complaint·July 17, 2023

Allegation: “Facility staff did not ensure that resident's blood sugars were being monitored properly while in care:” Resident #1 (R1) had high blood sugar and A1C levels and reporting party was concerned that R1’s blood sugars were not properly being monitored. LPA reviewed physician’s orders and documents obtained at the facility. Interview with R1 revealed the facility staff check R1’s blood sugar by helping R1 to poke their finger and measure blood sugar. However, R1 could not recall how long the facility has been assisting with measuring their blood sugar level. Physician’s orders dated 10/05/2022 indicate orders for “Accucheck am and record.” Med room staff sent a fax to R1’s physician on 10/10/2022 asking to “clarify the following orders. Pharmacy was unable to read.” Date stamp for return fax from R1’s physician was cut off, so LPA was unable to identify when the response was received. The faxed document was provided to the LPA during the 01/26/2023 visit, so it is clear that by the time of the visit, the facility had received the document, yet R1’s blood sugars were not monitored or recorded. Interviews revealed that the facility staff were unaware of the 10/05/2022 doctor’s orders or the 10/10/2022 clarification of doctor’s orders and indicated it wasn’t until February that R1’s physician wrote an order for R1’s blood sugar to be monitored. On 02/08/2023, med room staff sent a request to R1’s physician for a blood sugar check twice a day, per R1’s request. R1’s physician replied the same day and indicated to “check blood sugar (before breakfast, before dinner) daily and notify” physician within parameters given. Record review revealed that the facility staff began assisting R1 in checking their blood sugar beginning on 02/09/2023. However, record review revealed that the original doctor’s orders for Accucheck were written on 10/05/2022 and were not followed. Therefore, based on record review and interview, there is sufficient evidence to support the allegation and the allegation that “facility staff did not ensure that resident’s blood sugars were being monitored properly while in care” is deemed SUBSTANTIATED at this time. Pursuant to Title 22 of the California Code of Regulations Division 6, Chapter 8, the following deficiency was cited (refer to LIC 9099-D). Failure to correct the deficiency may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided. Allegation: “Facility staff did not ensure that resident received medication while in care:” The complaint alleges that facility staff did not ensure R1 received their diabetes medications, resulting in high blood sugar and A1C levels. Physician’s report indicates R1 can administer their own insulin pen with assistance. Interview with R1 revealed that facility staff regularly assist R1 with their diabetes medications, throughout the day as ordered by R1’s physician. Staff interviewed indicated that the medication technician sets up the insulin pen with the proper amount of insulin. Staff stated R1 is cooperative with medications, but sometimes, R1 requires hand-over-hand assistance for their diabetes care. LPA reviewed medication logs for R1 during the time of the complaint allegation. Medication logs indicate R1 received all 3 (three) injectable medications related to diabetic care as prescribed during the month of the complaint allegation. Interview with R1 revealed that the staff do assist R1 with medications and that the medication technicians come into R1’s room to administer injectable medications four (4) times daily. Staff interviews revealed that medications are administered and initialed either in the electronic MAR or paper MAR as appropriate for each resident. Based on record review and interview, although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation that “facility staff did not ensure that resident received medication while in care” is deemed UNSUBSTANTIATED at this time. Allegation: “Facility staff did not ensure that resident had a change of clean clothing while in care:” LPA reviewed the care assessment and service plan dated 10/25/2022 and labeled updated care plan for R1. Care plan indicates R1 is independent in dressing. Physician’s report dated 05/17/2022 indicates R1 requires supervision with grooming and hygiene needs, but is independent for dressing. During an unrelated visit on 06/13/2023, LPA interviewed R1 at 04:58PM. R1 indicated they pick out their own clothing and dress themselves. Laundry is washed twice weekly; it is taken on the resident’s designated laundry day and is delivered back to the resident’s room the same day by the housekeeping staff. LPA observed that all of R1’s clothing was clean, including what R1 was wearing during the visit. Staff interviews revealed that R1 is relatively independent, picks out their own clothes, and dresses themselves independently. Therefore, based on interview and record review, although the allegation may be valid, at this time there is insufficient evidence to support the allegation; as thus, the allegation that “facility staff did not ensure that resident had a change of clean clothing while in care” is deemed UNSUBSTANTIATED at this time. No citations issued in relation to the above allegations. Exit interview conducted with Administrator. A copy of the report was provided.