**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 agency and/or facility staff to work outside of their scope of practice, administering IV (intravenous) medications via midline catheters for 4 of 4 residents, Residents #2, #56, #138, and #237, without certification of education, training and validation of competency for IV medication infusion to residents who are administered IV medications. 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. Findings include: 1. Review of the medical record for Resident #56 documented the resident was admitted to the facility on [DATE] with diagnoses of encounter for other orthopedic aftercare, aftercare following explantation (re-implantation) of knee joint prothesis, acute systolic (congestive) heart failure, hyperlipidemia, atherosclerotic (disease of the arteries characterized by the deposition of plaques of fatty material on their inner walls) heart disease, major depressive disorder, anemia, personal history of transient ischemic attack (mini stroke) and cerebral infarction (stroke is a brain lesion in which a cluster of brain cells die when they do not get enough blood) without residual deficits, and essential primary hypertension. During an observation for IV medication administration for Resident #56 on 5/4/2022 at 7:37 AM, Staff E, Licensed Practical Nurse (LPN), stated, The medication is due at 9 AM. I will not be able to administer it until 8 AM. Staff E entered Resident #56's room. The resident had a right double lumen peripherally inserted central catheter (PICC, a thin flexible tube that is inserted into a vein in the upper arm and guided, threaded, into a large vein above the right side of the heart called the superior vena cava, it is used to give intravenous fluids, antibiotics, blood transfusions and other drugs). The PICC line had no needleless connector on the left port, only a green cap and two needleless connectors on the right port of the PICC line. An empty Vancomycin 1000 mg bag of antibiotics was connected to the right port of the PICC line. Staff E removed the empty bag of Vancomycin, did not perform hand hygiene, did not don gloves, did not clean the IV insertion site, and flushed the right port of the PICC line that had two needleless connectors with ten milliliters of normal saline. Staff E did not aspirate to check for line patency (this ensures the line is open and in the correct placement). After exiting Resident #56's room, Staff E was observed speaking to other staff members. During an interview on 5/4/2022 at 7:47 AM, Staff E, LPN, stated, You will have to have another nurse hang the antibiotic. I am not IV certified. I did not take the 30-hour IV course. I cannot administer the medication. I am not certified to take care of the PICC line. I did not clean the hub or check that the line was patent by aspirating before I pushed the normal saline. I didn't think I needed to. I was just doing a flush. Review of the physician order for Resident #56 dated 4/29/2022 read, Cefepime HCL [Hydrochloride] 2 gm [gram]/100 ml [milliliters] use 2 grams intravenously every morning and at bedtime. Review of the physician order for Resident #56 dated 4/29/2022 read, Vancomycin HCL solution 1000 mg [milligrams]/200 ml use 1000 mg [milligrams] intravenously in the morning for prosthetic knee infection for 17 days. Review of the physician order for Resident #56 dated 4/29/2022 read, Vancomycin HCL solution 1000 mg/200 ml use 1000 mg intravenously in the evening for prosthetic knee infection for 17 days. Review of the Medication Administration Record (MAR) for Resident #56 documented Staff O, LPN, administered IV Vancomycin HCL on 3/22/22 at 10:59, on 3/23/22 at 8:31 AM, on 3/24/22 at 10:31 AM, on 3/25/22 at 12:31 PM, on 3/29/22 at 9:34 AM, on 3/30/22 at 9:35 AM, on 3/31/22 at 9:24 AM, on 4/1/22 at 9:16 AM, on 4/2/22 at 9:59 AM, on 4/3/22 at 9:44 AM, 4/3/22 at 9:21 PM, on 4/5/22 at 9:29 AM, 4/6/22 at 9:43 AM, on 4/7/22 at 10:01 AM, 4/8/22 at 9:53 AM, 4/12/22 at 9:49 AM, on 4/13/22 at 9:00 AM, on 4/16/22 at 10:11 AM, on 4/17/22 at 9:39 AM, 4/19/22 at 9:48 AM, on 4/20/22 at 10:14 AM, 4/21/22 at 10:17 AM, and on 4/22/22 at 10:34 AM. Review of the MAR for Resident #56 documented Staff G, LPN, administered IV Cefepime HCL solution on 4/3/22 at 5:50 PM, on 4/4/22 at 5:08 AM, 4/12/22 at 5:01 PM, on 4/13/22 at 5:58 AM, and on 5/1/22 at 9:36 PM. Review of the MAR for Resident #56 documented Staff G, LPN, administered IV Vancomycin HCL solution on 4/12/22 at 9:15 PM, on 5/1/22 at 5:50 PM, and on 5/2/22 at 5:43 AM. Review of the MAR for Resident #56 documented Staff E, LPN, administered IV Cefepime HCL solution on 4/6/22 at 6:30 PM, and on 5/3/22 at 9:33 PM. Review of the MAR for Resident #56 documented Staff E, LPN, administered IV Vancomycin HCL solution on 5/3/22 at 4:40 PM. Review of the MAR for Resident #56 documented Staff A, LPN, administered IV Vancomycin HCL solution on 4/6/22 at 9:14 PM. Review of the MAR for Resident #56 documented Staff L, LPN, administration of IV Cefepime HCL solution on 4/18/22 at 10:54 PM, on 4/19/22 at 7:15 AM. Review of the MAR for Resident #56 documented Staff I, LPN, administered IV Cefepime HCL solution on 4/20/22 at 6:58 PM. Review of the MAR for Resident #56 documented Staff I, LPN, administered IV Vancomycin HCL solution on 4/20/22 at 9:21 PM. 2. Review of the medical record for Resident #2 documented the resident was admitted to the facility on [DATE] with diagnoses of pneumonia, sepsis (a life-threatening complication of infection in the blood stream), COVID-19 (Corona Virus Disease 2019), urinary tract infection, congestive heart failure, chronic kidney disease, type 2 diabetes mellitus. Review of Resident #2's physician orders dated 4/21/2022 read, Cefazolin sodium-dextrose solution reconstituted 2-3 gm-% (50 ml). Use 50 ml Intravenously every 12 hours for bacteremia [bacteria in the circulating blood] until 5/22/22. Review of Resident #2's physician orders dated 4/20/2022 read, Normal saline flush solution 0.9% sodium chloride (NS) flush - use 10 ml intravenously every shift for IV patency until 5/22/22 - flush with 10 ml normal saline prior to and after administration of medication. Review of the MAR for Resident #2 documented Staff F, LPN, administered IV Cefazolin Sodium-Dextrose on 4/20/22 at 9:00 PM, IV normal saline flush solution 0.9% sodium chloride (NS) on 4/20/22 at 9:35 PM, IV NS flush on 4/29/22 at 6:28 PM, and IV Cefazolin Sodium-Dextrose solution and IV NS flush on 4/29/22 at 9:45 PM. Review of the MAR for Resident #2 documented Staff I, LPN, administered IV Cefazolin Sodium-Dextrose solution on 4/21/22 at 9:25 PM, IV NS flush on 4/23/22 at 4:31 PM, and IV NS flush on 4/23/22 at 9:25 PM. Review of the MAR for Resident #2 documented Staff A, LPN, administered IV NS flush on 4/23/22 at 7:44 PM, IV NS flush on 4/24/22 at 10:09 AM, IV Cefazolin Sodium-Dextrose solution on 4/24/22 at 10:11 AM, and IV NS flush on 4/24/22 at 9:21 PM. Review of the MAR for Resident #2 documented Staff H, LPN, administered IV NS flush on 4/27/22 at 12:46 AM Review of the MAR for Resident #2 documented Staff E, LPN, administered IV NS flush on 4/27/22 at 3:47 PM, IV Cefazolin Sodium-Dextrose solution and a NS flush on 4/27/22 at 8:58 PM, IV NS flush on 5/3/22 at 3:51 PM, IV Cefazolin Sodium-Dextrose solution and IV NS flush on 5/3/22 at 9:00 PM, and IV NS flush on 5/4/22 at 11:03 AM. Review of the MAR for Resident #2 documented Staff J, LPN, administered IV NS flush on 4/30/22 at 6:24 PM, IV Cefazolin Sodium-Dextrose solution and IV NS flush on 4/30/22 at 9:51 PM, and IV NS flush on 5/1/22 at 4:29 AM. Review of the MAR for Resident #2 documented Staff G, LPN, administered IV Cefazolin Sodium-Dextrose solution and IV NS flush on 5/1/22 at 9:37 PM. 3. Review of the medical record for Resident #138 documented the resident was admitted to the facility on [DATE] with diagnoses to include disruption of external operation (surgical) wound, pseudomonas (type of bacteria that causes infection) as the cause of diseases, encounter for surgical aftercare following surgery on the skin and subcutaneous tissue, cellulitis (deep skin infection that spreads quickly), fall on same level from slipping, tripping and stumbling with subsequent striking against object, presence of right artificial hip joint, moderate protein calorie malnutrition, chronic obstructive pulmonary disease (chronic inflammatory lung disease), hyperlipidemia (elevated lipid levels), atherosclerotic heart disease of native coronary artery without angina pectoris, paroxysmal atrial fibrillation (abnormal heart rhythm), nonrheumatic aortic valve stenosis (narrowing of the valve), obstructive sleep apnea, essential primary hypertension, muscle weakness, lack of coordination, weakness and peripheral vascular disease. Review of Resident #138's physician orders dated 4/5/2022 read, Flush each valved PICC catheter lumen with 10 ml NS before and after each use every 12 hours every 7 days for PICC line maintenance. Review of Resident #138's physician orders dated 4/5/22 read, Cefepime HCL Solution 2 GM/100 ml Use 100 ml intravenously every 12 hours for pseudomonas infection of surgical hip site for 6 weeks. Review of the MAR for Resident #138 documented Staff F, LPN, administered IV Cefepime on 4/10/22 at 8:00 PM, on 4/11/22 at 8:58 PM, on 4/13/22 at 9:26 PM, on 4/14/22 at 10:03 PM, on 4/22/22 at 9:32 AM, on 4/23/22 at 10:37 PM, on 4/24/22 at 8:53 PM, on 4/25/22 at 8:26 PM, on 4/27/22 at 9:19 PM, and on 4/28/22 at 8:17 PM. Review of the MAR for Resident #138 documented Staff A, LPN, administered IV Cefepime on 4/16/22 at 10:20 AM, on 4/20/22 at 9:06 AM, on 4/20/22 at 9:36 PM, on 4/22/22 at 10:35 AM, on 4/27/22 at 11:13 AM, and on 4/29/22 at 8:23 AM. 4. Review of the medical record for Resident #237 documented the resident was admitted to the facility on [DATE] with diagnoses to include encounter for orthopedic aftercare, displaced bicondylar fracture of right tibia, tear of lateral meniscus, history of falling, hyperlipidemia, atherosclerotic heart disease, hypertension, gastroesophageal reflux disease (where the liquid content of the stomach refluxes into the esophagus), morbid obesity, hypothyroidism, benign prostatic hyperplasia (flow of urine is blocked due to the enlargement of prostate gland), anemia, major depressive disorder, and type 2 diabetes mellitus. Review of the physician orders for Resident #237 dated 5/2/2022 read, Sodium Chloride Solution 0.9%. Use 75 ml/hr [hour] IV every shift for dehydration for 1 day. IV fluids for 2 liters then stop fluids. Review of the MAR for Resident #237 documented Staff E, LPN, administered IV NS flush on 5/3/22 at 6:20 PM. During an interview on 5/4/2022 at 8:17 AM, the Acting Director of Nursing (DON) stated, I am responsible for all the care delivered in the facility. I spoke to the LPN, [Staff E's name] and he was saying he did an IV course, but it might not be the 30-hour course that he needs. We are checking with the agency and with human resources to determine what is true. I'm not sure who actually takes care of knowing an agency staff qualification if they are an LPN. I will check into this. A request was made for Staff E's 30-hour IV certification documentation. During an interview on 5/4/2022 at 8:25 AM, the Quality Improvement Nurse Manager stated, It is a nursing