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F0658
D

Failure to Prime Insulin Pen Prior to Administration

Boise, Idaho Survey Completed on 11-19-2025

Penalty

No penalty information released
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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 was identified when a registered nurse failed to prime an insulin pen prior to administering Insulin Lispro to a resident with diabetes, as observed during medication administration. The resident had a physician's order for Insulin Lispro 100 unit/ml, with instructions to inject two units subcutaneously before meals. During the observed administration, the nurse replaced the needle and sanitized the pen but did not prime it, stating that priming was only necessary for new pens. The Acting Director of Nursing later clarified that the insulin pen should be primed before each use. According to the Insulin Lispro manufacturer’s instructions, priming is required before every injection to ensure accurate dosing.

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