Failure to Prime Insulin Pens Results in Medication Error Rate Above 5%
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required, with a calculated error rate of 6.45% based on 31 observed medication administrations and two identified errors. Both errors involved the administration of insulin using pen injectors for two residents with diabetes and chronic kidney disease. In both cases, the LPNs administering the insulin did not prime the insulin pens prior to dialing the prescribed dose and administering the medication, contrary to manufacturer instructions and facility policy. The LPNs confirmed during interviews that they did not prime the pens, with one stating she only primes if air bubbles are visible and the other stating she did not believe priming was necessary. The residents involved were cognitively intact and had care plans and physician orders specifying insulin administration for diabetes management. The facility's policy and the insulin pen manufacturer’s instructions both require priming the pen after attaching a new needle and before setting the prescribed dose. The DON confirmed that the correct procedure was not followed in these instances. The deficiency was identified during a complaint investigation and was substantiated by direct observation, record review, and staff interviews.