standard of practice that the LPN must be certified with an IV course to administer IV medications in a central line. I am not responsible for the onboarding of staff and what their certifications and abilities are. I was not aware that there were LPNs who are not certified administering IV medications. We have a registered nurse or IV certified LPN available at all times and they are on call also for off hours. During an interview on 5/4/2022 at 8:30 AM, the Administrator was informed Staff E administered IV NS and Staff E then stated he did not have IV certification. When asked how the facility received information from the agencies related to IV certification, the Administrator stated, I don't know. During an interview on 5/4/2022 at 8:38 AM, the Acting DON stated, He [Staff E] only has 16 hours. A request was made for all IV certifications for all nurses on staff and all agency staff. During an interview on 5/4/2022 at 8:40 AM, the Education Coordinator stated, I am not responsible for maintaining staff competency. I am responsible for onboarding and education of brand-new staff. I work out of HR [Human Resources] and do orientation, Relias training, fire and life safety and HIPPA [Health Insurance Portability and Accountability Act] compliance. I do not deal with maintaining competency of agency staff that is the responsibility of the DON. During an interview on 5/4/2022 at 9:45 AM, Staff A, Agency LPN, stated, I am not IV certified and I would get a staff member who was if I had any to administer. I did administer medications if I signed that I did. If my initials are in the box, I must have administered them. I should not administer any IV medications or flush a PICC, midline or IV. I did administer IV medications to [Resident #138's name] on 4/16, 4/20, 4/22, 4/27 and 4/29. Those are my initials that I administered them. During an interview on 5/4/2022 at 3:20 PM, Staff F, Agency LPN, stated she was not IV certified. She was not aware that she needed to be IV certified in the state of Florida. She stated no one at this facility asked her for IV certification before giving IV medications. She has been administering IVs in the facility, hanging IVs and administering IV pushes. During an interview on 5/5/2022 at 9:02 AM, the Administrator stated the agency provided staff with baseline requirements and IV certification was not one of them. He stated he could not verify if any of the agency staff had IV certifications because that information was not requested. His expectation was that agency staff that were not IV certified should not administer IV medications. The facility posted staff openings on an application called on shift. The agency staff signed up for the shifts they wanted. The posting for the needed shift did not indicate if IV certification was required. Review of the Supplemental Staffing Agreement for Healthcare Professionals entered into August 22, 2021 between [Staffing Agency's name] and Lake Port Square, LLC, read, II. Temporary Placement. b. Candidate Qualifications. Except where prohibited by law, [Staffing Agency's name] will provide Client with qualifications of Candidates as reasonably necessary to establish competency, which may include completed employment application, clinical skills checklist(s), medication competency exam professional references, and verification of license. [Staffing Agency's name] will verify that each Candidate has the minimum experience requested by Client within the area of assignment. Furthermore, [Staffing Agency's name] will maintain compliance documentation on file for each Candidate referred to Client. Client agrees to maintain such compliance documentation in a trustworthy manner in a secure and confidential location and to protect such documentation from any unauthorized disclosure consistent with state and federal law. The required compliance documentation will be specified in writing by Client prior to Candidate's start date (the required documentation). Client may request additional compliance documentation; provided, however, [Staffing Agency's name] shall not be obligated to produce documentation in addition to the Required Documentation. If [Staffing Agency's name] does not produce additional documentation, Client may cancel the order. All Clients request for additional documentation requests must be made in writing. During an interview on 5/5/2022 at 9:05 AM, the Acting Director of Nursing (DON) stated, We use agency staff every day. Each staff from agency that we use should be aware of the need for the IV certification 30-hour course and not administer any medications they are not qualified to administer. There is a nurse on call 24 hours a day, an RN [Registered Nurse], so even if we did not have someone in the building who was certified they could call at any time and we would need to come administer the medication. I expect that our nurses would not sign for something that they have not administered. I would expect the nurses who administered the medication to follow the five rights of administration and would complete their own documentation. I can't give you a good answer as to why this wasn't happening. I was not aware that this wasn't happening. We do not have a specific competency for agency staff. I don't think we would need to post for a specifically IV certified LPN because we have someone available twenty-four hours a day, someone on call in case of emergencies and they should just call me if they have questions. The on-call schedule is posted at each nurse's station and the fulltime staff would always know they can call me. During an interview on 5/5/2022 at 9:23 AM, the Medical Director stated he was made aware of the fact that unqualified LPNs were administering IV medications to the residents in the facility, in which two of the residents [Residents #138 and #237's names] were directly under his care. He stated he received a call from the administrator from the facility on 5/4/2022. He stated he was not aware of the fact that the situation prior to the call/notification on 5/4/2022. During a telephone interview on 5/5/2022 at 2:17 PM, Staff H, LPN, stated, I have completed IV flushes and administered antibiotics when I have worked at [Facility's name]. I wasn't aware that I was not able to administer premixed medications. I thought that I could. I knew that I could not administer anything that needed to be mixed or start an IV, but I did think I could do flushes and hang antibiotics that were already mixed. I never asked anyone to do those for me. I am not IV certified and I haven't changed a PICC line dressing, I can't do that. I didn't know that I was supposed to get an IV certified nurse to give my antibiotics. During an interview on 5/5/2022 at 2:35 PM, the Staffing Coordinator stated, I do the scheduling for the health center. We do not have enough staff to cover all the shifts, so we use agency. I put any open shifts in 'On shift'. I can not specify whether they are IV certified. I can only request a CNA, LPN, or RN positions. I schedule five to six nurses during the day, five to six nurses on the second shift and four for overnight. I do not staff specifically for IV administration of medications due to the fact that we always have an RN on site or one on call. I do not have access to whether they are IV certified or not. If they are agency staff, I cannot see if they are IV certified either. During a telephone interview on 5/5/2022 at 2:35 PM, Staff M, LPN, stated, I did not administer any IV medications. A flush is not a medication. I do not consider a flush to be an IV medication. My initials are on the MAR and that means that I administered the medication. I have not administered any other IV medications. During an interview on 5/5/2022 at 2:45 PM, the Staffing Scheduler was requested to provide the nursing licenses and IV certifications of the 30-hour training for IV administration of medications for all facility and agency staff LPNs. During a telephone interview on 5/5/2022 at 2:56 PM, Staff J, LPN, stated, I have not administered IV medication for anyone. On Saturday, I think it was Saturday, I told them I was not IV certified and the nurse said don't worry about it someone else will do it. I just signed it off and I don't know if it was administered but I did not administer it. I did sign the MAR, thinking about this I guess I shouldn't have done that at all. I don't remember what nurse I told that to. During an interview on 5/5/2022 at 2:57 PM, the Staffing Coordinator stated, The facility has two agency contracts, [Staffing Agencies' names]. From these agencies, we get staff that work a permanent shift, for example 40 hours a week, every week. The required documents are documents that are needed for our facility like TB [tuberculosis], and background checks. IV certification documentation is not one of the required documents. During an interview on 5/5/2022 at 3:05 PM, the Staffing Scheduler entered the conference room. The requested documentation was not provided. A second request was made for the nursing licenses and IV certifications of the 30-hour training for IV administration of medications for all facility and agency staff LPNs. During a telephone interview on 5/5/2022 at 3:13 PM, Staff O, LPN, stated, I am not certified to do IV administration of medications. I always get someone else to do my IVs for me. I will get everything ready, get the medication, the tubing, and the flushes. We will go into the room together and they administer the IV medication when I give the other medications. We do those at the same time. We both go into the room at the same time. I didn't realize that I shouldn't sign for the medication unless I actually administer it. I was provided training in my orientation about medication administration. I guess I should have known not to do that, not to sign if I didn't administer it, but I thought it was okay because I saw it being hung. A request was made for names of nurses who hung the medications signed as administered by Staff O. No names were provided. Review of the MARs and nursing progress notes for Resident #56 for the period of 3/22/2022 through 5/1/2022 did not provide documentation for nurses who may have hung and/or provided NS flushes for Resident #56 other than Staff O. During a telephone interview on 5/5/2022 at 5:30 PM, the Medical Doctor (MD) (attending physician for Residents #2 and #56) stated that he was not made aware that unqualified LPNs were administering IV medications to the residents in the facility. He stated, I would have thought the facility would have a system in place to either get their nurses certified or not allow them to give IV medications. That was not too smart of them. I will inform the rest of my staff of the situation so the residents can be assessed for injury. During an interview on 5/6/2022 at 2:10 PM, when discussed the IV 30-hour certifications were not provided for Staff O, LPN, Staff G, LPN, Staff E, LPN, Staff A, LPN, Staff F, LPN, Staff L, LPN, Staff I, LPN, Staff H, LPN, and Staff J, LPN, the DON stated, I do not have IV certifications for any nurses that had not already been provided. Review of the policy and procedure titled. Abuse, Neglect and Exploitation with an approval date of 2/23/2022 read, Abuse, neglect and exploitation is a complex and often hidden problem. Everyone has the responsibility to make a report when abuse, neglect or exploitation is suspected. Neglect: The failure or omission on the part of the caregiver to provide care, supervision, and services necessary to maintain the physical and mental health of a vulnerable adult. The failure of the caregiver to make a reasonable effort to protect a vulnerable adult from abuse neglect and exploitation by others. Review of the policy and procedure titled, Abuse Prevention Program with an approval date of 2/23/2022 read, It is the policy of this community to provide each resident with an environment that is free from verbal, sexual physical and mental abuse, corporal punishment, and involuntary seclusion. We have established policies and procedures that will provide personnel (including consultants, contractors, volunteers, and other caregivers who provide care and services to residents) with the knowledge to further ensure each resident is treated with individual respect and dignity. II. Orientation and Training of Employees: To assist in identification of abuse, the following definitions of abuse are provided during training: a. Abuse is defined as the willful infliction of injury, unreasonable confinement: intimidation: punishment with resulting physical harm, pain or mental anguish; or deprivation by an individual, including a caretaker, of goods and services that are necessary to attain and maintain physical, mental and psychosocial well-being; g. Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. III, Preventing Resident Abuse- Establishing a Resident Sensitive Environment: This community desires to prevent abuse, neglect, or misappropriation of property by establishing a resident sensitive and resident secure environment. This will be accomplished by a comprehensive quality management approach including the following: Staff supervision: On a regular basis, supervisors will monitor the ability of the staff to meet the needs of residents, staff understanding of individual resident care needs, and situations such as inappropriate language, incentive handling or impersonal care will be corrected as they occur. Incidents short of willful abuse will be handled through counseling, training, and if necessary or repeated, the community's progressive discipline policy. Review of the policy and procedure titled, Midline Catheter Flushing and Locking with a revision date of July 1, 2012, and an approval date of 2/23/2022 read, 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. Review of the policy and procedure titled, Guidelines for Preventing Intravenous Catheter-Related Infections with a revision date of August 2014, and an approval date of 2/23/2022 read, Purpose: The purpose of this procedure is to maximally reduce the risk of infection associated with indwelling intravenous (IV) catheters. General Guidelines: 1. Facility staff who manage infusion catheters will have training and demonstrated clinical competency in intravenous therapy, including: b. proper procedures for the insertion and maintenance of IV catheters; and c. appropriate infection control measures to prevent IV catheter-related infections. Nurse Practice Guidelines to Prevent Catheter-Related Infections: Surveillance: 6. Any time that dressing is not intact or end caps are missing, the catheter has the potential for contamination. Catheter Site Dressing regimens: 1. Change the initial dressing after catheter placement within 24 hours. 4. Change TSM dressings on CVADs every 5-7 days or PRN (as needed) if damp, loosened, or visibly soiled. This does not require a doctor's order. Cleaning Needleless Connection devices: 2. Disinfect the needleless connector prior to each access using alcohol, tincture of iodine, or chlorohexidine gluconate/alcohol combination. Review of the policy and procedure titled, Administering Medications with an approval date of 2/23/2022 read, Policy statement: Medications shall be administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: 1. Only licensed persons licensed or permitted by this state to prepare, administer, and document the administration of medications may do so. 2. The Director of Nursing Services will supervise and direct all nursing personnel who administer medications and/or have related functions. Review of Florida Administrative Code under 64B9-12.005, Competency and Knowledge Requirements Necessary to Qualify the LPN to Administer IV Therapy, read, (1) Contents. The board endorses the Intravenous Therapy Course Guidelines issued by the Education Department of the National Federation of Licensed Practical Nurses, November, 1983. The intravenous therapy education must contain the following components: (a) Policies and procedures of both the Nurse Practice Act and the employing agency in regard to intravenous therapy. This includes legalities of both the Licensed Practical Nurse role and the administration of safe care. Principles of charting are also included. (b) Psychological preparation and support for the patient receiving IV therapy as well as the appropriate family members/ significant others. (c) Site and function of the peripheral veins used for veinpuncture. (d) Procedure for veinpuncture, including physical and psychological preparation, site selection, skin preparation, palpation of veins, and collection of equipment. (e) Relationship between intravenous therapy and the body's homeostatic and regulatory functions, with attention to the clinical manifestations of fluid and electrolyte imbalance. (f) Signs and symptoms of local and systemic complications in the delivery of fluids and medications and the preventive and treatment measures for these complications. (g) Identification of various types of equipment used in administering intravenous therapy with content related to criteria for use of each and means of troubleshooting for malfunction. (h) Formulas used to calculate fluid and drug administration rate. (i) Methods of administering drugs intravenously and advantages and disadvantages of each. (j) Principles of compatibility and incompatibility of drugs and solutions. (k) Nursing management of the patient receiving drug therapy, including principles of chemotherapy, protocols, actions, and side effects. (l) Nursing management of the patient receiving blood and blood components, following institutional protocol. Include indications and contraindications for use; identification of adverse reactions. (m) Nursing management of the patient receiving parenteral nutrition, including principles of metabolism, potential complications, and physical and psychological measures to ensure the desired therapeutic effect. (n) Principles of infection control in IV therapy, including aseptic technique and prevention and treatment of iatrogenic infection. (o) Nursing management of special IV therapy procedures that are commonly used in the clinical setting, such as heparin lock, central lines, and arterial lines. (p) Glossary of common terminology pertinent to IV fluid therapy. (q) Performance check list by which to evaluate clinical application of knowledge and skills. (2) Central Lines. The Board recognizes that through appropriate education and training, a Licensed Practical Nurse is capable of performing intravenous therapy via central lines under the direction of a registered professional nurse as defined in subsection 64B9-12.002(2), F.A.C. Appropriate education and training requires a minimum of four (4) hours of instruction. The requisite four (4) hours of instruction may be included as part of the thirty (30) hours required for intravenous therapy education specified in subsection (4) of this rule. The education and training[TRUNCATED]

**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 agency and/or facility staff to work outside of their scope of practice, administering IV (intravenous) medications via midline catheters for 4 of 4 residents, Residents #2, #56, #138, and #237, without certification of education, training and validation of competency for IV medication infusion to residents who are administered IV medications. 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. Findings include: 1. Review of the medical record for Resident #56 documented the resident was admitted to the facility on [DATE] with diagnoses of encounter for other orthopedic aftercare, aftercare following explantation (re-implantation) of knee joint prothesis, acute systolic (congestive) heart failure, hyperlipidemia, atherosclerotic (disease of the arteries characterized by the deposition of plaques of fatty material on their inner walls) heart disease, major depressive disorder, anemia, personal history of transient ischemic attack (mini stroke) and cerebral infarction (stroke is a brain lesion in which a cluster of brain cells die when they do not get enough blood) without residual deficits, and essential primary hypertension. During an observation for IV medication administration for Resident #56 on 5/4/2022 at 7:37 AM, Staff E, Licensed Practical Nurse (LPN), stated, The medication is due at 9 AM. I will not be able to administer it until 8 AM. Staff E entered Resident #56's room. The resident had a right double lumen peripherally inserted central catheter (PICC, a thin flexible tube that is inserted into a vein in the upper arm and guided, threaded, into a large vein above the right side of the heart called the superior vena cava, it is used to give intravenous fluids, antibiotics, blood transfusions and other drugs). The PICC line had no needleless connector on the left port, only a green cap and two needleless connectors on the right port of the PICC line. An empty Vancomycin 1000 mg bag of antibiotics was connected to the right port of the PICC line. Staff E removed the empty bag of Vancomycin, did not perform hand hygiene, did not don gloves, did not clean the IV insertion site, and flushed the right port of the PICC line that had two needleless connectors with ten milliliters of normal saline. Staff E did not aspirate to check for line patency (this ensures the line is open and in the correct placement). After exiting Resident #56's room, Staff E was observed speaking to other staff members. During an interview on 5/4/2022 at 7:47 AM, Staff E, LPN, stated, You will have to have another nurse hang the antibiotic. I am not IV certified. I did not take the 30-hour IV course. I cannot administer the medication. I am not certified to take care of the PICC line. I did not clean the hub or check that the line was patent by aspirating before I pushed the normal saline. I didn't think I needed to. I was just doing a flush. Review of the physician order for Resident #56 dated 4/29/2022 read, Cefepime HCL [Hydrochloride] 2 gm [gram]/100 ml [milliliters] use 2 grams intravenously every morning and at bedtime. Review of the physician order for Resident #56 dated 4/29/2022 read, Vancomycin HCL solution 1000 mg [milligrams]/200 ml use 1000 mg [milligrams] intravenously in the morning for prosthetic knee infection for 17 days. Review of the physician order for Resident #56 dated 4/29/2022 read, Vancomycin HCL solution 1000 mg/200 ml use 1000 mg intravenously in the evening for prosthetic knee infection for 17 days. Review of the Medication Administration Record (MAR) for Resident #56 documented Staff O, LPN, administered IV Vancomycin HCL on 