Resident 3 arrived at Dubois Nursing Home on December 19, 2025, at 5:30 p.m. from the hospital with a blood sugar of 182 and diabetic ulcers. Her physician had ordered a complex insulin regimen: sliding scale coverage three times daily with meals and at bedtime, plus specific units before breakfast, lunch and supper.
The nursing staff reviewed her medication orders with the provider at 6:06 p.m. that evening.
But nobody entered the orders into the electronic health record system.
The next morning at 9:20 a.m., staff found the resident still lying on hospital linens with a soiled disposable pad and brief. Her breathing was rapid at 33 breaths per minute — well above the normal range of 12 to 20. She had received no insulin or medications the night before.
Her blood sugar had spiked to 503.
Staff gave her insulin and checked again an hour later. Her blood sugar had risen to 530. At noon, after another insulin dose, it was 484. By 1:00 p.m., it remained dangerously high at 497.
The resident told staff she didn't feel well. A nurse was instructed to send her to the hospital.
She was admitted at 1:15 a.m. on December 21 with diabetic ketoacidosis, a life-threatening condition where the body breaks down fat for fuel when insulin is lacking, producing acidic ketones that build up in the blood. She also had altered mental status, acute kidney injury, encephalopathy and dehydration.
A review of her medication administration record revealed no orders were entered for December 19. An audit showed the orders were finally entered between 11 p.m. and midnight on December 19, but with a start date of December 20 — meaning she would miss her evening and bedtime insulin doses.
The Director of Nursing confirmed during a December 29 interview that the registered nurse responsible for entering orders "did not get around to entering them until around midnight on December 19, which pushed the start date of the orders until December 20."
The director acknowledged that Resident 3 did not receive her supper or bedtime insulin.
For diabetic patients, missing insulin doses can trigger a cascade of dangerous complications. When cells can't access glucose due to lack of insulin, the body begins breaking down fat stores for energy. This process produces ketones, which make the blood acidic and can cause nausea, vomiting, confusion and potentially coma or death if untreated.
The resident had been stable enough for discharge from the hospital just hours before arriving at the nursing home. Her blood sugar of 182 upon discharge, while elevated, was manageable with proper medication adherence.
The delay in entering medication orders violated basic nursing protocols. Professional standards require that physician orders be implemented promptly, especially for time-sensitive medications like insulin that diabetic patients depend on to prevent life-threatening complications.
Federal inspectors found that the facility failed to ensure residents received care and treatment according to professional standards of practice. The violation was classified as causing actual harm to the resident.
The inspection was triggered by a complaint and conducted on January 2, 2026. Inspectors reviewed clinical records and interviewed staff members to document the medication error.
The resident's condition upon discovery the next morning — lying in soiled linens, breathing rapidly, with blood sugar levels more than double the normal range — illustrated the immediate consequences of the delayed medication entry.
Despite multiple insulin doses throughout December 20, her blood sugar remained dangerously elevated, ultimately requiring hospitalization for diabetic ketoacidosis and its complications including kidney injury and brain dysfunction.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Dubois Nursing Home from 2026-01-02 including all violations, facility responses, and corrective action plans.