Health inspection·August 26, 2025

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 interview and record review, the facility failed to ensure care and treatment in accordance with the professional standards of practice were provided to Resident 1, when: 1. The Physician's Order (PO) for one time IV (intravenous, into the vein) 150 bolus (single, relatively large dose administered over a short period of time) was not clarified to specify the infusion duration; 2. The Licensed nurses (LNs) did not thoroughly document all aspects of the IV therapy, including the date and time of insertion, IV catheter gauge, IV site assessment results and patient response; 3. The LNs did not thoroughly document what time the MD order was faxed to the pharmacy and whether the order was received by the pharmacy to ensure timely delivery of IV supplies; and4. The LN did not document the start time and the end time of the IV bags administered including the IV bolus administration. These failures had the potential to result in fluid hydration treatment not met affecting the Resident 1's highest practicable well-being. During a review of Resident 1’s admission Record (AR), dated 1/2025, the AR indicated Resident 1 had diagnoses which included acute respiratory failure with hypoxia (low levels of oxygen in your body tissues), and hydration problems due to nausea and vomiting. Residents Affected - Few During a review of Resident 1’s PO, dated 2/6/25, the PO indicated the following: 1. May insert peripheral IV for IV hydration; 2. Peripheral IV to the right wrist: Change Dressing. Notify MD of any adverse changes, as needed if dressing is soiled/dislodged; 3. Peripheral IV to right wrist: Change dressing. Notify MD (Medical Doctor) of any adverse changes. every day shift every Wed (Wednesday); 4. Peripheral IV to right wrist: Monitor for adverse s/sx (signs and symptoms) of infiltration (leakage of IV fluids into surrounding tissue)/infection/phlebitis (inflammation of the walls of a vein). Notify MD if adverse s/sx are present for immediate intervention. Every Shift. 5. Dextrose-Sodium Chloride Intravenous Solution 5-0.45 % (Dextrose w/ Sodium Chloride) Use 75 ml intravenously every shift for poor intake for 6 days. *Give 150 bolus then 75ml/hour for a total of 5 liters. * During a review of the Nursing Progress Notes (NPN), dated 2/6/25 at 21:39 p.m. (9:39 p.m.), the NPN indicated, “continue monitoring IV Hydration for possible dehydration d/t N/V. first bag is running. Site right posterior hand, no s/sx infiltration; on 2/7/25 at 10:57 a.m., indicated already on IV hydration d/t poor intake, dehydration, N/V; and, on 2/7/25 at 13:11 p.m. (1:11 p.m.), indicated on monitoring for IV fluid hydration for possible dehydration D/T nausea and vomiting, Bag # 1 Page 1 of 2 555889 555889 08/26/2025 Mountain Manor Senior Residence 6101 Fair Oaks Boulevard Carmichael, CA 95608

F 0684 was infused @ about 0340am. Awaiting pharmacy delivery for the rest of the bags.” Level of Harm - Minimal harm or potential for actual harm During a review of the clinical records, there was no documented evidence the LNs did the following: clarification of the MD orders for IV bolus administration duration, nursing care and treatment for IV therapy administration, timely pharmacy follow up of the faxed MD order for IV supplies timely delivery, and the date and time of when the 1st IV bag was hung and done including the IV administration for bolus. Residents Affected - Few During a concurrent interview and record review on 8/26/25 at 11:12 a.m. with the Director of Nursing (DON), the DON confirmed the IV order for bolus administration should have been clarified and clearly written to avoid confusion. The DON confirmed the LN’s did not thoroughly document the following: 1. All aspects of the IV therapy, including the date and time of insertion, IV catheter gauge, IV site assessment results and patient response; 2. follow-up call what time the MD order was faxed to the pharmacy and whether the order was received to ensure timely delivery; and 3. The start time and the end time of the IV bags administered including the IV bolus. During an interview on 8/26/25 at 11:15 a.m. with the DON, the DON stated her expectations which included: LNs to clarify MD orders to ensure it would be carried out clearly; to document all aspects of the IV therapy, including the date and time of insertion, IV catheter gauge, IV site assessment results and patient response; to document what time the MD order was faxed to the pharmacy and whether the order was received to ensure timely delivery; to accurately document in the medical chart the start time and the end time of the IV fluids administered including the order for IV bolus. The DON further stated by not doing what was expected, there could be misinterpretation of the IV administration direction and the potential for adverse event like fluid overload and putting the resident at risk for electrolyte imbalance, it could create some break in the patient and team knowledge about the care provided, and there could be a delay of care which could result to the worsening of the patient condition, and, the change of condition could exacerbate. During a review of the undated facility’s policy and procedure (P&P) titled, “IV Therapy Staff Responsibilities,” the P/P indicated, “Verification and clarification of physician’s order for IV therapy, notification of pharmacy of new or changed orders, performance of peripheral venipunctures, initiation, monitoring and termination of all intravenous solutions and medications as ordered by the physician, maintenance of I.V. site, tubing and dressing, recognition of medication/solution visual incompatibilities, management of the care of the IV resident, including observation, assessment and initiation of appropriate nursing intervention, maintenance of established infection control and aseptic practices, knowledge and proficient technical ability in the use of IV equipment, and documentation of all aspects of IV therapy in residents medical record.” During a review of the undated document titled, Nursing Practice Act Rules and Regulations, the document indicated, Article 2. Scope of Regulation 2725 (b). The practice of nursing within the meaning of this chapter means those functions, including basic health care, that help people cope with difficulties in daily living that are associated with their actual or potential health or illness problems or the treatment thereof, and that require substantial amount of specific knowledge of the following: (2) Direct and indirect patient care services, including, but not limited to, the administration of medications and therapeutic agents, necessary to implement treatment, disease prevention, or rehabilitative regiment . ordered by and within the scope of licensure of a physician .as defined by Section 1316.5 of the Health and Safety Code. (Nursing Practice Act Rules and Regulations Issued by Board of Registered Nursing 1997 State of California Department of Consumer Affairs. pp. 5) 555889 Page 2 of 2