Failure to Rotate Insulin Injection Sites
Penalty
Summary
The facility failed to ensure that insulin injection sites were rotated for a resident with type 2 diabetes mellitus, as required by professional standards of practice and the facility's own policies. Record review showed that the resident, who had intact cognitive skills and required assistance with activities of daily living, consistently received insulin injections in the same location—the left lower quadrant of the abdomen—over multiple documented administrations. The Medication Administration Record (MAR) detailed repeated injections at this same site across several dates, without evidence of site rotation. During an interview, a registered nurse confirmed that insulin injection sites should be rotated to prevent injury and acknowledged that repeated injections at the same site can cause pain. Review of the facility's policies on insulin and medication administration further confirmed the requirement for site rotation and adherence to physician orders. The failure to rotate injection sites was identified through both interview and record review, and it was noted that this practice did not align with professional standards or facility policy.