Insulin Administration Error Due to Failure to Prime Pen
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
A deficiency occurred when a registered nurse failed to properly prepare and administer insulin to a resident with diabetes and heart failure. The resident had physician orders for Novolog insulin, including a scheduled dose and a sliding scale based on blood glucose readings. During medication administration, the nurse dialed the insulin pen to the correct total dose but did not prime the pen with 2 units as required before administering the insulin. The nurse later stated he was unaware of the need to prime the pen prior to use. The facility's Chief Nursing Officer confirmed that insulin pens should be primed with 2 units before administration.