Failure to Follow Manufacturer's Instructions for Insulin Pen Administration
Penalty
Summary
The facility failed to ensure that insulin was administered according to the manufacturer's instructions for two residents with diabetes mellitus who required insulin injections. Both residents had physician orders for insulin administration using a Humalog KwikPen. During medication administration observations, LPNs administered insulin to each resident but did not hold the pen needle in the skin for at least five seconds after injection, as required by the manufacturer's guidelines. Instead, the LPNs immediately withdrew the needle after injecting the insulin. Interviews with the LPNs confirmed that they did not follow the manufacturer's instructions regarding the required hold time after injection. The facility's policy stated that medications should be administered safely and as prescribed, and the insulin pen manufacturer's instructions were available online. The Unit Manager acknowledged that the instructions for insulin pen use could be found on the manufacturer's website.