**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were free from medical neglect by allowing unqualified facility staff to work outside of their scope of practice, administering intravenous (IV) medications via a peripherally inserted central catheter (PICC) line for 1 of 2 residents, Resident #84, without certification of education, training, and validation of competency for IV medication administration. IV infusion without IV certification and validation of competency could result in the likelihood of serious harm and/or death for residents who are administered IV medication infusions. This can result in an increased risk of infection, damage to veins and injection sites, an air embolism, phlebitis, and blood clots, which can occur from a poorly administered IV infusion. Phlebitis can cause blood clots, which can block important blood vessels, causing tissue damage or even be life-threatening. Lack of proper training and verification to assess IV patency (the line is open and not blocked allowing the treatment to flow directly into the patient's vein) can increase the spread of infection. Lack of training and verified competency to assess the insertion site for signs and symptoms of phlebitis or infection, fluid leaking (resulting in the treatment not being administered as ordered), redness, pain, tenderness, and swelling can result in the likelihood of increased risk of serious harm and/or death. Proper placement of the PICC through X-ray or ultrasound is required prior to the administration of medication; this knowledge is provided through training and education as part of the certification process. Findings include: Review of Resident #84's records revealed the resident was admitted to the facility on [DATE] with the diagnoses including atherosclerotic heart disease of native coronary artery (heart disease) with angina pectoris (chest pain), acquired absence of left leg below knee, acquired absence of right leg below knee, hyperlipidemia (high cholesterol), hypertension, local infection of the skin, major depressive disorder, pressure ulcer right buttock stage 3, and pressure ulcer left buttock stage 3. Review of the physician order dated 8/21/2022 for Resident #84 reads, Sodium Chloride Injection Solution 0.9% (Sodium Chloride), Use 75 ml [milliliter]/hr [hour] intravenously every shift related to encounter for other specified prophylactic measures (Z29.8) for 14 days. IV [intravenous] NS [normal saline] to run continuously until IV ABT [antibiotic] completed. Review of the physician order dated 8/28/2022 for Resident #84 reads, Vancomycin HCl in Dextrose Intravenous Solution 1-5 GM [grams]/200 (milliliters)-% (Vancomycin HCl- Dextrose) Use 1000 mg [milligrams] intravenously in the evening for wound for 14 days. Pharmacy to dose. Review of the physician order dated 8/21/2022 for Resident #84 reads, IVs: Type of Access PICC. Review of the physician order dated 8/21/2022 for Resident #84 reads, IVs: Evaluate site for leakage/ bleeding/ signs of infection every shift. Review of the IV company report dated 8/22/2022 for Resident #84 reads, Reason for Consultation: PICC (non-valved) . Reason for Insertion: Drugs . Post-Insertion Data. Line Insertion: 3 CG PICC. Comments: 4 FR [French] PICC inserted into R [Right] basilic vein successfully . Instructed to order CXR [chest x-ray] for verification of PICC line tip placement prior to use. Review of the radiology report dated 8/22/2022 at 3:12 PM for Resident #84 reads, Conclusion: No acute cardiopulmonary process. Right PICC line tip in the right jugular venous system, recommend repositioning. Review of the IV company report dated 8/23/2022 for Resident #84 reads, Reason for Consultation: PICC (non-valved) . Reason for Insertion: Drugs . Post-Insertion Data. Line Insertion: 3 CG PICC. Reinsertion: Yes. Reinsertion Due To: Malpositioned PICC. Comments: 4 FR PICC inserted into L [left] basilic vein successfully . Instructed to order CXR for verification of PICC line tip placement prior to use. Review of Resident #84's medical record indicated that no chest X-ray was ordered to confirm and verify proper placement prior to administering the medications. Review of Resident #84's medical record indicated that no [NAME] 3CG tip confirmation report (magnetic tracking of the tip of the PICC line that uses ECG (electrocardiogram) was present in the medical report. Review of the Medication Administration Record (MAR) documented that Staff J, Licensed Practical Nurse (LPN), administered Sodium Chloride 0.9% at 75 milliliters per hour on 8/22/2022 at 8:50 AM to Resident #84. Review of the MAR documented that Staff H, LPN, administered Sodium Chloride 0.9% at 75 milliliters per hour 8/23/2022 at 10:14 AM through a peripheral IV to Resident #84. Review of the MAR documented that Staff H, LPN, administered 10 milliliters of Normal Saline IV to Resident #84. Review of the MAR documented that Staff I, LPN, administered 10 milliliters of normal saline flush intravenously on 8/26/2022 at 11:38 AM through a left arm PICC line to Resident #84. Review of the MAR documented that Staff I, LPN, administered Sodium Chloride solution 0.9% at 75 milliliters per hour on 8/26/2022 at 11:38 AM through a left arm PICC line to Resident #84. Review of the MAR documented that Staff I, LPN, administered Vancomycin 1000 mg IV on 8/26/2022 at 11:38 AM through a left arm PICC line to Resident #84. Review of the MAR documented that Staff I, LPN, administered Vancomycin 1000 mg IV on 8/27/2022 at 8:39 AM through a left arm PICC line to Resident #84. Review of the MAR documented that Staff I, LPN, administered 10 milliliters of normal saline on 8/27/2022 at 8:40 AM intravenously through a left arm PICC line to Resident #84. Review of the MAR documented that Staff I, LPN, administered