Medication Error Rate Exceeds 5% Due to Improper Insulin Pen Administration
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as two errors were identified out of 27 observed opportunities, resulting in a 7.4% error rate. The errors involved a resident with type II diabetes mellitus who was severely cognitively impaired and required daily insulin injections. During medication administration, a registered nurse did not prime either of the two insulin pens before administering them to the resident, contrary to manufacturer instructions and facility policy. The nurse stated that he only primed insulin pens if they were brand new, and did not perform the priming step for pens that had been previously used. Additionally, the nurse administered the resident's morning insulin doses significantly later than the prescribed times and delayed the next scheduled dose due to the late administration. The DON confirmed that insulin pens should be primed before each use and that medications should be administered according to physician orders. Facility policy and insulin pen manufacturer instructions both require priming before each injection to ensure proper dosing and function.