Failure to Follow Insulin Pen Priming Protocols
Penalty
Summary
Staff failed to follow professional standards of practice for insulin pen preparation and administration for three residents. Facility policy required staff to prime the insulin pen by dialing 2 units, removing the needle cap, and holding the pen upright to ensure a drop of insulin appeared at the needle tip. However, observations revealed that a nurse primed insulin pens for two residents by dialing 3 units instead of 2, left the needle cap on, and held the pen horizontally rather than upright. Similarly, a medication aide primed an insulin pen for another resident by dialing the correct 2 units but also left the needle cap on and held the pen horizontally. These actions were directly observed during insulin administration for all three residents. During an interview, an administrative staff member confirmed that the expected practice was to prime the pen with the cap off and the needle pointed upward, as per facility policy. The failure to follow these procedures resulted in a deficiency related to not meeting professional standards of quality for medication administration.