Sodium Chloride solution 0.9% at 75 ml/hr on 8/27/2022 at 8:40 AM through a left arm PICC line to Resident #84. Review of the MAR documented that Staff I, LPN, administered Vancomycin 1000 mg IV on 8/28/2022 at 11:08 AM through a left arm PICC line to Resident #84. Review of the MAR documented that Staff I, LPN, administered 10 milliliters of normal saline IV on 8/28/2022 at 11:39 AM through a left arm PICC line to Resident #84. Review of the MAR documented that Staff I, LPN, administered Vancomycin 1000 mg IV on 8/28/2022 at 6:16 PM through a left arm PICC line to Resident #84. Review of the employee file for Staff J, LPN, showed no IV competency or PICC line competency training within the file. Review of the employee file for Staff I, LPN, showed no IV competency or PICC line competency training within the file. Review of the employee file for Staff H, LPN, no IV competency or PICC line competency training within the file. During an interview on 8/31/2022 at 8:40 AM, the Advanced Practice Registered Nurse (APRN) stated, I was not aware that we did not do an X-ray to confirm line placement prior to administering medications. There are possible complications related to infusing medications into any line that is not confirmed. During an interview on 8/31/2022 at 9:15 AM, the Attending Physician stated, I was made aware yesterday we did not complete an X-ray of the PICC line. Since then, we have obtained an X-ray showing the catheter is in place so there is no harm to the patient. I can't speak to harm to the patient as it is properly positioned at this time. I do expect for IV fluids to be administered per my orders and if they don't, they need to call me. During an interview on 8/31/2022 at 12:00 PM, Staff H, LPN, stated, I was the nurse on the day that [Resident #84's name] PICC line was reinserted. The nurse from the IV company came in and inserted it. I helped him with [Resident #84's name] arm. I held it, so he could get the dressing on. He told me that he thought it was in the right place. He did give me the paper that explained that I needed to get an X-ray. It is my signature on the sheet. I didn't know that I needed to get an X-ray. The nurse, he told me he didn't think he would need to come back. I just didn't know. I thought it was okay to use. I just attached it to his PICC line after the IV nurse left. I didn't know that I needed to get a chest X-ray. I should not have hung the IV. I really didn't think I was hanging it. I just connected it to the IV. I am not IV certified. I did not take the IV certification. I know that I can't hang antibiotics. I just didn't think that the normal saline was a problem. I have flushed PICC lines after antibiotics, but I haven't hung them. I just wanted him to get his fluids, so I did hang it. I did hang a new bag to the peripheral IV that the resident had before the PICC line was put in. Once they came to do the PICC, the IV was out and I just connected the normal saline to the PICC line as soon as the IV nurse left. During an interview on 8/31/2022 at 1:45 PM, the Director of Nursing (DON) stated, I was shocked that [Staff H, LPN's name] had done anything related to [Resident #84's name] PICC line. I heard her say that she did not have the IV certification and I was shocked. She was practicing outside her scope as an LPN. I was not aware that this was happening. I do not really know the process for verifying if an LPN is competent to do IVs. I just got here. I literally started the day you arrived for survey. We should have a copy of their 30-hour course when they are hired. We should not allow LPNs to administer IV medications unless we know that they have had the course. During a telephone interview on 8/31/2022 at 2:59 PM Staff I, LPN, stated, I took an 8-hour course many years ago. I guess I did not do the 30-hour IV course, so I guess I am not IV certified. I thought I was okay to do the IVs with what I had done. No one ever asked me for my certification to do IV med administration. I did administer the Vancomycin, flush the PICC line and do the normal saline that was ordered to run continuously to [Resident #84's name]. I wasn't aware that it would be a problem. I wish I had known. I did not do a competency specific to the care of the PICC line dressing when I was hired. During a telephone interview on 8/31/2022 at 3:10 PM, Staff J, LPN, stated, I did administer [Resident #84's name] IV and I hung the normal saline. I have been doing IV medications. I was told that as long as there is an RN [Registered Nurse] in the building that I could do it. I was told that by [Staff C, LPN's name] the unit manager. I am in school to be an RN and I was told that I could do it, so I have. I am aware that as an LPN without IV certification I cannot administer any IV medications because it's against the nurse practice act. But I was told it was okay because I was in nursing school. During an interview on 8/31/2022 at 3:20 PM, the Assistant Director of Nursing (ADON) stated, I was not aware that any LPNs who were not IV certified would be administering IV medications. I would not tell any staff that they could practice outside of the nurse practice act. I am not aware of anyone telling an LPN that it was acceptable to administer meds through a PICC or change dressings if they had not taken the course. During an interview on 8/31/2022 at 3:30 PM, Staff C, LPN, stated, I have not told anyone that they could administer IV medications if they are not IV certified as an LPN. I have not said that it is okay for any LPN to administer IV medications if there is an RN in the building. I know that we as LPNs have to follow our scope of practice and that if we have not had the additional training, we can't administer medications IV. During an interview