Downey Care Center
13007 South Paramount, Downey, CA 90242
Citation Number: 940008718
Citation Date: 01/24/2012
Violation Date: 3/10/2010
Class: AA
Penalty: $ 80,000

A 79 year old resident with diabetes developed a diabetic coma, became brain dead and died on 3/15/10 due to the facility's failure to monitor her blood sugar levels. The resident's diabetic history was well known to the facility because she had been admitted to the facility 5 separate times during the year prior to her death. Following her final admission on 2/9/10, her physician did not order needed blood sugar tests and the facility did not notify the physician to correct this oversight and to prevent complications from uncontrolled diabetes. On 3/10/10, paramedics transported her to the hospital where she was found to be suffering from a diabetic coma, urinary tract infection, sepsis, and acute renal failure. The ER physician reported that the nursing home indicated it had been unable to check the resident's blood sugar without a physician's order. There was no evidence the Downey Care Center ever brought the lack of an order to her doctor's attention during the 29 days prior to her hospitalization. The facility was cited because these failures were the direct proximate cause of the resident's death.