3/22/22 at 10:59, on 3/23/22 at 8:31 AM, on 3/24/22 at 10:31 AM, on 3/25/22 at 12:31 PM, on 3/29/22 at 9:34 AM, on 3/30/22 at 9:35 AM, on 3/31/22 at 9:24 AM, on 4/1/22 at 9:16 AM, on 4/2/22 at 9:59 AM, on 4/3/22 at 9:44 AM, 4/3/22 at 9:21 PM, on 4/5/22 at 9:29 AM, 4/6/22 at 9:43 AM, on 4/7/22 at 10:01 AM, 4/8/22 at 9:53 AM, 4/12/22 at 9:49 AM, on 4/13/22 at 9:00 AM, on 4/16/22 at 10:11 AM, on 4/17/22 at 9:39 AM, 4/19/22 at 9:48 AM, on 4/20/22 at 10:14 AM, 4/21/22 at 10:17 AM, and on 4/22/22 at 10:34 AM. Review of the MAR for Resident #56 documented Staff G, LPN, administered IV Cefepime HCL solution on 4/3/22 at 5:50 PM, on 4/4/22 at 5:08 AM, 4/12/22 at 5:01 PM, on 4/13/22 at 5:58 AM, and on 5/1/22 at 9:36 PM. Review of the MAR for Resident #56 documented Staff G, LPN, administered IV Vancomycin HCL solution on 4/12/22 at 9:15 PM, on 5/1/22 at 5:50 PM, and on 5/2/22 at 5:43 AM. Review of the MAR for Resident #56 documented Staff E, LPN, administered IV Cefepime HCL solution on 4/6/22 at 6:30 PM, and on 5/3/22 at 9:33 PM. Review of the MAR for Resident #56 documented Staff E, LPN, administered IV Vancomycin HCL solution on 5/3/22 at 4:40 PM. Review of the MAR for Resident #56 documented Staff A, LPN, administered IV Vancomycin HCL solution on 4/6/22 at 9:14 PM. Review of the MAR for Resident #56 documented Staff L, LPN, administration of IV Cefepime HCL solution on 4/18/22 at 10:54 PM, on 4/19/22 at 7:15 AM. Review of the MAR for Resident #56 documented Staff I, LPN, administered IV Cefepime HCL solution on 4/20/22 at 6:58 PM. Review of the MAR for Resident #56 documented Staff I, LPN, administered IV Vancomycin HCL solution on 4/20/22 at 9:21 PM. 2. Review of the medical record for Resident #2 documented the resident was admitted to the facility on [DATE] with diagnoses of pneumonia, sepsis (a life-threatening complication of infection in the blood stream), COVID-19 (Corona Virus Disease 2019), urinary tract infection, congestive heart failure, chronic kidney disease, type 2 diabetes mellitus. Review of Resident #2's physician orders dated 4/21/2022 read, Cefazolin sodium-dextrose solution reconstituted 2-3 gm-% (50 ml). Use 50 ml Intravenously every 12 hours for bacteremia [bacteria in the circulating blood] until 5/22/22. Review of Resident #2's physician orders dated 4/20/2022 read, Normal saline flush solution 0.9% sodium chloride (NS) flush - use 10 ml intravenously every shift for IV patency until 5/22/22 - flush with 10 ml normal saline prior to and after administration of medication. Review of the MAR for Resident #2 documented Staff F, LPN, administered IV Cefazolin Sodium-Dextrose on 4/20/22 at 9:00 PM, IV normal saline flush solution 0.9% sodium chloride (NS) on 4/20/22 at 9:35 PM, IV NS flush on 4/29/22 at 6:28 PM, and IV Cefazolin Sodium-Dextrose solution and IV NS flush on 4/29/22 at 9:45 PM. Review of the MAR for Resident #2 documented Staff I, LPN, administered IV Cefazolin Sodium-Dextrose solution on 4/21/22 at 9:25 PM, IV NS flush on 4/23/22 at 4:31 PM, and IV NS flush on 4/23/22 at 9:25 PM. Review of the MAR for Resident #2 documented Staff A, LPN, administered IV NS flush on 4/23/22 at 7:44 PM, IV NS flush on 4/24/22 at 10:09 AM, IV Cefazolin Sodium-Dextrose solution on 4/24/22 at 10:11 AM, and IV NS flush on 4/24/22 at 9:21 PM. Review of the MAR for Resident #2 documented Staff H, LPN, administered IV NS flush on 4/27/22 at 12:46 AM Review of the MAR for Resident #2 documented Staff E, LPN, administered IV NS flush on 4/27/22 at 3:47 PM, IV Cefazolin Sodium-Dextrose solution and a NS flush on 4/27/22 at 8:58 PM, IV NS flush on 5/3/22 at 3:51 PM, IV Cefazolin Sodium-Dextrose solution and IV NS flush on 5/3/22 at 9:00 PM, and IV NS flush on 5/4/22 at 11:03 AM. Review of the MAR for Resident #2 documented Staff J, LPN, administered IV NS flush on 4/30/22 at 6:24 PM, IV Cefazolin Sodium-Dextrose solution and IV NS flush on 4/30/22 at 9:51 PM, and IV NS flush on 5/1/22 at 4:29 AM. Review of the MAR for Resident #2 documented Staff G, LPN, administered IV Cefazolin Sodium-Dextrose solution and IV NS flush on 5/1/22 at 9:37 PM. 3. Review of the medical record for Resident #138 documented the resident was admitted to the facility on [DATE] with diagnoses to include disruption of external operation (surgical) wound, pseudomonas (type of bacteria that causes infection) as the cause of diseases, encounter for surgical aftercare following surgery on the skin and subcutaneous tissue, cellulitis (deep skin infection that spreads quickly), fall on same level from slipping, tripping and stumbling with subsequent striking against object, presence of right artificial hip joint, moderate protein calorie malnutrition, chronic obstructive pulmonary disease (chronic inflammatory lung disease), hyperlipidemia (elevated lipid levels), atherosclerotic heart disease of native coronary artery without angina pectoris, paroxysmal atrial fibrillation (abnormal heart rhythm), nonrheumatic aortic valve stenosis (narrowing of the valve), obstructive sleep apnea, essential primary hypertension, muscle weakness, lack of coordination, weakness and peripheral vascular disease. Review of Resident #138's physician orders dated 4/5/2022 read, Flush each valved PICC catheter lumen with 10 ml NS before and after each use every 12 hours every 7 days for PICC line maintenance. Review of Resident #138's physician orders dated 4/5/22 read, Cefepime HCL Solution 2 GM/100 ml Use 100 ml intravenously every 12 hours for pseudomonas infection of surgical hip site for 6 weeks. Review of the MAR for Resident #138 documented Staff F, LPN, administered IV Cefepime on 4/10/22 at 8:00 PM, on 4/11/22 at 8:58 PM, on 4/13/22 at 9:26 PM, on 4/14/22 at 10:03 PM, on 4/22/22 at 9:32 AM, on 4/23/22 at 10:37 PM, on 4/24/22 at 8:53 PM, on 4/25/22 at 8:26 PM, on 4/27/22 at 9:19 PM, and on 4/28/22 at 8:17 PM. Review of the MAR for Resident #138 documented Staff A, LPN, administered IV Cefepime on 4/16/22 at 10:20 AM, on 4/20/22 at 9:06 AM, on 4/20/22 at 9:36 PM, on 4/22/22 at 10:35 AM, on 4/27/22 at 11:13 AM, and on 4/29/22 at 8:23 AM. 4. Review of the medical record for Resident #237 documented the resident was admitted to the facility on [DATE] with diagnoses to include encounter for orthopedic aftercare, displaced bicondylar fracture of right tibia, tear of lateral meniscus, history of falling, hyperlipidemia, atherosclerotic heart disease, hypertension, gastroesophageal reflux disease (where the liquid content of the stomach refluxes into the esophagus), morbid obesity, hypothyroidism, benign prostatic hyperplasia (flow of urine is blocked due to the enlargement of prostate gland), anemia, major depressive disorder, and type 2 diabetes mellitus. Review of the physician orders for Resident #237 dated 5/2/2022 read, Sodium Chloride Solution 0.9%. Use 75 ml/hr [hour] IV every shift for dehydration for 1 day. IV fluids for 2 liters then stop fluids. Review of the MAR for Resident #237 documented Staff E, LPN, administered IV NS flush on 5/3/22 at 6:20 PM. During an interview on 5/4/2022 at 8:17 AM, the Acting Director of Nursing (DON) stated, I am responsible for all the care delivered in the facility. I spoke to the LPN, [Staff E's name] and he was saying he did an IV course, but it might not be the 30-hour course that he needs. We are checking with the agency and with human resources to determine what is true. I'm not sure who actually takes care of knowing an agency staff qualification if they are an LPN. I will check into this. A request was made for Staff E's 30-hour IV certification documentation. During an interview on 5/4/2022 at 8:25 AM, the Quality Improvement Nurse Manager stated, It is a nursing standard of practice that the LPN must be certified with an IV course to administer IV medications in a central line. I am not responsible for the onboarding of staff and what their certifications and abilities are. I was not aware that there were LPNs who are not certified administering IV medications. We have a registered nurse or IV certified LPN available at all times and they are on call also for off hours. During an interview on 5/4/2022 at 8:30 AM, the Administrator was informed Staff E administered IV NS and Staff E then stated he did not have IV certification. When asked how the facility received information from the agencies related to IV certification, the Administrator stated, I don't know. During an interview on 5/4/2022 at 8:38 AM, the Acting DON stated, He [Staff E] only has 16 hours. A request was made for all IV certifications for all nurses on staff and all agency staff. During an interview on 5/4/2022 at 8:40 AM, the Education Coordinator stated, I am not responsible for maintaining staff competency. I am responsible for onboarding and education of brand-new staff. I work out of HR [Human Resources] and do orientation, Relias training, fire and life safety and HIPPA [Health Insurance Portability and Accountability Act] compliance. I do not deal with maintaining competency of agency staff that is the responsibility of the DON. During an interview on 5/4/2022 at 9:45 AM, Staff A, Agency LPN, stated, I am not IV certified and I would get a staff member who was if I had any to administer. I did administer medications if I signed that I did. If my initials are in the box, I must have administered them. I should not administer any IV medications or flush a PICC, midline or IV. I did administer IV medications to [Resident #138's name] on 4/16, 4/20, 4/22, 4/27 and 4/29. Those are my initials that I administered them. During an interview on 5/4/2022 at 3:20 PM, Staff F, Agency LPN, stated she was not IV certified. She was not aware that she needed to be IV certified in the state of Florida. She stated no one at this facility asked her for IV certification before giving IV medications. She has been administering IVs in the facility, hanging IVs and administering IV pushes. During an interview on 5/5/2022 at 9:02 AM, the Administrator stated the agency provided staff with baseline requirements and IV certification was not one of them. He stated he could not verify if any of the agency staff had IV certifications because that information was not requested. His expectation was that agency staff that were not IV certified should not administer IV medications. The facility posted staff openings on an application called on shift. The agency staff signed up for the shifts they wanted. The posting for the needed shift did not indicate if IV certification was required. Review of the Supplemental Staffing Agreement for Healthcare Professionals entered into August 22, 2021 between [Staffing Agency's name] and Lake Port Square, LLC, read, II. Temporary Placement. b. Candidate Qualifications. Except where prohibited by law, [Staffing Agency's name] will provide Client with qualifications of Candidates as reasonably necessary to establish competency, which may include completed employment application, clinical skills checklist(s), medication competency exam professional references, and verification of license. [Staffing Agency's name] will verify that each Candidate has the minimum experience requested by Client within the area of assignment. Furthermore, [Staffing Agency's name] will maintain compliance documentation on file for each Candidate referred to Client. Client agrees to maintain such