F0684

E

Failure to Ensure Ongoing Physician Management of Insulin Therapy for Diabetic Resident

Glendora, California Survey Completed on 01-20-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure physician assessment and continued management of a high‑risk medication regimen for a resident with diabetes mellitus. The resident was admitted with diagnoses including diabetes mellitus with ketoacidosis and long‑term use of insulin, and had documented decision‑making capacity and intact cognitive skills. A Hemoglobin A1C result showed a level of 13.6%, and the resident had clear speech and was usually understood and able to understand others.

Review of the physician orders and Medication Administration Records showed that the resident had orders for Humalog insulin before meals and Lantus insulin every 12 hours beginning in October, with those orders ending on 11/20/2025. The records indicated there were no physician orders for any oral or injectable diabetes medications from 11/20/2025 through 11/27/2025, and the MAR confirmed that no diabetes medications were administered during that eight‑day period. Subsequent insulin orders were not written until 11/28/2025.

Progress notes dated 11/27/2025 documented that the resident was not on any diabetic medications because the hospital insulin orders had ended on 11/20/2025, and that the physician could not be reached. The note also indicated that the resident and a home health agency administrator requested that discharge be held until an insulin regimen was established. In interviews, an RN and the DON acknowledged that the resident did not receive insulin for eight days, that nursing staff should have clarified the discontinuation of insulin with the physician, and that it was facility policy and part of the nursing job responsibilities to monitor residents, recognize abnormalities, and consult with the physician regarding resident evaluation and care needs.