Insulin Pen Shared Between Residents by LPN
Penalty
Summary
A Licensed Practical Nurse (LPN) administered insulin to one resident using another resident's previously used insulin pen, resulting in potential exposure to bloodborne pathogens. The incident occurred when the LPN used the insulin pen belonging to one resident to administer a dose to a different resident after the latter had run out of their own insulin. This action was confirmed through staff interviews and review of the electronic medication administration records, which showed that both residents had active physician orders for insulin and that the medication was documented as given on the same day. Manufacturer instructions for the insulin pen and facility policy both explicitly state that insulin pens are for single-patient use and must not be shared between residents, even with a new needle, due to the risk of transmitting infections. The Centers for Disease Control and Prevention (CDC) also provides guidance that insulin pens should never be used for more than one patient because blood may be present in the pen after use. The facility's policy further reinforces that medications supplied for one resident are never to be administered to another resident. Despite these clear guidelines, the LPN administered insulin in a manner that violated both manufacturer and facility protocols.