Failure to Rotate Insulin Injection Sites Results in Medication Errors
Penalty
Summary
Surveyors identified that the facility failed to ensure residents were free from significant medication errors by not rotating subcutaneous insulin injection sites as required by professional standards, manufacturer guidelines, and facility policy. Multiple residents with diabetes, including those with cognitive impairments and complex medical histories, received repeated insulin injections in the same anatomical locations over extended periods. This practice was confirmed through review of medication administration records, interviews with nursing staff, and direct observation of documentation, which showed a pattern of non-rotation for both short-acting and long-acting insulin types. Nursing staff, including LVNs, acknowledged during interviews that injection sites should have been rotated to prevent complications such as pain, redness, irritation, and the development of lipodystrophy, which can affect insulin absorption. The DON also confirmed that failure to rotate sites is a medication error, as it does not follow professional standards, manufacturer instructions, or facility policy. The facility’s policies and procedures, as well as the insulin manufacturers’ guidelines, specifically require rotation of injection sites to ensure proper absorption and minimize adverse effects. The deficiency was observed in several residents, each with orders for insulin administration and care plans that included monitoring for side effects and ensuring medication was given as prescribed. Despite these directives, documentation revealed repeated use of the same injection sites, and staff interviews confirmed the lack of adherence to rotation protocols. The facility’s own policies defined medication errors to include administration not in accordance with prescriber’s orders or manufacturer’s specifications, further substantiating the finding.