Assisted Living: Insulin and Injectable Medications Management

Who can give injections?

An RN (registered nurse) or an LPN (licensed practical nurse) can give injections at an ADCC. An RN may assign an unlicensed ADCC staff member to give the injection (s. N 6.03 (3)).

Can an RN prepare and give insulin to residents?

Yes.

Can an LPN prepare and give insulin injections?

Yes. However, an RN or physician must provide supervision.

Can ADCC staff prepare and give insulin injections to residents?

Only if an RN assigns these tasks to a staff member. The RN must make sure the staff member is trained to give insulin injections.

Can an RN prepare insulin for ADCC staff to give to residents?

Yes. The RN must follow all rules for preparing, storing, and labeling insulin.

Can an LPN prepare insulin for ADCC staff to give to residents?

Only if an RN assigns the LPN to prepare insulin and the ADCC staff member to give the injection. However, the RN must supervise.

Can ADCC staff prepare insulin pen doses?

Yes, if the RN assigns this task to a staff member and trains them to use insulin pens.

An ADCC staff member may sometimes help residents verify the dose they have prepared on their insulin pen. However, staff members cannot prepare the dose themselves. They can only prepare the dose if an RN assigns this task to them.

Can ADCC staff perform finger-sticks and blood sugar checks with glucometers?

Yes. A Clinical Laboratory Improvement Amendments (CLIA) waiver is required (Section 353 of Public Service Health Act 1988).

How much supervision is needed when an RN assigns staff members to give injections?

The amount of supervision is up to the RN and their judgment. When deciding how much supervision to provide, the RN should consider:

• Whether the staff member is trained to give the injection.
• The resident's condition.

When insulin is prepared, does each syringe need to be labeled?

All prepared syringes must be labeled when stored.

Can an RN assign a staff member to give insulin injections to residents with sliding-scale orders?

Yes. However, the amount of supervision a staff member needs depends on the resident's condition. For example, unstable residents may require the RN to be in the building.

Who can give residents injections?

The following staff members can give injections at an AFH:

• An RN
• An LPN under the supervision of an RN or physician
• A physician
• A pharmacist
• A trained AFH staff member
• The resident and/or a family member (Wis. Admin. Code §§ DHS 88.07(2)(c) and DHS 88.07(3)(d))

Can an RN prepare and give insulin injections to residents?

Yes (Wis. Admin. Code §§ DHS 88.07(3)(d), N 6.03).

Can an LPN prepare and give insulin injections to residents?

Yes. However, an RN or physician must supervise the LPN (Wis. Admin. Code §§ DHS 88.07(3)(d), N 6.03, N 6.04).

Can AFH staff prepare or give insulin injections to residents?

Yes. RNs should train the staff member and be available to answer questions (Wis. Admin. Code §§ DHS 88.07(2)(c) and DHS 88.07(3)(d)). Residents and their families should be made aware that AFH staff may not have the same training as an RN or LPN.

Can an RN prepare insulin for AFH staff to give to residents?

Yes. An AFH staff member also can give a resident insulin without being assigned to do so by an RN.

In an AFH, an RN can prepare only one dose at a time. Only a physician or pharmacist can prepare more than one dose at a time (Wis. Admin. Code § N 6.03). The RN must follow all rules for preparing, storing, and labeling insulin.

Can an LPN prepare insulin for AFH staff to give to residents?

An LPN can prepare insulin only if an RN has assigned an AFH staff member to give insulin injections.

Can AFH staff prepare insulin pen doses?

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

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

Yes. Clinical Laboratory Improvement Amendments (CLIA) waivers are required (Section 353 of Public Service Health Act 1988).

How much supervision is needed when an RN assigns AFH staff to give injections?

RNs may use their own judgment when deciding how much supervision is needed.

Who can give residents injections?

Only an RN or an LPN can give injections. Some non-licensed staff members also may give injections (Wis. Admin. Code §§ DHS 83.37(2)(e), N 6.03).

Can an RN prepare and give insulin injections to residents?

Yes (Wis. Admin. Code §§ DHS 83.37(2)(e), N 6.03).

Can an LPN prepare and give insulin injections to residents?

An LPN can give insulin to residents if they are supervised by an RN or physician. LPNs can give insulin only to residents who are in stable medical condition (Wis. Admin. Code §§ DHS 83.37(2)(e), N 6.04).

