MONTEBELLO, CA - Federal inspectors documented serious communication failures at Rio Hondo Subacute & Nursing Center after staff delayed reporting critical laboratory results for a resident with pneumonia and sepsis, according to a March 2025 inspection report.
Critical Lab Results Delayed for Sepsis Patient
The most serious violation occurred when nursing staff failed to promptly notify physicians about dangerously abnormal lab results for a 180-year-old resident admitted with pneumonia and life-threatening sepsis. The resident's blood work on February 23, 2025, revealed a critically low blood glucose level of 60 mg/dL (normal range 65-99) and an extremely elevated white blood cell count of 39.59 cells per microliter (normal range 4-11).
These lab values indicated the resident faced immediate medical risks. Low blood glucose can cause confusion, seizures, loss of consciousness, and potentially death if untreated. The dramatically elevated white blood cell count suggested a severe ongoing infection requiring immediate antibiotic intervention.
Despite receiving these critical results at 11:48 PM on February 23, nursing staff waited until the morning of February 25 - approximately 34 hours later - before successfully contacting the covering nurse practitioner to obtain antibiotic orders. During this delay, the resident developed lethargy, generalized weakness, and elevated temperature.
Licensed Vocational Nurse 5 told inspectors she discovered an incomplete change-in-condition evaluation form on February 25 morning, showing that critical lab results from February 24 were still waiting for physician response. She then called the covering nurse practitioner around 9:30 AM to report the critical findings and received antibiotic orders.
Documentation Irregularities Compound Communication Failures
The facility's own documentation revealed significant inconsistencies about when physicians were contacted. LVN 5 admitted to inspectors that she "forgot to change the physician notification time" in the resident's medical record, leaving inaccurate timestamps that suggested earlier physician contact than actually occurred.
Licensed Vocational Nurse 10, who cared for the resident on February 24, stated he was instructed by an RN supervisor to wait for the physician to respond rather than making follow-up calls about the critical results. He reported that the resident became "slightly lethargic with generalized weakness, and elevated temperature" around 2 PM before he finally contacted the nurse practitioner for monitoring orders only.
The facility's Acting Director of Nursing acknowledged to inspectors that "critical lab results must be reported to the physician promptly to avoid delay in treatment." The facility's own policy requires that physicians be "promptly notified" of diagnostic test results, with the Director of Nursing Services or Charge Nurse responsible for such notifications.
Medical Significance of Delayed Treatment
Sepsis represents a medical emergency requiring immediate intervention. When the body's response to infection damages its own tissues and organs, timely antibiotic treatment becomes critical to prevent organ failure, septic shock, and death. The combination of sepsis with dangerously low blood glucose creates a particularly urgent situation requiring immediate medical attention.
Elevated white blood cell counts above 12,000 typically indicate bacterial infection, but levels approaching 40,000 suggest severe systemic infection requiring aggressive treatment. The 34-hour delay in antibiotic administration could have allowed the infection to progress, potentially causing irreversible organ damage.
Blood glucose levels below 65 mg/dL require immediate correction to prevent neurological complications. Severe hypoglycemia can cause brain damage within minutes, making prompt recognition and treatment essential for patient safety.
Additional Safety Violations Identified
Inspectors documented multiple additional violations affecting resident care and safety:
Menu and Food Service Failures: On February 25, the facility served turkey patties to 14 residents instead of the scheduled beef tacos, without notifying residents beforehand or obtaining registered dietitian approval for the menu substitution. Resident 5 told inspectors: "It is not okay for the facility to not notify the residents prior and not give them a choice in their meal items as he was looking forward to the beef tacos for lunch."
Resident 158 reported this was a recurring problem, stating the facility would "often put one thing on the menu and serve something different without asking or informing the residents or giving them a choice."
Food Safety Violations: Kitchen inspections revealed multiple sanitation failures, including unlabeled and undated pre-made cheese sandwiches stored in the walk-in refrigerator, improper storage of ice scoops outside designated containers, and kitchen staff preparing food without required gloves.
Expired Food Storage: Inspectors found resident food storage areas containing multiple expired items, including sausages with visible freezer burn stored in undated bags and ice cream products stored since October 2024 without proper expiration date tracking.
Regulatory Standards and Best Practices
Federal nursing home regulations require facilities to maintain comprehensive communication systems ensuring prompt physician notification of significant changes in resident condition. Critical laboratory values fall under immediate reporting requirements designed to prevent treatment delays that could harm residents.
Proper documentation standards require accurate recording of all physician communications, including specific times and dates of contact. These records serve as legal documents and clinical communication tools that other healthcare providers rely upon for treatment decisions.
Food service regulations mandate that menu changes receive registered dietitian approval to ensure nutritional adequacy and that residents receive proper notification when scheduled meals are unavailable.
Facility Response and Compliance Requirements
Rio Hondo Subacute & Nursing Center must submit a plan of correction addressing each identified violation. The facility faces potential penalties including increased monitoring, civil monetary penalties, or loss of Medicare and Medicaid funding for non-compliance with federal standards.
The inspection classified these violations as causing "minimal harm or potential for actual harm" to residents, but the delayed response to critical lab values could have resulted in more serious consequences for the affected resident.
This inspection report highlights the critical importance of timely communication systems in nursing home settings, where residents often depend entirely on facility staff for recognition and response to medical emergencies. The 34-hour delay in antibiotic treatment for a septic resident demonstrates how communication failures can directly impact resident safety and health outcomes.
For complete inspection details and facility response plans, the full report is available through the Centers for Medicare & Medicaid Services nursing home database.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Rio Hondo Subacute & Nursing Center from 2025-03-01 including all violations, facility responses, and corrective action plans.
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