**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility neglected to provide adequate oversight of staff to provide appropriate admission orders and skin assessments; and neglected to provide maintenance care and services for a peripherally inserted central line intravenous catheter (PICC) per standards of care for 1 of 1 resident reviewed for PICC lines, of a total sample of 109 residents, (#72). Resident #72 was readmitted to the facility from the hospital on 1/10/24 with a peripherally inserted central line catheter in his left upper arm. The 3008 Agency for Healthcare Administration Transfer and Discharge form dated 1/10/24 detailed the double lumen PICC, but the form did not give the date it was inserted, the date the dressing was last changed or the location. The admitting nurse at the facility documented the presence of a double lumen device under the skin assessment portion of the readmission documentation, but failed to mention it was a PICC. She documented the wrong location and did not obtain orders for discontinuance or maintenance/care of the intravenous central line. Resident #72 went for a short stay to the emergency room on 2/26/24, but otherwise remained at the facility for 7 weeks and 4 days without receiving care and services to maintain the PICC line or prevent infection. On 3/03/24 the PICC was brought to the attention of facility staff by the surveyor and was ordered removed on 3/04/24. Resident #72 required an ultrasound, an X-ray of his left arm and blood work to ensure he had no complications from the facility's neglect of the PICC line. The facility's failure to identify and provide necessary care and services for maintenance and use of a peripherally inserted central line catheter placed resident #72 and all residents who were admitted /readmitted with medical devices including PICCs at risk for serious injury/impairment/death. Without appropriate central line catheter care, there was high likelihood resident #72 could have developed severe infection, blood clots, vascular damage or even death. This failure resulted in Immediate Jeopardy (IJ) starting on 1/10/24. The IJ was removed on 3/06/24. Findings: Cross reference F684 and F726. Resident #72, a [AGE] year-old was admitted to the facility on [DATE] with diagnoses of pneumonia, acute respiratory failure with low oxygen, chronic lung disease, feeding tube to the stomach, low white blood count, heart failure, skin cancer, lung cancer and tongue cancer. Review of Florida Agency for Health Care Administration 5000-3008 Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated 1/10/24 revealed resident #72 was readmitted to the facility on [DATE] for vomiting blood. The Treatment Devices section of the form indicated under type, a double lumen PICC. The form did not indicate when it was inserted, when the device dressing was last changed or where it was located. The time sensitive medications section of the document did not list any antibiotics. A PICC line is a thin, flexible tube inserted into an upper arm vein and guided into the large vein on the right side of the heart. It is used for intravenous delivery of antibiotics or chemotherapy drugs. Delayed complications such as infection and device dysfunction are more gradual in onset and occur over weeks or sometimes months. The most common complication is infection which can lead to sepsis, shock, and death. The reported patient mortality rate was between 12% and 25% for central line related blood stream infections. Device dysfunctions occurred more often in central lines that have been in place for extended times and include catheter fracture and venous clots. Furthermore, cancer patients have amongst the highest risk of thrombosis at 41%. Current research showed no difference between PICCs and standard central lines for rates of complications (retrieved from www.ncbi.nlm.nih.gov on 3/11/24). Review of the Admission/readmit: Data Collection and Baseline Care Plan with effective date 1/10/24 at 3:45 PM, revealed Licensed Practical Nurse (LPN) BB documented on section 41 Skin Integrity resident #72 was admitted with the following skin issues, right arm- multiple bruises and she incorrectly documented right double lumen instead of left. The box for subsection i3 to Obtain physician orders for care instructions and monitoring, was checked. Section E, Drug Regimen Review detailed the drug regimen was reviewed by the practitioner on admission completed to include medication reconciliation completed upon admission/readmission, order entry warnings and any applicable pharmacy recommendations and found, No clinically significant findings. The subsections for date and time of follow up and follow up information/see new orders were left blank. On 3/03/24 at 2:25 PM, resident #72 was awake and alert, seated upright in bed. On his left upper arm, the double lumens of a PICC line were seen hanging down from his sleeve. Resident #72 stated he received the intravenous line (IV) in the hospital, but he could not recall how long he had it, nor why it was still there. Resident #72 lifted his sleeve to reveal a piece of worn, white tube-type gauze covering most of the IV site. He moved the gauze over to reveal the PICC dressing underneath was undated, unlabeled, and gaping open at the bottom where the double lumens hung out. He stated he could not recall receiving care for the PICC line while at the facility. On 3/03/24 at 2:34 PM, LPN Z stood at resident #72's bedside, and acknowledged she was aware of the IV in his arm. LPN Z verified the PICC catheter dressing was unlabeled with no date or initials on it and was loose at the bottom where the lumens emerged. She stated she did not know how long he had the line and was unable to say by looking at the unlabeled IV dressing. LPN Z explained she was