F0760

D

Failure to Prime Insulin Pens Before Administration

Oregon, Ohio Survey Completed on 01-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure insulin pens were primed prior to insulin administration, contrary to manufacturer instructions and facility policy, resulting in significant medication errors for two residents. For one resident with traumatic brain injury, type II diabetes mellitus, muscle weakness, depression, and dysphagia, the care plan directed staff to administer insulin per physician orders. The physician ordered Degludec insulin via pen-injector, 15 units subcutaneously in the morning. During continuous observation of a medication pass, an LPN attached a needle to the Degludec pen, dialed the pen directly to 15 units, entered the resident’s room, and administered the insulin subcutaneously without priming the pen.

The second affected resident had diagnoses including acute and chronic respiratory failure with hypoxia, type II diabetes mellitus, peripheral vascular disease, chronic kidney disease, and hypertension, and also had a care plan intervention to administer insulin per physician orders. The physician ordered Lispro insulin via pen-injector, 4 units subcutaneously before meals and at bedtime. During observed medication administration, the same LPN dialed the Lispro pen directly to 4 units and administered the insulin without priming. In a subsequent interview, the LPN confirmed that he did not prime the insulin pens for either resident and stated there was no need to do so. Manufacturer instructions for both Degludec and Lispro pens, as well as facility policy, required priming the pen (dialing 2 units, expelling air until a drop of insulin appears) before each injection to remove air and ensure correct dosing, and noted that not priming may result in too much or too little insulin being delivered.