Failure to Rotate Insulin Injection Sites for Multiple Residents
Penalty
Summary
Licensed nursing staff failed to rotate subcutaneous insulin administration sites for multiple residents with diabetes, as required by professional standards, facility policy, and manufacturer guidelines. For several residents, including those with diagnoses such as dementia, schizoaffective disorder, and metabolic encephalopathy, insulin injections were repeatedly administered in the same anatomical locations over extended periods. Documentation and interviews confirmed that injection sites were not rotated as required, with staff acknowledging the failure to follow established protocols. The residents involved had varying degrees of cognitive impairment and required assistance with activities of daily living. Their medical records indicated ongoing insulin therapy, with orders specifying both short-acting and long-acting insulin. Despite clear physician orders and care plan interventions to administer medications as ordered and monitor for side effects, the administration records showed repeated use of the same injection sites, such as the right lower quadrant (RLQ), left lower quadrant (LLQ), and upper arms, without appropriate rotation. Interviews with nursing staff and the Director of Nursing (DON) confirmed awareness of the requirement to rotate injection sites to prevent complications and ensure proper medication absorption. Facility policy and manufacturer guidelines, both reviewed and acknowledged by staff, explicitly stated the need for site rotation for injectable medications. The failure to rotate sites was observed across multiple residents and confirmed through record review, staff interviews, and policy documentation.