compliance documentation in a trustworthy manner in a secure and confidential location and to protect such documentation from any unauthorized disclosure consistent with state and federal law. The required compliance documentation will be specified in writing by Client prior to Candidate's start date (the required documentation). Client may request additional compliance documentation; provided, however, [Staffing Agency's name] shall not be obligated to produce documentation in addition to the Required Documentation. If [Staffing Agency's name] does not produce additional documentation, Client may cancel the order. All Clients request for additional documentation requests must be made in writing. During an interview on 5/5/2022 at 9:05 AM, the Acting Director of Nursing (DON) stated, We use agency staff every day. Each staff from agency that we use should be aware of the need for the IV certification 30-hour course and not administer any medications they are not qualified to administer. There is a nurse on call 24 hours a day, an RN [Registered Nurse], so even if we did not have someone in the building who was certified they could call at any time and we would need to come administer the medication. I expect that our nurses would not sign for something that they have not administered. I would expect the nurses who administered the medication to follow the five rights of administration and would complete their own documentation. I can't give you a good answer as to why this wasn't happening. I was not aware that this wasn't happening. We do not have a specific competency for agency staff. I don't think we would need to post for a specifically IV certified LPN because we have someone available twenty-four hours a day, someone on call in case of emergencies and they should just call me if they have questions. The on-call schedule is posted at each nurse's station and the fulltime staff would always know they can call me. During an interview on 5/5/2022 at 9:23 AM, the Medical Director stated he was made aware of the fact that unqualified LPNs were administering IV medications to the residents in the facility, in which two of the residents [Residents #138 and #237's names] were directly under his care. He stated he received a call from the administrator from the facility on 5/4/2022. He stated he was not aware of the fact that the situation prior to the call/notification on 5/4/2022. During a telephone interview on 5/5/2022 at 2:17 PM, Staff H, LPN, stated, I have completed IV flushes and administered antibiotics when I have worked at [Facility's name]. I wasn't aware that I was not able to administer premixed medications. I thought that I could. I knew that I could not administer anything that needed to be mixed or start an IV, but I did think I could do flushes and hang antibiotics that were already mixed. I never asked anyone to do those for me. I am not IV certified and I haven't changed a PICC line dressing, I can't do that. I didn't know that I was supposed to get an IV certified nurse to give my antibiotics. During an interview on 5/5/2022 at 2:35 PM, the Staffing Coordinator stated, I do the scheduling for the health center. We do not have enough staff to cover all the shifts, so we use agency. I put any open shifts in 'On shift'. I can not specify whether they are IV certified. I can only request a CNA, LPN, or RN positions. I schedule five to six nurses during the day, five to six nurses on the second shift and four for overnight. I do not staff specifically for IV administration of medications due to the fact that we always have an RN on site or one on call. I do not have access to whether they are IV certified or not. If they are agency staff, I cannot see if they are IV certified either. During a telephone interview on 5/5/2022 at 2:35 PM, Staff M, LPN, stated, I did not administer any IV medications. A flush is not a medication. I do not consider a flush to be an IV medication. My initials are on the MAR and that means that I administered the medication. I have not administered any other IV medications. During an interview on 5/5/2022 at 2:45 PM, the Staffing Scheduler was requested to provide the nursing licenses and IV certifications of the 30-hour training for IV administration of medications for all facility and agency staff LPNs. During a telephone interview on 5/5/2022 at 2:56 PM, Staff J, LPN, stated, I have not administered IV medication for anyone. On Saturday, I think it was Saturday, I told them I was not IV certified and the nurse said don't worry about it someone else will do it. I just signed it off and I don't know if it was administered but I did not administer it. I did sign the MAR, thinking about this I guess I shouldn't have done that at all. I don't remember what nurse I told that to. During an interview on 5/5/2022 at 2:57 PM, the Staffing Coordinator stated, The facility has two agency contracts, [Staffing Agencies' names]. From these agencies, we get staff that work a permanent shift, for example 40 hours a week, every week. The required documents are documents that are needed for our facility like TB [tuberculosis], and background checks. IV certification documentation is not one of the required documents. During an interview on 5/5/2022 at 3:05 PM, the Staffing Scheduler entered the conference room. The requested documentation was not provided. A second request was made for the nursing licenses and IV certifications of the 30-hour training for IV administration of medications for all facility and agency staff LPNs. During a telephone interview on 5/5/2022 at 3:13 PM, Staff O, LPN, stated, I am not certified to do IV administration of medications. I always get someone else to do my IVs for me. I will get everything ready, get the medication, the tubing, and the flushes. We will go into the room together and they administer the IV medication when I give the other medications. We do those at the same time. We both go into the room at the same time. I didn't realize that I shouldn't sign for the medication unless I actually administer it. I was provided training in my orientation about medication administration. I guess I should have known not to do that, not to sign if I didn't administer it, but I thought it was okay because I saw it being hung. A request was made for names of nurses who hung the medications signed as administered by Staff O. No names were provided. Review of the MARs and nursing progress notes for Resident #56 for the period of 3/22/2022 through 5/1/2022 did not provide documentation for nurses who may have hung and/or provided NS flushes for Resident #56 other than Staff O. During a telephone interview on 5/5/2022 at 5:30 PM, the Medical Doctor (MD) (attending physician for Residents #2 and #56) stated that he was not made aware that unqualified LPNs were administering IV medications to the residents in the facility. He stated, I would have thought the facility would have a system in place to either get their nurses certified or not allow them to give IV medications. That was not too smart of them. I will inform the rest of my staff of the situation so the residents can be assessed for injury. During an interview on 5/6/2022 at 2:10 PM, when discussed the IV 30-hour certifications were not provided for Staff O, LPN, Staff G, LPN, Staff E, LPN, Staff A, LPN, Staff F, LPN, Staff L, LPN, Staff I, LPN, Staff H, LPN, and Staff J, LPN, the DON stated, I do not have IV certifications for any nurses that had not already been provided. Review of the policy and procedure titled, Midline Catheter Flushing and Locking with a revision date of July 1, 2012, and an approval date of 2/23/2022 read, 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. Review of the policy and procedure titled, Guidelines for Preventing Intravenous Catheter-Related Infections with a revision date of August 2014, and an approval date of 2/23/2022 read, Purpose: The purpose of this procedure is to maximally reduce the risk of infection associated with indwelling intravenous (IV) catheters. General Guidelines: 1. Facility staff who manage infusion catheters will have training and demonstrated clinical competency in intravenous therapy, including: b. proper procedures for the insertion and maintenance of IV catheters; and c. appropriate infection control measures to prevent IV catheter-related infections. Nurse Practice Guidelines to Prevent Catheter-Related Infections: Surveillance: 6. Any time that dressing is not intact or end caps are missing, the catheter has the potential for contamination. Catheter Site Dressing regimens: 1. Change the initial dressing after catheter placement within 24 hours. 4. Change TSM dressings on CVADs every 5-7 days or PRN (as needed) if damp, loosened, or visibly soiled. This does not require a doctor's order. Cleaning Needleless Connection devices: 2. Disinfect the needleless connector prior to each access using alcohol, tincture of iodine, or chlorohexidine gluconate/alcohol combination. Review of the policy and procedure titled, Administering Medications with an approval date of 2/23/2022 read, Policy statement: Medications shall be administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: 1. Only licensed persons licensed or permitted by this state to prepare, administer, and document the administration of medications may do so. 2. The Director of Nursing Services will supervise and direct all nursing personnel who administer medications and/or have related functions. Review of Florida Administrative Code under 64B9-12.005, Competency and Knowledge Requirements Necessary to Qualify the LPN to Administer IV Therapy, read, (1) Contents. The board endorses the Intravenous Therapy Course Guidelines issued by the Education Department of the National Federation of Licensed Practical Nurses, November, 1983. The intravenous therapy education must contain the following components: (a) Policies and procedures of both the Nurse Practice Act and the employing agency in regard to intravenous therapy. This includes legalities of both the Licensed Practical Nurse role and the administration of safe care. Principles of charting are also included. (b) Psychological preparation and support for the patient receiving IV therapy as well as the appropriate family members/ significant others. (c) Site and function of the peripheral veins used for veinpuncture. (d) Procedure for veinpuncture, including physical and psychological preparation, site selection, skin preparation, palpation of veins, and collection of equipment. (e) Relationship between intravenous therapy and the body's homeostatic and regulatory functions, with attention to the clinical manifestations of fluid and electrolyte imbalance. (f) Signs and symptoms of local and systemic complications in the delivery of fluids and medications and the preventive and treatment measures for these complications. (g) Identification of various types of equipment used in administering intravenous therapy with content related to criteria for use of each and means of troubleshooting for malfunction. (h) Formulas used to calculate fluid and drug administration rate. (i) Methods of administering drugs intravenously and advantages and disadvantages of each. (j) Principles of compatibility and incompatibility of drugs and solutions. (k) Nursing management of the patient