Medication Error Rate Exceeds 5% Due to Improper Insulin Priming
Penalty
No penalty information released
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Summary
The facility failed to maintain a medication error rate below 5%, with an observed error rate of 5.41% affecting one of three residents whose medication administrations were observed. Specifically, a resident was prescribed a sliding scale insulin regimen, including Lantus insulin at 10 Units and Lispro insulin at 2 Units. During a medication pass, an LPN was observed priming both insulin pens with only 1 Unit of insulin instead of the required 2 Units before administering the prescribed doses. The LPN confirmed priming each pen with 1 Unit, which did not comply with the proper procedure for insulin administration.