on 9/1/2022 at 7:35 AM, the Human Resources Director stated, The process of hiring staff starts with the application. We do verify licenses for licensed staff, and we will ask LPNs who tell us they are IV certified. The process used to be for human resources to get all certification nurses have and the DON would know and keep record of any staff competencies for nurse. During a telephone interview on 9/1/2022 at 8:10 AM, the Medical Director stated, I came by yesterday and found out about this problem. I did not know we had LPNs who weren't IV certified, administering IV medications. I would expect nurses to practice within their scope of practice. We plan to implement a solution. I would expect that all nurses practice within their scope of practice. Review of the policy and procedure titled Abuse, Neglect, Exploitation & Misappropriation with an approval date of 8/8/2022 reads, Policy: It is inherent in the nature and dignity of each resident at the center that he/she be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, exploitation and/or misappropriation of property. The management of the facility recognizes these rights and hereby establishes the following statements, policies and procedures to protect these rights and to establish a disciplinary policy, which results in the fair and timely treatment of occurrences of resident abuse. Employees of the center are charged with a continuing obligation to treat residents so they are free from abuse, neglect, mistreatment, and/or misappropriation of property. No employee may at any time commit an act of physical, psychological, or emotional abuse, neglect, mistreatment, and/or misappropriation of property against any resident. Violation of this standard will subject employees to disciplinary action, including dismissal, provided herein. Definitions . Neglect is the failure of the center, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Examples include but are not limited to . Failure to take precautionary measures to protect the health and safety of the resident . Procedure: Acts of abuse directed against residents are absolutely prohibited. Such acts are cause for disciplinary action, including dismissal and possible criminal prosecution. Questions may arise as to what actions constitute abuse of a resident. Any action that may cause or causes actual physical, psychological or emotional harm, which is not caused by simple negligence, constitutes abuse. Review of the policy and procedure titled Administration of Intermittent Infusion with an approval date of 8/8/2022 reads, Guidance . 2. Documentation of central vascular access device (CVAD) tip location must be included in the medical record prior to administration of medications. Maintain catheter patency per flushing/locking protocol while awaiting confirmation. Documentation may include: 2.1. Copy of chest X-ray results reporting location of tip, or fluoroscopy report. Review of the policy and procedure titled Continuous infusion of Medications and Solutions with an approval date of 8/8/2022 reads, To be Performed by: Licensed nurses according to state law and facility policy. The nurse is responsible and accountable for obtaining and maintaining competence with infusion therapy within his or her scope of practice. Competency validation is documented in accordance with organizational policy . Guidance . 2. Documentation of central vascular access tip location must be included in the medical record prior to administration of medications. Maintain catheter patency per flushing/locking protocol while awaiting tip confirmation. Documentation may include: 2.1. Copy of chest x-ray or fluoroscopy report; 2.2. Telephone order from radiologist stating location of tip (e.g. cavoatrial junction, IVC); 2.3. Copy of ECG technology insertion report.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure licensed nurses had appropriate competencies and skills sets to provide nursing and related services to residents by allowing unqualified facility staff to work outside of their scope of practice, administering intravenous (IV) medications via a peripherally inserted central catheter (PICC) line for 1 of 2 residents, Resident #84, without certification of education, training, and validation of competency for IV medication administration. IV infusion without IV certification and validation of competency could result in the likelihood of serious harm and/or death for residents who are administered IV medication infusions. This can result in an increased risk of infection, damage to veins and injection sites, an air embolism, phlebitis, and blood clots, which can occur from a poorly administered IV infusion. Phlebitis can cause blood clots, which can block important blood vessels, causing tissue damage or even be life-threatening. Lack of proper training and verification to assess IV patency (the line is open and not blocked allowing the treatment to flow directly into the patient's vein) can increase the spread of infection. Lack of training and verified competency to assess the insertion site for signs and symptoms of phlebitis or infection, fluid leaking (resulting in the treatment not being administered as ordered), redness, pain, tenderness, and swelling can result in the likelihood of increased risk of serious harm and/or death. Proper placement of the PICC through X-ray or ultrasound is required prior to the administration of medication; this knowledge is provided through training and education as part of the certification process. Findings include: Review of Resident #84's records revealed the resident was admitted to the facility on [DATE] with the diagnoses including atherosclerotic heart disease of native coronary artery (heart disease) with angina pectoris (chest pain), acquired