Complaint Investigation Report

Record review revealed that R1 moved into the facility on 02/28/2020. R1’s physician’s report dated 02/21/2020 indicated R1’s diagnoses included hyperlipidemia, diabetes type 2, major depressive disorder, and atherosclerotic heart disease. Interview with family members revealed that prior to admittance to the facility, R1 had been diagnosed with stage 1 kidney failure. R1’s care plan dated 02/16/2020 indicates diabetic alerts, fall risk, vitals/weights monthly – every 1 st Wednesday. While residing at the facility, R1 had fallen on at least 4 dates in June 2020. Record review revealed R1’s physician was only notified of 2 out of the 4 total falls. And although R1’s physician’s orders state to “check fasting glucose levels daily. Please fax monthly report to (Primary Care Physician - PCP),” the facility did not fax record of blood glucose levels to R1’s PCP until after R1 was hospitalized on 06/23/2020. R1’s physician’s report dated 02/21/2020 indicated R1 weighed 189 pounds. Weight check conducted on 05/01/2020 revealed a weight loss of 24 pounds, as R1 weighed 165 pounds at that time. Record review revealed R1’s physician was not notified of this unplanned weight loss.

Review of R1’s daily blood sugar document revealed that R1 had episodes of hypoglycemia on 03/25/2020, 06/07/2020, 06/10/2020, 06/12/2020, 06/14/2020, 06/20/2020, 06/21/2020, and 06/22/2020. Progress notes indicate R1 did not have breakfast, lunch or dinner on 06/22/2020 and was hypoglycemic on this date. However, 2 medications ordered to be given with food were still administered. Blood glucose check performed by the facility Licensed Vocational Nurse (LVN) on 06/23/2020 at 07:00AM, indicated his blood glucose level was 23. Progress note indicated R1 was then given ½ cup of orange juice at 07:36AM. Another blood glucose check was performed at 08:16AM and measured even lower at 21. An additional ½ cup of orange juice was given to R1. As per niddk.nih.gov, orange juice is not to be given when one is having hypoglycemia for people with kidney disease, due to its high potassium content. Medication Administration Record (MAR) reviewed indicated both glimepiride and metformin scheduled at 09:00AM were given as well. At 10:51AM, R1 was transported via ambulance to the emergency department due to hypoglycemia. Emergency Department physician notes indicated R1 reported decreased consumption over the last several days. Additional hospital records reviewed indicated on 06/23/2020, R1’s labs were drawn and that R1 had both elevated potassium and creatine levels. That day, R1 was admitted to the hospital with diagnoses including “persistent hypoglycemia likely secondary to AKI (acute kidney injury) with oral antiDM (anti-diabetes mellitus) meds,” hyperkalemia (high potassium level in the blood), and dehydration.