Failure to Rotate Insulin Injection Sites Leads to Significant Medication Errors
Penalty
Summary
Surveyors identified that the facility failed to ensure residents were free from significant medication errors by not rotating subcutaneous insulin administration sites as required by physician orders, manufacturer guidelines, and professional standards. For one resident with dementia and type 2 diabetes, records showed repeated insulin injections were administered in the same anatomical areas over multiple dates, despite explicit orders and care plan interventions to rotate sites. Interviews with the MDS Coordinator and nursing staff confirmed that insulin administration sites were not rotated, and staff acknowledged this was contrary to both the physician's orders and best practice guidelines. A second resident, diagnosed with metabolic encephalopathy and diabetes with neuropathy, also received insulin injections without proper site rotation. Documentation revealed multiple instances where insulin was administered repeatedly in the same location, such as the left lower quadrant of the abdomen or the same arm, over several days. Nursing staff and the DON confirmed that the administration sites were not rotated as required, and acknowledged that staff should have checked previous administration sites in the electronic health record to avoid repetition. Review of facility policies and manufacturer guidelines for insulin administration further supported the requirement to rotate injection sites to prevent complications. The facility's own policy, as well as the prescribing information for the insulins used, specified that injection sites should be rotated within the same general area. Despite these clear directives, the facility did not ensure compliance, resulting in a significant medication error for both residents.