Failure to Follow Insulin Pen Administration Protocol
Penalty
Summary
A deficiency was identified when the Unit Coordinator failed to administer an insulin pen injection according to the facility's policy and professional standards. During a medication administration observation, the Unit Coordinator did not wait the required 6-10 seconds after fully depressing the insulin pen plunger before removing the needle from the resident's skin. Instead, the pen was removed immediately after the dose was delivered, which was observed to result in clear fluid draining from the injection site. The facility's policy specifically directs staff to keep the needle in the skin for up to 6-10 seconds after the dose is administered to ensure proper delivery of the medication. The resident involved had a diagnosis of type 2 diabetes and a physician's order for Novolog FlexPen insulin to be administered with meals. The Unit Coordinator, while preparing and administering the insulin, did not adhere to the required hold time after injection, and was unable to confirm how long the pen was held in place. Both the Unit Coordinator and the DON acknowledged that the policy was not followed during this administration, as the pen should not have been removed immediately after the dose was delivered.