absence of left leg below knee, acquired absence of right leg below knee, hyperlipidemia (high cholesterol), hypertension, local infection of the skin, major depressive disorder, pressure ulcer right buttock stage 3, and pressure ulcer left buttock stage 3. Review of the physician order dated 8/21/2022 for Resident #84 reads, Sodium Chloride Injection Solution 0.9% (Sodium Chloride), Use 75 ml [milliliter]/hr [hour] intravenously every shift related to encounter for other specified prophylactic measures (Z29.8) for 14 days. IV [intravenous] NS [normal saline] to run continuously until IV ABT [antibiotic] completed. Review of the physician order dated 8/28/2022 for Resident #84 reads, Vancomycin HCl in Dextrose Intravenous Solution 1-5 GM [grams]/200 (milliliters)-% (Vancomycin HCl- Dextrose) Use 1000 mg [milligrams] intravenously in the evening for wound for 14 days. Pharmacy to dose. Review of the physician order dated 8/21/2022 for Resident #84 reads, IVs: Type of Access PICC. Review of the physician order dated 8/21/2022 for Resident #84 reads, IVs: Evaluate site for leakage/ bleeding/ signs of infection every shift. Review of the IV company report dated 8/22/2022 for Resident #84 reads, Reason for Consultation: PICC (non-valved) . Reason for Insertion: Drugs . Post-Insertion Data. Line Insertion: 3 CG PICC. Comments: 4 FR [French] PICC inserted into R [Right] basilic vein successfully . Instructed to order CXR [chest x-ray] for verification of PICC line tip placement prior to use. Review of the radiology report dated 8/22/2022 at 3:12 PM for Resident #84 reads, Conclusion: No acute cardiopulmonary process. Right PICC line tip in the right jugular venous system, recommend repositioning. Review of the IV company report dated 8/23/2022 for Resident #84 reads, Reason for Consultation: PICC (non-valved) . Reason for Insertion: Drugs . Post-Insertion Data. Line Insertion: 3 CG PICC. Reinsertion: Yes. Reinsertion Due To: Malpositioned PICC. Comments: 4 FR PICC inserted into L [left] basilic vein successfully . Instructed to order CXR for verification of PICC line tip placement prior to use. Review of Resident #84's medical record indicated that no chest X-ray was ordered to confirm and verify proper placement prior to administering the medications. Review of Resident #84's medical record indicated that no [NAME] 3CG tip confirmation report (magnetic tracking of the tip of the PICC line that uses ECG (electrocardiogram) was present in the medical report. Review of the Medication Administration Record (MAR) documented that Staff J, Licensed Practical Nurse (LPN), administered Sodium Chloride 0.9% at 75 milliliters per hour on 8/22/2022 at 8:50 AM to Resident #84. Review of the MAR documented that Staff H, LPN, administered Sodium Chloride 0.9% at 75 milliliters per hour 8/23/2022 at 10:14 AM through a peripheral IV to Resident #84. Review of the MAR documented that Staff H, LPN, administered 10 milliliters of Normal Saline IV to Resident #84. Review of the MAR documented that Staff I, LPN, administered 10 milliliters of normal saline flush intravenously on 8/26/2022 at 11:38 AM through a left arm PICC line to Resident #84. Review of the MAR documented that Staff I, LPN, administered Sodium Chloride solution 0.9% at 75 milliliters per hour on 8/26/2022 at 11:38 AM through a left arm PICC line to Resident #84. Review of the MAR documented that Staff I, LPN, administered Vancomycin 1000 mg IV on 8/26/2022 at 11:38 AM through a left arm PICC line to Resident #84. Review of the MAR documented that Staff I, LPN, administered Vancomycin 1000 mg IV on 8/27/2022 at 8:39 AM through a left arm PICC line to Resident #84. Review of the MAR documented that Staff I, LPN, administered 10 milliliters of normal saline on 8/27/2022 at 8:40 AM intravenously through a left arm PICC line to Resident #84. Review of the MAR documented that Staff I, LPN, administered Sodium Chloride solution 0.9% at 75 ml/hr on 8/27/2022 at 8:40 AM through a left arm PICC line to Resident #84. Review of the MAR documented that Staff I, LPN, administered Vancomycin 1000 mg IV on 8/28/2022 at 11:08 AM through a left arm PICC line to Resident #84. Review of the MAR documented that Staff I, LPN, administered 10 milliliters of normal saline IV on 8/28/2022 at 11:39 AM through a left arm PICC line to Resident #84. Review of the MAR documented that Staff I, LPN, administered Vancomycin 1000 mg IV on 8/28/2022 at 6:16 PM through a left arm PICC line to Resident #84. Review of the employee file for Staff J, LPN, showed no IV competency or PICC line competency training within the file. Review of the employee file for Staff I, LPN, showed no IV competency or PICC line competency training within the file. Review of the employee file for Staff H, LPN, no IV competency or PICC line competency training within the file. During an interview on 8/31/2022 at 8:40 AM, the Advanced Practice Registered Nurse (APRN) stated, I was not aware that we did not do an X-ray to confirm line placement prior to administering medications. There are possible complications related to infusing medications into any line that is not confirmed. During an interview on 8/31/2022 at 9:15 AM, the Attending Physician stated, I was made aware yesterday we did not complete an X-ray of the PICC line. Since then, we have obtained an X-ray showing the catheter is in place so there is no harm to the patient. I can't speak to harm to the patient as it is properly positioned at this time. I do expect for IV fluids to be administered per my orders and if they don't, they need to call me. During an interview on 8/31/2022 at 12:00 PM, Staff H, LPN, stated, I was the nurse on the day that [Resident #84's name] PICC line was reinserted. The nurse from the IV company came in and inserted