Complaint Investigation Report

Allegation: Staff did not provide proper assistance to client in care. In regards to the allegation it was reported that when C1 experienced a hypoglycemic event and Staff #1(S1) failed to follow written protocol for handling such event which prolonged it by over 2 hours . LPA's review of the glucose chart outlines the steps a staff would have to take when a scenario arises for either a low glucose or high of a certain amount. LPA observed the chart was easily accessible to staff. LPA's review of the S1's daily log notes reveal they did the opposite that was on the flow chart indicating S1 may have confused the less than symbol with the more than symbol. Interviews with the administrator and staff revealed training was conducted when C1 was admitted to the facility. A copy of S1's training corroborates S1 participated in training on 03/05/2025 regarding C1's condition. Interview with the administrator further revealed there was communication between S1 and an RN over the phone first by phone call then by text messages. Review of S1's daily log revealed they contacted the RN after the second incorrect step was taken by S1. Times on the daily log and confirmation from administrator corroborate the event lasted approximately 2 hours. Although C1 was able to return to normal range, the response to C1's hypoglycemic event was prolonged by S1's failure to follow written protocol. Therefore, allegation is substantiated. Administrator stated they have removed S1 from providing care to C1 and training will be scheduled for all staff regarding C1's health condition and management.

Deficiency issued, refer to 9099-D. Exit interview conducted. Copy of this report and appeal rights provided.