Failure to Prime Insulin Pen Prior to Administration
Penalty
Summary
A deficiency occurred when a licensed practical nurse (LPN) failed to administer insulin according to the manufacturer's instructions for a resident with diabetes. The resident, who was cognitively intact and had a diagnosis of diabetes, was prescribed Lantus and Novolog insulin at specific times throughout the day. During an observation of medication administration, the LPN prepared the Novolog insulin pen by attaching a new sterile needle but did not prime the pen with 2 units of insulin before administering the dose, as required by the manufacturer's instructions. The LPN stated she had been instructed that priming was only necessary on the initial use and had never primed the pen before subsequent injections. Further review revealed that the facility's policy, as well as the manufacturer's instructions for the insulin pen, required priming with 2 units before each injection to ensure accurate dosing. Another nurse confirmed that she always primed the pen by wasting 2 units before drawing up the prescribed dose. The director of nursing also stated that staff are instructed to always prime insulin pens prior to administration. The failure to follow these procedures resulted in the resident not receiving insulin in accordance with the manufacturer's instructions.