Failure to Rotate Insulin Injection Sites
Penalty
Summary
The facility failed to rotate insulin injection sites as required for a resident with type 2 diabetes who had moderate cognitive impairment. Review of the resident's Medication Administration Records (MAR) over two months showed that insulin was repeatedly administered in the same arm at consecutive times, rather than rotating injection sites as per physician orders and facility policy. Both a Licensed Vocational Nurse and the Director of Nursing confirmed during interviews and record reviews that the injection sites were not rotated on multiple occasions. The facility's policy on insulin administration, dated December 2024, specifies that injection sites should be rotated to ensure safe administration. Despite this, the MARs indicated repeated use of the same injection sites for the resident, contrary to established guidelines. This failure was acknowledged by facility staff during interviews and was identified as having the potential to cause skin infection.