Complaint Investigation Report

Allegation: “Facility staff did not ensure that resident's blood sugars were being monitored properly while in care:”

Resident #1 (R1) had high blood sugar and A1C levels and reporting party was concerned that R1’s blood sugars were not properly being monitored. LPA reviewed physician’s orders and documents obtained at the facility. Interview with R1 revealed the facility staff check R1’s blood sugar by helping R1 to poke their finger and measure blood sugar. However, R1 could not recall how long the facility has been assisting with measuring their blood sugar level. Physician’s orders dated 10/05/2022 indicate orders for “Accucheck am and record.” Med room staff sent a fax to R1’s physician on 10/10/2022 asking to “clarify the following orders. Pharmacy was unable to read.” Date stamp for return fax from R1’s physician was cut off, so LPA was unable to identify when the response was received. The faxed document was provided to the LPA during the 01/26/2023 visit, so it is clear that by the time of the visit, the facility had received the document, yet R1’s blood sugars were not monitored or recorded. Interviews revealed that the facility staff were unaware of the 10/05/2022 doctor’s orders or the 10/10/2022 clarification of doctor’s orders and indicated it wasn’t until February that R1’s physician wrote an order for R1’s blood sugar to be monitored. On 02/08/2023, med room staff sent a request to R1’s physician for a blood sugar check twice a day, per R1’s request. R1’s physician replied the same day and indicated to “check blood sugar (before breakfast, before dinner) daily and notify” physician within parameters given. Record review revealed that the facility staff began assisting R1 in checking their blood sugar beginning on 02/09/2023. However, record review revealed that the original doctor’s orders for Accucheck were written on 10/05/2022 and were not followed. Therefore, based on record review and interview, there is sufficient evidence to support the allegation and the allegation that “facility staff did not ensure that resident’s blood sugars were being monitored properly while in care” is deemed SUBSTANTIATED at this time.

Pursuant to Title 22 of the California Code of Regulations Division 6, Chapter 8, the following deficiency was cited (refer to LIC 9099-D). Failure to correct the deficiency may result in civil penalties.

Exit interview conducted. A copy of the report and appeal rights were provided.