Failure to Prime Insulin Pen Leads to Medication Error
Penalty
Summary
The facility failed to ensure that residents are free of significant medication errors, as evidenced by an incident involving a resident with diabetes and high blood pressure. The resident was admitted to the facility with a physician's order to receive 12 units of Lantus insulin via a Solostar prefilled pen each morning. During a medication administration observation, an LPN set the insulin pen to the correct dose but neglected to perform the required priming procedure before administering the insulin. This priming step, as outlined in the manufacturer's guidelines, involves selecting a dose of two units, tapping the reservoir to remove air bubbles, and ensuring insulin comes out of the needle tip before administering the full dose. The LPN confirmed during an interview that she failed to prime the insulin pen prior to administering the medication to the resident. The Director of Nursing also confirmed that the facility did not administer the correct dose of insulin due to this oversight. This incident highlights a deviation from the facility's medication administration policy, which mandates that medications be administered safely, accurately, and in a timely manner, in accordance with good nursing principles and practices.
Plan Of Correction
The facility will ensure residents are free of significant medication errors. The facility cannot retroactively correct the concern identified for resident R3. The Director of Nursing or designee will re-educate licensed nurses on the facility policy and procedures for medication administration, detailing priming the insulin pen prior to administering medications. The Director of Nursing or designee will complete 5 nurse medication administration competencies weekly for four weeks, then monthly for three months to ensure insulin pens are primed prior to medication administration and residents are free from significant medication errors. The results of these audits will be forwarded to the monthly Quality Assurance and Performance Improvement Committee for review and frequency of audits.