Failure to Rotate Insulin Injection Sites per Professional Standards
Penalty
Summary
Licensed nursing staff failed to provide care in accordance with professional standards by not rotating subcutaneous insulin administration sites for two residents with diabetes. For one resident with dementia and severe cognitive impairment, records showed repeated insulin injections were administered in the same areas of the abdomen and arms over several months, despite physician orders and manufacturer guidelines specifying the need to rotate sites. Interviews with the MDS Coordinator and nursing staff confirmed that injection sites were not rotated as required, and staff acknowledged this practice was inconsistent with both facility policy and professional standards. A second resident, diagnosed with metabolic encephalopathy, diabetic neuropathy, and moderate cognitive impairment, also received insulin injections at repeated sites without proper rotation. Review of medical records and interviews with nursing staff revealed multiple instances where insulin was administered in the same location, contrary to physician orders and facility policy. The Director of Nursing confirmed that staff should have checked previous injection sites in the electronic health record to ensure proper rotation, which was not done. Facility policy and manufacturer guidelines for all types of insulin administered to these residents clearly indicated the necessity of rotating injection sites to prevent complications. Despite these clear directives, the nursing staff did not adhere to the required procedures, as evidenced by documentation and staff interviews. This failure to rotate injection sites was directly observed and confirmed during the survey process.