Failure to Rotate Insulin Injection Sites as Ordered
Penalty
Summary
Licensed nurses at the facility failed to rotate insulin injection sites as required by professional standards and physician orders for three residents with diabetes. For one resident, documentation showed repeated administration of insulin in the same area, such as the left arm or the right lower quadrant of the abdomen, over multiple days. The resident's care plan and physician orders specifically instructed staff to rotate injection sites, but this was not consistently followed, as confirmed by review of the Medication Administration Record (MAR) and interviews with nursing staff. A second resident also received insulin injections in the same location, the left lower quadrant of the abdomen, on consecutive days. The MAR and physician orders indicated the need to rotate injection sites, but this was not done for several days in March. Staff interviews confirmed that the injections were not rotated as required, and the Director of Nursing acknowledged the failure to follow the physician's orders and professional standards. A third resident received both long-acting and sliding scale insulin injections repeatedly in the left upper quadrant of the abdomen over several days, as documented in the MAR. Facility policy and manufacturer guidelines reviewed by surveyors also required rotation of injection sites. Interviews with the Assistant Director of Nursing confirmed that the injection sites were not rotated as required by policy and physician orders.