Failure to Rotate Insulin Injection Sites per Facility Policy
Penalty
Summary
The facility failed to administer insulin according to its policy by not rotating injection sites for a resident with type 2 diabetes. Review of the resident's Medication Administration Records (MAR) over two months showed that consecutive doses of insulin were given in the same abdominal quadrants on multiple occasions. Both a Licensed Vocational Nurse and the Director of Nursing confirmed that staff had access to previous injection site information and acknowledged that insulin should not be administered in the same location for consecutive doses. The facility's policy also required rotation of injection sites to ensure safe administration. The resident involved had moderate cognitive impairment and was receiving hypoglycemic medication for diabetes management. Physician orders specified subcutaneous administration of Humulin R Insulin per sliding scale before meals and at bedtime. Despite these orders and the facility's policy, staff failed to rotate injection sites, as confirmed during interviews and record reviews. This failure was identified through review of documentation and staff interviews, which indicated that the practice was not followed as required.