Other·July 16, 2021

The following reflects the findings of the California Department of Public Health during the investigation of complaint numbers 731381 and 731819. 42 CFR 483.10 (g)(14) Notification of Changes. 483.10 (g)(14) (i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is- 483.10(g)(14)(i)(B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications); 483.10(g)(14)(i)(C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment) On 4/12/21, an unannounced visit was conducted at the facility to investigate two complaints regarding a resident having an elevated blood sugar of 1130 (normal blood sugar 80-130 for a diabetic, a disease in which one's blood sugar levels are too high), and concerns that residents blood sugars were managed improperly. Based on interview and record review, the facility failed to notify the physician of a change in condition for two of three sampled residents (Resident 1 and Resident 2) when Resident 1 and Resident 2 experienced episodes of hyperglycemia (increased blood sugar). These failures resulted in Resident 1 being hospitalized with potentially life-threatening complications and Resident 2 having the potential for adverse side effects. Findings: 1. Resident 1 is a 75-year-old female who was admitted to the facility on 9/27/2020 and has a history of Diabetes Mellitus [Diabetes] due to an underlying condition with unspecified complications. During a review of Resident 1's "Progress Notes" (PN), dated 3/29/21, at 4:30 PM, the PN indicated, "Resident is noted to have increase heart rate of 129 (normal range 60-100), B/P (blood pressure) 122/85 (normal range is less than 120/80), SPO2 (peripheral capillary oxygen saturation, percentage of how much oxygen is in the blood) @ 96% (normal range 95-100 %) in room air, temp (temperature) 97.4 (normal range 97-99). Her face is flushed. Blood Glucose checked and glucometer (device used to determine the approximate concentration of glucose in the blood) states "high (reading too high for device)." She is alert and responding at this time. Called MD [Medical Doctor] and received new orders to send to [hospital name] ER [Emergency Room] for treatment and Eval..." During a review of the "History and Physical" (H&P), dated 3/30/21, the [hospital] H&P indicated, "Admit: 3/29/21... Assessment/Plan 1. AMS (altered mental status)... DKA (diabetic ketoacidoses [sic]-a serious diabetes complication where the body produces excess blood acids. This condition occurs when there isn't enough insulin in the body)... her blood sugar was 1130 (normal is 80-130 for a diabetic), she was diagnosed with hyperosmolar coma (serious condition caused by extremely high blood sugar levels) and started on insulin drip [medication infused through the vein to regulate the amount of glucose in the blood] and fluids." During a review of Resident 1's "Order Review Report" (ORR) from the facility, dated 3/1/21-3/31/21, the ORR indicated, "Blood sugar check in the morning." During a concurrent interview and record review, on 4/12/21, at 11:40 AM, with the Director of Nursing (DON), Resident 1's "Weights and Vitals Summary" (WVS), dated 4/12/21, was reviewed. The WVS indicated, the following blood sugar results for Resident 1: 3/18/21 4:50 AM 264 mg/dL (milligrams/deciliter-unit of measure) 3/19/21 4:51 AM 326 mg/dL 3/20/21 5:01 AM 302 mg/dL 3/21/21 5:07 AM 420 mg/dL 3/22/21 4:49 AM 410 mg/dL 3/23/21 5:20 AM 386 mg/dL 3/24/21 5:02 AM 294 mg/dL 3/25/21 4:41 AM 434 mg/dL 3/26/21 4:58 AM 455 mg/dL 3/27/21 5:09 AM 415 mg/dL 3/28/21 5:10 AM 480 mg/dL 3/29/21 4:53 AM 454 mg/dL. Resident 1's blood sugars were greater than 250 for more than 12 consecutive days. DON confirmed the findings and stated the physician was notified on 3/25/21 of the elevated blood sugars but did not respond. On 3/26/21 the physician was notified of the elevated blood sugars and gave orders to change Resident 1's diet and draw labs. Before the labs could be drawn Resident 1 was sent to the hospital and admitted with DKA. DON stated, per facility policy the physician should have been notified when the blood sugars were elevated greater than 250 more than once in a 24-hour period and greater than 300 more than once in two consecutive days. During an interview on 4/12/21, at 11:20 AM, with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, the physician should be notified when a resident's blood sugar is greater than 250. LVN 1, stated she did not notify the physician when Resident 1's blood sugar was in the 400's because night shift was responsible to take Resident 1's blood sugar. During an interview on 4/12/21, at 11:25 AM, with LVN 3, LVN 3 stated, the physician should be notified when a resident's blood sugar is greater than 160 when the physicians order does not indicate parameters. During an interview on 4/13/21, at 11:09 PM, with LVN 2, LVN 2 stated, she had taken care of Resident 1 and Resident 1's blood sugar were checked every morning and would normally run in the 100 range. LVN 1 stated, Resident 1's blood sugars went up in the 400's. LVN 1 stated, Resident 1's physician orders did not include parameters of when to notify the physician of elevated blood sugars but with no parameters, the physician should have been notified when the blood sugars were above 300. 2. Resident 2 is a 79-year-old male who was admitted to the facility on 8/31/2020 and has a history of Type 2 Diabetes Mellitus with Moderate No proliferative Diabetic Retinopathy with Macular Edema Bilateral [tiny blood vessels within the retina [thin layer of tissue that lines the eye] leak blood and or fluid and/or cholesterol] and Essential (Primary) Hypertension [high blood pressure]. During a review of Resident 2's ORR, dated 4/1/21-4/30/21, the ORR indicated, "Novolog Solution (medication used to lower blood sugar) 100 Unit/ML (milliliters-unit of measurement) inject as per sliding scale (used to determine amount of insulin administered based on blood sugar results) : ... 401-600 = 12 U (units) Notify MD ..." During a concurrent interview and record review, on 4/12/21, at 11:42 AM, with DON, Resident 2's "Weights and Vitals Summary" (WVS), dated, 4/12/21, was reviewed. The WVS indicated, the following blood sugar results for Resident 2: 3/27/21 8:19 PM 402 mg/dL 4/4/21 11:55 AM 491 mg/dL 4/10/21 8:47 PM 436 mg/dL. Resident 2's blood sugars were greater than 401. DON confirmed the findings and was unable to provide evidence of the physician being notified of the elevated blood sugars. DON stated, the physician should have been notified. During a review of the facility's policy and procedure (P&P) titled, "Nursing Care of the Older Adult with Diabetes Mellitus (Diabetes)," dated 11/2020, the P&P indicated, "Glycemic (blood sugar) Targets...Call as soon as possible when: 1. blood glucose values are regularly 70-100 mg/dL (for possible regimen adjustment); 2. blood glucose values are >250 mg/dL more than once within a 24-hr period; 3. blood glucose values are >300 mg/dL more than once over two consecutive days; reading is too high for glucometer ..." During a review of the facility's P &P titled, "Change in Resident's Condition or Status," dated 5/17, the P&P indicated, "A "significant change" of condition is a major decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions... b. Impacts more than one area of the resident's health status..." In violation of the above cited standards, the facility failed to notify the physician of Resident 1 and Resident 2's elevated blood sugars, resulting in Resident 1 being hospitalized with potentially life-threatening complications and Resident 2 having the potential for adverse side effects. This violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result and represents a Class "A" citation.