F0658

D

Improper Insulin Pen Use Contrary to Manufacturer Instructions

Keokuk, Iowa Survey Completed on 01-08-2026

Penalty

No penalty information released

Summary

Facility nursing staff failed to follow manufacturer instructions for administration of Admelog Solostar insulin, resulting in insulin being withdrawn from an insulin pen using a syringe rather than the manufacturer-approved pen needle. Resident #15, who had intact cognition with a BIMS score of 14 and a diagnosis of diabetes mellitus, had a physician order for Admelog U-100 insulin, 6 units subcutaneously with meals, and received insulin injections daily. During observation, Staff D, an LPN, prepared the resident’s lunch insulin by wiping the insulin pen hub with an alcohol pad and inserting an insulin syringe into the pen to withdraw 6 units, instead of attaching and using a pen needle as directed by the manufacturer. Staff D then checked the resident’s blood glucose, which was 140 mg/dL, and administered the insulin into the resident’s right arm.

In interviews, Staff D stated they did not use the pen needles because of cost and reported being trained at hire to draw insulin from the pen with a syringe. Staff A, an RN, reported also drawing insulin from the pen into a syringe, stating it was safer than using the non-safety pen needle and believed this resident was the only one prescribed an insulin pen. The DON confirmed that Resident #15 was the only resident using an insulin pen, expressed a preference for vials due to perceived lower risk of error, and stated they knew the resident received the correct insulin and did not think there was an issue with drawing insulin from the pen using a syringe. Manufacturer instructions for the Admelog Solostar pen explicitly stated not to use a syringe to remove insulin from the pen, and the facility’s Insulin Preparation and Administration Policy did not address following manufacturer instructions for insulin administration.