- Date
- 6/23/2025
- Report number
- CALMS - 00085984
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to comply with nursing delegation requirement
- Result
- Substantiated
- Findings
- Based on interview and record review, conducted during a site visit on 07/23/25, the facility’s failure to ensure that delegation and teaching must be provided and documented by an RN was substantiated for 2 of 2 sampled residents (#'s 1 and 2).
Findings include, but are not limited to:
An interview with Staff 1 (Executive Director) indicated that Staff 2 (MT) had provided insulin without having been delegated on five separate occasions to two residents. The facility self-reported the incident, and Staff 2 was now delegated. Staff 2 had been training with Staff 3 (RSS) on 06/23/25 and 06/24/25, where Staff 3 incorrectly told Staff 2 that s/he was delegated. Staff 3 had received corrective action on 07/09/25.
A review of Resident 1's records indicated the following:
Service plan dated 06/04/25, indicated resident was type 2 diabetic and was insulin-dependent, staff were to administer insulin. Physicians’ orders dated 05/05/25 and 05/19/25 indicated the following medications for type 2 diabetes: Aspart pen injector 100 unit/ml, inject six units under the skin three times daily before meals, hold if blood sugars are less than 90; and Glargine-YFGN pen injector 100 units, inject 38 units under the skin daily at bedtime.
Medication administration records (MARs) from 06/01/25 through 07/23/25 indicated Staff 2 administered Aspart at 5:00 pm and Glargine-YFGN at 8:00 pm on 06/23/25, 06/24/25, 07/02/25, 07/05/25, and 07/07/25.
A review of Resident 2's records indicated the following:
Service plan dated 06/13/25, indicated resident was type 2 diabetic and was insulin-dependent, staff were to administer insulin. Physicians’ orders dated 05/01/25 indicated the following medications for type 2 diabetes: Humalog pen injector 100 unit/ml, inject 15 units under the skin twice daily with breakfast and dinner; and Toujeo Solostar pen injector 300 unit/ml, inject 68 units under skin daily. MARs from 06/01/25 through 07/23/25 indicated Staff 2 administered Humalog at 5:00 pm and Toujeo at 8:00 pm on 06/23/25, 06/24/25, 07/02/25, 07/05/25, and 07/07/25.
A review of Staff 2's training and delegation records indicated that s/he had been delegated to administer insulin for Resident 1 and Resident 2 on 07/08/25.
The facility’s failure to ensure that delegation and teaching must be provided and documented by an RN was substantiated. An investigation determined that a licensing violation occurred.