Complaint Investigation Report

Unqualified staff are administering medication to residents.

On the allegation that staff are administering medications to residents, it is the reporting party’s concern that unqualified staff are conducting blood sugar tests and giving insulin injections to residents. To investigate the allegation, LPA Urena conducted staff and residents’ interviews and reviewed documents pertinent to the allegation. Residents’ interviews revealed that they receive insulin injections from different staff. Three (3) out of five (5) residents were able to provide the names of staff who administer the injections; the names provided names were of staff who are considered skilled professionals. The staff interviewed stated that the Licensed Vocational Nurse (LVN) give the insulin injections to residents who have prescriptions for insulin, and also conduct blood sugar testing. The staff added that they have seven residents with prescriptions for insulin. Six out of seven residents have a device called either Freestyle-Libre or Dexcone attached to their arm; these devices give automatic blood sugar level readings through an application on a reading phone type device. The arm devices are changed every two weeks by the LVNs. One resident is using the Freestyle device and uses the lancet to prick their finger and get a reading through a device used for this type of blood sugar testing. The residents receive the insulin injections once to three times a day, depending on the physicians’ orders. The insulin injections are administered to the residents in the comfort of their rooms. The insulin injections are administered in the residents’ abdomen area. The insulin injections are recorded in the facility’s electronic system ‘Acuflow-Electronic Medication Administration Record(E-MAR) by the staff who administered the injections. The initials of the staff are then recorded in the E-MAR.

LPA Urena conducted record review of printouts of the E-MAR and ‘Diabetic Flow Sheet’ (DFS). During the record review, it was observed that the initials of staff 1 (S1) are printed on the DFS for resident 1 (R1) as the staff who administered the insulin injection on 08/12/2023 at 8:00 a.m. Furthermore, LPA Urena observed that the E-MAR printouts for resident 2 (R2) dated for August 2023, have the initials of staff 2 (S2), and the initials are printed on at least seven (7) different dates during the month of August 2023, which shows that S2 administered insulin injections to R2 and conducted blood sugar testing. Additionally, it was observed that the E-MAR records for R3, R4 and R5, indicate that S3 administered insulin injections and conducted blood sugar testing during the month of August 2023. Staff S1, S2, and S3 are not appropriately skilled professionals to administer injections.