GLENDALE, CA - An inspection at Golden Haven Care Center revealed critical breakdowns in diabetes management that contributed to a resident's death from diabetic ketoacidosis, according to documentation from the Centers for Medicare & Medicaid Services.
Critical Insulin Management Failures
Golden Haven Care Center's mismanagement of a diabetic resident's care created a cascade of medical emergencies that ultimately proved fatal. The resident, who had been successfully managed at a local hospital with insulin therapy and blood sugar monitoring, experienced a complete breakdown in diabetes care upon admission to the facility in February 2024.
Hospital records from before the resident's nursing home admission documented proper diabetes management protocols. The resident's discharge documentation specifically noted the need for continued diabetes management and physician follow-up for diabetes care. The hospital records showed the resident's blood sugar was well-controlled at 157 mg/dL at discharge, with clear instructions for ongoing insulin administration.
However, once admitted to Golden Haven Care Center, the resident's insulin medication was discontinued without adequate justification. Medical records show that Insulin Lispro was discontinued with only the notation "clarification of order" as the reason, but no documentation exists explaining what clarification was needed or obtained from the attending physician.
The facility's care plan acknowledged the resident's diabetes diagnosis and included monitoring requirements for signs and symptoms of hyperglycemia and hypoglycemia. Despite this written plan, nursing staff failed to administer any insulin or monitor blood sugar levels throughout the resident's two-month stay at the facility.
Medical Consequences of Uncontrolled Diabetes
Diabetes management in nursing homes requires consistent blood sugar monitoring and appropriate insulin administration to prevent life-threatening complications. When blood glucose levels remain elevated without intervention, the body begins breaking down fat for energy, producing ketones that can poison the blood - a condition known as diabetic ketoacidosis.
The failure to monitor this resident's blood sugar created a dangerous medical situation that went undetected for weeks. Normal blood glucose levels should range between 70-100 mg/dL, with diabetic patients typically maintaining targets below 180 mg/dL. Without proper monitoring, blood sugar can rise to dangerous levels, causing dehydration, electrolyte imbalances, and potentially fatal complications.
Diabetic ketoacidosis occurs when the body cannot produce enough insulin to process glucose, forcing it to break down fat for energy. This process creates acidic ketones that accumulate in the blood, causing a dangerous drop in blood pH. Early warning signs include increased urination, extreme thirst, nausea, vomiting, and altered mental status - symptoms that require immediate medical intervention.
Emergency Transfer and Fatal Outcome
On the evening the resident was transferred to the hospital, nursing staff discovered the resident "refused her dinner and threw her juice on the floor and refused to eat." When staff reevaluated the situation, they found the resident "breathing heavily and not speaking." The facility's glucose meter reading showed dangerously high blood sugar levels.
Emergency medical tests at the receiving hospital revealed the severity of the resident's condition. Blood work showed a glucose level of 810 mg/dL - more than eight times the normal range. Additional laboratory results confirmed diabetic ketoacidosis with arterial blood gas showing a pCO2 level of 17.0 (normal range 35-45), indicating severe metabolic acidosis.
The resident's bicarbonate level measured 9.6 (normal range 22-26), confirming metabolic acidosis caused by ketoacidosis. Oxygen levels were also dangerously elevated at 306 (normal range 75-100), indicating respiratory complications from the body's attempt to compensate for the acidic blood condition.
Despite intensive care treatment including intravenous insulin therapy, the resident's condition continued to deteriorate. The hospital documentation shows the resident developed sepsis and ultimately experienced cardiac arrest, dying two days after admission. The death certificate listed diabetic ketoacidosis as the immediate cause of death, with diabetes mellitus type 2 as the underlying condition.
Systemic Gaps in Clinical Oversight
The inspection revealed multiple system failures beyond the immediate insulin management issues. The facility's Minimum Data Set assessment, a comprehensive standardized evaluation tool, failed to document the resident's diabetes diagnosis entirely. This critical omission meant the resident's diabetic condition was not properly flagged in the facility's primary assessment system.
The resident's physician orders lacked specific instructions for blood sugar monitoring or insulin administration, despite the hospital's discharge recommendations. When inspectors reviewed the Order Summary Report, they found missing signatures and dates, making it unclear who had reviewed and approved the medication changes.
The facility's interdisciplinary team conference records showed no discussion of the resident's diabetes management, despite this being a significant medical condition requiring ongoing attention. This represents a breakdown in the facility's care coordination process, where multiple healthcare professionals should collaborate to ensure comprehensive patient care.
The attending physician, when contacted during the investigation, acknowledged that "residents admitted to the facility from a hospital usually continues medications at the facility because the medications had been reviewed and optimized for the resident." The physician confirmed that the resident's "insulin should have been continued to be administered in the facility and there should have been an order for blood sugar monitoring."
Pharmacy Oversight Failures
Federal regulations require nursing homes to have licensed pharmacists conduct monthly medication regimen reviews to identify potential problems with residents' drug therapies. These reviews are designed to catch dangerous situations like discontinued insulin without proper medical justification.
The inspection found that Golden Haven's pharmacy consultant failed to identify and report the irregularity of discontinued insulin therapy for a diabetic resident. This represents a critical failure in the medication safety system that nursing homes are required to maintain.
Monthly pharmacy reviews should flag situations where essential medications like insulin are discontinued without clear medical rationale. The pharmacist should have questioned why a diabetic resident was not receiving any glucose-lowering medications and should have reported this concern to the medical director and director of nursing.
Additional Issues Identified
The inspection documented several other concerning violations at Golden Haven Care Center. These included inadequate nursing supervision, with charge nurses failing to ensure proper delegation and oversight of nursing tasks. The facility also failed to maintain proper nursing coverage ratios and documentation standards.
Environmental issues were noted, including problems with maintaining appropriate room temperatures and ensuring residents' comfort. Administrative violations included failures to properly report incidents to state authorities and maintain accurate resident care records.
Staff training deficiencies were identified, particularly regarding emergency response procedures and recognition of medical emergencies. The facility's quality assurance program showed gaps in identifying and addressing systemic care issues before they resulted in adverse outcomes.
The inspection findings highlight the critical importance of continuity of care when residents transfer from hospitals to nursing homes, particularly for complex medical conditions like diabetes that require ongoing monitoring and medication management.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Golden Haven Care Center from 2024-08-10 including all violations, facility responses, and corrective action plans.
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