GLENDALE, CA - Federal inspectors determined that medication management failures at Golden Haven Care Center contributed to a resident's death from diabetic ketoacidosis, according to inspection records from an August 2024 complaint investigation.
The resident, who had been receiving insulin treatment at a hospital prior to admission, died after facility staff discontinued the diabetes medication without establishing alternative treatment or monitoring protocols.
Critical Medication Discontinuation
Hospital discharge records showed the resident had been receiving insulin therapy with a blood sugar goal of less than 180 mg/dL. The discharge documentation specifically noted the need for continued diabetes management upon nursing home admission, with the resident's last hospital blood sugar reading at 157 mg/dL.
Despite these clear medical directives, facility records show that insulin was discontinued on the day of admission. A Licensed Vocational Nurse documented a telephone order to discontinue "Insulin Lispro Sliding Scale" with the reason listed as "Clarification of Order." However, inspection records found no replacement diabetes medication orders or justification for the discontinuation.
The facility's Order Summary Report confirmed that insulin was both ordered and discontinued on the same date, leaving the resident without any diabetes management despite a confirmed Type 2 diabetes diagnosis.
Absence of Blood Sugar Monitoring
Medical records revealed a complete absence of blood glucose monitoring following the insulin discontinuation. The resident's Medication Administration Record showed no evidence that staff administered diabetes medications or checked blood sugar levels during the stay.
Additionally, staff failed to monitor for signs and symptoms of hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar), despite these being included in the resident's care plan. This monitoring is essential for diabetic patients, as blood sugar fluctuations can cause serious complications including altered mental status, organ damage, and life-threatening conditions.
Pharmacy Oversight Breakdown
The facility's consultant pharmacist failed to identify the medication management gap during monthly reviews. Pharmacy records for February through April 2024 contained no recommendations regarding the resident's diabetes diagnosis or need for blood sugar monitoring.
During the investigation, the consultant pharmacist acknowledged that she only reviewed current medications, not discontinued ones or resident diagnoses. She stated that had she known about the diabetes diagnosis, she would have recommended blood sugar monitoring and diabetes medications.
This represents a failure in the medication regimen review process, which requires pharmacists to identify conditions that may warrant medication therapy initiation.
Medical Emergency and Death
In April 2024, staff discovered the resident in respiratory distress with a blood sugar level of 500 mg/dL. The resident exhibited altered mental status, oxygen desaturation, and severe hyperglycemia. Emergency services transported the resident to the hospital, where blood tests revealed a critical glucose level of 810 mg/dL (normal range: 70-100 mg/dL).
Hospital records documented a diagnosis of diabetic ketoacidosis (DKA), a life-threatening condition that occurs when the body cannot use glucose for energy due to insufficient insulin. The resident required intensive care treatment including insulin drip therapy and vasopressin support.
Despite intensive medical intervention, the resident's condition deteriorated. The death certificate listed diabetic ketoacidosis as the immediate cause of death, with Type 2 diabetes mellitus as the underlying condition.
Understanding Diabetic Ketoacidosis
Diabetic ketoacidosis develops when blood sugar levels become dangerously elevated due to insufficient insulin. Without insulin, cells cannot access glucose for energy and begin breaking down fat instead, producing toxic acids called ketones. This process can rapidly lead to dehydration, electrolyte imbalances, and organ failure.
Early symptoms include excessive thirst, frequent urination, fatigue, and confusion. As the condition progresses, patients may experience difficulty breathing, abdominal pain, and altered consciousness. DKA requires immediate medical treatment and can be fatal without proper intervention.
Standard Diabetes Care Protocols
Established medical protocols require careful transition of diabetes medications when patients move between care settings. This includes reviewing hospital discharge summaries, confirming medication orders with physicians, and establishing monitoring schedules.
Blood glucose monitoring should occur multiple times daily for insulin-dependent diabetics, with results documented and reported to physicians. Any changes to diabetes medications require physician approval and careful monitoring of patient response.
The facility's own policies required the consultant pharmacist to identify conditions warranting medication therapy and report irregularities to attending physicians and nursing leadership. These protocols were not followed in this case.
Interdisciplinary Care Failures
Records showed that the resident's diabetes diagnosis was not discussed during interdisciplinary team meetings, despite being a significant medical condition requiring ongoing management. The facility's Minimum Data Set assessment also failed to document the diabetes diagnosis or insulin orders.
This lack of communication among care team members contributed to the oversight that left the resident without necessary diabetes treatment. Effective nursing home care requires coordination between nurses, physicians, pharmacists, and other healthcare professionals to ensure all medical conditions receive appropriate attention.
Regulatory Violations
The inspection identified violations of federal regulations requiring facilities to provide necessary care and services to maintain each resident's highest possible level of well-being. Specifically, the facility failed to ensure that medications were administered according to physician orders and that residents received appropriate monitoring for their medical conditions.
The violation was classified as causing minimal harm with potential for actual harm, affecting few residents. However, in this case, the medication management failures contributed to a preventable death.
Physician and Staff Statements
The attending physician confirmed during the investigation that the resident's insulin should have been continued and blood sugar monitored. The physician stated that diabetic patients not receiving insulin could develop DKA, which can cause death.
The facility's MDS nurse acknowledged that there was no documented evidence of insulin administration or blood sugar monitoring for the resident. She confirmed that residents with diabetes diagnoses should have orders for blood glucose monitoring.
Implications for Patient Safety
This case highlights critical gaps in medication management and care coordination that can occur during nursing home admissions. The failure to properly transition diabetes care from hospital to long-term care setting resulted in a preventable medical emergency and death.
Proper diabetes management in nursing homes requires clear medication orders, regular blood sugar monitoring, staff training on diabetes complications, and effective communication among all members of the healthcare team. When these elements fail, residents face serious health risks that can prove fatal.
The inspection findings underscore the importance of robust medication management systems and oversight procedures to prevent similar tragedies in long-term care facilities.
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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