Failure to Prime Insulin Pen Prior to Administration
Penalty
Summary
A Licensed Practical Nurse (LPN) failed to prime an insulin pen prior to administering insulin to a resident diagnosed with diabetes, depression, and lack of coordination. The resident was observed receiving insulin injections daily, and during the observed medication administration, the LPN stated that priming was only necessary for the first use of the pen. The LPN proceeded to inject the resident with four units of insulin without priming the pen, contrary to the manufacturer's instructions, which require priming before each injection. Review of the resident's medication orders confirmed the use of a Humalog KwikPen with a sliding scale for insulin administration. The facility's policy on administering medications emphasized safe and timely administration as prescribed, but there was no specific policy regarding insulin pen use. The Director of Nursing confirmed that staff should prime insulin pens prior to each injection, and the manufacturer's instructions also directed priming before every use.