Incident investigation·February 8, 2024

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit to follow up on an incident report received by the department on 02/02/2024. LPA was greeted and granted entry into the facility and explained the reason for the visit. Incident report dated 01/28/2024 indicated that Staff 1 (S1) had inserted a diabetic sensor/ glucose monitor into Resident 1's (R1) arm. Facility investigation revealed that R1's new sensor had not arrived at the facility timely and the resident would need to utilize a finger stick instead of the sensor in the interim. Resident spoke with S1 regarding the situation and the staff inserted a spare sensor in the resident's arm. Facility observed the staff inserting the sensor on video surveillance. S1 is employed at the facility as an Activities Assistant and is not a skilled professional. S1 is receiving a write-up which was provided to LPA and further action from facility is pending. Based on the observations made from today's visit, deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the Administrator and a copy was provided to Administrator as well as Appeal Rights.