Failure to Rotate Insulin Injection Sites Resulting in Medication Error
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors by not rotating subcutaneous insulin injection sites as required by physician orders, manufacturer guidelines, and facility policy. Review of the resident's Medication Administration Record (MAR) showed repeated administration of insulin in the same anatomical areas, specifically the left upper and lower quadrants of the abdomen and the right arm, over multiple days. Interviews with nursing staff, including an LVN and an RN, confirmed that insulin administration sites should have been rotated with each dose, and acknowledged that this was not done for the resident in question. The resident involved had a history of diabetes mellitus, chronic obstructive pulmonary disease, and congestive heart failure, and was cognitively intact and able to make decisions. Facility policies and the manufacturer's guidelines for insulin glargine (Lantus) both required rotation of injection sites to prevent adverse effects. The Director of Nursing also confirmed that failure to rotate sites constituted a medication error. The deficiency was identified through review of records, staff interviews, and examination of facility policies and procedures.