F0684

D

Failure to Administer Ordered Blood Glucose Monitoring and Insulin

Dunbar, West Virginia Survey Completed on 01-29-2026

Penalty

No penalty information released

Summary

Surveyors identified a deficiency in which a resident with diabetes mellitus did not receive ordered blood glucose monitoring and insulin administration on a specific date. The resident had physician orders for fingerstick blood glucose checks twice daily with instructions to notify the MD if blood sugar was greater than 400 and to initiate a hypoglycemic protocol if blood glucose was below 70, with a start date of 02/17/2025. Record review showed no blood sugar values documented in the vitals section (blood sugar summary), the MAR, or the progress notes for that date, indicating the ordered fingerstick monitoring was not performed.

The same resident also had multiple active physician orders for insulin therapy, including insulin glargine-yfgn 24 units subcutaneously in the evening, insulin glargine-yfgn 46 units subcutaneously in the morning, and HumaLOG (insulin lispro) 4 units subcutaneously once daily, as well as an order for a hypoglycemia protocol to be followed if blood glucose was less than 70 mg/dL or at an ordered low parameter. On the date in question, there was no documentation that any of these insulin doses were administered. In an interview, the DON and the Administrator confirmed that the resident did not receive the ordered fingerstick blood glucose checks or any insulin on that date, and the report notes this had the potential to harm the resident due to not knowing if blood sugar levels were within an appropriate range.