Can CBRF staff prepare and give insulin injections to residents?

Yes. However, an RN must assign these tasks to staff members. The RN must also make sure CBRF staff are trained to give insulin injections (Wis. Admin. Code §§ DHS 83.37(2)(e), N 6.03).

Can an RN prepare insulin for CBRF staff to give to residents?

Yes. The RN must follow all rules for preparing, storing, and labeling insulin syringes (Wis. Admin. Code §§ DHS 83.37(2)(e), N 6.03).

Note: Insulin prepared in the assisted living environment only can be stored for one hour.

Can an LPN prepare insulin for staff to give to residents?

Yes, under the supervision of an RN. The RN may assign an LPN to prepare insulin and a CBRF staff member to give the injection (Wis. Admin. Code §§ DHS 83.37(2)(e), N 6.03).

Can CBRF staff prepare insulin pen doses?

Yes, if an RN assigns this task to a staff member and trains them to use insulin pens.

A CBRF staff member may sometimes help residents verify the dose they have prepared on their insulin pen. However, a staff member cannot prepare the dose themselves. An RN must assign this task to the staff member (Wis. Admin. Code §§ DHS 83.37(2)(e), N 6.03).

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

Yes. A Clinical Laboratory Improvement Amendments (CLIA) waiver is required (Section 353 of Public Service Health Act 1988).

How much supervision is needed when an RN assigns CBRF staff to give injections?

RNs may use their own judgment when deciding how much supervision is needed. RNs should make sure LPNs and CBRF staff members are trained to prepare or give insulin.

Does each syringe need to be labeled when insulin is prepared?

All syringes must be labeled when stored.

Who can give residents injections?

The following caregivers may give injections (Wis. Admin. Code § DHS 89.23(4)(a)2):

• An RN.
• An LPN when assigned to do so by an RN. The LPN must be supervised by an RN or a physician.
• RCAC staff when assigned to do so by an RN.

Can an RN prepare insulin and give it to residents?

Yes (Wis. Admin. Code §§ DHS 89.23(4)(a)2, N 6.03).

Can an LPN prepare and give insulin injections to residents?

Yes. However, an RN must assign this task to an LPN (Wis. Admin. Code §§ DHS 89.23(4)(a)2, N 6.03, N 6.04).

Can RCAC staff prepare and give insulin injections to residents?

Yes, if an RN assigns an RCAC staff member to prepare or give insulin to residents. The RN must make sure the RCAC staff member is trained and able to perform the task (Wis. Admin. Code §§ DHS 89.23(4)(a)2, N 6.03).

Can an RN prepare insulin for an RCAC staff member to give to residents?

Yes. The RN must follow all standards for preparing, storing, and labeling insulin (Wis. Admin. Code §§ DHS 89.23(4)(a)2, N 6.03).

Can an LPN prepare insulin for RCAC staff to give to residents?

Yes. However, an RN must assign these tasks. For example, an RN may ask an LPN to prepare insulin and a staff member to give the insulin (Wis. Admin. Code §§ DHS 89.23(4)(a)2, N 6.03, N 6.04).

Can RCAC staff prepare insulin pen doses?

Yes, if the RN assigns RCAC staff to give insulin to residents. The RN also must make sure staff are trained to use insulin pens (Wis. Admin. Code §§ DHS 89.23(4)(a)2, N 6.03).

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

Yes. Clinical Laboratory Improvement Amendments (CLIA) waivers are required (Section 353 of Public Service Health Act 1988).

How much supervision is needed when an RN assigns RCAC staff to prepare or give injections?

The RN must use their own judgment to decide how much supervision is needed (Wis. Admin. Code §§ DHS 89.23(4)(a)2, N 6.03).

Can an RN assign RCAC staff to give insulin injections to residents with sliding-scale orders?

Yes. However, the RN needs to provide supervision based on the resident's condition. For example, an RN may need to be in the facility if the resident is in unstable condition.

The Division of Quality Assurance (DQA) has observed instances in facilities where facility staff has not adhered to the standards of practice to prevent patient-to-patient transmission of blood-borne pathogens when using glucose meters. Patient-to-patient transmission of blood-borne pathogens is a well-known risk when lancets, needles, and syringes are reused between patients. However, patient-to- patient transmission of pathogens facilitated through the use of devices such as glucose meters may not be as well known.

