Complaint·July 26, 2025

During the visit, the LPA conducted a tour of the facility, conducted interviews, and requested and obtained pertinent documents related to the allegation above. The Administrator was advised that further investigation was needed prior to issuing findings. A review of R1’s care plan, dated 09/24/2024, noted R1 needed assistance with toileting and medication management. R1 needed assistance with mobility, used a wheelchair, was blind in the left eye, and not much vision in the right eye. R1 required a diabetic and renal diet and assistance with glucose monitoring. Safety checks were noted to be one time per shift, medications were noted as four medication passes per day, four injections per day. The care plan also included R1’s need for dialysis, a case manager, and home health services. According to information obtained from the Administrator and facility notes, R1 was scheduled for dialysis appointments on Tuesday, Thursday, and Saturday. R1 would sometimes refuse dialysis appointments or refuse medications. R1 was non-compliant with dialysis and with the diabetic diet. Staff would remind R1 not to eat chocolate, candy, snacks and fast food. Facility notes documented that R1 administered the insulin injection by themselves . “R1 is always asking for the maximum amount of insulin. Asking for the maximum units due to the bad diet. R1 has a sliding scale. Staff set up the insulin and R1 administers.” A review of the physician’s orders and facility medication assistance record (MAR) noted that R1 was to receive a certain number of units of insulin dependent on the sliding scale determined by the blood sugar readings. Per the physician’s orders, the maximum daily dose of Humalog Insulin 100U/ML SOL is 20 units. According to the Administrator, R1 did the blood sugar readings by themselves . There were no blood sugar readings provided, only some of the readings were indicated in the facility notes. The review of Unusual Incident/Injury Reports (SIRs) and facility notes related to R1 revealed that on 10/03/2024, R1’s glucose read high, R1 called emergency medical services (EMS) and was transferred to the hospital. R1 received dialysis and returned to the facility the same day. On 10/05/2024, R1’s dialysis transportation did not arrive, R1 called EMS and was taken to the hospital. R1 returned to the facility 10/07/2024 with no new orders. On 10/11/2024, R1 was transferred to the hospital due to high blood sugar. Continued on LIC 9099-C. On 10/12/2024, the facility progress notes documented that the hospital was contacted for a medical update and the facility was informed that R1 was admitted to the Intensive Care Unit (ICU) due to DKA (Diabetic Ketoacidosis). R1 did not return to the facility. R1 was moved to another facility to be closer to R1’s family. The Department’s investigation did not provide sufficient evidence to substantiate that staff mismanaged R1’s medication. Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview conducted, copy of this report issued.