complaint·December 10, 2021

Resident was admitted to facility on November 11, 2019, preplacement appraisal reflects no medications needed to treat diabetes. It was not until a doctor’s visit on December 27, 2019, that it was identified that R1 had high blood sugars and medication was prescribed. Additionally, R1 was ordered to monitor blood sugar levels twice a day, a task R1 did independently. Per interviews, elevated readings entered in medication record sheet were values reported by R1 not visually verified by caregivers. Medication for diabetes and sugar level readings were first started on December 27, 2019, per medication sheet. Prior to hospitalization glucose readings for R1 had been noted to be elevated. LPA verified that staff provided medication (metformin) had been dispensed as per physicians’ instructions. On December 12, 2019, staff called medical emergency 911 for observations of a change of condition; as staff noticed resident to be lethargic and weak. On January 1, 2020, R1 passed away at the hospital; hospital records note cause of death as septic shock, pneumonia, and type A flu. Additionally, reviewed medical records for R1 show that on January 1, 2020, a discussion was documented with R1’s family discussing that R1 had an Acute Respiratory failure due to pneumonia and severe ARDS (Acute Respiratory Distress Syndrome). As such this department deems the allegation of, Staff did not seek emergency medical services for resident on a timely manner to be UNSUBSTANTIATED; meaning that although the allegation may have happened or is valid, there is not enough preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Licensee/ Administrator, Noelia Garcia were a copy of this report was reviewed and provided.