Improper Insulin Administration and Infection Control Lapses
Penalty
Summary
A nurse failed to competently administer insulin to a resident with diabetes, as evidenced by video footage and interviews. The nurse, while wearing the same pair of gloves throughout the process, handled multiple surfaces, medication drawers, and insulin pens without changing gloves or performing hand hygiene. The nurse drew insulin from two different insulin pens into a syringe and administered two injections to the resident, rather than using the insulin pens as intended. The medication cart and insulin pens were left open and unattended during the process, contrary to facility policy. The resident, who was cognitively intact and had a diagnosis of type II diabetes, expressed concern about the insulin administration, specifically suspecting that the nurse may have miscalculated the dose and administered too much insulin. The resident reported experiencing a low blood sugar episode that night, although this was not documented in the vitals summary. The resident also noted that the nurse appeared unsure during the administration and that the method used—drawing insulin from pens into a syringe—was not appropriate. Interviews with the nurse, the DON, and the consulting pharmacist confirmed that drawing insulin from an insulin pen with a syringe is not an acceptable practice and is not included in the facility's competency checklist or policy. The nurse acknowledged the improper technique and infection control lapses, and the DON confirmed that the medication cart and medications should not be left unlocked or unattended. Facility policies reviewed did not support the actions taken by the nurse during the insulin administration.