Based on observation, interview, and document review the facility failed to ensure insulin was administered according to manufacturer's guidelines for 1 of 1 resident (R1) resulting in the potential for serious harm or death when R1 had to be sent to emergency department (ED) for hypoglycemia (low blood sugar (BS)) when staff administered R1's insulin without ensuring he ate within the required time frame of 5-10 minutes. The IJ began on 2/5/24, when licensed practical nurse (LPN)-A failed to follow manufacturer guidelines when administering Novolog (a rapid acting insulin) to R1. R1 was administered insulin at 11:14 a.m. without being fed any type of meal or sustenance within 5-10 minutes of administration and was subsequently sent to the ED with severe hypoglycemia for medical treatment. The facility administrator and director of nursing (DON) were notified of the IJ on 2/21/24 at 2:22 p.m., which was identified at the scope and severity of J-ISOLATED. The IJ was removed on 2/22/24 at 11:37 a.m., but non-compliance remained at the lower scope and severity of D: No actual harm with potential for more than minimal harm, that is not immediate jeopardy. Findings include: Review of current, Novolog manufacturer guidelines for Novolog, located at https://www.mynovoinsulin.com/insulin-products/novolog/home.html, identified it was a rapid acting insulin and patients using Novolog should eat a meal within 5 to 10 minutes after taking it. Review of the 2/7/24, report to the State Agency (SA) identified LPN-A had checked R1's blood sugar at 11:14 a.m., then immediately administered 10 units of rapid acting Novolog insulin. R1 was found in his room unresponsive approximately 1 hour and 20 minutes later. It was discovered he had not eaten any of his dinner (normal was to consume 100% of his meals). R1's blood sugar was checked and found to be 39 (severe hypoglycemia requiring medical attention). He was given a tube of glucose gel. The DON and LPN-A suspected possible seizure activity and called for ambulance transport to the hospital's ED for evaluation and treatment. The DON identified in the report R1 was a brittle diabetic and should not have been administered his rapid acting insulin that long prior to receiving his meal or some form of sustenance. R1's 12/14/23, Minimum Data Set (MDS) identified R1 had a diagnosis of diabetes mellitus type II (DM) and he required staff assistance with meal tray set up or clean up. R1's 2/20/24, diagnosis list identified he had a developmental disorder and other signs and symptoms involving cognitive functioning. R1's Novolog physician orders identified the following on: 1) 6/20/23, R1 was to be given Novolog 10 units 2 x a day. No other instructions were noted on the order. 2) 2/9/24, R1 was to be given Novolog 10 units 2 x a day, however staff were to hold his insulin if his BS was less than 100 milligrams per deciliter (mg/dL). 3) 2/21/24, R1 was to be given Novolog per sliding scale. If R1's BS was 0-100 mg/dL, staff were to hold his insulin. It was also noted staff were to administer R1's insulin within 5-10 minutes before a meal. Meal times were listed as 12:00 noon and 4:50 p.m Staff were to ensure the resident received a meal within 10 minutes of administration. There was no mention staff should call the provider if the insulin was held to determine when they would potentially give it. R1's 2/5/24, Medication Administration Audit Report related to the above incident identified LPN-A checked R1's blood sugar which was 85 mg/dL and administered 10 units of Novolog at 11:14 a.m. at the time his insulin was administered. Observation on 2/20/24 at 11:45, with LPN-A identified she checked R1's blood sugar and documented it as being 86 mg/dL. She administered 4 ounces of orange juice and left the room. LPN-A was unable to be interviewed at this time. Interview on 2/20/24 at 12:30 p.m., with LPN-B identified staff were to check R1's blood sugar (BS) prior to dinner. If it was below 100 milligrams mg/dL, facility management advised staff they were to give him orange juice and give him dinner to artificially raise his BS to 100 mg/dL or above, and then go back and recheck his blood sugar so they could then administer his insulin, even though that was not according to the physician order noted above. She identified staff have no access to manufacturer's guidelines, nor had they any professional references to follow. Interview on 2/20/24 at 2:30 p.m., with the medical director (MD)-A identified while at the facility doing rounds on 2/9/24, he had been notified of the incident that occurred on 2/5/24 with R1. His understanding was R1's BS was at the lower end of normal when R1 was administered 10 units of Novolog. When made aware of how low R1's BS had gotten after the administration at the time of the 2/5/24 incident, MD-A stated R1 should not have been administered his insulin without getting food within 10-15 minutes of administration at the latest, and agreed that was what caused R1's acute hypoglycemic episode. After the incident, MD-A reviewed R1's medications on 2/9/24, and placed a new order for staff to hold his insulin if his BS was less than 100 mg/dL. He was unaware nursing staff were currently giving R1 orange juice in an attempt to elevate his BS so they could administer insulin (as seen in the above observation on 2/20/24 at 11:45 a.m.). MD-A identified this was not in accordance with his physician order. He would not expect staff to give orange juice unless R1's BS was below 70 mg/dL, as intentionally raising his BS prior to insulin would be counter-productive and not according to his MD order or manufacturer's guidelines. Interview on 2/20/24, at 2:40 p.m., with the DON identified she was unaware staff were not following the physician's current order for R1's insulin by holding his insulin if it dropped less than 100 mg. She was unaware there was no physician order to give R1 orange juice to artificially raise his blood sugar prior to administer insulin. She agreed