Failure to Follow Infection Control Procedures During Insulin Administration
Penalty
Summary
The facility failed to adhere to infection control procedures during medication administration for three residents. Observations revealed that Employee 1 did not cleanse the rubber tip of the Basaglar Kwikpen before attaching the insulin needle for Resident 53. Similarly, Employee 1 neglected to swab the rubber tips of the Lantus Solostar and Novolog Flexpen before administering insulin to Resident 23. Employee 2 also failed to cleanse the rubber tip of the Insulin Aspart Flexpen before injecting insulin into Resident 18. The manufacturer's instructions for the insulin pens, including Basaglar Kwikpen, Lantus Solostar, Novolog Flexpen, and Insulin Aspart Flexpen, specify that the rubber tip should be swabbed with an alcohol swab before attaching the needle to prevent infection. During a staff interview, the Nursing Home Administrator confirmed that the facility's expectation was for employees to cleanse the rubber tips of insulin pens prior to needle attachment. This deficiency was identified under 28 Pa code 211.12(d)(1)(5) Nursing services.
Plan Of Correction
The residents suffered no ill effects from this deficient practice. The rubber tips of the insulin pens will be cleansed prior to Resident 53, Resident 23, and Resident 18's insulin injections. All residents who receive insulin injections will have the rubber tip cleansed prior to use. Licensed nurses will be educated on the insulin pen policy/procedure. Audits will be completed by direct observation on 3 residents per week for one quarter to ensure that the rubber tips are properly cleansed prior to the insulin injections. After that, the audits will be completed on one resident per week for a month to ensure compliance. Results of these audits will be reported to the Quality Assurance and Performance Improvement Committee. Corrective action will be completed by 1/31/25.