Health inspection·July 21, 2022

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 observation, interview, record review, and facility policy and procedure review, the facility failed to provide treatment and care in accordance with professional standards of practice, by failing to contact the physician for a blood glucose reading of Hi for one (Resident #55) of seven residents observed during medication administration, from a total of 34 residents in the sample. Residents Affected - Few The findings include: On 7/19/22 at 11:29 AM, Licensed Practical Nurse (LPN) A was observed performing point-of-care blood glucose testing for Resident #55. After obtaining a blood sample, the blood glucose monitor (BGM) read HI. LPN A prepared the resident's Novolog (insulin) flexpen to administer 12 units subqutaneously. When asked if there was a facility protocol requiring the nurse to notify the physician for blood glucose results that read HI, LPN A stated no, the nursing staff just cover with the insulin. She stated she would notify the resident's physician of the HI reading. Further review of the medical record revealed an active 10/6/2020 physician's order for Novolog Flexpen (insulin), 100 units per milliliter, Fingerstick blood glucose monitoring four times daily before meals and at bedtime. Inject sub-Q (subcutaneously) per sliding scale. For a blood glucose reading of 150-200, administer 2 units, 201-205 = 4 units, 251-300 = 6 units, 301-350 = 8 units, 351-400 = 10 units; Greater than 401 = 12 units for a diagnosis of diabetes mellitus. Scheduled times for blood glucose testing and administration of sliding scale insulin were at 6:30 AM, 11:30 AM, 4:30 PM, and 9:00 PM. A line was drawn through the MAR referring the reader to the monitoring flow sheet. (Copy obtained) A review of the resident's July 2022 Novolog Flexpen Flow Sheet, revealed that on 7/19/22, Resident #55's blood glucose result was HI. The nurse initialed the entry and under Comment, marked a zero with a line through it. The amount of insulin administered was not documented. At 4:30 PM the same day, which was the next scheduled time for blood glucose monitoring with sliding scale coverage (if needed), the resident was documented as having refused. The nurse initialed the entry and under Comment, documented a zero with a line through it. The form was blank indicating insulin was not administered on 7/1 at 9:00 PM, 7/2 at 9:00 PM, 7/4 at 4:30 PM, 7/6 at 4:30 PM, or 7/7 at 9:00 PM. Resident #55 was documented as having refused blood glucose monitoring on 7/2 at 4:30 PM and 7/4 at 9:00 PM. (Copy obtained) A review of the resident's Minimum Data Set (MDS) assessment, dated 6/3/22, revealed a Brief Interview for Mental Status (BIMS) score of 3 out of a possible 15 points, indicating severe cognitive impairment. She was documented with inattention and disorganized thinking. She usually understood others and could sometimes respond appropriately. She received insulin injections on each day of the 7-day lookback period, as well as antipsychotic and antidepressant medications on each day of the 7-day Page 1 of 5 105721 105721 07/21/2022 Cedar Hill Nursing and Rehab Center 5888 Blanding Blvd Jacksonville, FL 32244

F 0684 lookback period. Level of Harm - Minimal harm or potential for actual harm On 7/19/22 at 3:15 PM, an interview was conducted with LPN A and LPN/Unit Manager B in reference to the observation of the BGM reading for Resident #55 earlier in the day. LPN A was asked what the physician had recommended when she contacted her about the HI blood glucose reading. LPN A stated she had not called the physician because she covered the HI blood glucose with insulin. At that time, LPN/Unit Manager B told LPN A, You still need to let the physician know of the HI result, because he would likely order a repeat check of the resident's blood glucose. The Unit Manager stated she would contact the resident's physician. Residents Affected - Few Resident #55's medical record was reviewed on 7/20/22 at 9:20 AM. A nurse's noted dated 7/19/22 at 2:00 PM read, BS (blood sugar) Hi, 12 units Novolog given. MD notified. Received order to check again in one hour. Resident refused accucheck. On 7/20/22 at 2:05 PM, during an interview with the DON, she was asked how LPN A was doing and stated LPN A was no longer employed at the facility. On 7/21/22 at 2:15 PM, an interview was conducted with LPN D, who stated for BGM readings greater than 401 or HI, the physician was notified and it was documented in the resident's medical record. A review of the facility's policy for Obtaining a Fingerstick Glucose Level (Revised 12/2011), revealed the following: The person performing this procedure should record the following information in the resident's medical record: 3. All assessment data obtained during the procedure 4. How the resident tolerated the procedure 5. If the resident refused the procedure, the reason(s) why and the intervention taken. 6. The blood sugar results. Follow facility policies and procedures for appropriate nursing interventions regarding blood sugar results (if resident is on sliding scale coverage, and/or physician intervention is needed to adjust insulin or oral medication doses), etc. Under Reporting was documented: 1. Report results promptly to the supervisor and the Attending Physician. 2. Notify the supervisor if the resident refuses the procedure. 3. Report other information in accordance with facility policy and professional standards of practice. A review of the facilitys policy and procedure for Administering Medications (Revised 12/2012), revealed: As required or indicated for a medication, the individual administering the medication will record in the resident's medical record: 105721 Page 2 of 5 105721 07/21/2022 Cedar Hill Nursing and Rehab Center 5888 Blanding Blvd Jacksonville, FL 32244

