Failure to Prime Insulin Pens Prior to Administration
Penalty
Summary
A deficiency was identified when nursing staff failed to prime insulin pens prior to administering insulin to a resident with type II diabetes mellitus. The resident, who was severely cognitively impaired and required daily insulin injections, had physician orders for Basaglar and Admelog insulin pens to be administered at specific times. During an observed medication administration, a registered nurse attached new needles to both insulin pens, dialed in the prescribed doses, but did not perform the required priming procedure before injecting the insulin subcutaneously. The nurse later confirmed that he only primed insulin pens if they were brand new, contrary to manufacturer instructions and facility policy, which require priming before each use to ensure proper dosing. Further review of the resident's care plan and physician orders confirmed the necessity of administering medications as prescribed and in a timely manner. The Director of Nursing verified that insulin pens should be primed before every use and that medications must be given according to physician orders. The facility's policy and the insulin pen instruction manuals both specify the need for priming before each injection to ensure the pen and needle are functioning correctly and to deliver the correct dose. The failure to prime the insulin pens constituted a significant medication error affecting the resident.