Resident 3 arrived at Dubois Nursing Home on December 19, 2025, at 5:30 p.m. from the hospital with diabetic ulcers and a blood sugar of 182. Her physician had ordered six different insulin treatments — some with meals, others at bedtime, including sliding scale coverage to adjust doses based on blood sugar readings.
A nurse reviewed the orders with the provider at 6:06 p.m. that evening. But the insulin never came.
The next morning at 9:20 a.m., staff found the resident still lying on hospital linens with soiled pads and briefs, breathing 33 times per minute. Normal breathing ranges from 12 to 20 breaths per minute. Her blood sugar had climbed to 503.
She had received no insulin or medications the night before.
Staff gave her insulin immediately. An hour later, her blood sugar hit 530. Her breathing remained rapid and labored.
At noon, her blood sugar measured 484. More insulin. At 1:00 p.m., it was 497. The resident said she didn't feel well. Nurses sent her to the hospital.
She arrived at the emergency room at 1:15 a.m. on December 21 with diabetic ketoacidosis, a potentially fatal condition where the body breaks down fat for fuel when insulin is unavailable. The process produces acidic ketones that build up in the blood. She also had altered mental status, acute kidney injury, brain dysfunction, and dehydration.
The medication administration record showed no insulin orders entered for December 19. An audit revealed the truth: the registered nurse had finally entered all the orders between 11 p.m. and midnight on December 19, but set them to start December 20.
The delay meant the resident missed her supper insulin and bedtime insulin on her first night at the facility.
During a December 29 interview, the Director of Nursing confirmed what happened. The registered nurse responsible for entering the 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 confirmed that Resident 3 did not receive her supper or bedtime insulin that first night.
The inspection found this represented actual harm to the resident. Federal investigators determined the facility failed to ensure residents received care according to professional standards by not following physician orders.
For a diabetic patient with existing ulcers, missing insulin doses can trigger a cascade of complications. Blood sugar levels above 400 put patients at immediate risk for ketoacidosis, which can cause coma or death without emergency treatment.
The resident had been stable enough for discharge from the hospital with a blood sugar of 182. Within 17 hours of missing her medications, that number had nearly tripled.
The facility's electronic health record system should have flagged the missing orders. Nursing staff conducting routine checks should have noticed the absence of required medications for a newly admitted diabetic patient.
Instead, the resident spent her first night at the nursing home deteriorating while her body fought without the insulin it needed to process sugar. By morning, she was in respiratory distress, lying in her own waste, and facing a medical emergency that required immediate hospitalization.
The nurse's decision to delay entering orders until nearly midnight on December 19 meant the computer system automatically scheduled them to begin the following day, creating an unnecessary and dangerous gap in care for a vulnerable diabetic resident who had just been discharged from the hospital.
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.