complaint·December 6, 2024

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. Continue on LIC9099-C. Page 2 of 4. Based on the review of R1 and R2's physician report, R1 and R2 are unable to conduct injection by themselves. Based on the checking of the S1's nurse license document, S1's LVN license was issued on 10/22/2024. Staff are not administering residents’ insulin as prescribed: The allegation is that resident R1 and R2 have been times residents have not received their insulin. On 2/22/2024, LPA interviewed previous Executive Director (PED). PED stated the facility administer insulin to residents based on doctor prescription/order. LPA interviewed staff S2. S2 stated the facility nurses deliver insulin to residents. S2 stated if residents are able to inject insulin self then residents inject insulin by self, if residents unable to inject insulin by self then nurses inject insulin for the residents. S2 stated he/she delivers/injects insulin based on the doctor prescription in the computer system. S2 stated usually he/she delivers/injects short acting insulin 30 minutes before meals and long acting insulin one and half hours before bed time for residents. S2 stated she always sticks to doctor prescription/orders to administer insulin to residents.. LPA interviewed resident R1 and R2. Both stated they did not have experience of medication error or missing medication incidents. Based on the review of R1 and R2 Medication Administration Records (MAR) in January 2024 and February 2024, there are some entries were observed missing insulin injections for R1. PED and staff S2 explained the empty entries were due to computer error and staff were unable to enter data in the computer MAR system. Continue On LIC9099-C. Page 3 of 4. Based on documents reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegation did or did not occur. No citations noted for today’s visit. Exit interview was conducted with ED. A copy of this report was provided to ED. Page 4 of 4.