Assisted Living Medication Management: Insulin and Injectable Medications

Giving medications sometimes can be perceived like feeding or bathing someone. Giving medications is just another care giving task.

However giving medications can have similar risks as other invasive medical interventions.

Giving medications can be a high risk intervention which requires attention to detail, training and quality assurance.

Injecting medications bring an entirely different level of risk compared to administering other medications.  Insulin and other injectable medications create scenarios that often are complex in assisted living facilities.  

Complex considerations include:

  • Who can give injections?
  • What is training is required to give injections?
  • What monitoring is required for individuals receiving medications by injection?
  • How are injectable medications administered and stored?

AFH
FAQ

1.  Who can administer injections?

When there is a physician’s order for injections, injections can be administered by: A registered nurse (RN); a licensed practical nurse (LPN) under the general supervision of a registered nurse, or under the direction of a physician; a physician; a pharmacist; or appropriately–trained, non-licensed AFH staff. Injections can also be administered by the resident and/or a family member.  [Wis. Admin. Code §§ DHS 88.07(2)(c) and DHS 88.07(3)(d)]

2.  Can a registered nurse draw up insulin and administer the insulin to residents?

An RN has the authority, by virtue of their license, to draw up and administer insulin.  [Wis. Admin. Code §§ DHS 88.07(3)(d), N 6.03]

3.  Can a licensed practical nurse draw up insulin and administer the insulin to residents?

An LPN has the authority, by virtue of their license, to draw up and administer insulin. An LPN, however, is restricted, by virtue of nurse licensure, to perform tasks under general or direct supervision of a RN or by direction of a physician. [Wis. Admin. Code §§ DHS 88.07(3)(d), N 6.03, N 6.04]

4.  Can staff draw up insulin and administer insulin to residents?

Yes. Staff can perform this task if they have received the appropriate training.  AFH staff, however, may not be licensed; and residents and families should be made aware that unlicensed AFH staff may not have the amount of training that an RN or LPN may have. If unlicensed AFH staff is administering injections, it is recommended that they receive training from an RN, and that an RN be available for consultation. [Wis. Admin. Code §§ DHS 88.07(2)(c) and DHS 88.07(3)(d)]

5.  Can an RN pre-draw insulin for AFH staff to administer?

Yes. If the RN is delegating insulin administration, then the RN may decide to pre-draw insulin for AFH staff to administer.  RN delegation is not required in an AFH for staff to administer insulin.  The RN must be aware of the standards for pre-drawing insulin, storing, and labeling.  In addition, in an AFH an RN can only pre-draw one dose at a time, because medication transfer from the pharmacy container is limited to physicians or pharmacists, unless the transfer is for a single dose. [Wis. Admin. Code § N 6.03]

6.  Can an LPN pre-draw insulin for staff to administer?

No. An LPN cannot delegate, and therefore, cannot pre-draw insulin for staff to administer.  If there is an RN who is delegating insulin administration to AFH staff, then an LPN can pre-draw insulin, but only a single syringe.

7.  Can AFH staff dial in the dose on an insulin pen?

Yes. [Wis. Admin. Code §§ DHS 88.07(2)(c) and DHS 88.07(3)(d)]

8.  Can AFH staff conduct finger-sticks and blood sugar checks with glucometers?

Yes. CLIA waivers are required.  [Section 353 of Public Service Health Act 1988]  

9.  When a registered nurse delegates insulin administration, how often must the nurse be present for proper supervision?

The amount of supervision is dependent on the professional judgment of the RN. RN delegation is not required in an AFH, but may occur.

CBRF
FAQs

1.  Who can administer injections?

Other administration. Injectables, nebulizers, stomal and enteral medications, and medications, treatments or preparations delivered vaginally or rectally shall be administered by a registered nurse or by a licensed practical nurse within the scope of their license. Medication administration described under sub. (2) (e) may be delegated to non-licensed employees pursuant to s. N 6.03 (3).  [Wis. Admin. Code § DHS 83.37(2)(e)]

2.  Can a registered nurse draw up insulin and administer the insulin to residents?

A registered nurse has the authority, by virtue of Wis. Admin. Code ch. DHS 83 and their license, to draw up and administer insulin.  [Wis. Admin. Code §§ DHS 83.37(2)(e), N 6.03]

3.  Can a licensed practical nurse draw up insulin and administer the insulin to residents?

A licensed practical nurse has the authority, by virtue of Wis. Admin. Code ch. DHS 83 and their license, to administer insulin only under the general supervision of a registered nurse or under the direction of a physician. Wis. Admin. Code ch. DHS Ch. 83 limits administration of insulin by an LPN to residents who have stable medical conditions. [Wis. Admin. Code §§ DHS 83.37(2)(e), N 6.04]

4.  Can staff draw up insulin and administer insulin to residents?

Yes. An RN must delegate administration of insulin and other injections to CBRF staff. Delegation can include the process of drawing up the dose of insulin. The RN must assure that the CBRF staff is trained and competent to perform the task. [Wis. Admin. Code §§ DHS 83.37(2)(e), N 6.03]

5.  Can an RN pre-draw insulin for CBRF staff to administer?

Yes the RN may decide when they delegate, to pre-draw insulin for CBRF staff to administer. The RN must be aware of the standards for pre-drawing insulin, storing and labeling.  [Wis. Admin. Code §§ DHS 83.37(2)(e), N 6.03]  Please be aware that pre-drawing insulin for storage is extremely limited. Most insulin pre-drawn by nurses in the assisted living environment is only good for 1 hour of storage.

