Failure to Administer Insulin per Policy and Physician Orders
Penalty
Summary
The facility failed to ensure that insulin was administered according to physician orders and facility policy for two residents who required insulin injections via insulin pen. For one resident with type two diabetes, an LPN primed the insulin pen before attaching the needle, rather than after, and then administered the insulin without repriming, contrary to policy. For another resident with type one diabetes, an LPN administered insulin without priming the pen at all, as confirmed by both observation and staff interview. In both cases, the facility's policy required priming the insulin pen with the needle attached and dialing two units before each injection to ensure correct dosing. Both residents involved were cognitively intact and had documented care plans and physician orders specifying the administration of insulin via pen-injector. The facility's policy, reviewed and dated July 2024, clearly outlined the steps for proper insulin pen priming and administration, which were not followed by the nursing staff. These failures were identified through direct observation, staff interviews, and review of medical records and facility policy.