F0760

D

Missed Sliding Scale Insulin Doses for Diabetic Resident

Black River Falls, Wisconsin Survey Completed on 03-23-2026

Penalty

No penalty information released

Summary

The facility failed to ensure that a resident was free from significant medication errors related to insulin administration. Facility policy on diabetic blood sugar monitoring, last reviewed in 11/2022, requires that blood sugars be measured and recorded per physician orders and that sliding scale insulin be given as ordered. The resident, admitted with type 2 diabetes mellitus without complications, had a physician order for insulin lispro on a sliding scale four times daily, with specific unit doses tied to blood glucose ranges and an instruction to call the physician for readings over 400. Review of the medication administration record showed that on 02/28/26 the resident’s morning blood sugar was 154, which required administration of 2 units of insulin lispro per the sliding scale order, but no insulin was given.

Further review showed that on 03/15/26 the resident’s lunchtime blood sugar was 192, again requiring 2 units of insulin lispro per the physician’s sliding scale order, and no insulin was administered. During an interview on 03/23/26, the Clinical Services Consultant explained that every other weekend a med tech obtains diabetic blood sugars and informs the nurse of the results so the nurse can administer insulin. On 02/28/26, another resident experienced a fall, and the nurse became busy and forgot to administer the ordered insulin dose. On 03/15/26, the med tech did not inform the nurse of the resident’s blood sugar result, and the nurse did not administer the lunchtime insulin dose. The Clinical Services Consultant confirmed that these missed doses constituted medication errors and that insulin should have been administered on both occasions.