it. I helped him with [Resident #84's name] arm. I held it, so he could get the dressing on. He told me that he thought it was in the right place. He did give me the paper that explained that I needed to get an X-ray. It is my signature on the sheet. I didn't know that I needed to get an X-ray. The nurse, he told me he didn't think he would need to come back. I just didn't know. I thought it was okay to use. I just attached it to his PICC line after the IV nurse left. I didn't know that I needed to get a chest X-ray. I should not have hung the IV. I really didn't think I was hanging it. I just connected it to the IV. I am not IV certified. I did not take the IV certification. I know that I can't hang antibiotics. I just didn't think that the normal saline was a problem. I have flushed PICC lines after antibiotics, but I haven't hung them. I just wanted him to get his fluids, so I did hang it. I did hang a new bag to the peripheral IV that the resident had before the PICC line was put in. Once they came to do the PICC, the IV was out and I just connected the normal saline to the PICC line as soon as the IV nurse left. During an interview on 8/31/2022 at 1:45 PM, the Director of Nursing (DON) stated, I was shocked that [Staff H, LPN's name] had done anything related to [Resident #84's name] PICC line. I heard her say that she did not have the IV certification and I was shocked. She was practicing outside her scope as an LPN. I was not aware that this was happening. I do not really know the process for verifying if an LPN is competent to do IVs. I just got here. I literally started the day you arrived for survey. We should have a copy of their 30-hour course when they are hired. We should not allow LPNs to administer IV medications unless we know that they have had the course. During a telephone interview on 8/31/2022 at 2:59 PM Staff I, LPN, stated, I took an 8-hour course many years ago. I guess I did not do the 30-hour IV course, so I guess I am not IV certified. I thought I was okay to do the IVs with what I had done. No one ever asked me for my certification to do IV med administration. I did administer the Vancomycin, flush the PICC line and do the normal saline that was ordered to run continuously to [Resident #84's name]. I wasn't aware that it would be a problem. I wish I had known. I did not do a competency specific to the care of the PICC line dressing when I was hired. During a telephone interview on 8/31/2022 at 3:10 PM, Staff J, LPN, stated, I did administer [Resident #84's name] IV and I hung the normal saline. I have been doing IV medications. I was told that as long as there is an RN [Registered Nurse] in the building that I could do it. I was told that by [Staff C, LPN's name] the unit manager. I am in school to be an RN and I was told that I could do it, so I have. I am aware that as an LPN without IV certification I cannot administer any IV medications because it's against the nurse practice act. But I was told it was okay because I was in nursing school. During an interview on 8/31/2022 at 3:20 PM, the Assistant Director of Nursing (ADON) stated, I was not aware that any LPNs who were not IV certified would be administering IV medications. I would not tell any staff that they could practice outside of the nurse practice act. I am not aware of anyone telling an LPN that it was acceptable to administer meds through a PICC or change dressings if they had not taken the course. During an interview on 8/31/2022 at 3:30 PM, Staff C, LPN, stated, I have not told anyone that they could administer IV medications if they are not IV certified as an LPN. I have not said that it is okay for any LPN to administer IV medications if there is an RN in the building. I know that we as LPNs have to follow our scope of practice and that if we have not had the additional training, we can't administer medications IV. During an interview on 9/1/2022 at 7:35 AM, the Human Resources Director stated, The process of hiring staff starts with the application. We do verify licenses for licensed staff, and we will ask LPNs who tell us they are IV certified. The process used to be for human resources to get all certification nurses have and the DON would know and keep record of any staff competencies for nurse. During a telephone interview on 9/1/2022 at 8:10 AM, the Medical Director stated, I came by yesterday and found out about this problem. I did not know we had LPNs who weren't IV certified, administering IV medications. I would expect nurses to practice within their scope of practice. We plan to implement a solution. I would expect that all nurses practice within their scope of practice. Review of the policy and procedure titled Administration of Intermittent Infusion with an approval date of 8/8/2022 reads, Guidance . 2. Documentation of central vascular access device (CVAD) tip location must be included in the medical record prior to administration of medications. Maintain catheter patency per flushing/locking protocol while awaiting confirmation. Documentation may include: 2.1. Copy of chest X-ray results reporting location of tip, or fluoroscopy report. Review of the policy and procedure titled Continuous infusion of Medications and Solutions with an approval date of 8/8/2022 reads, To be Performed by: Licensed nurses according to state law and facility policy. The nurse is responsible and accountable for obtaining and maintaining competence with infusion therapy within his or her scope of practice. Competency validation is documented in accordance with organizational policy . Guidance . 