F0583

E

Failure to Protect Resident Privacy and Dignity During Glucose Checks and Insulin Administration

El Paso, Texas Survey Completed on 03-19-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain privacy, dignity, and confidentiality when performing blood glucose checks and administering insulin to four residents. On a specified date, RN A conducted glucose testing and insulin injections for four male residents in a TV room/common area rather than in a private setting. More than 15 other residents were in close proximity during these procedures, allowing others to see and potentially overhear the residents’ glucose readings, insulin type, and dosage. This occurred despite facility policy stating that residents have a right to personal privacy and confidentiality of their personal and medical records, including during medical treatment.

The four residents involved all had diabetes mellitus and varying degrees of cognitive impairment as documented in their MDS assessments and medical records. One resident had a BIMS score of 3 and diagnoses of Alzheimer’s dementia and type 2 diabetes, with a care plan focus on disorientation from dementia and interventions to provide choices and assist with decision making. Another resident had a BIMS score of 6, diagnoses of type 2 diabetes, dementia, and bipolar disorder, and a care plan focus on impaired communication with interventions to allow adequate response time and evaluate comprehension. A third resident had a BIMS score of 4, required daily insulin injections, and had a care plan for diabetes management including monitoring for hypo/hyperglycemia, rotating injection sites, and monitoring food intake. The fourth resident had a BIMS score of 11, required daily insulin, and had care plan interventions addressing cognition, including asking simple questions, not rushing, and explaining procedures, along with diagnoses of hearing loss, type 2 diabetes, and dementia.

Interviews with facility leadership confirmed that the observed practice of performing glucose checks and insulin injections in a common area was contrary to expectations and resident rights. The Supervisor RN stated that glucose checks should be done in residents’ rooms to uphold dignity and prevent others from overhearing blood sugar levels, insulin brand, and dosage, and that residents could feel embarrassed if care was provided in the open. The Unit Manager stated that blood sugar readings and insulin injections are treatments that must be completed in residents’ rooms to protect privacy and that all patient-related care should occur in residents’ rooms, including for those on a memory unit. The ADON stated that residents needed to be in their rooms for glucose readings and insulin injections because skin would be exposed and that providing such care in open areas created dignity and HIPAA concerns by disclosing glucose readings, diagnoses, dosages, and insulin types. The Administrator acknowledged that providing treatment in open areas was a privacy concern and that residents’ diagnoses, medications, glucose levels, vitals, and exposed stomachs could be seen by others, conflicting with the facility’s stated practice of providing privacy when residents receive care.