Failure to Follow Insulin Pen Priming Procedure
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) failed to follow the manufacturer's instructions for priming a Humalog insulin pen prior to administering insulin to a resident with Type 2 diabetes. The LVN did not prime the pen with 2 units as required, but instead dialed in an extra unit and pushed out 1 unit before administering the prescribed dose. The LVN was unaware of the correct priming procedure, which is necessary to ensure the accurate delivery of insulin. The resident involved was a female with a diagnosis of Type 2 diabetes, who was prescribed Humalog insulin per a sliding scale. Observation confirmed that the LVN did not prime the pen according to manufacturer instructions, and interviews revealed a lack of knowledge regarding the correct procedure. Additionally, the facility's medication administration policy did not include specific procedures for the use of insulin pens.