Mountain Manor Senior Residence

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.

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:

• 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)

Facility ID: