Insulin Administration Errors in LTC Facility
Penalty
Summary
The facility failed to administer insulin correctly to two residents, leading to significant medication errors. Resident #31, who has diabetes and renal insufficiency, was observed receiving Novolog insulin via a flexpen. The LPN administering the insulin did not follow the manufacturer's instructions, which require the needle to remain in the skin for at least 6 seconds to ensure the full dose is delivered. Instead, the needle was removed after only one second. The facility lacked a specific policy for insulin flexpen use, and the Co-Director of Nursing was unaware of the proper procedure, relying instead on manufacturer instructions. Similarly, Resident #41, who has diabetes and macular degeneration, was administered Lispro insulin incorrectly. The LPN did not prime the insulin pen properly, as required by the manufacturer's instructions, and did not hold the needle in the skin for the recommended 5 seconds. The LPN also failed to check that the dose counter showed zero after administration, which is necessary to confirm the full dose was given. These actions resulted in the residents potentially receiving incorrect insulin dosages, as the facility did not have adequate procedures in place to ensure proper insulin administration.