Complaint Investigation Report

During the investigation, LPA reviewed medical records for C1 and interviewed facility staff. Based on the medical records, C1’s blood sugar level is tested about 5 times a day, and the staff refer to a sliding scale to provide the number of insulin units. C1 also has a physician’s order dated 9/24/2024, which stated “call MD if BS remained above 250 consistently.”

LPA gathered and reviewed C1’s BS level readings and medication logs for September 2024 – November 2024, and the facility shift notes. C1’s records revealed that the C1’s BS levels remained above 250 after insulin was given and/or one to two hours after presumed meal consumption for several occasions. For the period, 09/27/24 through 09/30/24, C1’s BS levels remained mostly above 200 mg/dL, on five occasions the readings were above 250 mg/dL. On 10/29/24, from 11:48am to 7:02pm, there were three consecutive BS readings above 250 mg/dL. On 11/05/24, the BS levels remained above 200 mg/dL for at least five hours in the morning even after insulin was administered. Due to the frequent high BS levels, staff did not contact C1’s physician as directed in C1’s physician order dated 9/24/2024, therefore staff did not obtain timely medical treatment for C1’s restricted health condition.

Five (5) out of five staff interviewed did not have a clear understanding and could not explain what the C1’s physician meant by the term “consistently” as listed on C1’s written order. Staff stated they were not persistent in contacting C1's physician when C1's BS levels went above 250 mg/dL. Staff also acknowledged that there was no staff training provided to staff regarding C1’s restricted health condition.

Based on LPA observations, interviews conducted, and record review, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 and Chapter 1), are being cited on the attached LIC 9099D. There is no civil penalty assessed today. The licensee was informed that a civil penalty might be assessed based on the Health & Safety Code 1569.49(e) or (f), or 1548(e) or (f), or 1568.0822(e) or (f).

An exit interview was conducted. The Plan of Correction was reviewed and developed with the Administrator. A copy of this report and appeal rights were provided.