Improper Insulin Pen Use for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain an infection prevention and control program when administering insulin via an insulin pen. Facility policy dated November 2025 and CDC guidance both state that insulin pens are for single-patient use only and must never be used for more than one person. Despite this, an LPN obtained an insulin pen prescribed for one resident and used it to administer Lantus insulin to another resident, using a new needle but the same pen. The facility’s own investigation documented that the LPN used another resident’s insulin pen after not finding Lantus in the emergency kit. Resident #1, an older adult with type 2 diabetes mellitus with diabetic chronic kidney disease and unspecified dementia with mood disturbance, had severe cognitive impairment with a BIMS score of six and required partial to moderate assistance with activities of daily living. A recent MDS indicated a change in the insulin order for this resident. When the ordered Lantus was not available in the emergency kit, the LPN chose to use another resident’s insulin pen instead of obtaining the medication through other available means, such as STAT pharmacy delivery or nearby hospitals, as described by another LPN. This action directly violated CDC guidance and the facility’s insulin pen use policy, resulting in a failure to follow proper infection control practices during insulin administration.
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