Health inspection·September 4, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on record review and interviews, the facility failed to identify and provide needed care and services in accordance with professional standards of practice, by failing to monitor blood glucose levels for one (Resident #3) of two residents reviewed for blood glucose monitoring. Residents Affected - Few The findings include: A record review for Resident #3's medical record revealed an admission date of 5/10/24. Her diagnoses included type 2 Diabetic Mellitus with diabetic chronic kidney disease, type 2 Diabetic Mellitus with diabetic polyneuropathy, and hypertension. Review of the resident's current physician orders included: - Humulin N Subcutaneous Suspension (Insulin NPH (Human Isophane) Inject 5 units subcutaneously in the evening for Diabetes with order date 5/10/24. Insulin Aspart Solution 100 unit/ml, inject 5 units subcutaneously as needed for Diabetes Mellitus - may administer 5 units when Humulin N (Insulin NPH) is out of stock per primary provider with order date of 6/11/24. (Photographic evidence obtained) Review of Resident #3's medication administration record (MAR) for the month of July, August, and September 2024 revealed of Humulin N was administered each day per the physician's order, except for 8/14/24, when the ordered substitute, Insulin Aspart was administered. (Photographic evidence obtained) Review of Resident #3's past physician orders revealed Accu-check TID (three times a day) for three days with order date of 8/6/24 and D/C (discontinue) date of 8/16/24. (Photographic evidence obtained) Review of the blood sugar summary for Resident #3 showed accu-checks were taken during the following days: Once on 5/22/2024 Twice on 6/5/2024 Twice on 6/6/2024 Once on 6/21/2024 No blood glucose monitoring was documented between 6/21/2024 and 8/5/2024. Page 1 of 7 105682 105682 09/04/2024 Palm Garden of Jacksonville 5725 Spring Park Road Jacksonville, FL 32216

F 0684 Once on 8/6/2024 Level of Harm - Minimal harm or potential for actual harm Three times from 8/7-8/8/2024 Twice on 8/9 Residents Affected - Few Three times from 8/10-8/15/2024 Once on 8/16/2024 (Photographic evidence obtained) Review of progress notes revealed one notation of a blood sugar check on 6/17/24 with a result of 74mg/dL (milligrams per deciliter). No other physician orders for accu-checks (blood sugar monitoring) were found. On 9/4/24 at 1:26 pm, an interview was conducted with Licensed Practical Nurse (LPN) A. When asked how she knew when to check blood sugar levels, she stated, she would check the orders for accu-checks. If insulin is ordered, or if something's going on with the resident, then she would check vitals and blood sugar (even if no history of diabetes). She stated the policy for accu-checks is before they eat for anyone on insulin or if they have an order for just being monitored without insulin ordered. If the resident refuses a blood sugar check, she will call the family and the MD. On 9/4/24 at 2:55 pm, an interview was conducted with the Director of Education. When asked if she had ever had an instance of a resident getting insulin without accu-checks? She replied, If a resident is getting insulin, they should be getting accu-checks, and there should be an order. On 9/4/2024 at 3:18 pm, and interview was conducted with the Unit Manager/LPN. She stated, they just had an audit last week related to accu-check/blood sugar (BS) orders, and residents should have an order to check it if they are receiving insulin. Some orders are for twice a day, some are done 3 times a day, it just depends. If a resident is refusing BS checks, then there should be documentation of refusal, and the MD should be notified. On 9/4/24 at 3:55 pm, an interview was conducted with the DON. She stated if a resident was receiving a long-acting insulin, they may not have an order for accu-checks, but they should for a short-acting insulin. When asked if the facility had a policy for documentation of blood sugars, insulin administration, or for accu-checks/blood sugar, she replied she would have to check. On 9/4/24 at 4:24 pm, a follow-up interview was conducted with the DON. She stated the facility had no policy for documentation of blood sugars, insulin administration specifically, or for accu-checks/blood sugar checks; it goes by the Physician's order. There should be order for short acting insulin from the doctor. According to the American Diabetes Association (ADA), at (https://diabetes.org/living-with-diabetes/treatment-care/checking-your-blood-sugar) (Accessed on 9/17/24 at 5:28 pm), under Clinical Significance: Blood glucose (blood sugar) monitoring is the primary tool you have to find out if your blood 105682 Page 2 of 7 105682 09/04/2024 Palm Garden of Jacksonville 5725 Spring Park Road Jacksonville, FL 32216

