F0684

D

Inconsistent Insulin Administration and Inadequate Hypoglycemia Management

Mankato, Minnesota Survey Completed on 03-06-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to administer long‑acting insulin at consistent times, failure to appropriately respond to abnormal blood glucose (BG) levels, and failure to monitor and follow up after hypoglycemia interventions for residents with diabetes. One resident with type 2 diabetes mellitus, diabetic retinopathy, and use of a Dexcom continuous glucose monitor (CGM) had a care plan and physician orders directing daily glargine insulin, sliding‑scale Novolog, hypoglycemia treatment, and specific notification parameters for BG values. However, the MAR showed glargine ordered as "every day shift" with an administration window of 6:30 a.m.–1:00 p.m., and actual administration times varied widely from early morning to early afternoon. On multiple days, glargine was given at different times (e.g., between about 9:00 a.m. and 2:45 p.m.), and on some days it was not administered at all with no explanation. Facility staff, including a nursing assistant who transcribed orders and nurses who confirmed them, acknowledged that the order was entered as a broad shift‑range rather than a specific time and that this could affect BG control.

The same resident experienced multiple episodes of low BG where staff did not follow the facility’s hypoglycemia protocol or the physician’s orders. On one occasion, the Dexcom alarmed for a low reading in the dining room, and a family member obtained orange juice and notified staff. An LPN reported difficulty locating glucose tablets, did not clearly recall whether a manual fingerstick was obtained, and administered glucagon from the emergency kit based on the CGM reading. Documentation showed BG readings of 54 and 57, administration of orange juice and glucagon, and then the resident leaving the facility for appointments, with instructions to the family member to recheck BG later. There was no comprehensive assessment documented for signs/symptoms of hypoglycemia and no documented monitoring to ensure BG returned to safe levels after glucagon; the next recorded BG was not until several hours later. The van driver and clinic nurse reported they were not informed of the low BG event, and the physician later stated the BG should have been manually checked and that such low levels could lead to coma or death.

Additional documentation for this resident showed repeated low BG readings (e.g., in the 50s, 60s, and low 70s) where interventions such as orange juice were given but follow‑up BG checks were delayed or incompletely documented, contrary to the facility’s diabetes and hypoglycemia protocols that called for rechecking every 15 minutes until BG was at least 70 mg/dL and the resident was without symptoms. The Dexcom order initially lacked clear instructions on how to change the sensor, verify readings with fingersticks, or set alarm parameters, and staff reported relying on internet videos to learn sensor changes. During surveyor observation, the resident’s Dexcom displayed a message to start a new sensor, and the resident ate most of his breakfast before any BG was obtained; a TMA later took a manual BG of 153 and then an LPN administered both long‑acting and short‑acting insulin after the meal. Family reported that the Dexcom sensor had fallen off the previous day and staff had not noticed. A second resident with type 2 diabetes and multiple diabetic complications also had glargine ordered daily, but MAR review showed long‑acting insulin administered at widely varying morning times, from just before 7:00 a.m. to after noon, despite staff and the consulting pharmacist stating that long‑acting insulin should be given at approximately the same time each day and BG should be checked before meals and insulin administration.

The facility’s own Diabetes‑Clinical Protocol and Insulin Administration policies required assessment of diabetic residents, incorporation of orders and reporting parameters into the MAR and care plan, consistent monitoring of BG, and specific hypoglycemia treatment steps including 15‑minute rechecks and continued monitoring after glucagon. Standing orders for CGM use required setting alarms, verifying initial readings with fingersticks, and performing fingersticks when readings were <100 or >400 or when accuracy was in question. Interviews with nursing staff, the clinical manager, and the pharmacist confirmed that long‑acting insulin should not be administered at random times across a broad shift window and that BG should be checked before meals and insulin dosing. Despite these policies and professional expectations, the facility did not ensure consistent timing of long‑acting insulin for two residents, did not consistently verify or respond to abnormal BG readings according to protocol, and did not document timely reassessment after hypoglycemia interventions for one resident.