Helia Healthcare Of Energy

for three times a day 7AM-10AM, 11AM-1PM, and 3PM- 6PM with sliding scale Regular Insulin per results.R1's Medication Administration Record dated 8/1/2025-8/31/2025 at 4:00AM-6:00AM documents R1 received Lantus Solostar Insulin 15 units subcutaneous and documents that it was administered by V19 (Registered Nurse). On 8/30/2025 at 7:00AM-10:00AM R1's blood sugar is documented as Low. On 9/5/2025 at 11:05AM, V2 stated she was made aware of the medication error and R1 was sent to the emergency room and was admitted for Hypoglycemia. V2 stated an investigation was initiated. V2 stated that V9 was educated on Medication Administration.R1's Event Summary Report dated 8/30/2025 at 8:42AM documents the medication error under event details and the type of error as incorrect medication.

This report documents under Interventions that V2 (Assistant Director of Nursing) was notified and R1's blood glucose level dropped to 44 and R1 was given orange juice with sugar raising R1 blood glucose to 77 after 20 minutes.

Report shows Physician was notified on 8/30/2025 at 9:00AM, Family was notified at 9:00AM, and Care Plan was reviewed at 9:00AM.

Evaluation: Sent to emergency room for evaluation and treatment.On 9/5/2025 at 7:15AM, V17 (Emergency Medical Technician/EMT) stated he has gone to the facility twice to pick up R1. V17 said one time was to transport R1 to the hospital due to R1 receiving the wrong medications that were actually for another resident. V17 stated the medications that were accidently given to R1 was documented on the run report. R1's (Emergency Medical Service) Report from the local EMS agency dated 8/30/2025 documents a chief medical complaint of Accidental Medication Administration Multiple and a secondary complaint of hypoglycemia.

The report documents On arrival to scene, crew received a brief verbal report from the patients nurse.

Nurse reported the following; medications were administered at approx. 08:05 today, 20mg Furosemide (diuretic), Aspirin 81mg, Colace 100mg, Ferrow [SIC] Sulfate 325mg, Gabapentin 100mg, Januvia 100mg (antidiabetic), Metformin 750mg (antidiabetic), Fish oil & Vit (vitamin) D3.

They noted patient appeared lethargic and more confused to baseline, noted BGL (blood glucose level) 40s, administered oral glucose/glucagon prior to EMS arrival.

Patient is baseline confused due to Alzheimer's. discharged from (name of local hospital) last week for infection of wound site on antibiotics.R1's records from the local hospital document an admission date of 8/30/25 and a discharge date of 8/31/25. R1's Hospital Discharge Summary under Details of Hospital Stay documents (R1) is a [AGE] year-old woman with diabetes who lives in a group home.

She was inadvertently given another resident's medications, including diabetes medications.

She became hypoglycemic and was brought to the emergency room.

She was given intravenous dextrose, oral nutrition and monitored with frequent AccuCheks.

Her blood sugars normalized, and then she was discharged back to her nursing facility where she will resume her own previous medications.The facility policy titled Medication Administration (undated) documents under Procedures, Five Rights- Right resident, right drug, right dose, right route, and right time are applied to each medication being administered. A triple check of these 5 rights is recommended in the process of preparation of a medication for administration: 1) when the medication is selected, 2) when the dose is removed from the container, and finally 3) just after the dose is prepared and the medication put away.On 9/5/2024 at 3:10PM attempted to call V18 (Physician) but did not receive a call back.A facility policy for Medication Errors was requested from V2 on 9/5/2025 at 11:05AM.

V2 stated she would see if they had one, but she was not sure.

There was no policy provide by the end of survey on 9/12/25.

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