Failure to Ensure Resident Privacy During Insulin Administration
Penalty
Summary
The facility failed to ensure that each resident was treated with respect and dignity, as evidenced by the administration of insulin to a resident in a public area without privacy. Specifically, a Licensed Practical Nurse (LPN) administered insulin to a resident while they were seated in the hallway, where other residents were walking by, without providing any form of privacy. The facility's policy on dignity, which mandates the protection of resident privacy during treatment procedures, was not adhered to in this instance. The resident involved had moderately impaired cognition and required insulin injections daily. During the medication administration task, the LPN asked the resident if they had checked their blood sugar and, upon confirmation, proceeded to administer the insulin in the hallway. Interviews with the LPN and the Resident Nurse Manager revealed that the resident often refused to go to their room for insulin administration due to impatience. Despite this, the Director of Nursing stated that privacy should have been ensured, even in the hallway, by using available screens.
Plan Of Correction
Plan of Correction: Approved April 9, 2025 Corrective Actions for Residents Identified ò For Resident # 40 there were no negative outcomes from the deficient practice as evidenced by vocalization and observation. ò Licensed Practical Nurse #3 was in-serviced on resident’s dignity on (MONTH) 14, 2025. Residents At Risk ò All residents have the potential to be affected by this practice. ò All nurses were assessed for competency. DNS and designee observed random medication administration to ensure compliance. Systemic Changes ò The policy and Procedure “Quality of Life-Dignity” was reviewed, and no revision needed. ò All nurses are being in-serviced on “Quality of Life-Dignity” Policy and Procedure, with emphasis on privacy during medication administration. ò The medication administration competency observation was revised; dignity during med pass was added. ò The audit tool was developed for monitoring compliance. Monitoring Of Corrective Actions ò On a weekly basis for one quarter, ADNS or designee will observe 1-3 nurses during medication pass to ensure resident’s dignity is maintained. ò Any outstanding issues will be addressed immediately and reported to DNS. ò On a monthly basis, ADNS or designee will report findings to DNS. ò On a monthly basis, DNS or designee will report findings to Administrator. ò On a quarterly basis, DNS or designee will report findings to QAPI Committee. ò QAPI Committee to determine if further action is required. Responsible person: Director of nursing