Failure to Rotate Insulin Injection Sites for Multiple Residents
Penalty
Summary
The facility failed to provide care in accordance with professional standards for three residents who were prescribed insulin, as staff did not rotate subcutaneous insulin injection sites as required by physician orders, manufacturer guidelines, and facility policy. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, records showed repeated insulin injections were administered in the same area, such as the left arm or right lower quadrant of the abdomen, over multiple dates. Both the registered nurse and the Director of Nursing confirmed that injection sites were not rotated, which was contrary to the physician's orders and the facility's own policy on subcutaneous injections. Another resident with schizoaffective disorder, type 2 diabetes, and impaired upper extremity function also received insulin injections at the same site, specifically the left lower quadrant, on several occasions. The MDS Coordinator and the DON both acknowledged that the administration sites were not rotated, despite clear physician orders and care plan instructions to do so. The facility's policy and the manufacturer's prescribing information both require rotation of injection sites to prevent complications. A third resident, with hemiplegia following a stroke and severe cognitive impairment, similarly received insulin injections repeatedly in the same area, such as the right arm or left lower quadrant. The MDS Coordinator and the DON confirmed that the sites were not rotated as ordered. In all three cases, the failure to rotate injection sites was documented through record review and staff interviews, and was inconsistent with professional standards, physician orders, and the facility's own procedures.