Health inspection·December 28, 2023

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Based on observation, interview and record review, the facility failed to prevent the willful neglect of one of three sampled residents (Resident 1) when Licensed Vocational Nurse (LVN) 1 intentionally neglected to check Resident 1's blood sugars and administer insulin (a medication to lower blood sugar) as ordered by the physician, then LVN 1 falsified Resident 1's medication record by recording blood sugar results that she never obtained and insulin coverage that she never provided, nine times between November and December, 2023. This failure resulted in abnormal blood sugar levels requiring additional insulin to stabilize Resident 1's blood sugars and had the potential to have serious negative outcomes to Resident 1's health, by not monitoring and controlling his blood sugars with insulin. Findings: The facility's policy titled, Abuse Identification dated 5/25/22, was reviewed. The policy indicated that, Abuse is defined as: a. The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish; and b. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being; and c. Having the knowledge and ability to provide care and services, but choosing not to, constitutes abuse. Resident 1 (R1), was admitted to the facility with a diagnoses that included diabetes and dementia. R1 required blood sugar monitoring four times daily and administration of insulin. A review of R1's Physician's Orders for the month of December 2023, reflected that R1's physican had ordered; a. Blood sugar checks three times a day before meals. b. Novalog (a regular fast acting insulin) 100 units (U-100)subcutaneous (SQ, just into the superficial fat layer under the skin), to be given per a sliding scale (SS- insulin is given according to the level of the blood sugar), as followed: for blood sugars between 150-200 give 2 units, 201-250 give 4 units, 251-300 give 6 units, 301-350 give 8 units, 351-400 give 10 units, 401-450 give 12 units Page 1 of 2 555221 555221 12/28/2023 Surprise Valley Community Hospital D/P Snf 741 N. Main Street Cedarville, CA 96104

F 0600 and notify the physician. Level of Harm - Minimal harm or potential for actual harm c. Victoza (a long lasting insulin), 1.2 milligrams (mg) SQ, every morning. Residents Affected - Few On 12/06/23 at 1:15 PM, during a concurrent interview and record review with the Director of Nursing (DON), R1's Medication Administration Records (MARs) for November and December 2023, were reviewed. LVN 1 had recorded blood sugar results as well as recorded amounts of insulin that had been given to R1, for the months of November and December, 2023. The DON indicated that during an audit, the DON initially found that R1 had high blood sugars when LVN 1 was on duty and assigned to R1's care. Upon further investigation, the DON indicated that the Glucometer (a hand held device to check blood sugars and records the date, time and results of blood sugars), had no recorded blood sugars for R1 which matched the blood sugar numbers that LVN 1 had recorded, on November 8, 9, 10, and 11, or on December 22, 23, 24, 25 and 26 of 2023, when LVN 1 had worked. The DON stated she interviewed LVN 1 and, I couldn't believe what she [LVN 1] told me. When I confronted her [LVN 1], she openly admitted to not checking [R1's] blood sugars or giving him insulin and stated that she had just made up the numbers and wrote them in because she said that she just did not have time. The DON then provided the facility's policy titled, Adverse Drug Reaction and Medication Errors. Under the heading, Policy Interpretation and Implementation section 6a. Omission- a drug is ordered but not administered. is one of the Examples of medications errors . Under the same heading, section 9 the policy requires that, Nursing staff will document appropriately detailed accounts of any incidents on an appropriate form. 555221 Page 2 of 2