The VA has had Type 1 diabetes since they were 6 years old and now is 44 years old.  The VA lives in an adult foster care setting for the past seven years with three other individuals.  The VA enjoys walking the dog, going to work 5 days a week, and being active in the community.  

The VA has a protocol that all staff are trained on and due to this regimen it is difficult to have any fill in staff cover shifts at the adult foster care home.  The VA completes the blood sugar checks without assistance from staff with an Accuchek machine.  The machine then tells the staff how much insulin is required at that time depending on how many carbs the VA is going to eat at that meal time for both medications.  The VA gets novolox 4x/day and the tuojeo 1x/day at dinner.   The protocol goes onto say if the numbers are within this range give this much insulin and if they are within this much give this amount.  The VA takes two different types of insulin along with several other medications. This protocol is listed on the computer within the MAR system that the provider utilizes to document medications and communications amongst the staff.   

The staff will then “dial up” the insulin for the VA and they will give themselves the insulin injections.  The insulin medications are not labeled with the amount of units that are to be given due to the variances based off of the blood sugar numbers and the amount of carbs that are about to be eaten by the VA.  The VA is aware of the regimen and understands the necessity to take her insulin each day. 

The VA is unable to feel the effects of having blood sugar numbers out of the normal range (80-120) and their numbers will reach as high as 300-400 without any signs (dizzy, light headed, sweaty, etc.).  The VA understands when their numbers are high if they exercise they can reduce the numbers.  The VA had a checkup with their doctor regarding the blood sugar being high, although the staff will educate the VA on proper eating choices and the VA exercises frequently.  The doctor stated the Tuojeo needed to go from 15 units to 17 units at dinner time.  The supervisor of the house had taken the VA to the appointment and came home and documented this in the MAR and in the staff notes of the change and had given the VA the change in medications when giving the medication that evening.  The supervisor gave the other staff the information to follow.  

The nurse found the error in the medications after different staff had worked and not just the supervisor and the staff that was informed on 8/29/19 after the VA went to the doctor appointment.  The supervisor had been doing compliance checks once a week of the medications, however did not see it because the medications and the MAR don’t match because they never have matched because of the variances in the medication that is given based off what the numbers are and how many carbs are being eaten.  There are many moving parts to giving the insulin medications while the staff also must follow the protocol.  The staff typically give the medication after the supervisor has left for the day as well due to the supervisor working from 9a-5pm and the VA gets this medication at dinner time.   
