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 prescriber orders, manufacturer specifications, and accepted professional standards. For two residents with diabetes mellitus, staff repeatedly administered insulin injections in the same anatomical areas over an extended period, as documented in the Location of Insulin Administration Reports. This practice was confirmed through record reviews and interviews with facility leadership, who acknowledged that injection site rotation was not consistently performed. One resident, admitted with type 2 diabetes mellitus, muscle weakness, and mild protein-calorie malnutrition, had intact cognition and was able to make medical decisions. The resident's orders specified the use of a sliding scale for Novolog insulin and explicitly required rotation of injection sites. However, records showed that insulin was frequently administered in the same areas, particularly the right arm, over multiple dates. Facility staff, including the Director of Staff Development and Assistant Director of Nursing, confirmed that this failure to rotate sites constituted a medication error and could lead to complications such as bruising, skin injury, and impaired insulin absorption. A second resident, also with type 2 diabetes mellitus and diabetic chronic kidney disease, had similar orders for insulin administration with instructions to rotate injection sites. Despite this, documentation revealed repeated use of the same injection sites, including the right and left arms and the abdomen. Interviews with facility staff again confirmed that the lack of site rotation was a medication error. Facility policies and manufacturer guidelines reviewed during the survey also emphasized the importance of rotating injection sites to prevent adverse effects and ensure proper medication administration.