Failure to Rotate Injection Sites and Administer Medication as Ordered
Penalty
Summary
The facility's licensed nursing staff failed to adhere to professional standards by not rotating the subcutaneous administration sites for insulin and heparin for three residents. Resident 65, who has type 2 diabetes mellitus and requires insulin, had multiple instances where insulin was administered in the same area, contrary to the physician's orders and facility policy. This practice was confirmed by both the Licensed Vocational Nurse and the Director of Nursing, who acknowledged that the failure to rotate injection sites could lead to adverse effects such as bruising and skin conditions. Similarly, Resident 29, who was on heparin for deep vein thrombosis prophylaxis and insulin for diabetes, also experienced repeated administration in the same site. The Registered Nurse and Director of Nursing both noted the importance of rotating injection sites to prevent skin damage and ensure proper medication absorption. Despite the facility's policy and manufacturer's guidelines, the staff did not comply with the required rotation of injection sites. Additionally, Resident 52, who has type 2 diabetes and cognitive impairments, received insulin injections repeatedly in the same area. The Registered Nurse and Director of Nursing confirmed the oversight, emphasizing the risk of skin damage and impaired medication absorption. Furthermore, Resident 197 did not receive three doses of levothyroxine as ordered, which could affect thyroid function. The Director of Nursing acknowledged this as a medication error, highlighting the need for adherence to prescribed medication schedules.
Plan Of Correction
F 658 The DSD/designee will complete weekly audits of residents receiving subcutaneous injections to ensure licensed nurses are rotating injection sites routinely to ensure residents do not experience tissue damage to the extent possible. The DSD/designee will run an injection administration audit through PCC weekly to audit. Concerns identified will be reported to the Director of Nursing for further review, analysis, and follow-up. The Director of Staff Development will re-educate licensed nurses on the facility policy and procedure, "Physician Orders," with emphasis on following physician orders including ordered time and frequency of administration on or before 3/21/2025. D. How the facility plans to monitor its performance to make sure solutions are sustained: The Consultant Pharmacist monitors licensed nurses' proper administration of medication during routine facility audits and reports the findings to the QAA Committee, at a minimum quarterly for the purpose of process improvement. The Director of Nursing will monitor the DSD audits of resident subcutaneous injection sites by licensed nurses to ensure sites are rotated to mitigate tissue damage to the extent possible and to identify continued compliance or the need for further education or progressive disciplinary action through use of the injection administration audit on PCC. The Director of Medical Records/designee will audit the administration times of residents with Levothyroxine orders to ensure residents receive medication during acceptable timeframe for medication administration, monthly. Results of the medication administration audit will be given to the Director of Nursing for further review, analysis, and follow-up as indicated. Compliance concerns identified will be corrected immediately and reported to the Director of Nursing for further corrective action as indicated. Trends identified in the injection site rotation audits will be reported by the Director of Staff Development to the Quality Assurance committee during the quarterly QA&A meeting for the purpose of process improvement changes to ensure continued compliance with this plan of correction. Allegation of Compliance Date 3/25/2025 F 658 F 658 F 658 F 658 F 658 F 658 F677 A. How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: CNA 1 received one-to-one re-education regarding grooming and personal hygiene including cleaning the overbed table before and after placing washcloths onto it, hand hygiene prior to and following providing grooming assistance to the residents, and removing gloves prior to leaving the room to reduce the potential adversely affecting residents' psychosocial well-being. Certified Nurse Assistants are performing hand hygiene prior to donning and following doffing of gloves. Resident 65 is receiving grooming care in a manner that promotes his psychosocial well-being. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action was taken: All residents are potentially affected by the facility practice. C. What measures will be put into place or what systematic changes the facility will make to ensure that the deficient practice does not recur: The DSD/designee will re-educate nursing staff on the facility's policy "Activity of Daily Living" with emphasis on hand hygiene prior to and after.