Health inspection·April 13, 2023

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview and record review, the facility failed to ensure one of 3 sampled residents, Resident 1, was checked for a blood glucose level and administered insulin medication before eating breakfast as ordered by the physician. This failure had the potential for Resident 1 to further elevate her blood glucose level and cause undesirable symptoms or a life-threatening complication such as coma (unconscious state). Findings: During an interview on 3/30/23, at 11:50 a.m., Resident 1 stated her blood glucose remained high and was not checked by a nurse all morning. Resident 1 stated her blood glucose was high before eating breakfast and was not administered insulin (hormone that helps your body use sugar for energy). Resident 1 stated she wears a device that registers her glucose results to her cellphone. Resident 1 stated her current blood glucose result is 229 and was concerned she was not going to receive insulin before lunchtime. Review of the most recent Quarterly Assessment, Minimum Data Set (MDS-a standardized assessment tool that measures health status), dated 1/28/23, indicated Section B: Speech - B0600=Speech Clarity=0. Clear speech, B0700=Makes Self Understood=0. Understood, and Section C: Cognitive Patterns – C0500 BIMS (Brief Interview for Mental Status) Score: 15 = cognitively intact. Review of the physician order dated 12/10/22, it indicated Humalog injection solution 100 unit/ml (Insulin Lispro). Inject as per sliding scale: if 70 - 120 = 0 units; 121 - 150 = 2 units; 151 - 200 = 4 units; 201 - 250 = 6 units; 251 - 300 = 8 units; 301- 350 = 10 units; 351 - 400 = 12 units and notify MD, subcutaneously before meals and at bedtime for Diabetes Mellitus (DM, a condition when blood sugar is elevated). During an interview on 3/30/23 at 1:10 P.M., RN 1 stated she administered insulin 8 units for breakfast and 6 units for lunch. Review of the document, titled Location of Administration Report , dated 3/1/2023 thru 3/31/2023, it indicated Scheduled Time: 03/30/23 07:00 A.M., Administration Time: 03/30/23 11:00 A.M., Administered by: RN 1, Route: subcutaneously (injection), Location of Admin: Arm – right. Another record, titled Weights and Vitals Summary , it indicated the date: 3/30/23 , time: 11:00 and blood glucose: 266 . During an interview on 3/30/23 at 2:35 p.m., RN 1 stated she was called to work today and arrived Page 1 of 2 555710 555710 04/13/2023 Tice Valley Post Acute 1975 Tice Valley Blvd. Walnut Creek, CA 94595

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few late, after 9:00 a.m. RN 1 stated the previous nurse did not update her of Resident 1's immediate needs. RN 1 stated she noticed the insulin order was not signed off on the MAR for 7:00 A.M., this meant insulin was not given to Resident 1. RN 1 stated the nurse who was there at 7:00 A.M. should have verified the blood glucose and administered the insulin prior to breakfast meal. RN 1 stated Resident 1 informed her of a blood glucose level: 266 and verified the result registered on Resident 1's cellphone. RN 1 stated she administered 8 units of insulin because Resident 1 still wanted it. When asked What happens when insulin is not given prior to meal? RN 1 stated the resident will become hyperglycemic and experience dizziness. During an interview on 3/30/23 at 2:41 P.M., certified nurse assistant (CNA)1 stated, Resident 1 checks her own blood glucose. CNA 1 stated Resident 1 usually tells her about needing insulin before breakfast then CNA 1 informs the nurse. CNA 1 stated Resident 1 ate when the breakfast tray was served this morning, Resident 1 did not say anything about wanting insulin. CNA 1 stated Resident 1 would experience shaking, sweat and possibly throwing up if blood glucose is very high. During an interview on 3/30/23 at 2:55 P.M., the Director of Nursing (DON) stated RN 2 was the covering nurse who is supposed to verify Resident 1's blood glucose and administer insulin. DON stated insulin administration should not be delayed. During an interview on 4/12/23 at 10:18 A.M., RN 2 stated Resident 1 usually asks for her insulin to be administered because she eats at different times. RN 2 stated if she administered insulin to Resident 1, she recorded it in the chart immediately. RN 2 stated she does not remember the details for 3/30/23 and confirms that Resident 1 is a reliable source, though forgetful at times. RN 2 stated she makes notations in the progress notes to explain administering outside the prescribed time. Review of the policy and procedure, Medication Administration: Medication Pass , dated 06/2021, indicated to administer medication in accordance with frequency prescribed by physician -within 60 minutes before or after prescribed dosing time and according to specific procedure, such as oral, topical, injection, etc. 555710 Page 2 of 2