Complaint Investigation Report

A non-medical skilled professional is administering insulin injections to diabetic residents:

The allegation is that a staff who is not a nurse and administers insulin injection to resident.

On 2/22/2024, LPA interviewed previous Executive Director (PED). PED stated he/she just started to work for the facility in January 2024. PED stated the facility checks the nurse license when the facility hires nurse and the facility nurse should maintain the valid nurse license. PED printed out the evidence of staff S1 and S2's nurse licenses. ED stated if residents can inject insulin by themselves, then Med Techs or nurses deliver the insulin and the residents inject the insulin by themselves. PED stated if the residents cannot inject insulin by themselves, then the facility nurses deliver the insulin and inject insulin for residents. PED stated only facility nurses can inject insulin for residents, caregivers and Med Techs were not allowed to inject insulin for residents.

LPA interviewed staff S2. S2 stated the facility checked his/her LVN license before the facility hired him/her. S2 stated Med Techs and facility nurses deliver medications to residents, but only the facility nurses deliver and inject insulin for residents. S2 stated he/she checked the computer for residents' prescription. S2 stated he/she usually deliver and inject the fast-acting insulin 30 minutes before the meals and one and half hours before bedtime for the long-acting insulin. S2 stated he/she follows the doctor orders which specifies exactly what to administer insulin to residents..

LPA interviewed 2 Med Techs. 2 Out of 2 Med Techs stated they don't conduct the insulin injection for residents.

LPA interviewed 4 residents (R1 - R4). 2 Out of 4 residents stated they don't have insulin injection. Resident R1 stated only facility nurses conducted insulin injection for him/her. R1 stated staff S1 and S2 conducted insulin injection for him/her. Resident R2 stated only facility nurses conducted insulin injection for him/her. R2 was unable to remember the names of the facility nurses.

On 9/27/2024, LPA interviewed staff S1. S1 stated he/she was in nursing school and had the permit to do the duty of facility nurse when shadowed with other facility nurses. S1 stated he/she will have LVN license next month. S1 stated he/she submitted his/her permit to the facility. S1 stated he/she only did insulin injection with nurses.