she had directed staff to give orange juice to elevate his BS. She placed a re-education document in each nurse's mailbox for them to review after the incident occurred which included R1's insulin order. She identified all the staff signed and returned the printed information except for LPN-A who incorrectly administered R1's insulin at the time of the incident. She did not follow up with LPN-A to see if she had received the re-education document, and confirmed LPN-A had worked several more shifts following the incident. She did not complete any face-to-face training with any of the nursing staff and did not complete any competencies to confirm the training was successful. She identified LPN-B was contracted from an agency, and she does not do any re-education or competencies with contracted nurses. Review of the 2/7/24, Reportable Incident Re-education, identified signs and symptoms of hypoglycemia, which was also noted to be identified by a BS below 70 mg/dL regardless of the presence of symptoms. The document advised staff to not give fast acting insulin unless the resident will be eating in 20-30 minutes, if blood sugar is low you should wait to administer insulin until closer to meal-time or give an oral equivalent to increase their blood glucose level prior to administering the insulin. The document included a signature line for staff to sign indicating they read and understand the education and directions to return the form to the DON. The training document did not provide the correct administration guidelines for Novolog rapid acting insulin that was administered to R1 on 2/5/24. R1's current care plan printed 2/20/24, identified he had a diagnosis of DM and was at risk for alteration in glucose levels. Staff were to ensure R1 received his diet and medications as ordered, staff should be aware, observe, and report signs and symptoms of hypoglycemia (low blood sugar). Interview on 2/21/24 at 9:07 a.m., with dietary aid (DA)-A who delivered and picked up R1's meal tray the date of the incident identified that day staff were running behind in the kitchen. The dietary manager (DM) had gone to the assisted living area of the facility and did not return until 12:00 noon. Staff finished serving the residents in the dining room and then served the room trays. I delivered R1 his meal tray around 12:15, and I noticed he was 'loopy'. DA noted she had not reported R1's abnormal mental function to the nurse she observed when she delivered his room tray. DA-A reported she continued delivering room trays and returned to R1's room later around 12:45 to collect his tray and noticed he had not consumed any food and found R1 to be incoherent. DA-A left the room and reported to the nurse that something was wrong. Interview on 2/21/24 at 8:11 a.m., with LPN-A identified she had checked R1's blood sugar and administered Novolog on 2/5/24, at 11:15 a.m. She was not certain when he received his meal tray, and she did not alert the kitchen R1 had received his insulin or that he needed a meal tray right away. When she was told R1 was in his room and unresponsive, she went to assess R1 and found him to have a blood sugar of 39 mg/dL. She was able to arouse him enough to give him sips of orange juice and call the DON to bring the emergency kit to the room. He was diaphoretic (sweating) and swaying back and forth, and his speech was slurred. Glucose gel (sugar gel used in diabetic emergencies for low BS) from the emergency kit was administered. R1 started to display seizure like activity. LPN-A used her personal cell phone to call emergency services (EMS) for an emergency transport to the ED for evaluation and treatment. R1's 2/5/24, ED provider notes identified R1 presented to the ED at 1:45 p.m., after being found to be hypoglycemic and having a blood sugar of 39 mg/dL. R1 was diagnosed as having had an episode of acute hypoglycemia due to insulin administration. He had received glucose prior to arrival and was served a plate of food while at the ED. R1 returned to baseline, laboratory tests were completed and R1 was discharged from the ED back to the facility at 4:45 p.m. Interview on 2/21/24, at 9:36 a.m., with administrator identified he would have expected the DON to provide face to face training and competencies with all licensed nurses following the incident and prior to their next shift to avoid an incident like this from happening again. Review of the current, undated Insulin Pen and Storage Policy identified how staff were to administer insulin. Staff were to always review the physician order prior to administering any medication. Next, the procedure was described, however, monitoring for signs or symptoms of hypoglycemia was not present, nor was there any indication staff should contact the physician and hold the insulin if it fell below acceptable parameters. Review of the 3/17/17 Notification of Changes in Resident Condition policy identified a significant change in status was noted to be a deterioration in health that could lead to a life-threatening condition or clinical complications. The objective of the policy was to ensure staff made the appropriate notification to a physician where there was a change in a residents condition that may require physician intervention. There was no mention on any specifics related to insulin administration or hypoglycemia noted to identify when those situations would require an immediate call to EMS or the physician. The IJ was removed on 2/22/24 at 11:37, when it could be verified through observation, staff interviews, and document review, the facility medical director reviewed R1's current physician order and made appropriate changes to follow manufacturers guidelines. Face-to-face education was provided to licensed nurses on how to manage diabetics with respect to low BS or changes of condition, insulin administration, review of the facility's insulin pen policy and manufacturer guidelines for Novolog and was completed prior to licensed staff returning to work on the unit.