIT/ML 34 units. He stated when he received the call from the nurse (could not remember the name) he advised to give the resident orange juice, milk, cookies, and a Glucagon shot. He further stated after the snacks given and the Glucagon shot the residents blood sugar level was at an 88 and he advised that the resident be sent to out the hospital for further evaluation and treatment. He stated if the levels get too low the person could have a seizure, lower potassium that could cause heart arrythmia or heart failure (death). During an interview on [DATE] at 4:20pm with ADM, revealed once notified of the incident she and the DON immediately came to the facility and removed LVN A from the floor. She stated LVN A, administered the wrong medication to Resident #1. She further stated it was her expectation that any staff administering medications follow their policy and procedure when verifying and ensuring that they are giving the correct medication, to the correct person, and the correct dosage. She stated this medication error could have been much worse for the resident. She stated all nursing staff are trained and have regular in-services conducted by the DON. During an interview on [DATE] at 1:25pm with LVN B, stated she was working the day of the incident [DATE]. She stated LVN A came and got her stating she messed up and gave a resident the wrong medication. She stated they immediately contacted the PCP and was advised to give the resident orange juice, milk, cookies, and the glucagon shot. She further stated they stay on the phone with the doctor after giving the snacks and Resident #1 BGL was at 88, he advised to send the resident to the hospital for further treatment. LVN B stated, if they wouldn't have caught the error in time the residents BGL could have dropped and could have caused him to become unresponsive and possibly die. During an interview on [DATE] at 4:50pm with LVN C and LVN D, stated they were trained on the 10 steps of medication administration, insulin administration, the difference in long acting and Fast acting insulin. LVN C and LVN D reported the long acting and short acting pens and vials have been marked for visual queuing to help them ensure that they have the correct medication. The stated when giving any medications the MAR should be checked at least three times before any medication is administered. Record review of Resident #1 BGL readings dated [DATE], reflected BGL initial reading at 86, after wrong medication administered and snacks provided the reading reflected 88. Record review of Resident #1 BGL readings prior to [DATE] before the medication error occurred and after Resident #1 returned from the hospital on [DATE], the BGL's are as follows: [DATE]- 11:22 96mg/dL [DATE]- 07:40 102 mg/dL [DATE]- 07:14 101 mg/dL [DATE]- 07:29 94mg/dL [DATE]- 07:21 92mg/dL [DATE]- 12:33 86mg/dL Once resident returned from the hospital the readings were as follows: discharged from hospital on [DATE]: [DATE]- 08:14 117mg/dL [DATE]- 07:55 102mg/dL [DATE] -07:22 123mg/dL [DATE]- 08:19 113mg/dL [DATE]- 07:28 107mg/dL [DATE]- 07:33 173mg/dL Records review of facility in-services and safety measures revealed the facility took the following steps prior to surveyor entering the building for past non-compliance: 1. The LVN was immediately removed from the floor suspended for 6 days, given a written warning. LVN is not able to administer medications currently. LVN is only able to do vital signs while under the supervision of DON. 2. Staff trained on [DATE] - 10 step medication administration training. Signed by nursing staff 3. Nursing staff training on [DATE]- long-acting vs fast acting insulin the difference. Signed by nursing staff 4. All insulin medications labeled long/ short acting with different colors to allow for a visual queuing 5. Facility followed their own internal policy on medication administration 6. LVN A was trained on insulin by the facility prior to the incident. Record review of employee personnel file and disciplinary document revealed LVN A received a written warning. Review of LVN A time sheets, revealed the time reported by DON of suspension for 6 days [DATE]-[DATE]. Observation of LVN A clinical skills trainings which included the following: Administering a subcutaneous injection Glucose testing and Proficiency Nutrition, hydration, and medication administration Observation at 4:46pm, on [DATE] of insulin administration, by LVN C. Per MAR in the PCC (Point Click Care) system the order for this observation stated. Hum along solution 100 unit/ML(Insulin Lispro) vial sliding scale before meals and at bedtime. LVN C verified residents name on the MAR and medication vial, verified date [DATE] of medication on MAR and vial, cleaned glucometer allow to dry for 2min before using / to check the blood glucose level, observed wearing gloves / sanitized hands before putting on gloves, explained to resident what she was preparing to do, explained what medication she was preparing to give the resident, cleaned table to set up medication, got out first test strip (for glucometer machine), used alcohol pad clean resident finger before taking reading, BGL reading 195, LVN C sanitized her hands after taking the reading to prepare the insulin, set out lancet gauze, LVN C administered the insulin medication in residents lower abdomen, cleaned machine with anti- bacterial wipes let dry for 2min. LVN C cleaned in between each resident, changed gloves at the end clicked button in PCC (Point Click Care) system that the medication had been administered. Observation at 5:45pm on [DATE], of medication labeling of long acting/short acting insulin medications, labeled in red for visual queuing. Policy Reviewed regarding Administration Medications dated, [DATE] indicated the following: Policy: 1. Only persons licensed or permitted by this state to prepare, administer and document the administration of medications may do so. 2. The Director of Nursing Services will supervise and direct all nursing personnel who administer medications and / or have related functions 3. Medications must be administered in accordance with the orders, including any required time frames 26. New personnel authorized to administer medications will not be permitted to prepare or administer medications until they have been oriented to the medication administration system used by the facility. 27. The charge nurse must accompany new nursing personnel on their medication rounds for a minimum of three days to ensure established procedures are followed and proper resident identification methods are learned.