Health inspection·December 27, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to check the blood sugar as ordered for one of two sampled residents (1). As a result, Resident 1 had an episode of low blood sugar which was not immediately identified. Findings: Per the facility ' s admission Record, Resident 1 was admitted to the facility on [DATE] with diagnoses to include diabetes (abnormal blood sugar levels). Per the facility ' s Progress Note, dated 1/26/23 at 2:52 P.M., .The change in condition/s .were .altered level of consciousness .labored or rapid breathing .chest pain/tightness .Resident presented signs of slurred speech . Per the facility ' s Progress Note, dated 1/26/23 at 9:07 P.M., .paramedics were called to have resident taken to ER (hospital emergency room). Once paramedics arrived, resident was found with a critically low blood glucose (sugar) level . Per the facility ' s Medication Administration Record (MAR), dated 11/21/23, there was an order on 11/19/22 to check Resident 1 ' s blood sugar levels before meals and at bedtime. The MAR was unsigned for all opportunities from 11/19/22 through the morning of 1/26/23. The first signed blood sugar check was on 1/26/23 at 430pm. On 12/15/23 at 11 A.M., a telephone interview was conducted with Licensed Nurse (LN) 1. LN 1 stated, the nurse who was assigned to give a resident their medication was also responsible for checking their blood sugar. LN 1 further stated, if there was an order to check a resident ' s blood sugar, it should have been signed on the MAR each time it was completed, and there was nowhere else to sign that it was done aside from the MAR. On 12/26/23 at 3:30 P.M., a telephone interview was conducted with the Director of Nursing (DON). The DON stated, normally when there was an order to check a resident ' s blood sugar it was signed in the MAR to show it was done. The DON further stated, the order to check Resident 1 ' s blood sugar was entered into the system incorrectly so that it did not show up on the MAR for the nurses to sign. The DON stated, the order was corrected on 1/26/23 so that nurses would be able to sign the MAR, but the nurse who entered the order on 11/19/23 should have entered it correctly. Page 1 of 2 555764 555764 12/27/2023 Palomar Heights Post Acute 1260 E Ohio Avenue Escondido, CA 92027

F 0656 The nurse who entered the order for blood sugar checks was not available for interview. Level of Harm - Minimal harm or potential for actual harm The facility did not have a policy which directed nurses to follow physician ' s orders. Residents Affected - Few 555764 Page 2 of 2