Failure to Rotate Insulin Injection Sites Results in Significant Medication Error
Penalty
Summary
The facility failed to rotate insulin injection sites as required when administering insulin to one resident with diabetes mellitus, cerebral vascular accident, hypertension, and major depressive disorder. Multiple nurses administered insulin injections to the same site repeatedly over several dates, as confirmed by review of the resident's Location of Administration Report for two consecutive months. Both the LVN and DON acknowledged that the facility did not follow the physician's orders, professional standards, or manufacturer specifications, all of which require rotation of injection sites to ensure proper absorption of insulin. The resident in question was dependent on staff for mobility and activities of daily living and had difficulty communicating. Facility policy and procedure documents reviewed indicated that injection sites should be rotated and defined a medication error as any administration not in accordance with physician orders or accepted standards. The DON confirmed that the repeated failure to rotate injection sites by multiple nurses constituted a significant medication error, as it did not comply with the prescribed method of insulin administration.