F0726

E

Failure to Competently Manage Hypoglycemia and Follow Insulin Parameters for Diabetic Residents

Wyoming, Michigan Survey Completed on 01-28-2026

Penalty

No penalty information released

Summary

The deficiency involves failures in recognizing and managing hypoglycemia and in administering insulin according to physician orders for three diabetic residents. One resident with Type 1 diabetes had orders for blood glucose (BG) checks before meals and at bedtime, with specific hypoglycemia treatment orders including oral glucose tablets and glucagon nasal spray. On the morning in question, an LPN obtained a BG of 69 mg/dL, documented only in a nursing note, encouraged the resident to eat cookies, and then left the room without rechecking the BG or reassessing the resident as required by the facility’s hypoglycemia policy. There was no documentation of a repeat BG within approximately 15 minutes, no documentation that the resident’s clinical status was monitored during this period, and no documentation that the resident was medically stable until vital signs were taken about 1 hour and 45 minutes later.

When the resident was next assessed, vital signs showed an oxygen saturation of 84% on room air and a BG of 46 mg/dL. Documentation and interviews indicate the resident was unresponsive at that time, with a critically low BG and elevated blood pressure. Staff did not document application of supplemental oxygen after the low oxygen saturation was identified, and there is no documentation that ordered emergency hypoglycemia treatments (glucagon) were administered by facility staff prior to EMS arrival. EMS and hospital records reflect that staff reported the resident’s sugar had been found low earlier, that the resident had been told to eat and left alone, and that staff stated they did not have glucagon or glucose to give, despite existing orders for oral glucose tablets and glucagon nasal spray. EMS found the resident unresponsive, hypoxic, and with a BG of 24 mg/dL, and administered glucagon.

The deficiency also includes failures to follow physician orders for insulin administration parameters for two other residents with diabetes. One resident with Type 2 diabetes had an order for nightly Lantus insulin with instructions to hold the dose if BG was less than 100 mg/dL, and to obtain a BG prior to administration. Review of records showed multiple dates on which no BG was assessed in the evening, yet all Lantus doses were documented as given, with no rationale or documentation of BG refusals. Another resident with Type 2 diabetes had an order for nightly Lantus with instructions to hold if BG was less than 100 mg/dL, but there was no corresponding order for routine BG assessments. Over a several-week period, only four BG readings were documented, while Lantus was administered on most nights, including nights without a recorded BG. The DON confirmed that BGs were not consistently obtained prior to insulin administration and that nurses were expected to review full order summaries to follow provider-ordered parameters.