F 0684 a. The date and time the medication was administered; Level of Harm - Minimal harm or potential for actual harm b. The dosage; c. The route of administration; Residents Affected - Few d. The injection site (if applicable); e. Any complaints or symptoms for which the drug was administered; f. Any results achieved and when those results were observed; and g. The signature and title of the person administering the drug. . 105721 Page 3 of 5 105721 07/21/2022 Cedar Hill Nursing and Rehab Center 5888 Blanding Blvd Jacksonville, FL 32244

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on observation, interview, record review, and facility policy and procedure review, the facility failed to maintain medical records on each resident that were complete and accurately documented for one (Resident #55) of seven residents observed during medication administration, from a total of 34 residents in the sample. The findings include: On 7/19/22 at 11:29 AM, Licensed Practical Nurse (LPN) A was observed performing point-of-care blood glucose testing for Resident #55. A review of Resident #55's July 2022 Medication Administration Record (MAR), revealed injection sites were not documented. On 7/19/22 at 12:17 PM, LPN A was observed documenting the administration of Resident #55's insulin. A review of the July 2022 MAR revealed no injection site was documented. On 7/20/22 at 12:45 AM, an interview was conducted with LPN/Unit Manager B. She stated the only injectable medication nursing documented the injection site for was Levemir (insulin). They did not document an injection site for Novolog (insulin) or other injectable medications. She stated the surveyor should ask the Director of Nursing (DON) about the documentation. A review of the July 2022 MAR revealed an active 10/6/2020 physician's order for Novolog Flexpen (insulin), 100 units per milliliter, Fingerstick blood glucose monitoring four times daily before meals and at bedtime. Inject sub-Q (subcutaneously) per sliding scale. Scheduled times for blood glucose testing and administration of sliding scale insulin were at 6:30 AM, 11:30 AM, 4:30 PM, and 9:00 PM. Each place for an entry included Result, Dose, Site. A line was drawn through the MAR referring the reader to the monitoring flow sheet. (Copy obtained) A review of the resident's July 2022 Novolog Flexpen Flow Sheet, revealed no place specific to document the injection site. Spaces were noted for result, signature, comment. Under the column headed Comment, nursing documented the number of units administered. No injection sites were documented. (Copy obtained) Further review of the resident's July 2022 MAR revealed and active 6/17/2022 physician's order for Levemir Flextouch, 100 units per milliliter. Inject 22 units subcutaneously twice daily. Scheduled times for the administration of this insulin were at 6:30 AM and 4:30 PM. Each place for an entry included Site. On July 1, 2, 3, 6, 7, 10, 11, 15 and 17, 2022, no injection site was documented. (Copy obtained) On 7/20/22 at 2:05 PM, an interview was conducted with the DON, who stated injection sites should be documented for every injectable medication. A review of the facility's policy and procedure for Administering Medications (Revised 12/2012), page 6, Policy interpretation and Implementation, Item #20: As required or indicated for a medication, the individual administering the medication will record in the resident's medical record: a. The date and time the medication was administered; 105721 Page 4 of 5 105721 07/21/2022 Cedar Hill Nursing and Rehab Center 5888 Blanding Blvd Jacksonville, FL 32244

F 0842 b. The dosage; Level of Harm - Minimal harm or potential for actual harm c. The route of administration; d. The injection site (if applicable); Residents Affected - Few e. Any complaints or symptoms for which the drug was administered; f. Any results achieved and when those results were observed; and g. The signature and title of the person administering the drug. . 105721 Page 5 of 5