F0759

D

Failure to Prime Insulin Pens Resulting in Elevated Medication Error Rate

Cynthiana, Kentucky Survey Completed on 01-22-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain a medication error rate at or below 5%, as required, resulting in a calculated error rate of 7.41% (2 errors out of 27 observed medication administration opportunities). Surveyors observed that nursing staff did not follow manufacturer instructions for priming insulin pens before administration. The facility’s general medication administration policy required adherence to the “five rights” and recommended triple-checking these rights, but the Director of Health Services acknowledged there was no facility policy specific to insulin use. The Interim Executive Director and the Director of Health Services both stated that nurses were expected to follow manufacturer guidelines for insulin pen use, including priming.

One resident, admitted with type 2 diabetes mellitus with hyperglycemia and ordered insulin aspart U-100 via sliding scale, was observed when an LPN attached a needle to the insulin aspart pen, dialed 10 units, and proceeded toward the resident without priming the pen; the LPN stated she was unaware that priming was required. Another resident, admitted with type 2 diabetes mellitus with ketoacidosis without coma and diabetic neuropathy and ordered Humalog KwikPen insulin 5 units three times daily with meals, was observed when an RN attached a needle, dialed 5 units, and began to administer the dose without priming; the RN acknowledged she was supposed to prime with 2 units. Another LPN and the Director of Health Services both stated that insulin pens should be primed with 2 units before dialing the ordered dose to ensure the full amount is administered, and manufacturer instructions for both NovoLog and Humalog pens specified priming with 2 units before each injection to remove air and ensure proper dosing.