Failure to Rotate Insulin Injection Sites and Inadequate Resident Supervision
Penalty
Summary
Licensed nursing staff failed to provide care in accordance with professional standards for multiple residents, specifically in the administration of insulin and the management of resident safety. For three residents with diabetes, staff did not rotate subcutaneous insulin injection sites as required by physician orders, facility policy, and manufacturer guidelines. Documentation and interviews confirmed repeated use of the same injection sites, despite the availability of electronic medication administration records that could track previous injection locations. Both the RN and ADON acknowledged that this practice was inconsistent with professional standards and could lead to complications such as skin irritation and poor insulin absorption. In addition to the insulin administration deficiencies, staff failed to adequately address the safety and supervision needs of a resident at risk for elopement, aspiration, and falls. The care plan for this resident did not include comprehensive, person-centered interventions for elopement risk, and staff did not provide the ordered supervision during meals. The resident was able to leave the facility unsupervised and experienced a fall upon return. There were also failures to monitor the resident's blood pressure as ordered, to implement the facility's monitoring policy requiring checks every two hours, and to conduct shift change endorsements at the bedside as required by facility policy. The report provides detailed evidence from record reviews, interviews with nursing staff, and policy documents, all confirming that the facility did not meet professional standards of quality in these areas. The deficiencies were observed across multiple residents and involved both medication administration and resident safety protocols, with staff and leadership acknowledging the lapses during interviews.