Complaint Investigation Report

Allegation 1: Staff do not ensure that residents’ medical condition is properly managed.

It is alleged that staff do not ensure that a resident’s medical condition is properly managed resulting in the resident was admitted to the hospital due to a blood sugar of 40.

The investigation revealed that on 05/09/24, LPA Richard interviewed the Resident Care Director Liza Bond, (RCD) regarding the above allegation, the (RCD) denied the allegation above. The (RCD) stated that, blood sugars are checked according to the Doctors orders, and can be checked from 1 time a day to 2 times a day. The (RCD) stated that R1 was diagnosed with type 2 diabetes at the time of admission. LPA reviewed and obtained resident R1’s physician’s medication management dated from 10/05/23 to 04/15/24, and there was no instruction about having R1 blood sugar checked. On 04/15/24, R1 physician increase R1 medication without any mentioned of any new order of needing to check the blood sugar. LPA interviewed five staff (S1-S5) regarding the above allegation, 3 out of 5 staff interviewed did not assist with medication administration, 1 of the 5 staff interviewed denied the above allegation. Staff S1 interviewed, stated that blood sugars are checked and documented daily according to doctors’ orders. On 05/09/24 LPA interviewed with residents (R2-R6) regarding the above allegation, 2 out of 5 residents interviewed were unable to provide information regarding allegation above, 3 out of 5 residents interviewed reported the facility do not conducted any blood sugar for them. Records reviewed during the investigation showed that LPA did not find sufficient evidence to support the allegation that staff do not ensure resident's medical condition is properly managed.