Complaint Investigation Report

It was alleged that staff did not ensure injections are administered by an appropriately skilled professional. It was reported that Resident #1 (R1) is prescribed four units of Lantus every 12 hours, administered via an injection pen. However, R1 is unable to administer the injection independently. Interviews conducted with staff and R1 revealed that R1 is responsible for self-administering their medication. R1 stated that facility staff assist by bringing the injection pen to them but confirmed that they perform the injection themselves. During interview, R1 demonstrated to the LPA where and how they administer the injection. Additionally, a review of R1’s physician’s report dated 10/10/2024, lists R1’s primary diagnoses as mild cognitive impairment (MCI) and diabetes. Regarding the diabetes management, the report states that R1 is capable of managing their own treatment, medication, and equipment. Based on record review and interviews conducted, the Department has insufficient evidence to support the allegation or that a violation occurred. Therefore, allegation, “staff did not ensure injections are administered by an appropriately skilled professional” is deemed Unsubstantiated at this time.

It was also alleged that staff are not documenting medications appropriately. It was reported that the medication Lispro is supposed to be administered; however, it is not being documented as administered by facility staff. A review of R1’s medications, the Centrally Stored Medication and Destruction Record (CSMDR), and Medication Administration Records (MARs) revealed that Insulin Lispro, administered via injection pen, is being administered four (4) times per day. Staff interviews confirmed that R1’s blood glucose levels are being checked four times daily and that R1 self-administers their insulin injections. Staff also stated that the MARs are updated shortly after medications are distributed to all residents in the facility. Furthermore, at the time of the visit, the medications appeared to be properly documented on the CSMDR. Based on medication review and record review, the Department has insufficient evidence to support the allegation or that a violation occurred. Therefore, allegation “staff are not documenting medications appropriately” is deemed Unsubstantiated at this time.