Failure to Prime Insulin Pen Prior to Administration
Penalty
Summary
A deficiency occurred when staff failed to ensure a resident was free from significant medication errors during insulin administration. Specifically, an LPN administered insulin using an insulin pen without priming it beforehand, as observed during medication administration. The LPN confirmed in an interview that the priming step was omitted prior to giving the insulin injection. The resident involved had a history of sepsis, osteomyelitis, type 2 diabetes mellitus, hypertension, and bilateral below-knee amputations, and was cognitively intact and used a wheelchair. Physician orders required the use of an insulin pen for scheduled and sliding scale doses. Manufacturer instructions for the insulin pen explicitly state that priming is necessary before each injection to ensure accurate dosing, but this step was not followed during the observed administration.