Failure to Rotate Injection Sites and Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically in the administration of insulin and anticoagulants. For three residents, the facility did not rotate the subcutaneous injection sites for insulin and heparin as required by physician orders and professional standards. This failure to rotate injection sites was observed in the administration records and confirmed by interviews with nursing staff, including Licensed Vocational Nurses and the Director of Nursing. The lack of rotation could lead to adverse effects such as bruising, lipodystrophy, and cutaneous amyloidosis. Resident 65, who has type 2 diabetes and requires insulin, had multiple instances where insulin was administered in the same area of the abdomen without rotation. Similarly, Resident 29, who is on DVT prophylaxis with heparin and insulin for diabetes, also had repeated injections in the same abdominal area. Resident 52, who has type 2 diabetes and cognitive impairments, received insulin injections in the same site without rotation. These practices were identified as medication errors by the nursing staff and the Director of Nursing, as they did not adhere to the physician's orders or the manufacturer's guidelines. Additionally, the facility failed to administer three doses of levothyroxine as ordered for Resident 197, who has hypothyroidism. The resident reported not receiving the medication consistently, and a review of the medication administration records confirmed that doses were missed. The Director of Nursing acknowledged that this was a medication error and emphasized the importance of administering medications as ordered to manage the resident's condition effectively.
Plan Of Correction
F760 A. How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; Licensed Nurses are rotating injection sites for Resident 65, 29, and 52 and all residents who receive routine injections. 1. Resident 197 discharged on 3/4/25. Resident's MD declined to have thyroid hormone level checked after the discovery of missed doses. 2. MD was notified about the missed doses on 2/28/25 with no new orders. 3. Licensed nurses are administering Resident 197's Levothyroxine in accordance with physician order. 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; Residents receiving routine injections in the same injection sites and who are not administered medications per physician order are potentially affected. The Director of Nurses/designee audited residents who receive routine injections from 2/15/2025 through 2/25/2025 to identify other residents who may be affected by the facility practice. The Director of Nurses/designee audited residents who receive Levothyroxine on 3/21/2025 to identify residents who did not receive the medication. A total of 19 residents receive Levothyroxine. 19 of 19 resident records accurately reflect doses remaining, indicating residents received their medication. Resident injection sites were rotated; and no other residents were identified as 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 Director of Staff Development/designee will re-educate the licensed nurses regarding the facility policy and procedure, "Diabetes Management," with emphasis on rotation of injection sites to avoid tissue damage from repeated injections on or before 3/21/2025. 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. The Director of Medical Records/designee will audit the administration times of residents with Levothyroxine orders to ensure residents receive medication during acceptable timeframes 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