Failure to Properly Prime Insulin Pen Before Administration
Penalty
Summary
Surveyors identified a deficiency in medication preparation and administration involving insulin for Resident #2. The resident, who had multiple diagnoses including diabetes and anxiety, had physician orders for Basaglar (insulin glargine) 15 units subcutaneously and insulin lispro per sliding scale. On 1/27/26 at 8:27 AM, an LPN was observed removing the glargine insulin pen from the medication cart and dialing it directly to 15 units without first priming the pen with 2 units, as required. At 8:32 AM, the LPN administered the unprimed glargine insulin dose to the resident. At 8:37 AM, the LPN acknowledged she had not primed the insulin pen on that occasion and stated she only sometimes primed the pen before administration. On 1/28/26 at 4:18 PM, the DON confirmed that insulin pens should be primed with 2 units prior to administering the ordered insulin dosage. This failure to consistently prime the insulin pen before dialing and administering the ordered dose resulted in the resident not being ensured freedom from significant medication preparation and administration errors and placed the resident at risk for not receiving the prescribed medication dosage and other adverse outcomes, as stated in the report.
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