F0755

J

Failure to Transcribe Hospital Diabetes Orders Resulting in Missed Insulin Therapy

Greenfield, Indiana Survey Completed on 03-23-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to correctly transcribe and enter a hospital’s discharge orders for a newly admitted resident with type 2 diabetes into the facility’s electronic health record. The resident was admitted for a short-term rehab stay with diagnoses including type 2 diabetes, acute upper respiratory infection, unspecified dementia, weakness, dehydration, and hydrocephalus. The hospital discharge orders dated 2-6-26 specified that the resident had type 2 diabetes and was to receive glargine (Lantus) 16 units subcutaneously twice daily, with blood glucose (BG) monitoring before meals or three times daily. These diabetes-related orders, including the diagnosis and insulin regimen, were not transcribed into the facility’s electronic health record at admission and were not entered until 2-12-26.

Multiple facility staff, including the Director of Health Services (DHS), MDS staff, a Nurse Practitioner, and two nurses, reviewed the hospital discharge paperwork and entered orders into the electronic health record but failed to identify and transcribe the diabetes diagnosis and associated insulin and BG monitoring orders. The DHS later explained that the initial page of the hospital discharge summary did not specifically mention the diabetes diagnosis, which was located further into the document, and that staff did not locate this information during the initial review. The omission was discovered on 2-11-26 during an initial care planning meeting when a family member inquired about the resident’s BG levels, prompting a more thorough review of the hospital discharge documents.

During the period when the diabetes diagnosis and insulin orders were not in place, the resident did not receive the ordered long-acting insulin for five days and had only one insulin injection documented since admission. The resident’s BG levels during this time were significantly elevated, with readings including 399, 451, 496, 316, 360, 356, 422, and 354. The resident, who was already severely cognitively impaired per the 5-day MDS assessment, experienced diminished cognitive levels and lethargy and was ultimately sent to the local hospital at the family’s request. Hospital records from that subsequent admission documented altered mental status possibly related to dehydration, infection, or diabetic ketoacidosis, and identified the resident’s diabetes as uncontrolled at that time.