Health inspection·January 24, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the licensed nurse (LN) re-checked the resident's blood pressure (BP - a measure of the heart pumping blood around the body) after administering the medication as ordered by the physician for 1 of 4 sampled residents (1). This failure could delay Resident 1's care needs. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses that included hypertension (high blood pressure), per the admission Record. A review of Resident 1's medical record was conducted. Per the Physician's Order dated 9/29/23, the LN was to administer Clonidine Hydrochloride (a medication to lower the BP) three times a day as needed, give if the systolic BP is greater than 160, and re-check the BP after 15 minutes. Per the Resident 1's Weight and Vital Signs Summary: On 1/7/24 at 8 A.M., Resident 1's BP was 184/94 On 1/7/24 at 8:13 A.M., Resident 1's BP was 162/84 On 1/7/24 at 9:40 A.M., Resident 1's BP was 102/54 On 1/7/24 at 10:35 A.M., Resident 1's BP was 102/84 A review of Resident 1's Medication Administration Record, dated 1/7/24. LN 4 administered Lisinopril (a medication to lower the BP) 40 milligrams (mg) and Clonidine Hydrochloride 0.1 mg for a BP reading of 162/84. There was no documented evidence that Resident 1's BP was re-checked after 15 minutes. On 1/18/24 at 3:45 P.M., an interview was conducted with LN 4. LN 4 stated that the Certified Nursing Assistant (CNA) told her Resident 1's BP was 180, and she checked the BP with a manual BP machine, which was 160 plus [162/84]. LN 4 stated Resident 1 had routine BP medication and an as-needed order, and she administered the medicines together. LN 4 further said she continued her medication administration and saw Resident 1 when the family Page 1 of 2 055964 055964 01/24/2024 Friendship Manor Nursing & Rehab Center 902 South Euclid Avenue National City, CA 91950

F 0656 member was present and requested assistance around 10 A.M. Level of Harm - Minimal harm or potential for actual harm On 1/24/24 at 3:15 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated the physician's order was to give Clonidine when the BP was above 160 and to re-check in 15 minutes; the LN should have followed the physician's order, and there was no evidence that the LN did so. Residents Affected - Few Per the facility's policy and procedure, titled Physician Orders, dated 1/17, Orders for medications and treatments will be consistent with principles of safe and effective order . 055964 Page 2 of 2