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F0658
D

Failure to Prime Insulin Pens Prior to Administration

Omaha, Nebraska Survey Completed on 07-28-2025

Penalty

No penalty information released
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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

The facility failed to ensure that insulin was administered in accordance with professional standards of practice for three residents. For each of these residents, licensed nursing staff administered insulin using insulin pens without priming the pens prior to injection. Specifically, one resident had an order for Lispro insulin to be given three times daily with meals, and the LPN administered the insulin without priming the pen. Another resident, with an order for Novolog insulin per sliding scale, also received insulin from an unprimed pen. A third resident, ordered Admelog insulin per sliding scale, was similarly administered insulin without the pen being primed. Interviews with the LPNs involved confirmed that the insulin pens were not primed before administration, and one LPN incorrectly believed that only insulin syringes required priming. The facility's own competency procedure for insulin administration specifies that insulin pens must be primed with 2 units and the dose wasted to verify proper functioning. The RN Nurse Consultant confirmed that priming insulin pens is a standard of practice. These actions resulted in the facility not meeting professional standards of quality for medication administration.

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