Failure to Prime Insulin Pen Prior to Administration
Penalty
Summary
A deficiency occurred when a staff member failed to properly prime an insulin pen prior to administering insulin to a resident diagnosed with type 2 diabetes mellitus and diabetic chronic kidney disease. According to the facility's insulin administration instructions, the pen should be primed by selecting two units and pressing the plunger to ensure a drop of insulin appears at the needle tip before injection. During a medication administration observation, the Infection Preventionist attached a needle to the insulin pen, set the dose, and administered the injection without priming the pen as required by protocol. The Infection Preventionist later confirmed in an interview that she was unaware of the need to prime the pen and did not recall receiving training on this procedure. The Education Coordinator also stated that staff should prime the insulin pen before use, but acknowledged that she had not yet begun training staff on medication administration since starting her position over a month prior. This lapse in following proper medication administration procedures led to the identified deficiency.