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few glucose levels are within your target range. This tells you your blood glucose level at any one time. It's important for blood glucose levels to stay in a healthy range. If glucose levels get too low, we can lose the ability to think and function normally. If they get too high and stay high, it can cause damage or complications to the body over the course of many years. The logging of your results is vital. The ADA Standards of Care in Diabetes includes the ADA ' s current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Diabetes management in older adults requires regular assessment of medical, psychological, functional, and social domains. According to the National Library of Medicine, NPH Insulin, last update: June 12, 2023), and National Library of Medicine, Aspart Insulin, last update: June 8, 2024 (Accessed on 9/17/24 at 5:28 pm), under Clinical Significance: Insulin is used to manage type 1 diabetes mellitus and some cases of type 2 diabetes mellitus. Insulin therapy has the well-known adverse side effect of hypoglycemia if its administration is not managed effectively. Patients with insulin-dependent diabetes will benefit from regular blood glucose monitoring. Regular daily blood glucose monitoring is recommended for those with diabetes mellitus using insulin therapy. Humulin N (Insulin NPH) is an intermediate-acting insulin with a slower onset of action and a longer duration of activity than that of regular human insulin. The time course of action of insulin, such as HUMULIN N may vary in different individuals or within the same individual, typically, NPH Insulin has an onset between 2 to 4 hours after injection, it peaks between 4 to 12 hours after injection and may have duration of 12 to 18 hours after injection. Aspart Insulin is a rapid-acting, human insulin analog and glucose-reducing effects occur within 1 to 3 hours and may last 3 to 5 hours. Insulin aspart is equipotent to regular insulin but has a faster onset and shorter duration of action. Non-critically ill patients on insulin aspart should routinely monitor their blood glucose. According to the Cleveland Clinic at https://my.clevelandclinic.org/health/treatments/17956-blood-sugar-monitoring (Accessed on 9/18/24 at 9:10 am.): If you have diabetes, monitoring your blood sugar (glucose) is key to finding out how well your current treatment plan is working. It gives you information on how to manage your diabetes on a daily - and sometimes even hourly - basis. Monitoring your blood sugar is important when you have diabetes, especially if you use insulin. The results of blood sugar monitoring can help you make decisions about food, physical activity and dosing insulin. Several things can affect your blood sugar. That's why it's important to check your blood sugar regularly . It's the only way to know for sure when your blood sugar levels are changing. According to the Mayo Clinic at www.mayoclinic.org/diseases-conditions/diabetes/in-depth/blood-sugar/art-20046628 (Accessed on 9/18/24 at 9:15 am.): If you have diabetes, testing your blood sugar levels can be a key part of staying healthy. Blood sugar testing helps many people with diabetes manage the condition and prevent health problems. If you take insulin to manage type 2 diabetes, you may need blood sugar testing several times a day. The exact number of times depends on the type and amount of insulin you use. Often, testing is advised before meals and at bedtime if you take more than one shot of insulin a day. You may need to test only before breakfast and sometimes before dinner or at bedtime if you use an intermediate- or a long-acting insulin. Blood sugar testing gives useful information to manage diabetes. It can help you: Track the effect of diabetes medicine on blood sugar levels. 105682 Page 3 of 7 105682 09/04/2024 Palm Garden of Jacksonville 5725 Spring Park Road Jacksonville, FL 32216

