F0755

D

Failure to Administer Insulin, Reglan, and Blood Glucose Monitoring at Ordered Times

Morrison, Illinois Survey Completed on 02-24-2026

Penalty

No penalty information released

Summary

Surveyors identified a deficiency in the facility’s provision of pharmaceutical services related to medication and blood glucose administration for one resident with diabetes mellitus. The resident’s admission record documented a diagnosis of diabetes and physician orders for blood glucose (Accu-check) monitoring before meals and at bedtime, specifically at 6:30 AM, 11:30 AM, 4:30 PM, and 9:00 PM. The resident also had orders for Humulin R insulin, 3 units SQ with meals at 7:30 AM, 12:00 PM, and 5:30 PM, and Reglan 10 mg to be given before meals at 6:30 AM, 11:30 AM, and 4:30 PM. The resident’s POA reported that staff were not checking the resident’s blood glucose levels as ordered and were administering medications late.

On the morning observed, the resident was seated in the dining room with breakfast and had already consumed approximately 25% of the meal and stated to staff that he was done eating. At 8:33 AM, an LPN checked the resident’s blood glucose after he had eaten, obtaining a reading of 256, and then administered 3 units of Humulin R at 8:39 AM, more than two hours after the ordered 7:30 AM administration time. At 8:56 AM, the LPN administered 10 mg of Reglan, also more than two hours late and after the resident had eaten, contrary to the order for administration before meals. The DON confirmed that medications are to be given at the scheduled time per physician order, that medication is considered late if given more than one hour past the scheduled time, and that blood sugars are to be checked prior to eating. Facility policies on blood glucose monitoring, timely administration of insulin, and medication administration all required adherence to physician orders and correct timing, which was not followed in this case.