Failure to Properly Prime Insulin Pen Resulting in Medication Error
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from a significant medication error when insulin was administered incorrectly. Resident #7, admitted with type II diabetes mellitus and care planned for diabetes management with medications to be administered as ordered, had a physician’s order for insulin lispro 100 units/ml, six units SQ before meals, to be held if blood sugar was less than 150. A quarterly MDS showed the resident had severe cognitive impairment with a BIMS score of 2/15, did not reject care, and was independent with eating, transfers, and oral hygiene, requiring supervision for toileting hygiene and showers. During observation of a medication pass, LPN #207 checked Resident #7’s blood sugar, which was 238, then prepared an insulin lispro pen by attaching a needle and dialing the pen to six units without priming the pen before administration. The LPN then administered the insulin SQ. In a subsequent interview, LPN #207 confirmed she did not prime the insulin pen and stated that she believed pens should never be primed to avoid air. Review of the insulin pen instruction manual showed that a safety test (priming) of two units must be performed before each injection to ensure the pen and needle are working properly and to ensure the correct dose is delivered. Facility policy on administering medications required medications to be administered in a safe manner and as prescribed. The failure to prime the insulin pen before dialing and administering the ordered dose constituted the medication error identified during the complaint investigation.
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