Health inspection·April 28, 2023

On 3/20/2023 the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint regarding quality of care. As a result of the investigation, the Department determined that the facility failed to: 1. Properly identify Resident 1 prior to being administered Glipizide that was prescribed for Resident 3 in accordance with facility's policy and procedures titled, "Medication Administration," revised on 1/1/2012. 2. Ensure Resident 1 was not administered Glipizide (a medication for diabetes mellitus [DM-high blood glucose/sugar levels]) on 2/9/2023 in accordance with the facility's policies and procedures titled," Medication Errors," dated 7/2018, and "Medication Administration," revised on 1/1/2012. This deficient practice resulted in Resident 1 having altered mental status (AMS - a change in mental status that can be life threatening), diaphoresis (excessive sweating), and seizure activity (sudden uncontrolled body movements) on 2/9/2023. Resident 1's blood glucose level was 24 (below 40 is considered severe hypoglycemia [severely low blood sugar], a life-threatening and needs immediate medical treatment, if not treated can result in a coma and/or death. Normal blood glucose range is 70 to 99) milligrams (mg- unit of measurement) per deciliter (dL- unit of measurement). Resident 1 was treated at a general acute care hospital (GACH) for hypoglycemia (a condition in which blood glucose level is lower than the standard range) on 2/9/2023. A review of Resident 1's admission record indicated the facility originally admitted Resident 1 on 6/7/2022 and re-admitted Resident 1 on 1/23/2023 with diagnoses including Parkinson's disease (a progressive disease of the nervous system marked by tremors, muscular rigidity, and slow movements) and dementia (progressive or persistent loss of intellectual functioning with memory and abstract thinking impairment), urinary calculi (kidney stones), and chronic kidney disease (the presence of either kidney damage or decreased kidney function for three or more months). The admission record did not indicate Resident 1 had DM. A review of Resident 1's Medication Administration Record (MAR) for the month of 2/2023, did not indicate Resident 1 should receive any medications for DM. A review of Resident 1's facility progress notes dated 2/9/203 timed at 4 p.m., indicated, on 2/9/2023 at 4 p.m., Resident 1 had a change of condition (COC - a deterioration in health, mental, or psychosocial status which can be life threatening) exhibited by AMS, seizure episode, and a very low blood sugar of 24 mg/dl. A review of Resident 1's Change of Condition form dated 2/9/2023 timed at 4:40 p.m., indicated Resident 1 was noted with AMS, diaphoresis and seizure like activity manifested by constant jerking. Resident 1's blood glucose level was checked and resulted at 24 mg/dL. The Medical Doctor 1 (MD 1) was notified and gave an order to transfer Resident 1 to a local GACH emergency department. A review of Resident 1's GACH Emergency Department (ED) Provider Note dated 2/9/2023, indicated Resident 1 presented with AMS and low blood sugar. Resident 1 was administered glucose and felt better. The ED provider note indicated Resident 1 "had numerous episodes of hypoglycemia" in the ED and was placed on D5 (Dextrose in water - hydration fluid) intravenously (IV - inside a vein). The ED provider note indicated the reason for Resident 1's hypoglycemia was unknown. Resident 1 was admitted to the GACH for further work-up (evaluation). A review of Resident 1's GACH hypoglycemic agent laboratory records dated 2/9/2023, indicated Resident 1's blood tested "Positive" for "Glipizide" (reference value of negative to 5ng/ml [normal liters per minute - unit of measurement]). A review of the facility's document titled "Glucotrol (Glipizide) Tablet" dated 9/2008, indicated, "Glucotrol is an adjunct (optional) to diet and exercise to improve blood glucose levels in adults with type 2 DM. The primary mode of action is to stimulate insulin (a hormone [A substance made by in the body and circulate in the bloodstream to control actions of certain cells or organs] that helps control blood sugar) released from the ... pancreas (an organ in the body that produces insulin). The document indicated that blood sugar control persists in some patients for up to 24 hours after a single dose ... The half-life (time it takes for a drug's active substance in the body to reduce by half) of elimination (remove) ranges from two to four hours ... The metabolism (the physical and chemical processes in the body that convert or use energy) and excretion of Glucotrol may be slowed in patients with impaired renal (When the kidneys [An organ that removes waste and extra water from the blood or keep body chemicals in balance] stop working) ... Under hypoglycemia section, indicated that, "Renal (kidney) insufficiency may cause elevated (raised blood levels of Glucotrol ... increases the of serious hypoglycemic (low blood sugar) reactions." A review of Resident 1's Minimum Data Set (MDS-a standardized assessment care screening tool) dated 3/10/2023, indicated Resident 1 had severely impaired (very hard time remembering things, making decisions, concentrating, or learning) cognition (mental ability to make decisions of daily living). The MDS indicated Resident 1 required extensive staff assist with bed mobility, eating, dressing