F0684

D

Failure to Follow Insulin and Diuretic Parameters for a Medically Complex Resident

Indianapolis, Indiana Survey Completed on 01-28-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to administer medications according to physician orders and established parameters for a resident with type 2 diabetes mellitus. The resident’s care plan, dated 1/10/25, directed staff to administer diabetic medications as ordered. A physician’s order dated 9/11/25 required 5 units of aspart insulin before meals, to be held if blood sugar was less than 100. Despite this, the January 2026 MAR showed that staff administered 5 units of aspart insulin on multiple mornings when the resident’s blood sugar readings were below 100 (94 on 1/8/26, 92 on 1/13/26, and 89 on 1/17/26). A subsequent order dated 1/21/26 changed the dose to 3 units of aspart insulin before meals, to be held if blood sugar was less than 110, yet the MAR documented administration of 3 units when blood sugar readings were below 110 on several occasions, including readings of 71 and 84 on 1/25/26, 93 on 1/26/26, and 102 on 1/27/26.

The resident also had an order for glargine insulin related to diabetes management. A physician’s order dated 11/19/25 directed staff to administer 20 units of glargine insulin in the mornings, with instructions to hold the insulin if the resident’s blood sugar was less than 110. The January 2026 MAR indicated that staff administered 20 units of glargine insulin on multiple dates when the resident’s blood sugar was below 110, including readings of 94, 80, 92, 83, 89, 91, 106, 90, 71, 93, and 102 on various dates between 1/8/26 and 1/27/26. In an interview on 1/27/26, the Director of Nursing acknowledged that staff had administered the resident’s insulins when they should have been held according to the prescribed parameters.

The deficiency also includes failure to follow physician orders for a resident with congestive heart failure, hypertension, chronic kidney disease, and leg swelling related to heart valve replacement. The care plan dated 1/22/25 instructed staff to monitor vital signs, notify the medical provider of abnormalities, and give medications as ordered. A physician’s order dated 9/23/25 required administration of 40 mg (two 20 mg tablets) of torsemide daily, with instructions not to give the medication if the resident’s systolic blood pressure was less than 100. The January 2026 MAR showed that the resident received 40 mg of torsemide every morning from 1/1/26 through 1/27/26, but there were no blood pressure readings obtained prior to administration as required by the order. The Director of Nursing stated she was unable to find blood pressure readings taken before giving the torsemide and reported that the order had not been set up correctly in the electronic medication system. The facility’s medication administration policy required medications to be administered as ordered by the physician and to obtain and record vital signs when applicable, holding medications when vital signs were outside prescribed parameters.