Failure to Rotate Insulin Injection Sites Results in Medication Errors
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors by not rotating subcutaneous insulin injection sites as required by physician orders, manufacturer guidelines, and professional standards. For three residents with diabetes, review of medical records and interviews with nursing staff revealed repeated administration of insulin in the same anatomical locations, despite clear orders and policies mandating site rotation. The electronic medication administration record system had the capability to track previous injection sites, yet staff did not utilize this feature to prevent repeated use of the same sites. One resident with type 2 diabetes and diabetic neuropathy received multiple insulin injections in the same abdominal quadrants over several weeks, as documented in the Location of Administration Report. Both the registered nurse and assistant director of nursing confirmed that this practice did not follow the physician's orders or facility policy, and acknowledged that it constituted a medication error. Similar findings were observed for two other residents, one with end-stage renal disease and metabolic encephalopathy, and another with severe cognitive impairment and total dependence for activities of daily living. In each case, insulin was administered repeatedly in the same areas, and staff interviews confirmed that site rotation was not performed as required. Facility policies and procedures, as well as manufacturer guidelines for both insulin aspart and insulin glargine, were reviewed and all specified the necessity of rotating injection sites to prevent adverse effects. The failure to rotate sites was consistently identified by nursing leadership and staff as a medication error, as it did not comply with physician orders, manufacturer instructions, or accepted professional standards. Documentation requirements for injection site assessment were also outlined in facility policy, but the records reviewed indicated non-compliance with these standards.