Failure to Rotate Insulin Injection Sites and Timely Replace Emergency Medication Kits
Penalty
Summary
The facility failed to provide pharmaceutical services that met the needs of its residents by not ensuring consistent rotation of injection sites for subcutaneous insulin administration for five residents. Medical record reviews for these residents showed repeated administration of insulin injections at the same anatomical sites over consecutive days. For example, one resident received Lantus insulin in the same arm for multiple days, while others received insulin injections repeatedly in the same quadrant of the abdomen. Interviews with nursing staff confirmed that injection sites were not rotated as required, and staff acknowledged that sites should have been rotated to prevent complications such as lipohypertrophy and non-absorption of insulin. Additionally, the facility did not adhere to its policy and procedure regarding the timely replacement of emergency medication kits. The policy required that emergency kits for intravenous and oral medications be replaced within 72 hours of being opened. However, documentation showed that items were removed from the emergency kits, and the kits were not replaced within the specified timeframe. Nursing staff verified that the replacement did not occur as required by facility policy. The residents involved in these deficiencies had significant medical needs, including diabetes mellitus requiring regular insulin administration. Several residents lacked the capacity to make medical decisions, as documented in their histories and physicals. The failure to rotate injection sites and to timely replace emergency medication kits was confirmed through interviews with nursing staff and review of facility records and policies.
Plan Of Correction
F 755 Pharmacy services - Insulin injection sites not rotated. 5 residents affected. IV and oral e-kit were not replaced within 72 hours. How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. The five identified residents were checked by DSD and ADON. Skin assessments done on 6/20/25. No lipodystrophy (lypohypertrophy) noted on all 5 sample residents. Skilled nursing pharmacy was called and asked to replace the IV and oral emergency kits on 6/16/25. IV e-kit and oral e-kit were delivered on 6/16/26. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. An audit of residents with insulin injections was done by DSD on 7/3/25. Identified 4 residents with insulin injection sites not rotated. 1:1 training with the nurses who made the errors will be completed by 7/4/25 by DON/designee on proper administration of insulin. All new e-kits were delivered by Skilled Nursing Pharmacy on 6/16/25 and replaced by the ADON. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur. Med records will check documentation of insulin injection sites during weekdays x 3 months. Findings will be reported to DON for follow up. Inservice for replacement of e-kit in for all licensed nurses on 7/2/25. Inservice for rotating insulin injection sites initiated on 6/20/25 by DON/designee and will be completed by 7/11/25. ADON/designee will check IV and oral e-kits daily Monday to Friday weekly x 3 months. How the facility plans to monitor its performance to make sure that solutions are sustained. The POC is integrated into the QA system. The IP/designee will provide a summary trend analysis of the findings to the facility's monthly QAPI Committee x 3 months or until such time consistent substantial compliance has been achieved as determined by the committee. Date of compliance: 7/11/25