F0760

D

Failure to Administer Insulin and Antibiotic Eye Drops as Ordered

Spokane, Washington Survey Completed on 03-04-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to administer medications as ordered by providers for two residents, specifically related to insulin and antibiotic eye drops. One resident with diabetes was admitted on 12/26/2025 and had orders dated 12/12/2025 for long-acting insulin twice daily and short-acting insulin three times daily with meals, plus a sliding scale. On 12/16/2025, the short-acting insulin order was changed from 20 units with meals to 10 units with meals plus sliding scale, with explicit parameters to hold the insulin if the blood sugar was less than 110 mg/dl. Despite this, the December 2025 MAR showed the short-acting insulin was administered nine times when the blood sugar was below 110 mg/dl, and the January 2026 MAR showed it was administered five times under the same condition. The RCM stated that for this resident, staff should have held the insulin when blood sugar readings were under 110 mg/dl, and the Administrator confirmed that insulin had not been held as ordered.

Another resident with kidney disease and diabetes had an order for antibiotic eye drops after reporting blurry vision, redness, and tearing in the left eye. On 02/02/2026, the physician ordered antibiotic eye drops to the left eye twice daily for 10 days. The February 2026 MAR documented that the drops were started as ordered, but 3 of 6 possible doses were not administered. On 02/05/2026, after the resident’s left eye vision improved and the right eye developed yellow discharge, the order was changed to antibiotic eye drops in both eyes four times daily for 10 days. Documentation showed that 7 of 40 possible doses under this revised order were missed. The Administrator confirmed that doses of the antibiotic drops had not been given as ordered.