Failure to Rotate Insulin Injection Sites for Two Residents
Penalty
Summary
The facility failed to provide care in accordance with professional standards for two residents who were prescribed subcutaneous insulin, by not rotating the injection sites as required by physician orders, facility policy, and manufacturer guidelines. For one resident with severe cognitive impairment and total dependence on staff for activities of daily living, insulin was repeatedly administered in the same abdominal quadrants over several weeks, despite clear orders and documentation requiring site rotation. Both the registered nurse and the director of nursing confirmed that the administration sites were not rotated, acknowledging that this was not in compliance with professional standards or the physician's orders. Another resident, who was alert and oriented but had a history of diabetes and hemiplegia, also received insulin injections at the same sites on the abdomen and arm over a period of months. Medication administration records showed multiple instances where the injection sites were not rotated, contrary to the facility's policy and the manufacturer's prescribing information. Nursing staff confirmed that the sites were not rotated as required, and the director of nursing acknowledged that this practice did not follow established guidelines. Facility policy on insulin administration, as well as the manufacturer's guidelines for both types of insulin used, specifically require rotation of injection sites to prevent complications. The failure to rotate sites was confirmed through interviews with nursing staff and review of medical records, which documented repeated use of the same injection locations for both residents. This practice was not in accordance with professional standards, physician orders, or the facility's own procedures.