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Care Facility Fined $8K for Neglecting a Diabetic

Care Facility Fined $8K for Neglecting a Diabetic

Arizona Daily Star

October 02, 2009

A specialized Tucson long-term care facility has agreed to pay $8,000 in fines to the state health department for failing to follow state rules on caring for four patients, including a diabetic who died with elevated blood sugar.

The fine followed an Arizona Department of Health Services investigation in March, which was prompted by four complaints about Cornerstone Hospital of Southeast Arizona. The investigation details problems with medication errors, including giving drugs to the wrong patient, and facility’s failure to adhere to its own policies on staff training.

Most of the fine – $6,000 – related to the care of one of those patients, the diabetic who died Feb. 22. The patient had elevated blood sugar and there was no documentation of the patient’s vital signs from 4 a.m. to the time of death at 3:30 p.m., state records show.

State investigators say Cornerstone failed to follow a physician’s order on administering insulin to the patient who died, and also failed to notify a doctor that the patient’s blood sugar level was greater than 400 milligrams per deciliter. Normal is typically considered to be 140 mg/dl or below.

The agreement also said that Cornerstone failed to discontinue giving an extremely potent controlled substance – Fentanyl – to the patient who died. The patient received six doses of Fentanyl after the discontinue order was issued, records show.

Cornerstone is a 34-bed acute care facility that specializes in helping patients with complex conditions who need long-term hospital stays, according to a profile on the Web site of its owners from the Texas-based Cornerstone Healthcare Group. It is located at 7220 E. Rosewood St., near Speedway and Kolb.

Calls to the company’s corporate headquarters on Monday and Tuesday were not returned.

Cornerstone has since submitted an acceptable plan of correction and is now considered in compliance with state rules and regulations, said Alan Oppenheim, deputy assistant director for the Arizona Department of Health Services’ division of licensing.

As part of its agreement with the state, Cornerstone has promised to provide education and training about diabetic management, including reviewing its diabetic policies and procedures, with its nursing staff. Cornerstone paid the fine Aug. 13.

Some of the problems stemmed from not properly training the contracted personnel it uses to supplement staffing, state documents show.

The state also found that Cornerstone failed to administer insulin as ordered by a physician to a second patient, and did not adequately document neurological changes in a third patient.

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