6.  Can an LPN pre-draw insulin for staff to administer?

Yes, under general supervision of an RN. There must be an RN who is delegating insulin administration to CBRF staff. The RN may delegate pre-drawing of insulin to the LPN, and actual administration of the insulin to CBRF staff. [Wis. Admin. Code §§ DHS 83.37(2)(e), N 6.03]

7.  Can CBRF staff dial in the dose on an insulin pen?

If the RN delegates insulin administration to staff and trains them to use insulin pens, then they can do so.  

If there is no RN delegating, the CBRF staff may, on occasion, assist a resident to verify the dose the resident has dialed in. CBRF staff, however, who dial in the dose are no longer supervising self administration; rather they are administering insulin, which requires RN delegation. [Wis. Admin. Code §§ DHS 83.37(2)(e), N 6.03]

8.  Can CBRF staff perform finger-sticks and blood sugar checks with glucometers?

Yes.  A CLIA waiver is required.  [Section 353 of Public Service Health Act 1988]  

9.  When a registered nurse delegates insulin administration, how often must the nurse be present for proper supervision?

The amount of supervision is dependent on the professional judgment of the RN. In Wis. Admin. Code ch. DHS 83, "Supervision" means oversight of a resident's daily functioning, keeping track of a resident's whereabouts and providing guidance and intervention when needed by a resident. In the case of administration of insulin injections, the RN should judge a caregiver’s competency to administer insulin injections correctly. The competency level of the caregiver and the resident’s condition should determine the amount of supervision a RN must provide to that caregiver in order to provide protective oversight for that resident.

10. When insulin is pre-drawn does each syringe need to be labeled?

Each syringe is to be labeled when stored.

RCAC
FAQs

1.  Who can administer injections?

An injection can be administered by a registered nurse, a licensed practical nurse under the general supervision of a registered nurse, under the direction of a physician, and by RCAC staff when a registered nurse delegates administration to the RCAC staff. [Wis. Admin. Code § DHS 89.23(4)(a)2]

2.  Can a registered nurse draw up insulin and administer the insulin to residents?

A registered nurse has the authority, by virtue of Wis. Admin. Code ch. DHS 89 and their license, to draw up and administer insulin.  [Wis. Admin. Code §§ DHS 89.23(4)(a)2, N 6.03]

3.  Can a licensed practical nurse draw up insulin and administer the insulin to residents?

A licensed practical nurse has the authority, by virtue of their license, to draw up and administer insulin.  Wis. Admin. Code ch. DHS 89 limits medication administration to a resident by staff only to those RCACs that have an RN who delegates medication administration. An RCAC can have an LPN administer medications only when an RN delegates that activity. [Wis. Admin. Code §§ DHS 89.23(4)(a)2, N 6.03, N 6.04]

4.  Can staff draw up insulin and administer insulin to residents?

Yes. An RN must delegate administration of insulin and other injections to RCAC staff. Delegation can include the process of drawing up the dose of insulin. The RN must assure that the RCAC staff is trained and competent to perform the task. [Wis. Admin. Code §§ DHS 89.23(4)(a)2, N 6.03]

5.  Can an RN pre-draw insulin for RCAC staff to administer?

Yes.  The RN may decide, when they delegate, to pre-draw insulin for RCAC staff to administer. The RN must be aware of the standards for pre-drawing insulin, storing, and labeling. [Wis. Admin. Code §§ DHS 89.23(4)(a)2, N 6.03]

6.  Can an LPN pre-draw insulin for staff to administer?

Yes.  There must be an RN who is delegating insulin administration to RCAC staff. The RN may delegate pre-drawing of insulin to the LPN and actual administration of the insulin to RCAC staff. [Wis. Admin. Code §§ DHS 89.23(4)(a)2, N 6.03, N 6.04]

7.  Can RCAC staff dial in the dose on an insulin pen?

If the RN delegates insulin administration to staff and trains them to use insulin pens, they may do so. [Wis. Admin. Code §§ DHS 89.23(4)(a)2, N 6.03]

8.  Can RCAC staff do finger-sticks and blood sugar checks with glucometers?

Yes. CLIA waivers are required. [Section 353 of Public Service Health Act 1988]  

9.  When a registered nurse delegates insulin administration, how often must the nurse be present for proper supervision?

The amount of supervision is dependent on the professional judgment of the RN. [Wis. Admin. Code §§ DHS 89.23(4)(a)2, N 6.03]

10.  Can the Registered Nurse delegate insulin administration for a resident who has a sliding-scale order?

Registered nurses can delegate a wide range of tasks, including sliding-scale insulin. Typically, the issue that arises is the level of supervision that is required when a registered nurse delegates activities. For sliding-scale insulin, a resident who is stable may only require general supervision, whereas, a resident who is unstable getting sliding-scale insulin may require that the delegating RN provide direct supervision (be in the building).

Resources

Relevant
Regulations


ADC:
Certification Standard I.F.(1)
Certification Standard I.F.(3)

AFH:
Wis. Admin. Code. § DHS 88.07(3)(d)  

RCAC:
Wis. Admin. Code. § DHS 89.23(4)(a)2  

CBRF:
Wis. Admin. Code. § DHS 83.37(2)(e)  

Last Revised: June 19, 2019