Failure to Rotate Insulin Injection Sites as Ordered
Penalty
Summary
The facility failed to ensure proper rotation of insulin injection sites for one resident, as required by physician orders and facility policy. Record reviews showed that the resident, who had a history of type 2 diabetes mellitus, peripheral vascular disease, and bilateral above-knee amputations, received subcutaneous insulin injections in the same anatomical locations on consecutive days. Specifically, injections were administered to the right lower quadrant, left deltoid, and left upper quadrant on multiple consecutive days, contrary to best practices and the facility's own insulin administration policy. Interviews with nursing staff, including an LVN, RN, and the DON, confirmed that insulin injection sites should have been rotated and acknowledged that the electronic medical record system displayed previous injection sites to help prevent repeated use of the same site. Despite this, staff administered insulin in the same location on consecutive days. The staff interviewed were aware of the need for site rotation and the potential for tissue damage if not followed, but the practice was not consistently implemented for this resident. The facility's policy and procedure for insulin administration, dated January 2025, specified that injection sites should be rotated within the same general area to ensure safe administration. The failure to rotate injection sites as documented in the resident's Location of Administration Report was in direct violation of this policy and the physician's orders, resulting in a deficiency related to the administration of care according to orders and established guidelines.