complaint·May 29, 2025

Allegation: Staff are not ensuring that resident is being assisted with glucose testing Investigation Finding: Unsubstantiated During investigation, LPA interviewed reporting party (RP), staff (ADM) and reviewed hospice resident’s (R1) admission agreement, physician’s report, hospice care plan, centrally stored medication logs, after visit summary report, discontinued orders of glucose testing and insulin medication from R1’s PCP. Review of R1’s physician’s report dated 03/28/25 showed he was not diabetic and did not require glucose testing. On 04/29/25, he was sent to the hospital for a change in condition. Review of the hospital after visit report dated 05/03/25 showed doctor’s orders for glucose testing and insulin shots to be administered 2X per day. ADM assisted R1 with glucose testing and insulin shots from 05/04/25 until 05/26/25. LPA reviewed written records of R1’s glucose testing and insulin shots from 05/04/25 until 05/26/25. Review of R1’s medical records showed R1’s glucose testing and insulin medication were discontinued by his PCP on 05/26/25. On 05/27/25 at 3PM, RP confirmed with LPA that R1’s glucose testing and insulin medication were discontinued by his primary care physician (PCP) on 05/26/25 since he was under hospice comfort care. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff are not ensuring that resident is being assisted with glucose testing is unsubstantiated. Allegation: Staff falsified resident’s glucose readings Investigation Finding: Unfounded During investigation, LPA interviewed reporting party (RP) and staff (ADM) and reviewed hospice R1’s medical records. LPA reviewed written records of R1’s glucose testing and insulin shots from 05/04/25 until 05/26/25. On 05/27/25 at 3PM, RP confirmed with LPA that R1’s glucose testing and insulin medication were discontinued by his primary care physician (PCP) on 05/26/25 since he was under hospice comfort care Staff denied falsifying R1’s glucose readings. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff falsified resident’s glucose readings is unsubstantiated. No deficiencies cited. Exit Interview conducted and a copy of this report provided.