Health inspection·June 5, 2024

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the tube feeding (the amount of formula) order on the Medication Administration Record (MAR) was the same as the physician's order for one of three sampled residents (1). As a result, there was a potential for Resident 1 to receive an incorrect tube feeding amount. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses that included diabetes (a disease that occurs when the blood glucose [blood sugar} is too high) and gastrostomy (artificial opening to the stomach to feed), per the admission Record. On 5/7/24 at 1 P.M., an observation was conducted. Resident 1 was with a family member. The tube feeding had a label for Glucerna 1.5 (the name of the tube feeding formula) 50 millimeters per hour (ml/hr). A record review was conducted. Per the Order Summary Report, dated 4/11/24, Resident 1 was to receive Glucerna 1.5 at 60 ml/hr for eight hours, to start at 8 P.M. until 4 A.M. or until the volume order was completed. Per the Medication Administration Record (MAR) for April 2024, Resident 1 had an order for Glucerna 1.5 at 60 ml/hr for eight hours from 8 P.M. until 4 A.M., or until the volume order was completed, with a start [order] date of 4/12/24; however, there was no signatures from the licensed nurses that this order was followed. Per the same MAR, The licensed nurses signed the order for Resident 1's Glucerna 1.5 at 50 ml/hr for 20 hours, from 12 noon until 8 A.M., or until the volume order was completed, with a start [order] date of 3/20/24. The licensed nurses consistently signed the MAR on the morning, evening, and night shifts, indicating that Resident 1 received 50 ml/hr for 20 hrs of the formula instead of 60 ml/hr for 8 hrs. On 6/4/24 at 11 A.M., a joint interview and record review was conducted with the Registered Dietitian (RD). The RD stated Resident 1 was eating well by mouth and recommended that the physician change the tube feeding volume so that Resident 1 could increase meal intake by mouth without being connected to the feeding machine. The RD further stated the MAR did not match the physician's order, which Page 1 of 2 555158 555158 06/05/2024 El Centro Post-Acute Care 1700 S. Imperial Ave El Centro, CA 92243

F 0693 could affect Resident 1's weight and ability to eat more food by mouth. Level of Harm - Minimal harm or potential for actual harm On 6/5/24 at 9:10 A.M., a joint interview and record review was conducted with the Assistant Director of Nursing (ADON). The ADON stated they noted a discrepancy between the physician's order and the MAR. The ADON further stated the physician orders should match the MAR. Residents Affected - Few The facility did not provide a policy and procedure. 555158 Page 2 of 2