Failure to Disinfect Insulin Pen Septum Prior to Administration
Penalty
Summary
A deficiency was identified when a licensed practical nurse (LPN) failed to disinfect the rubber septum of a resident's insulin pen with an alcohol wipe prior to attaching the needle and administering insulin. The incident was observed during a medication administration for a resident with type 2 diabetes, who was receiving Novolog Flex Pen U-100 Insulin per sliding scale. The LPN removed the pen cap and immediately attached the needle without disinfecting the septum, then proceeded to prime the pen and inject the insulin into the resident's abdomen. The LPN later confirmed that the same pen was used daily and acknowledged that the rubber top was expected to be wiped with alcohol before each use. The facility's policy on safe injection practices, dated September 2023, requires that the rubber stopper of medication vials and the neck of glass ampules be disinfected with sterile 70% alcohol before inserting a needle. The director of nursing (DON) confirmed that the rubber septum of an insulin pen should be disinfected with an alcohol wipe prior to each dose. The failure to follow this protocol was confirmed through observation, staff interview, and review of facility policy and resident records.