Failure to Rotate Insulin Injection Sites for Two Residents
Penalty
Summary
The facility failed to ensure that insulin administration sites were rotated for two residents who were prescribed subcutaneous insulin, as required by physician orders, manufacturer guidelines, and professional standards. For one resident with a history of hemiplegia, diabetes mellitus, and gastrostomy status, records showed that insulin injections were repeatedly administered in the same abdominal quadrants over an extended period. Both the registered nurse and the Director of Nursing confirmed that the administration sites were not rotated as ordered, acknowledging that this practice did not comply with the physician's instructions, manufacturer recommendations, or facility policy. Another resident, diagnosed with type 2 diabetes mellitus and other conditions, also received insulin injections at non-rotated sites, primarily in the same abdominal quadrants. Medication administration records indicated multiple instances where the injection sites were not alternated. Interviews with nursing staff and the DON confirmed that the failure to rotate sites was a medication error, as it was not in accordance with the physician's order, manufacturer specifications, or accepted professional standards. Facility policies and procedures, as well as manufacturer guidelines for both types of insulin used, explicitly required rotation of injection sites to prevent adverse effects and ensure proper absorption. The facility's own definition of a medication error included failure to follow these requirements. The survey findings were based on direct record review, staff interviews, and policy examination, all of which demonstrated that the facility did not adhere to established protocols for insulin administration for the two residents reviewed.