F 0684 Adjust doses of diabetes medicines with the guidance of your treatment team. Level of Harm - Minimal harm or potential for actual harm Find out if blood sugar levels are high or low. Then, if needed, change treatment to treat high blood sugar or take fast-acting carbohydrates to treat low blood sugar. Residents Affected - Few Track progress in reaching your treatment goals. Learn how diet and exercise affect blood sugar levels. Understand how other factors, such as sickness or stress, affect blood sugar levels. According to the American Nurse Journal at www.myamericannurse.com (Accessed on 9/18/24 at 9:20 am.), under Monitoring Guidelines: Blood glucose monitoring should be ordered for all inpatients with diabetes or hyperglycemia and for those at high risk for hyperglycemia. Point-of-care results need to be readily available to all staff to identify the patient's response to treatment, hyperglycemia trends, and hypoglycemia episodes. In general, premeal and bedtime testing is recommended for patients who are eating, whereas testing every 4 to 6 hours is advised for those who can't have oral intake. . 105682 Page 4 of 7 105682 09/04/2024 Palm Garden of Jacksonville 5725 Spring Park Road Jacksonville, FL 32216

F 0711 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. Based on record reviews, interviews, and observations, the facility failed to 1) Ensure that the physician/physician representative reviewed the resident's total program of care, including medications and treatments, and 2) Sign and date all orders for one (Resident #3) of two residents reviewed for blood glucose monitoring. The findings include: A record review for Resident #3's medical record revealed an admission date of 5/10/24. Her diagnoses included type 2 Diabetic Mellitus with diabetic chronic kidney disease, type 2 Diabetic Mellitus with diabetic polyneuropathy, and hypertension. Review of the resident's current physician orders included: - Humulin N Subcutaneous Suspension (Insulin NPH (Human Isophane) Inject 5 units subcutaneously in the evening for Diabetes with order date 5/10/24. Insulin Aspart Solution 100 unit/ml, inject 5 units subcutaneously as needed for Diabetes Mellitus - may administer 5 units when Humulin N (Insulin NPH) is out of stock per primary provider with order date of 6/11/24. (Photographic evidence obtained) Review of Resident #3's medication administration record (MAR) for the month of July, August, and September 2024 revealed of Humulin N was administered each day per the physician's order, except for 8/14/24, when the ordered substitute, Insulin Aspart was administered. (Photographic evidence obtained) Review of Resident #3's past physician orders revealed Accu-check TID (three times a day) for three days with order date of 8/6/24 and D/C (discontinue) date of 8/16/24. (Photographic evidence obtained) Review of the blood sugar summary for Resident #3 showed accu-checks were taken during the following days: Once on 5/22/2024 Twice on 6/5/2024 Twice on 6/6/2024 Once on 6/21/2024 No blood glucose monitoring was documented between 6/21/2024 and 8/5/2024. Once on 8/6/2024 Three times from 8/7-8/8/2024 Twice on 8/9 Three times from 8/10-8/15/2024 105682 Page 5 of 7 105682 09/04/2024 Palm Garden of Jacksonville 5725 Spring Park Road Jacksonville, FL 32216

F 0711 Once on 8/16/2024 Level of Harm - Minimal harm or potential for actual harm (Photographic evidence obtained) Residents Affected - Few Review of progress notes revealed one notation of a blood sugar check on 6/17/24 with a result of 74mg/dL (milligrams per deciliter). No other physician orders for accu-checks (blood sugar monitoring) were found. On 9/4/24 at 1:26 pm, an interview was conducted with Licensed Practical Nurse (LPN) A. When asked how she knew when to check blood sugar levels, she stated, she would check the orders for accu-checks. If insulin is ordered, or if something's going on with the resident, then she would check vitals and blood sugar (even if no history of diabetes). She stated the policy for accu-checks is before they eat for anyone on insulin or if they have an order for just being monitored without insulin ordered. If the resident refuses a blood sugar check, she will call the family and the MD. On 9/4/24 at 2:55 pm, an interview was conducted with the Director of Education. When asked if she had ever had an instance of a resident getting insulin without accu-checks? She replied, If a resident is getting insulin, they should be getting accu-checks, and there should be an order. On 9/4/2024 at 3:18 pm, and interview was conducted with the Unit Manager/LPN. She stated, they just had an audit last week related to accu-check/blood sugar (BS) orders, and residents should have an order to check it if they are receiving insulin. Some orders are for twice a day, some are done 3 times a day, it just depends. If a resident is refusing BS checks, then there should be documentation of refusal, and the MD should be notified. On 9/4/24 at 3:55 pm, an interview was conducted