receiving drug therapy, including principles of chemotherapy, protocols, actions, and side effects. (l) Nursing management of the patient receiving blood and blood components, following institutional protocol. Include indications and contraindications for use; identification of adverse reactions. (m) Nursing management of the patient receiving parenteral nutrition, including principles of metabolism, potential complications, and physical and psychological measures to ensure the desired therapeutic effect. (n) Principles of infection control in IV therapy, including aseptic technique and prevention and treatment of iatrogenic infection. (o) Nursing management of special IV therapy procedures that are commonly used in the clinical setting, such as heparin lock, central lines, and arterial lines. (p) Glossary of common terminology pertinent to IV fluid therapy. (q) Performance check list by which to evaluate clinical application of knowledge and skills. (2) Central Lines. The Board recognizes that through appropriate education and training, a Licensed Practical Nurse is capable of performing intravenous therapy via central lines under the direction of a registered professional nurse as defined in subsection 64B9-12.002(2), F.A.C. Appropriate education and training requires a minimum of four (4) hours of instruction. The requisite four (4) hours of instruction may be included as part of the thirty (30) hours required for intravenous therapy education specified in subsection (4) of this rule. The education and training required in this subsection shall include, at a minimum, didactic and clinical practicum instruction in the following areas: (a) Central venous anatomy and physiology; (b) CVL site assessment; (c) CVL dressing and cap changes; (d) CVL flushing; (e) CVL medication and fluid administration; (f) CVL blood drawing; and (g) CVL complications and remedial measures. Upon completion of the intravenous therapy training via central lines, the Licensed Practical Nurse shall be assessed on both theoretical knowledge and practice, as well as clinical practice and competence. The clinical practice assessment must be witnesses by a Registered Nurse who shall file a proficiency statement regarding the Licensed Practical Nurse's ability to perform intravenous therapy via central lines. The proficiency statement shall be kept in the Licensed Practical Nurse's personnel file. The Immediate Jeopardy was removed onsite after the receipt of an acceptable immediate jeopardy removal plan. The survey team verified the facility's actions for removal of immediacy to prevent the likelihood of harm and/or possible death as evidenced by review of Abuse and Neglect training provided by the Education Coordinator completed on 5/4/2022; review of Abuse and Neglect training provided by the Administrator completed on 5/4/2022 to include all leadership staff; review of daily audits dated 5/4/2022, 5/5/2022 and 5/6/2022 on current IV residents; review of the on-call schedule for May 2022 documenting an RN scheduled on call for each day of May; review of the posted list of the approved IV certified agency nurses posted at both nursing stations; review of the Ad Hoc Quality Assurance Meeting dated 5/4/2022 to discuss LPN staff qualifications to administer IV medications; interviews conducted on 5/6/2022 PM with six agency LPNs and three facility LPNs, five facility registered nurses who verified the provided training related to IV certification requirement to administer IV medications, and abuse and neglect; interviews with the Administrator, the Acting DON, the MDS Nurse, and the Quality Improvement Nurse Manager on 5/6/2022, who verified receiving training on scope of practice of LPNs, IV certifications, and abuse and neglect.

**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 agency and/or facility staff to work outside of their scope of practice, administering IV (intravenous) medications via midline catheters for 4 of 4 residents, Residents #2, #56, #138, and #237, without certification of education, training and validation of competency for IV medication infusion to residents who are administered IV medications. 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. Findings include: Review of the job description for the Administrator (effective date August 3, 2021) read, General summary/major function: The administrator is responsible for assisting the Chief Administrative Officer/Executive Director in the overall administration of the Community. S/he supervises the operation of the service departments as directed by the Executive Director, with primary emphasis on the health center. Essential duties and responsibilities: Supervise assigned department directors, attend and participate in department director meetings Monitor in-service education for employees, oversee/conduct in-service education for employees. Review of the job description for the Director of Clinical Services (Director of Nursing) (effective date 02/2020) read, The Director of Clinical Services is responsible for the overall supervision, provision, and quality of nursing care in the Health center and residential apartments. He/She is responsible for the selection, training, discipline, and supervision for all nursing related Health center personnel. Principle Duties: Essential job duties . 7. Develops and participates in a new staff orientation program for his/her employees, including private duty and agency staff. Review of the job description for the Quality Improvement Nurse (effective date 02/2020) read, General Summary: Monitors and manages the quality measures and indicators of the community through planning, developing, directing and evaluating educational and clinical training programs. Evaluates and develops policies for the community's risk management systems in accordance with regulations to protect residents, staff and facility from loss. Principle duties: 2, documents and reviews medication and treatment sheets for accuracy and compliance with physician orders, professional standards, federal and state regulations and company policies. 5. Directs and coordinates all in-service educational programs of the facility in accordance with regulations. Develops, maintains and directs orientation programs for skilled nursing personnel. 1. Review of the medical record for Resident #56 documented the resident was admitted to the facility on [DATE] with diagnoses of encounter for other orthopedic aftercare, aftercare following explantation (re-implantation) of knee joint prothesis, acute systolic (congestive) heart failure, hyperlipidemia, atherosclerotic (disease of the arteries characterized by the deposition of plaques of fatty material on their inner walls) heart disease, major depressive disorder, anemia, personal history of transient ischemic attack (mini stroke) and cerebral infarction (stroke is a brain lesion in which a cluster of brain cells die when they don't get enough blood) without residual deficits, and essential primary hypertension. During an observation on 5/4/2022 at 7:37 AM, when the surveyor requested Staff E, Licensed Practical Nurse (LPN), to observe IV medications administration for Resident #56, Staff E stated, The medication is due at 9 AM. I will not be able to administer it until 8 AM. Staff E entered Resident #56's room. The resident had a right double lumen peripherally inserted central catheter (PICC, a thin flexible tube that is inserted into a vein in the upper arm and guided, threaded, into a large vein above the right side of the heart called the superior vena cava, it is used to give intravenous fluids, antibiotics, blood transfusions and other drugs). The PICC line had no needleless connector on the left port, only a green cap and two needleless connectors on the right port of the PICC line. An empty Vancomycin 1000 mg bag of antibiotics was connected to the right port of the PICC line. Staff E removed the empty bag of Vancomycin, did not perform hand hygiene, did not don gloves, did not clean the IV insertion site, and flushed the right port of the PICC line that had two needleless connectors with ten milliliters of normal saline. Staff E did not aspirate to check for line patency (this ensures the line is open and in the correct placement). After exiting Resident #56's room, Staff E was observed speaking to other staff members. During an interview on 5/4/2022 at 7:47 AM, Staff E, LPN, stated, You will have to have another nurse hang the antibiotic. I am not IV certified. I did not take the 30-hour IV course. I cannot administer the medication. I am not certified to take care of the PICC line. I did not clean the hub or check that the line was patent by aspirating before I pushed the normal saline. I didn't think I needed to. I was just doing a flush. Review of the physician order for Resident #56 dated 4/29/2022 read, Cefepime HCL [Hydrochloride] 2 gm [gram]/100 ml [milliliters] use 2 grams intravenously every morning and at bedtime. Review of the physician order for Resident #56 dated 4/29/2022 read, Vancomycin HCL solution 1000 mg [milligrams]/200 ml use 1000 mg [milligrams] intravenously in the morning for prosthetic knee infection for 17 days. Review of the physician order for Resident #56 dated 4/29/2022 read, Vancomycin HCL solution 1000 mg/200 ml use 1000 mg intravenously in the evening for prosthetic knee infection for 17 days. Review of the Medication Administration Record (MAR) for Resident #56 documented Staff O, LPN, administered IV Vancomycin HCL on 3/22/22 at 10:59, on 3/23/22 at 8:31 AM, on 3/24/22 at 10:31 AM, on 3/25/22 at 12:31 PM, on 3/29/22 at 9:34 AM, on 3/30/22 at 9:35 AM, on 3/31/22 at 9:24 AM, on 4/1/22 at 9:16 AM, on 4/2/22 at 9:59 AM, on 4/3/22 at 9:44 AM, 4/3/22 at 9:21 PM, on 4/5/22 at 9:29 AM, 4/6/22 at 9:43 AM, on 4/7/22 at 10:01 AM, 4/8/22 at 9:53 AM, 4/12/22 at 9:49 AM, on 4/13/22 at 9:00 AM, on 4/16/22 at 10:11 AM, on 4/17/22 at 9:39 AM, 4/19/22 at 9:48 AM, on 4/20/22 at 10:14 AM, 4/21/22 at 10:17 AM, and on 4/22/22 at 10:34 AM. Review of the MAR for Resident #56 documented Staff G, LPN, administered IV Cefepime HCL solution on 4/3/22 at 5:50 PM, on 4/4/22 at 5:08 AM, 4/12/22 at 5:01 PM, on 4/13/22 at 5:58 AM, and on 5/1/22 at 9:36 PM. Review of the MAR for Resident #56 documented Staff G, LPN, administered IV Vancomycin HCL solution on 4/12/22 at 9:15 PM, on 5/1/22 at 5:50 PM, and on 5/2/22 at 5:43 AM. Review of the MAR for Resident #56 documented Staff E, LPN, administered IV Cefepime HCL solution on 4/6/22 at 6:30 PM, and on 5/3/22 at 9:33 PM. Review of the MAR for Resident #56 documented Staff E, LPN, administered IV Vancomycin HCL solution on 5/3/22 at 4:40 PM. Review of the MAR for Resident #56 documented Staff A, LPN, administered IV Vancomycin HCL solution on 4/6/22 at 9:14 PM. Review of the MAR for Resident #56 documented Staff L, LPN, administration of IV Cefepime HCL solution on 4/18/22 at 10:54 PM, on 4/19/22 at 7:15 AM. Review of the MAR for Resident #56 documented Staff I, LPN, administered IV Cefepime HCL solution on 4/20/22 at 6:58 PM. Review of the MAR for Resident #56 documented Staff I, LPN, administered IV Vancomycin HCL solution on 4/20/22 at 9:21 PM. 2. Review of the medical record for Resident #2 documented the resident was admitted to the facility on [DATE] with diagnoses of pneumonia, sepsis (a