F0760

J

Significant Insulin Reconciliation Error and Failure to Access Glucagon for Hypoglycemia

Greenville, Texas Survey Completed on 03-27-2026

Penalty

Fine: $22,925

Summary

The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors related to insulin administration and emergency hypoglycemia treatment. The resident, an older male with Type II diabetes mellitus and multiple comorbidities including COPD, chronic kidney disease, atherosclerotic heart disease, atrial fibrillation, gout, and dysphagia, was originally admitted and later discharged following a hypoglycemic episode with a blood glucose level of 35. Upon readmission from the hospital, the discharge instructions included an order for Insulin Glargine 12 units once daily and regular insulin on a sliding scale before meals, with explicit instructions to stop Insulin degludec (Tresiba) 40 units once daily. The facility’s March 2026 MAR showed that these new insulin orders were not transcribed and that the prior order for Tresiba 40 units at bedtime was continued.

On the readmission date, LVN A completed admission assessments but did not review the hospital discharge medication list, stating that two nurses typically split admission tasks and that the charge nurse handled the medication review. LVN B, the charge nurse on the readmission date, reported that he completed the medication reconciliation but acknowledged he failed to accurately reconcile the medications and transcribe the correct insulin orders, resulting in continuation of Tresiba instead of initiating Insulin Glargine and regular insulin per hospital instructions. The attending physician later stated he had instructed the facility to follow hospital orders and expected nurses to accurately review discharge instructions and call with accurate information when verifying orders.

On the night of the incorrect insulin administration, RN C, who was aware the resident had been readmitted but relied on the prior shift’s reconciliation, followed the existing physician orders and administered 40 units of Tresiba at bedtime after a blood glucose reading of 135. At approximately 5:10 a.m. the following morning, RN C obtained a blood glucose reading of 35. The resident was alert, able to sit upright, and had no difficulty swallowing. RN C administered sugar dissolved in peach juice and water while awaiting EMS. RN C reported being unable to locate the facility emergency kit containing glucagon injection or gel at that time. The DON later confirmed that glucagon gel and an injection were present in the emergency kit in the medication room but required 45 minutes of searching to locate it. The facility’s own policies on medication reconciliation and medication errors defined the need for accurate reconciliation of pre- and post-discharge medications and identified wrong-drug administration as a medication error, which was not followed in this case.