2. Documentation of central vascular access tip location must be included in the medical record prior to administration of medications. Maintain catheter patency per flushing/locking protocol while awaiting tip confirmation. Documentation may include: 2.1. Copy of chest x-ray or fluoroscopy report; 2.2. Telephone order from radiologist stating location of tip (e.g. cavoatrial junction, IVC); 2.3. Copy of ECG technology insertion report.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility administration failed to effectively and efficiently attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident by not assuming full responsibility for the day to day operations of the facility by allowing unqualified facility staff to work outside of their scope of practice, administering intravenous (IV) medications via a peripherally inserted central catheter (PICC) line for 1 of 2 residents, Resident #84, without certification of education, training, and validation of competency for IV medication administration. IV infusion without IV certification and validation of competency could result in the likelihood of serious harm and/or death for residents who are administered IV medication infusions. This can result in an increased risk of infection, damage to veins and injection sites, an air embolism, phlebitis, and blood clots, which can occur from a poorly administered IV infusion. Phlebitis can cause blood clots, which can block important blood vessels, causing tissue damage or even be life-threatening. Lack of proper training and verification to assess IV patency (the line is open and not blocked allowing the treatment to flow directly into the patient's vein) can increase the spread of infection. Lack of training and verified competency to assess the insertion site for signs and symptoms of phlebitis or infection, fluid leaking (resulting in the treatment not being administered as ordered), redness, pain, tenderness, and swelling can result in the likelihood of increased risk of serious harm and/or death. Proper placement of the PICC through X-ray or ultrasound is required prior to the administration of medication; this knowledge is provided through training and education as part of the certification process. Findings include: Review of the job description for the Executive Director 1, with an effective date of 8/8/2022, reads, Purpose of Your Job Position: The Executive Director 1 is responsible for management of the facility in a manner which exemplifies Consulate Health Care's standard of operational excellence, to include but not limited to creating an environment in which employees demonstrate Compassion, Honesty, Integrity and Respect for one another and everyone they come into contact with, and business practices are conducted with Passion. The primary purpose of the Executive Director is to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern nursing facilities to ensure that the highest degree of quality care can be provided to our residents at all times. You are entrusted to provide innovative, responsible healthcare with the creation and implementation of new ideas and concepts that continually improve systems and processes to achieve superior results. Review of the job description for Director of Clinical Services I, with an effective date of 8/22/2022, reads, Purpose of Your Job Position: As a Consulate Health Care Director of Clinical Services, you are entrusted with the responsibility of caring for our residents, families, co-workers, visitors, and all others; as well as demonstrating in all interactions, Consulate Health Care's five core values of Compassion, Honesty, Integrity, Respect, and Passion. The primary purpose of your job position is to plan, organize, develop, and direct the overall operation of our Nursing Service Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be directed by the Executive Director to ensure that the highest degree of quality care is maintained at all times. You are entrusted to provide innovative, responsible healthcare with creation and implementation of new ideas and concepts that continually improve systems and processes to achieve superior results . Duties and Responsibilities . 5. Set and monitor achievement of goals and objectives for the nursing department consistent with established philosophy and standard of practice. 6. Recruit and hire a sufficient number of qualified nursing staff to deliver efficient resident care in accordance with the established staffing plan. 7. Establish, implement, and continually update competency/ skills checklists for nursing staff . 9. Maintain and guide the implementation of current policies and procedures, which reflect adherence to corporate and external regulatory guidelines . 11. Establish and monitor compliance with an effective medical record documentation system . 14. Actively participate in the quality improvement process for the facility . 15. Participate in and/or provide in-service education sessions. Review of Resident #84's records revealed the resident was admitted to the facility on [DATE] with the diagnoses including atherosclerotic heart disease of native coronary artery (heart disease) with angina pectoris (chest pain), acquired absence of left leg below knee, acquired absence of right leg below knee, hyperlipidemia (high cholesterol), hypertension, local infection of the skin, major depressive disorder, pressure ulcer right buttock stage 3, and pressure ulcer left buttock stage 3. Review of the physician order dated 8/21/2022 for Resident #84 reads, Sodium Chloride Injection Solution 0.9% (Sodium Chloride), Use 75 ml [milliliter]/hr [hour] intravenously every shift related to encounter for other specified prophylactic measures (Z29.8) for 14 days. IV [intravenous] NS [normal saline] to run continuously until IV ABT [antibiotic] completed. Review of the physician order dated 8/28/2022 for Resident #84 reads, Vancomycin HCl in Dextrose Intravenous Solution 1-5 GM [grams]/200 (milliliters)-% (Vancomycin HCl- Dextrose) Use 1000 mg [milligrams] intravenously in the evening for wound for 14 days. Pharmacy to dose. Review of the physician order dated 8/21/2022 for Resident #84 reads, IVs: Type of Access PICC. Review of the physician order dated 8/21/2022 for Resident #84 reads, IVs: Evaluate site for leakage/ bleeding/ signs of infection every shift. Review of the IV company report dated 8/22/2022 for Resident #84 reads, Reason for Consultation: PICC (non-valved) . Reason for Insertion: Drugs . Post-Insertion Data. Line Insertion: 3 CG PICC. Comments: 4 FR [French] PICC inserted into R [Right] basilic vein successfully . Instructed to order CXR [chest x-ray] for verification of PICC line tip placement prior to use. Review of the radiology report dated 8/22/2022 at 3:12 PM for Resident #84 reads, Conclusion: No acute cardiopulmonary process. Right PICC line tip in the right jugular venous system, recommend repositioning. Review of the IV company report dated 8/23/2022 for Resident #84 reads, Reason for Consultation: PICC (non-valved) . Reason for Insertion: Drugs . Post-Insertion Data. Line Insertion: 3 CG PICC. Reinsertion: Yes. Reinsertion Due To: Malpositioned PICC. Comments: 4 FR PICC inserted into L [left] basilic vein successfully . Instructed to order CXR for verification of PICC line tip placement prior to use. Review of the medical record indicated that no Chest X ray was ordered to confirm and verify proper placement prior to administering medications. Review of the medical record indicated that no [NAME] 3CG tip confirmation report (magnetic tracking of the tip of the PICC line that uses ECG (electrocardiogram) was present in the medical report. Review of the Medication Administration Record (MAR) documented that Staff J, Licensed Practical Nurse (LPN), administered Sodium Chloride 0.9% at 75 milliliters per hour on 8/22/2022 at 8:50 AM to Resident #84. Review of the MAR documented that Staff H, LPN, administered Sodium Chloride 0.9% at 75 milliliters per hour 8/23/2022 at 10:14 AM through a peripheral IV to Resident #84. Review of the MAR documented that Staff H, LPN, administered 10 milliliters of Normal Saline IV to Resident #84. Review of the MAR documented that Staff I, LPN, administered 10 milliliters of normal saline flush intravenously on 8/26/2022 at 11:38 AM through a left arm PICC line to Resident #84. Review of the MAR documented that Staff I, LPN, administered Sodium Chloride solution 0.9% at 75 milliliters per hour on 8/26/2022 at 11:38 AM through a left arm PICC line to Resident #84. Review of the MAR documented that Staff I, LPN, administered Vancomycin 1000 mg IV on 8/26/2022 at 11:38 AM through a left arm PICC line to Resident #84. Review of the MAR documented that Staff I, LPN, administered Vancomycin 1000 mg IV on 8/27/2022 at 8:39 AM through a left arm PICC line to Resident #84. Review of the MAR documented that Staff I, LPN, administered 10 milliliters of normal saline on 8/27/2022 at 8:40 AM intravenously through a left arm PICC line to Resident #84. Review of the MAR documented that Staff I, LPN, administered Sodium Chloride solution 0.9% at 75 ml/hr on 8/27/2022 at 8:40 AM through a left arm PICC line to Resident #84. Review of the MAR documented that Staff I, LPN, administered Vancomycin 1000 mg IV on 8/28/2022 at 11:08 AM through a left arm PICC line to Resident #84. Review of the MAR documented that Staff I, LPN, administered 10 milliliters of normal saline IV on 8/28/2022 at 11:39 AM through a left arm PICC line to Resident #84. Review of the MAR documented that Staff I, LPN, administered Vancomycin 1000 mg IV on 8/28/2022 at 6:16 PM through a left arm PICC line to Resident #84. Review of the employee file for Staff J, LPN, showed no IV competency or PICC line competency training within the file. Review of the employee file for Staff I, LPN, showed no IV competency or PICC line competency training within the file. Review of the employee file for Staff H, LPN, no IV competency or PICC line competency training within the file. During an interview on 8/31/2022 at 8:40 AM, the Advanced Practice Registered Nurse (APRN) stated, I was not aware that we did not do an X ray to confirm line placement prior to administering medications. There are possible complications related to infusing medications into any line that is not confirmed. During an interview on 8/31/2022 at 9:15 AM, the Attending Physician stated, I was made aware yesterday we did not complete an x-ray of the PICC line. Since then, we have obtained an x-ray showing the catheter is in place so there is no harm to the patient. I can't speak to harm to the patient as it is properly positioned at this time. I do expect for IV fluids to be administered per my orders and if they don't, they need to call me. During an interview on 8/31/2022 at 12:00 PM, Staff H, LPN, stated, I was the nurse on the day that [Resident #84's name] PICC line was reinserted. The nurse from the IV company came in and inserted it. I helped him with [Resident #84's name] arm. I held it, so he could get the dressing on. He told me that he thought it was in the right place. He did give me the paper that explained that I needed to get an X-ray. It is my signature on the sheet. I didn't know that I needed to get an X-ray. The nurse, he told me he didn't think he would need to come back. I just didn't know. I thought it was okay to use. I just attached it to his PICC line after the IV nurse left. I didn't know that I needed to get a chest X-ray. I should not have hung the IV. I really didn't think I was hanging it. I just connected it to the IV. I am not IV certified. I did not take the IV certification. I know that I can't hang antibiotics. I just didn't think that the normal saline was a problem. I have flushed