F0684

J

Failure to Follow Hypoglycemia Orders and Inappropriate Insulin Administration

Edmond, Oklahoma Survey Completed on 02-27-2026

Penalty

Fine: $26,685

Summary

The deficiency involves the facility’s failure to assess, monitor, and intervene according to physician orders for a resident with hypoglycemia. Resident #129 had a diagnosis that included type 2 diabetes mellitus with hyperglycemia. Facility records showed that on 11/27/24 at 8:00 p.m., the resident’s finger stick blood sugar (FSBS) was 64. The resident had a physician order for a Glucagon Emergency Injection Kit 1 mg to be given intramuscularly as needed for FSBS less than 71, along with cola/orange juice and/or a high carbohydrate snack, and to notify the physician. Despite this order, the resident was not given Glucagon or the ordered treatments, and the physician was not notified of the low blood sugar.

Instead of following the hypoglycemia treatment orders, RN #1 documented administering 40 units of Toujeo SoloStar, a long-acting insulin, to Resident #129 after the FSBS of 64 was obtained. The facility’s Blood Glucose Monitoring Guideline, dated 01/2026, directed staff to follow physician orders based on finger stick results and to notify the physician if no follow-up orders were in place and signs or symptoms of hypo/hyperglycemia were noted. The medical director later stated that for a blood sugar of 64, depending on the resident’s status, they would expect juice to be given if the resident was awake or a Glucagon injection if unresponsive, and that they would not expect a nurse to administer a long-acting insulin in that situation.

On 11/28/24 at 9:07 a.m., a nurse’s progress note documented that Resident #129 was assessed as unresponsive and not reacting even to a sternal rub. Vital signs were obtained, and 911 was called. Emergency medical services arrived and reported the resident’s FSBS was 41, and the resident was transported to the hospital. The facility’s investigation and survey findings concluded that the facility failed to assess, monitor, and intervene appropriately for hypoglycemia for this resident, despite existing physician orders and facility policy, and this failure led to the determination of an Immediate Jeopardy situation.

Removal Plan

• In-service all licensed nursing staff on signs and symptoms of hypoglycemia and treatment within the physician's orders with staff acknowledgment and verbalized understanding of parameters, treatments, and following physician orders for hypoglycemia.
• Audit all residents with hypoglycemia or diabetes to ensure physician treatment orders with parameters are in place.
• Add monitoring orders for appropriate residents for signs and symptoms of hypoglycemia.
• Place parameter orders for all residents with hypoglycemia below 70.
• Initiate compliance rounds to ensure licensed nursing staff understand signs and symptoms of hypoglycemia and provide treatment following physician orders.
• Complete a root cause analysis of the event.