Unauthorized Resident Access to Medication Storage Room During Insulin Administration
Penalty
Summary
A licensed practical nurse (LPN) was observed bringing a resident into the medication storage room to administer insulin. The LPN primed a Humulin Kwik pen, checked the resident's blood sugar, administered 20 units of insulin to the resident's abdomen, and disposed of the needle in the sharps container. The LPN stated that she typically did not administer insulin in the medication room, but did so in this instance because she was the only licensed nurse on duty and needed to give all the insulins in the facility. She also mentioned that the resident had left the dining room before she could administer the insulin, prompting her to bring the resident into the medication room for the procedure. Further interviews revealed that the assistant director of nursing (ADON) had also previously taken residents into the medication room to provide privacy for insulin administration. The director of nursing (DON) was unaware that nurses had been bringing residents into the medication room for this purpose and acknowledged concerns regarding infection control and medication storage, particularly if a resident were left unattended in the room. Facility policy specifies that the medication supply is only accessible to licensed nursing personnel, authorized staff, or pharmacy personnel.