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F0760
D

Failure to Properly Prime Insulin Pen Before Administration

Pueblo, Colorado Survey Completed on 06-05-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a licensed practical nurse (LPN) failed to properly prime an insulin pen before administering a dose of Humalog insulin to a resident. According to manufacturer guidelines, priming the insulin pen with the needle attached is necessary to remove air from the needle and cartridge, ensuring the correct dose is delivered. During observation, the LPN dialed two units and pushed on the cartridge before attaching the disposable needle, then dialed the prescribed dose and administered the insulin to the resident without priming the pen with the needle in place. The resident involved was under 65 years old, had diagnoses including hypertension and diabetes, and was cognitively intact with a BIMS score of 15. The resident required assistance with some activities of daily living. The failure to follow proper insulin administration technique was confirmed through staff interviews and review of manufacturer instructions, which specify that the needle must be attached before priming to ensure accurate dosing.

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