life-threatening complication of infection in the blood stream), COVID-19 (Corona Virus Disease 2019), urinary tract infection, congestive heart failure, chronic kidney disease, type 2 diabetes mellitus. Review of Resident #2's physician orders dated 4/21/2022 read, Cefazolin sodium-dextrose solution reconstituted 2-3 gm-% (50 ml). Use 50 ml Intravenously every 12 hours for bacteremia [bacteria in the circulating blood] until 5/22/22. Review of Resident #2's physician orders dated 4/20/2022 read, Normal saline flush solution 0.9% sodium chloride (NS) flush - use 10 ml intravenously every shift for IV patency until 5/22/22 - flush with 10 ml normal saline prior to and after administration of medication. Review of the MAR for Resident #2 documented Staff F, LPN, administered IV Cefazolin Sodium-Dextrose on 4/20/22 at 9:00 PM, IV normal saline flush solution 0.9% sodium chloride (NS) on 4/20/22 at 9:35 PM, IV NS flush on 4/29/22 at 6:28 PM, and IV Cefazolin Sodium-Dextrose solution and IV NS flush on 4/29/22 at 9:45 PM. Review of the MAR for Resident #2 documented Staff I, LPN, administered IV Cefazolin Sodium-Dextrose solution on 4/21/22 at 9:25 PM, IV NS flush on 4/23/22 at 4:31 PM, and IV NS flush on 4/23/22 at 9:25 PM. Review of the MAR for Resident #2 documented Staff A, LPN, administered IV NS flush on 4/23/22 at 7:44 PM, IV NS flush on 4/24/22 at 10:09 AM, IV Cefazolin Sodium-Dextrose solution on 4/24/22 at 10:11 AM, and IV NS flush on 4/24/22 at 9:21 PM. Review of the MAR for Resident #2 documented Staff H, LPN, administered IV NS flush on 4/27/22 at 12:46 AM Review of the MAR for Resident #2 documented Staff E, LPN, administered IV NS flush on 4/27/22 at 3:47 PM, IV Cefazolin Sodium-Dextrose solution and a NS flush on 4/27/22 at 8:58 PM, IV NS flush on 5/3/22 at 3:51 PM, IV Cefazolin Sodium-Dextrose solution and IV NS flush on 5/3/22 at 9:00 PM, and IV NS flush on 5/4/22 at 11:03 AM. Review of the MAR for Resident #2 documented Staff J, LPN, administered IV NS flush on 4/30/22 at 6:24 PM, IV Cefazolin Sodium-Dextrose solution and IV NS flush on 4/30/22 at 9:51 PM, and IV NS flush on 5/1/22 at 4:29 AM. Review of the MAR for Resident #2 documented Staff G, LPN, administered IV Cefazolin Sodium-Dextrose solution and IV NS flush on 5/1/22 at 9:37 PM. 3. Review of the medical record for Resident #138 documented the resident was admitted to the facility on [DATE] with diagnoses to include disruption of external operation (surgical) wound, pseudomonas (type of bacteria that causes infection) as the cause of diseases, encounter for surgical aftercare following surgery on the skin and subcutaneous tissue, cellulitis (deep skin infection that spreads quickly), fall on same level from slipping, tripping and stumbling with subsequent striking against object, presence of right artificial hip joint, moderate protein calorie malnutrition, chronic obstructive pulmonary disease (chronic inflammatory lung disease), hyperlipidemia (elevated lipid levels), atherosclerotic heart disease of native coronary artery without angina pectoris, paroxysmal atrial fibrillation (abnormal heart rhythm), nonrheumatic aortic valve stenosis (narrowing of the valve), obstructive sleep apnea, essential primary hypertension, muscle weakness, lack of coordination, weakness and peripheral vascular disease. Review of Resident #138's physician orders dated 4/5/2022 read, Flush each valved PICC catheter lumen with 10 ml NS before and after each use every 12 hours every 7 days for PICC line maintenance. Review of Resident #138's physician orders dated 4/5/22 read, Cefepime HCL Solution 2 GM/100 ml Use 100 ml intravenously every 12 hours for pseudomonas infection of surgical hip site for 6 weeks. Review of the MAR for Resident #138 documented Staff F, LPN, administered IV Cefepime on 4/10/22 at 8:00 PM, on 4/11/22 at 8:58 PM, on 4/13/22 at 9:26 PM, on 4/14/22 at 10:03 PM, on 4/22/22 at 9:32 AM, on 4/23/22 at 10:37 PM, on 4/24/22 at 8:53 PM, on 4/25/22 at 8:26 PM, on 4/27/22 at 9:19 PM, and on 4/28/22 at 8:17 PM. Review of the MAR for Resident #138 documented Staff A, LPN, administered IV Cefepime on 4/16/22 at 10:20 AM, on 4/20/22 at 9:06 AM, on 4/20/22 at 9:36 PM, on 4/22/22 at 10:35 AM, on 4/27/22 at 11:13 AM, and on 4/29/22 at 8:23 AM. 4. Review of the medical record for Resident #237 documented the resident was admitted to the facility on [DATE] with diagnoses to include encounter for orthopedic aftercare, displaced bicondylar fracture of right tibia, tear of lateral meniscus, history of falling, hyperlipidemia, atherosclerotic heart disease, hypertension, gastroesophageal reflux disease (where the liquid content of the stomach refluxes into the esophagus), morbid obesity, hypothyroidism, benign prostatic hyperplasia (flow of urine is blocked due to the enlargement of prostate gland), anemia, major depressive disorder, and type 2 diabetes mellitus. Review of the physician orders for Resident #237 dated 5/2/2022 read, Sodium Chloride Solution 0.9%. Use 75 ml/hr [hour] IV every shift for dehydration for 1 day. IV fluids for 2 liters then stop fluids. Review of the MAR for Resident #237 documented Staff E, LPN, administered IV NS flush on 5/3/22 at 6:20 PM. During an interview on 5/4/2022 at 8:17 AM, the Acting Director of Nursing (DON) stated, I am responsible for all the care delivered in the facility. I spoke to the LPN, [Staff E's name] and he was saying he did an IV course, but it might not be the 30-hour course that he needs. We are checking with the agency and with human resources to determine what is true. I'm not sure who actually takes care of knowing an agency staff qualification if they are an LPN. I will check into this. A request was made for Staff E's 30-hour IV certification documentation. During an interview on 5/4/2022 at 8:25 AM, the Quality Improvement Nurse Manager stated, It is a nursing standard of practice that the LPN must be certified with an IV course to administer IV medications in a central line. I am not responsible for the onboarding of staff and what their certifications and abilities are. I was not aware that there were LPNs who are not certified administering IV medications. We have a registered nurse or IV certified LPN available at all times and they are on call also for off hours. During an interview on 5/4/2022 at 8:30 AM, the Administrator was informed Staff E administered IV NS and Staff E then stated he did not have IV certification. When asked how the facility received information from the agencies related to IV certification, the Administrator stated, I don't know. During an interview on 5/4/2022 at 8:38 AM, the Acting DON stated, He [Staff E] only has 16 hours. A request was made for all IV certifications for all nurses on staff and all agency staff. During an interview on 5/4/2022 at 8:40 AM, the Education Coordinator stated, I am not responsible for maintaining staff competency. I am responsible for onboarding and education of brand-new staff. I work out of HR [Human Resources] and do orientation, Relias training, fire and life safety and HIPPA [Health Insurance Portability and Accountability Act] compliance. I do not deal with maintaining competency of agency staff that is the responsibility of the DON. During an interview on 5/4/2022 at 9:45 AM, Staff A, Agency LPN, stated, I am not IV certified and I would get a staff member who was if I had any to administer. I did administer medications if I signed that I did. If my initials are in the box, I must have administered them. I should not administer any IV medications or flush a PICC, midline or IV. I did administer IV medications to [Resident #138's name] on 4/16, 4/20, 4/22, 4/27 and 4/29. Those are my initials that I administered them. During an interview on 5/4/2022 at 3:20 PM, Staff F, Agency LPN, stated she was not IV certified. She was not aware that she needed to be IV certified in the state of Florida. She stated no one at this facility asked her for IV certification before giving IV medications. She has been administering IVs in the facility, hanging IVs and administering IV pushes. During an interview on 5/5/2022 at 9:02 AM, the Administrator stated the agency provided staff with baseline requirements and IV certification was not one of them. He stated he could not verify if any of the agency staff had IV certifications because that information was not requested. His expectation was that agency staff that were not IV certified should not administer IV medications. The facility posted staff openings on an application called on shift. The agency staff signed up for the shifts they wanted. The posting for the needed shift did not indicate if IV certification was required. Review of the Supplemental Staffing Agreement for Healthcare Professionals entered into August 22, 2021 between [Staffing Agency's name] and Lake Port Square, LLC, read, II. Temporary Placement. b. Candidate Qualifications. Except where prohibited by law, [Staffing Agency's name] will provide Client with qualifications of Candidates as reasonably necessary to establish competency, which may include completed employment application, clinical skills checklist(s), medication competency exam professional references, and verification of license. [Staffing Agency's name] will verify that each Candidate has the minimum experience requested by Client within the area of assignment. Furthermore, [Staffing Agency's name] will maintain compliance documentation on file for each Candidate referred to Client. Client agrees to maintain such compliance documentation in a trustworthy manner in a secure and confidential location and to protect such documentation from any unauthorized disclosure consistent with state and federal law. The required compliance documentation will be specified in writing by Client prior to Candidate's start date (the required documentation). Client may request additional compliance documentation; provided, however, [Staffing Agency's name] shall not be obligated to produce documentation in addition to the Required Documentation. If [Staffing Agency's name] does not produce additional documentation, Client may cancel the order. All Clients request for additional documentation requests must be made in writing. During an interview on 5/5/2022 at 9:05 AM, the Acting Director of Nursing (DON) stated, We use agency staff every day. Each staff from agency that we use should be aware of the need for the IV certification 30-hour course and not administer any medications they are not qualified to administer. There is a nurse on call 24 hours a day, an RN [Registered Nurse], so even if we did not have someone in the building who was certified they could call at any time and we would need to come administer the medication. I expect that our nurses would not sign for something that they have not administered. I would expect the nurses who administered the medication to follow the five rights of administration and would complete their own documentation. I can't give you a good answer as to why this wasn't happening. I was not aware that this wasn't happening. We do not have a specific competency for agency staff. I don't think we would need to post for a specifically IV certified LPN because we have someone available twenty-four hours a day, someone on call in case of emergencies and they should just call me if they have