Failure to Rotate Insulin Injection Sites and Administration of Expired Insulin
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors related to the administration of insulin. Specifically, licensed staff did not rotate subcutaneous insulin injection sites for three residents, despite physician orders and manufacturer guidelines requiring site rotation to prevent complications such as lipodystrophy and impaired insulin absorption. Documentation and interviews confirmed that insulin was repeatedly administered in the same anatomical locations for these residents, and staff acknowledged that this practice was not in accordance with professional standards or the prescriber's orders. Additionally, the facility did not remove expired insulin from a medication cart, resulting in the administration of four doses of expired insulin to a resident by several LVNs. The expired insulin was not discarded as required by facility policy and manufacturer instructions, which state that opened insulin pens must be used or discarded within 28 days. Both the LVN and the DON confirmed that expired insulin was administered, and that this constituted a significant medication error, as expired insulin may not be effective in controlling blood sugar levels. The residents involved had complex medical histories, including diagnoses of type 2 diabetes mellitus, cognitive impairment, and other comorbidities. The errors were identified through record reviews, interviews with nursing staff and the DON, and direct observation of medication storage and administration practices. Facility policies and manufacturer guidelines reviewed during the investigation clearly outlined the requirements for medication storage, administration, and site rotation, all of which were not followed in these instances.