with the DON. She stated if a resident was receiving a long-acting insulin, they may not have an order for accu-checks, but they should for a short-acting insulin. When asked if the facility had a policy for documentation of blood sugars, insulin administration, or for accu-checks/blood sugar, she replied she would have to check. On 9/4/24 at 4:24 pm, a follow-up interview was conducted with the DON. She stated the facility had no policy for documentation of blood sugars, insulin administration specifically, or for accu-checks/blood sugar checks; it goes by the Physician's order. There should be order for short acting insulin from the doctor. According to the American Diabetes Association (ADA), at (https://diabetes.org/living-with-diabetes/treatment-care/checking-your-blood-sugar (Accessed on 9/17/24 at 5:28 pm), under Clinical Significance: Blood glucose (blood sugar) monitoring is the primary tool you have to find out if your blood glucose levels are within your target range. This tells you your blood glucose level at any one time. It's important for blood glucose levels to stay in a healthy range. If glucose levels get too low, we can lose the ability to think and function normally. If they get too high and stay high, it can cause damage or complications to the body over the course of many years. The logging of your results is vital. The ADA Standards of Care in Diabetes includes the ADA ' s current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Diabetes management in older adults requires regular assessment of medical, psychological, functional, and social domains. 105682 Page 6 of 7 105682 09/04/2024 Palm Garden of Jacksonville 5725 Spring Park Road Jacksonville, FL 32216

F 0711 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few According to the National Library of Medicine, NPH Insulin, last update: June 12, 2023), and National Library of Medicine, Aspart Insulin, last update: June 8, 2024 (Accessed on 9/17/24 at 5:28 pm), under Clinical Significance: Insulin is used to manage type 1 diabetes mellitus and some cases of type 2 diabetes mellitus. Insulin therapy has the well-known adverse side effect of hypoglycemia if its administration is not managed effectively. Patients with insulin-dependent diabetes will benefit from regular blood glucose monitoring. Regular daily blood glucose monitoring is recommended for those with diabetes mellitus using insulin therapy. Humulin N (Insulin NPH) is an intermediate-acting insulin with a slower onset of action and a longer duration of activity than that of regular human insulin. The time course of action of insulin, such as HUMULIN N may vary in different individuals or within the same individual, typically, NPH Insulin has an onset between 2 to 4 hours after injection, it peaks between 4 to 12 hours after injection and may have duration of 12 to 18 hours after injection. Aspart Insulin is a rapid-acting, human insulin analog and glucose-reducing effects occur within 1 to 3 hours and may last 3 to 5 hours. Insulin aspart is equipotent to regular insulin but has a faster onset and shorter duration of action. Non-critically ill patients on insulin aspart should routinely monitor their blood glucose. According to the Cleveland Clinic at https://my.clevelandclinic.org/health/treatments/17956-blood-sugar-monitoring (Accessed on 9/18/24 at 9:10 am.): If you have diabetes, monitoring your blood sugar (glucose) is key to finding out how well your current treatment plan is working. It gives you information on how to manage your diabetes on a daily - and sometimes even hourly - basis. Monitoring your blood sugar is important when you have diabetes, especially if you use insulin. The results of blood sugar monitoring can help you make decisions about food, physical activity and dosing insulin. Several things can affect your blood sugar. That's why it's important to check your blood sugar regularly . It's the only way to know for sure when your blood sugar levels are changing. According to the American Nurse Journal at www.myamericannurse.com (Accessed on 9/18/24 at 9:20 am.), under Monitoring Guidelines: Blood glucose monitoring should be ordered for all inpatients with diabetes or hyperglycemia and for those at high risk for hyperglycemia. Point-of-care results need to be readily available to all staff to identify the patient's response to treatment, hyperglycemia trends, and hypoglycemia episodes. In general, premeal and bedtime testing is recommended for patients who are eating, whereas testing every 4 to 6 hours is advised for those who can't have oral intake. . 105682 Page 7 of 7