Failure to Rotate Insulin Injection Sites and Adhere to Medication Hold Parameters
Penalty
Summary
Surveyors identified that the facility failed to ensure residents were free from significant medication errors, specifically in the administration of insulin and midodrine. For three residents receiving insulin, staff did not rotate injection sites as ordered by physicians and as required by facility policy. Documentation in the Medication Administration Records (MARs) showed repeated administration of insulin in the same anatomical area over consecutive days, despite clear orders to rotate sites. Interviews with nursing staff and the Director of Nursing confirmed that this practice was not followed, and that such failures were considered medication errors. Additionally, for one resident prescribed midodrine for hypotension, staff did not adhere to the physician's hold parameters. The medication was administered even when the resident's systolic blood pressure exceeded the threshold specified in the order. This was confirmed through MAR review and staff interviews, with the Director of Nursing acknowledging that the medication should not have been given under those circumstances and that this constituted a medication administration error. The residents involved had complex medical histories, including diabetes, end-stage renal disease, major depressive disorder, acute kidney failure, and dementia. All were dependent on staff for various activities of daily living and required careful medication management. The facility's own policies, as well as manufacturer guidelines for insulin, emphasized the importance of rotating injection sites and administering medications according to prescriber orders, but these were not followed in the cited instances.