Failure to Prime Insulin Pens Prior to Administration
Penalty
Summary
A deficiency occurred when a Licensed Practical Nurse (LPN) failed to prime insulin pens prior to administering insulin to a resident on two separate occasions. The resident had a medical history that included diabetes mellitus, renal insufficiency, and osteomyelitis of the right ankle and foot, and was cognitively intact. The resident's orders included daily administration of two types of insulin via pen injectors. During direct observation, the LPN attached new needles to both insulin pens, dialed the prescribed doses, but did not prime the pens before administering the medication. Interviews with the Director of Nursing and the LPN confirmed that the expected procedure was to prime the insulin pen with 2 units and waste those units before administration, which was not done in these instances. Review of the facility's insulin administration policy did not provide specific instructions for insulin pen use, only for syringe administration. The failure to prime the insulin pens as required resulted in a significant medication error for the resident.