Failure to Properly Date and Administer Insulin Using a Flexpen
Penalty
Summary
The deficiency involves the incorrect administration of insulin to a cognitively intact resident with diagnoses including hypertension, kidney failure, diabetes mellitus, and morbid obesity, who required insulin injections daily. The resident’s physician order directed staff to administer 10 units of short-acting insulin with meals using a flexpen, and the care plan instructed staff to check blood sugars as needed and administer insulin as ordered. The resident reported using insulin and experiencing elevated blood sugars after lunch, and the Treatment Administration Record showed lunchtime blood sugars ranging from 166 mg/dL to 398 mg/dL during the month. During a continuous medication observation, an RN prepared and administered the resident’s insulin using a flexpen that had been previously opened but was not dated, contrary to facility policy requiring multi-dose containers to be dated when opened. The RN attached a new pen needle, dialed the dose to 10 units, and injected the insulin into the resident’s upper arm without first priming the needle to remove air and ensure delivery of the full dose. After administration, the surveyor noted the absence of an open date on the pen, and the RN acknowledged that the pen should have been dated, that he had not checked the date before use, and that he had forgotten to prime the needle despite it being part of proper insulin administration. The CMA and DON both stated that staff are expected to verify medication rights, date newly opened medications, correctly assemble insulin pens, prime needles, and verify dates before administration, confirming that these steps were not followed in this instance.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.