F0760

K

Failure to Implement Antibiotic and Diabetes Management Orders Resulting in Significant Medication Errors

El Paso, Texas Survey Completed on 03-13-2026

Penalty

Fine: $53,825

Summary

The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors related to antibiotic therapy and blood glucose management. An [AGE]-year-old female resident with diagnoses including vesicointestinal fistula, hypertension, type 2 diabetes mellitus with hyperglycemia, and early-onset Alzheimer’s disease was admitted following hospitalization and surgery for colostomy placement. Her physician orders included long-acting insulin (Semglee), sliding-scale insulin (NovoLOG), blood glucose monitoring before meals and at bedtime with provider notification for values <60 or >400 mg/dL, a continuous glucose monitoring (CGM) sensor (FreeStyle Libre 2), and prophylactic antibiotics (Ciprofloxacin and Metronidazole) along with other medications. Record review showed that from admission through several days, the antibiotic orders were not transcribed onto the MAR and no doses were administered, and the CGM sensor was not implemented.

During the same period, the resident’s blood glucose readings were repeatedly and significantly elevated, with documented values of 512 mg/dL, 482 mg/dL, 459 mg/dL, and 492 mg/dL. Despite an order to notify the provider if blood glucose was <60 or >400 mg/dL, there was no evidence in the record that the physician was notified of these out-of-parameter results. Additionally, there was no documentation of nighttime blood glucose checks, even though orders required blood glucose monitoring before meals and at bedtime. Staff interviews revealed that some medications, including long-acting insulin, were not immediately available or did not appear on the MAR, and that staff relied on sliding-scale insulin without obtaining new physician orders or consistently documenting provider notifications. Nursing staff also reported communication delays with on-call providers and PACE, and acknowledged that no new orders were obtained despite persistently elevated blood glucose levels.

Multiple interviews with PACE clinicians and facility leadership confirmed that the ordered prophylactic antibiotics and CGM device were not implemented as prescribed, and that providers were not notified of missed medications or abnormal blood glucose values. PACE staff stated that antibiotics (Ciprofloxacin and Metronidazole), probiotics, insulin, and other routine medications had been ordered upon discharge from the hospital, but the facility failed to administer the antibiotics and did not apply the ordered glucose monitoring sensor. The DON and ADON acknowledged that medication reconciliation was not completed upon admission for this resident, that there was no standardized process to ensure baseline blood glucose assessment or consistent review of hospital records, and that oversight of admission orders and blood glucose monitoring was inconsistent. The resident ultimately required transfer to the hospital, where she was admitted to the ICU with DKA and septic shock, and hospital staff documented hyperglycemia, UTI, markedly elevated WBC, and the need for sepsis protocol, IV antibiotics, and insulin drip.

Facility policies in place at the time required that blood glucose monitoring be completed per provider orders, that physicians be notified when glucose results were outside ordered parameters, and that insulin be administered only upon a physician’s order. The physician orders policy required that all physician orders be valid, safe, and clarified if unclear prior to implementation. Interviews with the DON, ADON, and other staff indicated that these policies were not consistently followed: there was no daily process to review medications for accuracy or completeness, medication pass audits were intermittent, and staff did not consistently notify physicians when medications were unavailable or when ordered treatments (such as the CGM sensor) could not be implemented. Communication gaps with external providers, particularly PACE, and lack of a standardized admission and reconciliation process contributed to the failure to transcribe and administer antibiotics, to perform ordered bedtime blood glucose checks, to notify providers of critical glucose values, and to implement the ordered continuous glucose monitoring device for this resident.