Complaint Investigation Report

Allegation: Facility staff did not administer medication to resident according to physician's instructions. Unsubstantiated.

It was alleged that facility staff did not administer medication to resident (R1) according to physician's instructions. Reporting party (RP) stated R1 was admitted to the facility on 2016, and from 2016 to 2019, R1 was administered insulin. It was further alleged that the Humalog injection was discontinued on 2019, and facility retained R1 that the facility could no longer care for as R1 has diabetes and needs insulin. These dates are all prior to the current License for this facility issued on 10/09/2020.

R1’s family member (FM) was interviewed who stated R1 was admitted to the facility 2016 and had (Humalog) insulin medication which facility discontinued to administer July 2019. FM received a bill in October 2019 that did not include R1’s insulin medications. FM indicated that staff S1 (facility’s registered nurse) told FM that as of October 2019, staff stopped giving R1 insulin injections. Review of records showed the facility sent request to R1’s primary care physician (PCP) to discontinue the Humalog sliding scale as Casa Sandoval scope of service does not allow the use of sliding scale insulin since non-clinical caregivers are assisting with the injections. PCP ordered Humalog sliding scale to be discontinued on July 24, 2019. When R1 was seen by PCP the After Visit Summary dated November 5, 2019 showed medications that were ordered to be continued included Humalog and Novolog. PCP indicated during interview on January 6, 2022 that during R1’s visit on November 5, 2019, R1 was still to be on insulin injections and nothing was changed with the dosages. However, it was not established that this information had been conveyed to the current Licensee.

Hospice care was ordered for R1 and was started on November 22, 2019. Some medications were discontinued (dc’d) by hospice doctor (MD1), and while MD1 stated during interview that all medications would have been discontinued when the resident was placed on hospice, MD1’s list didn’t include Humalog and Novolog to be discontinued. November 2019 Medication Administration Record showed Humalog was not administered from 11/05/19 to 11/22/19, and Novolog was discontinued on November 22, 2019. R1 was discharged from hospice care June 20, 2020. These actions took place prior to the current License. Further, the PCP stated having had no knowledge of the resident being placed on hospice and changes made to the resident’s medication regimen.