F0760

D

Unauthorized Hypoglycemia Treatment and Missing MAR Documentation

Lancaster, California Survey Completed on 03-05-2026

Penalty

No penalty information released

Summary

The facility failed to ensure a resident was free from significant medication errors when staff administered hypoglycemia treatments without proper orders and documentation. The resident, admitted with diagnoses including type 2 diabetes mellitus, major depressive disorder, and essential hypertension, had a discontinued order for glucose gel 40% as of 1/15/2019 and an active order for glucagon 1 mg IM for blood sugar levels less than 70 mg/dL as of 5/11/2024. The resident’s MDS dated 10/24/2025 showed severely impaired cognitive skills for daily decision making, and the care plan for diabetes, last revised on 12/17/2025, directed licensed nurses to provide diabetes medications according to physician orders and to monitor, document, and report signs and symptoms of hypoglycemia.

On 12/21/2025, during a change of condition, the resident was observed with labored breathing, altered level of consciousness, and a blood sugar level of 45 mg/dL at 4:50 a.m. The SBAR Communication for change of condition form documented that the resident received glucagon 1 mg IM and glucose gel 40% and was transferred to an acute care hospital. RN 1 stated she witnessed an LVN administer both glucagon 1 mg and glucose gel 40% during this hypoglycemic episode. LVN 2 confirmed that the glucose gel 40% order had been discontinued and that the resident was given glucose gel without an active physician order. Review of the MAR for December 2025 showed no documented administration of glucagon on the date of the event, despite its use being recorded on the change of condition form. The DON stated that physician orders are required before administering medications and that medications given must be documented on the MAR, and acknowledged the failures to obtain an order for glucose gel and to document the glucagon administration.