F0755

D

Failure to Follow Glipizide Hold Parameters for Diabetic Resident

Torrance, California Survey Completed on 03-18-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to administer a hypoglycemic medication according to the physician’s ordered parameters for a resident with type 2 DM and severe cognitive impairment. The resident, who required significant assistance with activities of daily living and lacked decision-making capacity, had a care plan goal to remain free of signs and symptoms of hypoglycemia, with an intervention for staff to administer hypoglycemic medications as ordered. A physician’s order dated 3/4/2026 directed that the resident receive glipizide 2.5 mg once daily for DM, with instructions to hold the dose if the resident’s CBG was less than 120.

Review of the MAR for the month showed that on eight separate days the resident’s CBG levels were below 120 (ranging from 96 to 119), yet glipizide 2.5 mg was administered at 9 a.m. on each of those days. During interview, the LVN who administered the medication acknowledged giving glipizide outside the ordered parameters multiple times, stated he was unaware the order included a hold parameter for CBG less than 120, and reported he did not see the complete order when administering the medication. He also stated he was not familiar with glipizide having parameters and that he should not have assumed the medication did not have parameters. RN 1 confirmed that glipizide was administered when CBG was less than 120 and that there was no documentation in nursing progress notes or change of condition reports regarding these medication errors. RN 2 confirmed that when the telephone order was taken, the hold parameter for CBG less than 120 was included and read back to the physician. The facility’s medication error policy defined a medication error as administration of a medication that is not currently prescribed or given at the wrong dose or time.