Failure to Prime Insulin Pens Prior to Administration
Penalty
Summary
The facility failed to ensure that nursing staff followed manufacturer instructions for priming insulin pens prior to administering insulin to two residents with Type 2 diabetes. In the first instance, a nurse performed a fingerstick blood sugar test for a female resident, determined the required insulin dose per sliding scale, and administered the insulin using an Insulin Aspart pen without priming it. The nurse later stated she was unaware of the need to prime the pen before each dose and had not been instructed on this step during her training. In the second instance, another nurse administered Lyumjev insulin to a male resident after receiving a physician's order for a specific dose, again without priming the insulin pen. This nurse acknowledged awareness of the priming requirement but stated she forgot to perform the step. The Director of Nursing confirmed that insulin pens are to be primed before each injection and that failure to do so could result in residents not receiving the prescribed amount of insulin. Facility policy and manufacturer instructions both require priming of insulin pens before each use.