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F0760
D

Insulin Administration Not Performed per Manufacturer and Physician Instructions

Carlisle, Iowa Survey Completed on 07-31-2025

Penalty

Fine: $37,177
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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 staff failed to administer insulin according to both physician's orders and manufacturer instructions for a resident with diabetes and diabetic neuropathy. During a medication pass, an LPN used a new Novolog insulin flexpen, labeled and dated it, attached a needle, and primed the pen by dialing to 2 units and expelling insulin. The LPN then set the pen to 3 units, donned gloves, and injected the insulin into the resident's abdomen. However, the LPN removed the needle from the injection site within 1-2 seconds, rather than following the required procedure to keep the needle in the skin for at least 6 seconds to ensure the full dose was administered. Facility competency guidelines and manufacturer instructions both specify that after pressing the injection button, the needle should remain in the skin for a specified period to ensure the complete dose is delivered. The LPN did not adhere to this step, potentially resulting in an incomplete dose. The DON confirmed the correct procedure for insulin pen use, including the importance of priming and ensuring the full dose is administered, but the observed practice did not align with these standards.

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