questions. The on-call schedule is posted at each nurse's station and the fulltime staff would always know they can call me. During an interview on 5/5/2022 at 9:23 AM, the Medical Director stated he was made aware of the fact that unqualified LPNs were administering IV medications to the residents in the facility, in which two of the residents [Residents #138 and #237's names] were directly under his care. He stated he received a call from the administrator from the facility on 5/4/2022. He stated he was not aware of the fact that the situation prior to the call/notification on 5/4/2022. During a telephone interview on 5/5/2022 at 2:17 PM, Staff H, LPN, stated, I have completed IV flushes and administered antibiotics when I have worked at [Facility's name]. I wasn't aware that I was not able to administer premixed medications. I thought that I could. I knew that I could not administer anything that needed to be mixed or start an IV, but I did think I could do flushes and hang antibiotics that were already mixed. I never asked anyone to do those for me. I am not IV certified and I haven't changed a PICC line dressing, I can't do that. I didn't know that I was supposed to get an IV certified nurse to give my antibiotics. During an interview on 5/5/2022 at 2:35 PM, the Staffing Coordinator stated, I do the scheduling for the health center. We do not have enough staff to cover all the shifts, so we use agency. I put any open shifts in 'On shift'. I can not specify whether they are IV certified. I can only request a CNA, LPN, or RN positions. I schedule five to six nurses during the day, five to six nurses on the second shift and four for overnight. I do not staff specifically for IV administration of medications due to the fact that we always have an RN on site or one on call. I do not have access to whether they are IV certified or not. If they are agency staff, I cannot see if they are IV certified either. During a telephone interview on 5/5/2022 at 2:35 PM, Staff M, LPN, stated, I did not administer any IV medications. A flush is not a medication. I do not consider a flush to be an IV medication. My initials are on the MAR and that means that I administered the medication. I have not administered any other IV medications. During an interview on 5/5/2022 at 2:45 PM, the Staffing Scheduler was requested to provide the nursing licenses and IV certifications of the 30-hour training for IV administration of medications for all facility and agency staff LPNs. During a telephone interview on 5/5/2022 at 2:56 PM, Staff J, LPN, stated, I have not administered IV medication for anyone. On Saturday, I think it was Saturday, I told them I was not IV certified and the nurse said don't worry about it someone else will do it. I just signed it off and I don't know if it was administered but I did not administer it. I did sign the MAR, thinking about this I guess I shouldn't have done that at all. I don't remember what nurse I told that to. During an interview on 5/5/2022 at 2:57 PM, the Staffing Coordinator stated, The facility has two agency contracts, [Staffing Agencies' names]. From these agencies, we get staff that work a permanent shift, for example 40 hours a week, every week. The required documents are documents that are needed for our facility like TB [tuberculosis], and background checks. IV certification documentation is not one of the required documents. During an interview on 5/5/2022 at 3:05 PM, the Staffing Scheduler entered the conference room. The requested documentation was not provided. A second request was made for the nursing licenses and IV certifications of the 30-hour training for IV administration of medications for all facility and agency staff LPNs. During a telephone interview on 5/5/2022 at 3:13 PM, Staff O, LPN, stated, I am not certified to do IV administration of medications. I always get someone else to do my IVs for me. I will get everything ready, get the medication, the tubing, and the flushes. We will go into the room together and they administer the IV medication when I give the other medications. We do those at the same time. We both go into the room at the same time. I didn't realize that I shouldn't sign for the medication unless I actually administer it. I was provided training in my orientation about medication administration. I guess I should have known not to do that, not to sign if I didn't administer it, but I thought it was okay because I saw it being hung. A request was made for names of nurses who hung the medications signed as administered by Staff O. No names were provided. Review of the MARs and nursing progress notes for Resident #56 for the period of 3/22/2022 through 5/1/2022 did not provide documentation for nurses who may have hung and/or provided NS flushes for Resident #56 other than Staff O. During a telephone interview on 5/5/2022 at 5:30 PM, the Medical Doctor (MD) (attending physician for Residents #2 and #56) stated that he was not made aware that unqualified LPNs were administering IV medications to the residents in the facility. He stated, I would have thought the facility would have a system in place to either get their nurses certified or not allow them to give IV medications. That was not too smart of them. I will inform the rest of my staff of the situation so the residents can be assessed for injury. During an interview on 5/6/2022 at 2:10 PM, when discussed the IV 30-hour certifications were not provided for Staff O, LPN, Staff G, LPN, Staff E, LPN, Staff A, LPN, Staff F, LPN, Staff L, LPN, Staff I, LPN, Staff H, LPN, and Staff J, LPN, the DON stated, I do not have IV certifications for any nurses that had not already been provided. Review of the policy and procedure titled, Midline Catheter Flushing and Locking with a revision date of July 1, 2012, and an approval date of 2/23/2022 read, 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. Review of the policy and procedure titled, Guidelines for Preventing Intravenous Catheter-Related Infections with a revision date of August 2014, and an approval date of 2/23/2022 read, Purpose: The purpose of this procedure is to maximally reduce the risk of infection associated with indwelling intravenous (IV) catheters. General Guidelines: 1. Facility staff who manage infusion catheters will have training and demonstrated clinical competency in intravenous therapy, including: b. proper procedures for the insertion and maintenance of IV catheters; and c. appropriate infection control measures to prevent IV catheter-related infections. Nurse Practice Guidelines to Prevent Catheter-Related Infections: Surveillance: 6. Any time that dressing is not intact or end caps are missing, the catheter has the potential for contamination. Catheter Site Dressing regimens: 1. Change the initial dressing after catheter placement within 24 hours. 4. Change TSM dressings on CVADs every 5-7 days or PRN (as needed) if damp, loosened, or visibly soiled. This does not require a doctor's order. Cleaning Needleless Connection devices: 2. Disinfect the needleless connector prior to each access using alcohol, tincture of iodine, or chlorohexidine gluconate/alcohol combination. Review of the policy and procedure titled, Administering Medications with an approval date of 2/23/2022 read, Policy statement: Medications shall be administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: 1. Only licensed persons licensed or permitted by this state to prepare, administer, and document the administration of medications may do so. 2. The Director of Nursing Services will supervise and direct all nursing personnel who administer medications and/or have related functions. Review of Florida Administrative Code under 64B9-12.005, Competency and Knowledge Requirements Necessary to Qualify the LPN to Administer IV Therapy, read, (1) Contents. The board endorses the Intravenous Therapy Course Guidelines issued by the Education Department of the National Federation of Licensed Practical Nurses, November, 1983. The intravenous therapy education must contain the following components: (a) Policies and procedures of both the Nurse Practice Act and the employing agency in regard to intravenous therapy. This includes legalities of both the Licensed Practical Nurse role and the administration of safe care. Principles of charting are also included. (b) Psychological preparation and support for the patient receiving IV therapy as well as the appropriate family members/ significant others. (c) Site and function of the peripheral veins used for veinpuncture. (d) Procedure for veinpuncture, including physical and psychological preparation, site selection, skin preparation, palpation of veins, and collection of equipment. (e) Relationship between intravenous therapy and the body's homeostatic and regulatory functions, with attention to the clinical manifestations of fluid and electrolyte imbalance. (f) Signs and symptoms of local and systemic complications in the delivery of fluids and medications and the preventive and treatment measures for these complications. (g) Identification of various types of equipment used in administering intravenous therapy with content related to criteria for use of each and means of troubleshooting for malfunction. (h) Formulas used to calculate fluid and drug administration rate. (i) Methods of administering drugs intravenously and advantages and disadvantages of each. (j) Principles of compatibility and incompatibility of drugs and solutions. (k) Nursing management of the patient receiving drug therapy, including principles of chemotherapy, protocols, actions, and side effects. (l) Nursing management of the patient receiving blood and blood components, following institutional protocol. Include indications and contraindications for use; identification of adverse reactions. (m) Nursing management of the patient receiving parenteral nutrition, including principles of metabolism, potential complications, and physical and psychological measures to ensure the desired therapeutic effect. (n) Principles of infection control in IV therapy, including aseptic technique and prevention and treatment of iatrogenic infection. (o) Nursing management of special IV therapy procedures that are commonly used in the clinical setting, such as heparin lock, central lines, and arterial lines. (p) Glossary of common terminology pertinent to IV fluid therapy. (q) Performance check list by which to evaluate clinical application of knowledge and skills. (2) Central Lines. The Board recognizes that through appropriate education and training, a Licensed Practical Nurse is capable of performing intravenous therapy via central lines under the direction of a registered professional nurse as defined in subsection 64B9-12.002(2), F.A.C. Appropriate education and training requires a minimum of four (4) hours of instruction. The requisite four (4) hours of instruction may be included as part of the thirty (30) hours required for intravenous therapy education specified in subsection (4) of this rule. The education and training required in this subsection shall include, at a minimum, didactic and clinical practicum instruction in the following areas: (a) Central venous anatomy and physiology; (b) CVL site assessment; (c) CVL dressing and cap changes; (d) CVL flushing; (e) CVL medication and fluid admi[TRUNCATED]