and toileting. A review of Resident 3's (Resident 1's roommate) admission record indicated the facility originally admitted Resident 3 on 6/12/2020 and readmitted Resident 1 on 2/20/2021 with diagnoses including chronic obstructive pulmonary disease (COPD - condition involving blockage of the airways causing difficulty breathing), DM, hypertension (HTN- high blood pressure), cognitive communication deficit (difficulty thinking and how someone uses language) and seizures (sudden, uncontrolled body movements and changes in behavior that occur because of abnormal activity in the brain). A review of Resident 3's MDS dated 2/21/2023, indicated Resident 3 had severely impaired cognition and required extensive staff assist with bed mobility, eating, dressing and toileting. A review of Resident 3's Order Summary Report dated 12/8/2021, indicated Resident 3 had an order to receive Glipizide 10 mg give one tablet by mouth one time a day at 6:30 a.m. before breakfast and five (5) mg tablet by mouth in the evening before dinner. A review of Resident 3's MAR for the month of 2/2023 timed at 6:30 a.m., indicated Resident 3 was to receive Glipizide 10mg at 6:30 a.m. before breakfast. On 3/23/2023 at 11:30 a.m., during an interview, MD 1 confirmed and stated Resident 1 was admitted at a GACH for hypoglycemia related to Glipizide. MD 1 confirmed and stated Resident 1 did not have a history of DM and was not prescribed Glipizide. MD 1 (also the primary physician for Resident 3) stated he suspected Resident 1 received Resident 3's (roommate) Glipizide by mistake. MD 1 stated he notified the facility's DON that Resident 1 received Resident 3's Glipizide. MD 1 stated, "We may see some initial confusion followed by lethargy and diaphoresis over a four-hour time frame," when asked what could happen if Glipizide was administered to a person with no diagnosis of diabetes. On 3/28/2023 at 10:04 a.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) confirmed and stated he was the medication nurse on 2/9/2023 between the hours of 6 a.m. and 7:30 a.m. LVN 1 stated he was certain he administered Glipizide to Resident 3 and not to Resident 1. LVN 1 further added he will no longer work night shift because his blood pressure was affecting his short-term memory (The capacity to hold a small amount of information available for a short period of time). LVN 1 stated he medicated the correct resident because prior to administering medication, he (LVN 1) makes sure he has the correct resident by calling the resident's name and checks the resident's medication against the physician's order. LVN 1 stated the facility was aware that Resident 1's blood tested positive for Glipizide. On 3/28/2023 at 3:09 p.m., during an interview, Registered Nurse 1 (RN 1) confirmed and stated that on 2/9/2023 between 3:45 p.m. and 4 p.m., Resident 1 had a COC. RN 1 stated Resident 1's shoulders were jerking on and off but Resident 1 remained alert. RN 1 stated Resident 1's vital signs (blood pressure, temperature, heart rate and respiratory rate) were checked and were within normal limits. RN 1 stated Resident 1's blood glucose level was 24mg/dl and Resident 1 received glucagon (medication to correct hypoglycemia/increase the blood sugar). RN 1 stated Resident 1 was transported to a GACH via 911 services (universal telephone number the gives the public direct access to the Public Safety. Answering point where emergency services such as the fire department, police or paramedics can be dispatched to a location) on 2/9/2023 at 4:43 p.m. RN 1 stated Resident 1's blood was collected at the GACH, and Resident 1 tested positive for Glipizide. A review of the facility's policy and procedures titled, "Medication Administration," revised on 1/1/2012, indicated, the purpose is, "to ensure the accurate administration of medications for residents in the facility. ... VI. Medication Rights A. Nursing Staff will keep in mind the seven "rights" of medication when administering medication. B. The seven "rights" of medication are: i. The right medication. ii. The right amount. iii. The right resident. iv. The right time. v. The right route ..." A review of the facility's policy and procedures titled," Medication Errors," dated 7/2018, indicated, "upon discovery of an error, notification will immediately be given to the director of nursing services and the administrator. ...The director of nursing services or his/her designee will investigate the error to determine the cause." As a result of the investigation, the Department determined that the facility failed to: 1. Properly identify Resident 1 prior to being administered Glipizide that was prescribed for Resident 3 in accordance with facility's policy and procedures titled, "Medication Administration," revised on 1/1/2012. 2. Ensure Resident 1 was not administered Glipizide (a medication for diabetes mellitus on 2/9/2023 in accordance with the facility's policies and procedures titled," Medication Errors," dated 7/2018, and "Medication Administration," revised on 1/1/2012. This deficient practice resulted in Resident 1 having AMS diaphoresis, and seizure activity on 2/9/2023. Resident 1's blood glucose level was 24 mg/dl. Resident 1 was treated at a GACH for hypoglycemia on 2/9/2023. The above violations jointly, separately, or in any combination, presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result Resident 1.