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F0658
D

Failure to Administer Diabetes Medication as Prescribed

Carmichael, California Survey Completed on 09-23-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a resident with type 2 diabetes was not administered glipizide as prescribed by the physician. The physician's order specified that the medication should be given 30 minutes before meals and held if the resident's blood glucose was less than 100. During a medication administration observation, a licensed nurse gave the resident glipizide after the resident had already finished breakfast, contrary to the physician's instructions. The licensed nurse confirmed during an interview that the medication was not administered according to the order. The Director of Nursing also stated that nursing staff are expected to administer medications as ordered by the physician. A review of the facility's policy indicated that medications should be administered as prescribed and in accordance with good nursing practices.

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