Insulin Lispro Dosing Errors Outside Ordered Blood Glucose Parameters
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors related to insulin administration. A female resident with Type 2 Diabetes Mellitus without complications, hypothyroidism, bipolar disorder, and an anxiety disorder was admitted to the facility and had a care plan that included receiving insulin as ordered, with monitoring and documentation for side effects and effectiveness. Her admission MDS dated 12/25/25 showed a BIMS score of 12/15, indicating moderate cognitive impairment, and she required some help with dressing and eating. The resident’s MAR and physician orders reflected an order for Insulin Lispro Injection Solution, 2 units subcutaneously three times a day for Type 2 Diabetes Mellitus, with parameters to hold insulin for blood sugar less than 150 or if the resident was not eating, and a hypoglycemic protocol for finger-stick blood sugar less than 60. Record review and the DON’s audit revealed that between 12/19/2025 and 12/30/2025, the resident was administered insulin on multiple occasions outside the prescribed blood sugar parameters. Specifically, the DON identified that LVN B administered insulin outside of parameters on several dates in December, including when the resident’s blood sugar readings were 117 and 148 on 12/30/2025, which were below the ordered threshold for administration. On that date, the resident received insulin at 11:30 a.m. despite a blood sugar of 117, and did not receive insulin at 5:00 p.m. when the blood sugar was 148, both readings documented as outside the parameters. The resident’s meal intake on 12/30/2025 was recorded as 51–75% for breakfast and lunch and 76–100% for dinner. On 12/31/2025 at 6:30 a.m., the resident was reported to have stroke-like symptoms including lethargy and slurred speech and was transported to the hospital, where the diagnosis was hypoglycemia. An NP later stated that Insulin Lispro is short-acting and that, given the resident’s good food intake, the 11:30 a.m. insulin dose on 12/30/2025 would have worn off by the following morning and could not be definitively linked to the low blood sugar at 6:00 a.m. the next day.
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