PICC lines after antibiotics, but I haven't hung them. I just wanted him to get his fluids, so I did hang it. I did hang a new bag to the peripheral IV that the resident had before the PICC line was put in. Once they came to do the PICC, the IV was out and I just connected the normal saline to the PICC line as soon as the IV nurse left. During an interview on 8/31/2022 at 1:45 PM, the Director of Nursing (DON) stated, I was shocked that [Staff H, LPN's name] had done anything related to [Resident #84's name] PICC line. I heard her say that she did not have the IV certification and I was shocked. She was practicing outside her scope as an LPN. I was not aware that this was happening. I do not really know the process for verifying if an LPN is competent to do IVs. I just got here. I literally started the day you arrived for survey. We should have a copy of their 30-hour course when they are hired. We should not allow LPNs to administer IV medications unless we know that they have had the course. During a telephone interview on 8/31/2022 at 2:59 PM, Staff I, LPN, stated, I took an 8-hour course many years ago. I guess I did not do the 30-hour IV course, so I guess I am not IV certified. I thought I was okay to do the IVs with what I had done. No one ever asked me for my certification to do IV med administration. I did administer the Vancomycin, flush the PICC line and do the normal saline that was ordered to run continuously to [Resident #84's name]. I wasn't aware that it would be a problem. I wish I had known. I did not do a competency specific to the care of the PICC line dressing when I was hired. During a telephone interview on 8/31/2022 at 3:10 PM, Staff J, LPN, stated, I did administer [Resident #84's name] IV and I hung the normal saline. I have been doing IV medications. I was told that as long as there is an RN [Registered Nurse] in the building that I could do it. I was told that by [Staff C, LPN's name] the unit manager. I am in school to be an RN and I was told that I could do it, so I have. I am aware that as an LPN without IV certification I cannot administer any IV medications because it's against the nurse practice act. But I was told it was okay because I was in nursing school. During an interview on 8/31/2022 at 3:20 PM, the Assistant Director of Nursing (ADON) stated, I was not aware that any LPNs who were not IV certified would be administering IV medications. I would not tell any staff that they could practice outside of the nurse practice act. I am not aware of anyone telling an LPN that it was acceptable to administer meds through a PICC or change dressings if they had not taken the course. During an interview on 8/31/2022 at 3:30 PM, Staff C, LPN, stated, I have not told anyone that they could administer IV medications if they are not IV certified as an LPN. I have not said that it is okay for any LPN to administer IV medications if there is an RN in the building. I know that we as LPNs have to follow our scope of practice and that if we have not had the additional training, we can't administer medications IV. During an interview on 9/1/2022 at 7:15 AM, the Administrator stated, I am ultimately responsible for all that occurs in the building, and I had asked about whether all the LPNs were IV certified and knew that there were several LPNs needing the course. We had not arranged the course yet because I was waiting for the new director of nursing to get here. During the onboarding process, we should be verifying whether LPNs are IV certified and keeping record of this within their employee files. This should have been done and I can't tell you why it has not been. During an interview on 9/1/2022 at 7:35 AM, the Human Resources Director stated, The process of hiring staff starts with the application. We do verify licenses for licensed staff, and we will ask LPNs who tell us they are IV certified. The process used to be for human resources to get all certification nurses have and the DON would know and keep record of any staff competencies for nurse. During a telephone interview on 9/1/2022 at 8:10 AM, the Medical Director stated, I came by yesterday and found out about this problem. I did not know we had LPNs who weren't IV certified, administering IV medications. I would expect nurses to practice within their scope of practice. We plan to implement a solution. I would expect that all nurses practice within their scope of practice. Review of the policy and procedure titled Administration of Intermittent Infusion with an approval date of 8/8/2022 reads, Guidance . 2. Documentation of central vascular access device (CVAD) tip location must be included in the medical record prior to administration of medications. Maintain catheter patency per flushing/locking protocol while awaiting confirmation. Documentation may include: 2.1. Copy of chest X-ray results reporting location of tip, or fluoroscopy report. Review of the policy and procedure titled Continuous infusion of Medications and Solutions with an approval date of 8/8/2022 reads, To be Performed by: Licensed nurses according to state law and facility policy. The nurse is responsible and accountable for obtaining and maintaining competence with infusion therapy within his or her scope of practice. Competency validation is documented in accordance with organizational policy . Guidance . 2. Documentation of central vascular access tip location must be included in the medical record prior to administration of medications. Maintain catheter patency per flushing/locking protocol while awaiting tip confirmation. Documentation may include: 2.1. Copy of chest x-ray or fluoroscopy report; 2.2. Telephone order from radiologist stating location of tip (e.g. cavoatrial junction, IVC); 2.3. Copy of ECG technology insertion report.