Improper Insulin Administration Due to Supply Shortage
Penalty
Summary
The facility failed to adhere to professional standards of quality in medication administration when a Licensed Practical Nurse (LPN) used improper supplies to administer insulin. According to the facility's Clinical Skills Fair Guide, the correct procedure for using a FlexPen, a pre-filled insulin delivery device, involves attaching a new needle to the pen, dialing the required units, and injecting the insulin directly. However, during an observation, LPN A was seen drawing insulin from the FlexPen into an insulin syringe instead of using the pen as intended. LPN A explained that the facility had run out of FlexPen needles a few days prior, and this method was previously suggested in January. The Director of Nursing (DON) was unaware of the shortage of FlexPen needles and the alternative method being used by the staff. During an interview, the DON mentioned that the pharmacy had previously indicated that using an insulin syringe was acceptable, although she could not recall who provided this information. However, a subsequent interview with the pharmacist revealed that none of the pharmacists remembered any conversation about drawing insulin from the FlexPen with an insulin syringe, indicating a communication breakdown and lack of proper oversight in medication administration procedures.