Complaint Investigation Report

Per record reviews, and conducted interviews, R1's glucose checks are being done by the Nursing staff as required before each insulin dose time, three (3) times a day, which includes an additional order of insulin that is provided twice (2) a day within the time of the first insulin order above. There is a PRN as needed insulin order, and if needed this would be provided to R1. Insulin is provided on a sliding scale, which means the Nurse must do a glucose check in order to provide the specific needed dosage to R1. Per record review there is no Dr's Order for late night and/or through the night glucose checks. R1 does have a small device on their arm that provides blood sugar levels/readings. Resident is alert and able to use pendant to alert staff as needed. There was no information obtained that care staff are not providing glucose checks as needed for R1. No sufficient information was obtained to support that a violation occurred.

Based on the interviews, record/document reviews, and related information obtained during the investigation, the allegation "staff left resident in a soiled diaper for a long period of time, and staff are not ensuring that resident's glucose levels are checked" are Unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

Exit interview was conducted with the Administrator Karina Tapia.