F0755

D

Failure to Maintain Emergency Insulin Supply and Proper Medication Management

El Paso, Texas Survey Completed on 03-12-2026

Penalty

Fine: $124,950

Summary

The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications, specifically insulin, for a resident with diabetes mellitus. The resident had multiple active diagnoses including coronary artery disease, hypertension, peripheral vascular disease, diabetes mellitus, post-procedural pain, and aftercare following a left below-knee amputation. The care plan identified diabetes mellitus with approaches including diabetes medication as ordered, monitoring for side effects and effectiveness, and monitoring for signs and symptoms of hypoglycemia and infection. The resident was cognitively intact with a BIMS score of 15 and had an existing physician order for insulin glargine (Lantus) 10 units subcutaneously at bedtime and insulin lispro per a sliding scale.

On the day of the incident, the resident complained of abdominal pain and diarrhea, and the attending physician had recently evaluated the resident and ordered Bentyl and Zofran PRN. Later, the resident reported abdominal pain rated 8/10, for which PRN hydrocodone was administered. A family member checked the resident’s blood glucose, which was in the 470s mg/dL range, and the physician was notified. The physician ordered blood glucose checks before meals and at bedtime with a moderate sliding scale and a STAT dose of 10 units of lispro, which the LVN reported administering, although he did not document the actual times of the blood glucose checks or insulin administration in the electronic record. A recheck of blood glucose approximately 45 minutes later showed an increase to over 500 mg/dL, and the resident became clammy and reported feeling sleepy.

After the blood glucose remained elevated, the physician was notified again and ordered discontinuation of the moderate sliding scale, initiation of a high sliding scale, a STAT dose of 14 units of lispro, and administration of 10 units of Lantus. The facility’s emergency insulin kit did not contain Lantus, so the weekend RN supervisor obtained a new vial of Lantus that belonged to another resident and used it to administer the ordered dose, then discarded the vial in a biohazard container. This borrowing of medication from another resident occurred despite staff training and facility policy stating that medications must be administered as prescribed, that single-dose vials are not to be used for multiple residents, and that medication administration details, including date, time, dosage, route, and results, must be documented. The physician’s STAT order for Lantus and its administration were not entered on the physician order summary or the MAR. Subsequently, the resident’s condition deteriorated, with a blood glucose reading in the 560s mg/dL range, tachycardia, clamminess, and unresponsiveness, leading to EMS activation and transfer to the hospital, where the resident was treated for altered mental status and later pronounced dead. The surveyors concluded that the facility failed to ensure the emergency insulin kit contained Lantus and that staff borrowed insulin from another resident, constituting a failure to provide required pharmaceutical services.

The hospital emergency department record documented that the resident arrived unresponsive with a blood glucose of 561 mg/dL, low blood pressure, and oxygen saturation less than 90%, requiring bagging and chest compressions by EMS. The ED course included emergent intubation, CPR, findings of hyperkalemia, severe acidosis, and hypoxia, and eventual cessation of resuscitation efforts at the family’s request, with time of death recorded. Facility nursing notes and interviews confirmed that lab results from a prior day showing rising glucose had not been reported to the physician until the day of the event, that the resident’s glucose continued to trend upward, and that the DON was informed the resident had received 14 units of lispro and 10 units of Lantus per MD order. Interviews with the LVN and RN supervisor confirmed that Lantus was not available in the insulin emergency kit, that a vial was borrowed from another resident, and that this practice was contrary to their training and facility policy. The physician’s STAT Lantus order and its administration were not reflected in the physician order summary or MAR, further evidencing failures in documentation and medication management.

Overall, the survey findings show that the facility did not ensure that its emergency insulin kit contained Lantus as needed for STAT administration and that staff resorted to borrowing another resident’s Lantus vial to comply with the physician’s order. Additionally, required documentation of blood glucose checks and insulin administration times, as well as entry of the STAT Lantus order on the physician order summary and MAR, was missing. These actions and omissions were inconsistent with the facility’s own medication administration policy, which requires medications to be administered as prescribed, prohibits using single-dose vials for multiple residents, and mandates complete documentation of medication administration details in the resident’s medical record.