The CDC has published recommendations for infection control and safe injection practices to prevent patient-to-patient transmission of blood-borne pathogens. Facility staff should evaluate practices related to glucose meter, lancet, and needle use, especially related to insulin administration, as these constitute practices for which DQA staff has observed problems.

Following are specific infection control recommendations published by the CDC that focus on diabetes care procedures in healthcare and group residence settings:

• Prepare medications such as insulin in a centralized medication area; multiple dose insulin vials should be assigned to individual patients and labeled appropriately.
• Never reuse needles, syringes, or lancets.
• Restrict use of finger-stick capillary blood sampling devices to individual patients.
• Consider selecting single-use lancets that permanently retract upon puncture.
• Dispose of used finger-stick devices and lancets at the point of use in an approved sharps container.
• Environmental surfaces and equipment such as glucose meters should be decontaminated regularly and at any time contamination with blood or body fluids occurs or is suspected.
• Glucose meters should be assigned to individual patients. If glucose meters are shared between patients, the devices should be cleaned and disinfected between each patient use.
• Maintain supplies and equipment such as finger-stick devices and glucose meters within individual patient rooms, if possible.
• Any trays or carts used to deliver medications or supplies to individual patients should remain outside patient rooms.
• Do not carry supplies and medications in pockets. Because of possible inadvertent contamination, unused supplies and medications taken to a patient’s bedside during finger-stick monitoring or insulin administration should not be used for another patient.
• Wear gloves during finger-stick blood glucose monitoring, administration of insulin, and any other procedure involving potential exposure to blood or body fluids.
• Change gloves between patient contacts and after every procedure that involves potential exposure to blood or body fluids, including finger-stick blood sampling.
• Perform hand hygiene with soap and water or alcohol hand sanitizer immediately after removing gloves and before touching medical supplies used on other patients.

Additional information regarding diabetes care recommendations and other activities is available on the CDC Considerations for Blood Glucose Monitoring and Insulin Administration webpage.

Specific guidelines for cleaning glucose meters may vary with the manufacturer. The manufacturer should be consulted to determine which cleaning procedures, specific to glucose meter sharing, should be adhered to. If the manufacturer does not have specific requirements, there are CDC guidelines for environmental care in healthcare facilities.

Insulin is available from drug manufacturers in three basic packages: vials, pens, or cartridges. General insulin storage requirements are as follows:

1. Never freeze; frozen insulin should be thrown away.
2. Never use insulin beyond the expiration date stamped on the vial, pen, or cartridge that is supplied from the drug manufacturer.
3. Never expose insulin to direct heat or light.
4. Inspect insulin prior to each use. Any insulin that has clumps or solid white particles should not be used. Insulin that is supposed to be clear should not have any cloudy appearance.
5. Check storage guidelines specific to the insulin formulation. This is usually in the product package insert.
6. Unopened, not-in-use insulin should be stored in a refrigerator at a temperature of 36-46º F.
7. Opened, in-use insulin should be stored at a room temperature below 86º F.
8. If receiving insulin through the mail, always confirm that the insulin is going to be stored under proper conditions.

Mixing insulin in vials or in syringes is a generally acceptable approach to customize insulin treatment and minimize injections. It is recommended that the same technique or procedure to mix and store these customized preparations be utilized. Some types of insulin may react with each other when mixed. Therefore, it is recommended that all mixtures be stored for a consistent amount of time before using or that they be used immediately. When mixing insulin, it is extremely important that the rapid-acting insulin be drawn into the syringe first, followed by the long acting. Before mixing insulin, a pharmacist or physician should be consulted.

More guidance

The following resources were collected to address specific expiration or beyond-use dating guidelines that apply to insulin products. These resources also include onset of action information. This information is not intended to be used as a tool to prescribe medication or provide other clinical services. Please consult with a pharmacist for the most up-to-date information on insulin.

• American Diabetes Association Insulin Storage and Syringe Safety
• CDC Insulin types
• CDC Managing Insulin in an Emergency
• PubMed Insulin Storage: A Critical Reappraisal Storage, Recommendations for Different Insulin Products in the United States and European Union With the Shelf Life In-Use and the Maximum Temperature In-Use
• PharMerica Did You Know Guides & Fact Sheets - This webpage offers fact sheets on common medications and conditions in long-term care, for easy reference by clinical staff. Search the list of resources for insulin and you will find clinical guidance around pen devices, mixing administration, and insulin drug comparison charts.