Unlabeled Insulin Pen Administered to Resident
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) administered insulin to a resident using an insulin pen that was not labeled with the resident's name. The insulin pen, which was for Aspart 100 units/mL, was found on the medication tray with an open date but no identifying label. The LVN stated she usually labels insulin pens but did not know why this one was not labeled. She identified the pen as belonging to the resident because the resident was the only one on the hall using that type of insulin. The Director of Nursing (DON) confirmed that insulin pens are required to be labeled and that the pen should not have been on the medication cart without a name. The Assistant Director of Nursing (ADON) indicated that insulin pens are logged and accounted for upon arrival, but in this case, the family had brought in the insulin and labeling was missed. The resident involved had multiple diagnoses, including cerebral palsy, type 2 diabetes mellitus, mild intellectual disabilities, and anxiety, and was severely cognitively impaired, requiring staff assistance for activities of daily living and daily insulin injections. The facility's policy and the LVN's training both required adherence to the six or seven rights of medication administration, including verifying the correct resident and medication. Despite this, the insulin was administered from an unlabeled pen, which was only labeled after the deficiency was observed.