Failure to Follow Insulin Pen Administration Protocols
Penalty
Summary
A deficiency was identified when a nurse failed to follow manufacturer instructions for administering insulin using an insulin pen for a resident with diabetes mellitus. The nurse removed the resident's Lantus Glargine pen from the medication cart, checked the physician's order, and set the pen to the prescribed dose of 45 units. However, the nurse did not prime the pen with two units of insulin as required by the manufacturer's guidelines. The nurse then injected the insulin into the resident's lower right abdominal quadrant, pushed the button to administer the dose, and withdrew the pen without holding it in place for the recommended 10 seconds. Interviews with other nursing staff revealed that the expected practice is to prime the insulin pen with one or two units until insulin is visible at the needle tip, then administer the prescribed dose and hold the pen at the injection site for several seconds to ensure full delivery. The facility's policy, consistent with manufacturer instructions, directs staff to prime the pen and hold it in place for 6-10 seconds during administration. The Director of Nursing confirmed that staff are expected to follow these procedures. The failure to prime the pen and hold it for the appropriate duration constituted a significant medication error for the resident.