not IV certified and would have to notify the supervisor if it needed to be assessed or needed care. She stated she was supposed to look at the dressing to check if it was intact, clean and for the date of the last dressing, but said she was at the end of her shift and had not done that. She stated she had not noticed there was no date on the dressing at all. LPN Z stated she did not know when the last time resident #72's PICC dressing had been changed. A few minutes later, LPN Z left resident #72's room and looked in the electronic health record to check the physician's orders. She said she could not find any orders for resident #72's PICC line. She said she had never noticed there were no physician orders for resident #72's PICC. LPN Z stated care and maintenance of a PICC line was important because it was a central line and could get infected without proper care. Review of the Abuse Prevention Program policy with most recent date of August 2020 revealed the facility designated and implemented processes which strived to reduce the risk of abuse and neglect. The document described those policies would assist the facility to reduce the risk of abuse and neglect including staff burnout which might increase the likelihood of such events. The definition of neglect was described as the failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. In interviews on 3/03/24 at 2:53 PM and 3/04/24 at 10:47 AM, the C wing Unit Manager (UM) said she was told by LPN Z of resident #72's PICC line having no orders. She was unable to say how long he had had the IV, when it was inserted, why he had had it or why it was still in place. She stated she thought resident #72's IV was a midline he received at the hospital but was not sure when. She verified there were no orders to care for the IV, no care plan for it, nor was it on the Medication Administration or Treatment Administration record for February 2024. The C wing UM explained the line needed to be flushed every shift, before and after any medications going into it along with dressing changes and assessment. She described the admission process for the assigned nurse who should do a full body head to toe assessment of the resident and note any devices or skin impairments on the resident. The C wing UM explained the nurse looked at all of the hospital paperwork including the hospital transfer form in order to transcribe the orders needed for the resident at the facility to determine if there were any changes, new medications or devices when a resident returned to the facility from the hospital. She stated it was important for the nurse to read all of the hospital papers to determine if there were any changes that happened since the resident went to the hospital. The C wing UM indicated the assigned nurse would call the physician to verify the orders. She stated the next day the UM would perform a chart audit using the admission checklist on all newly admitted or readmitted residents along with performing a second head to toe skin assessment. She described the chart audit would include the UM again checking the paperwork from the hospital for anything pertinent related to the care of the resident including skin, devices like an IV or catheter or even follow up appointments. The C wing UM detailed that on the skin assessment they were to document anything that was not normally found on the skin or going into the skin/body. She stated there were batch orders for IVs and other things that allowed the nurse to place all the needed orders to care and maintain an IV including a PICC. The C wing UM detailed the UMs would hand the audits to the DON and said she assumed they were checking it as well. The C wing UM explained the UMs would then summarize information about the newly admitted or readmitted resident during the clinical meeting every morning. The C wing UM explained the nurse should call the doctor for orders if a resident had a PICC line to determine if the line should be discontinued or implement orders for its care and maintenance. She acknowledged the second skin assessment she documented for resident #72 was inaccurate and stated she did not recall seeing his PICC line on his left arm when she did the second head to toe skin assessment. The C wing UM stated the LPN BB should have called the physician about resident #72's PICC line when she did the admission. She admitted she should have documented the PICC on the second skin assessment she performed and must have overlooked it. She stated she also did not catch it when she reviewed the hospital transfer form and therefore did not call the physician for the necessary orders. The C wing UM explained she was aware of resident #72's PICC and had even spoken to the physician about the PICC the previous week in regard to some labs that were needed but could not explain why she did not ask for orders for its care and maintenance at that time. She admitted she notified the on-call physician on 3/03/24 after being made aware by the State Surveyor there was a resident with an IV that she needed orders for. She acknowledged she did not inform the on-call physician of the details that resident #72 had a PICC that had not received care and services since January. The C wing UM instead received approval to put in the batch orders for resident #72's PICC without the physician knowing all of the circumstances concerning his PICC not receiving care. The C wing UM acknowledged she was aware that resident neglect meant not receiving care and services that were required for a resident's health and wellbeing. She reiterated a PICC needed to be kept clean, with an intact dressing, needed dressing changes and care because it could cause infections like sepsis or an infection in your heart. Review of the medical record revealed resident #72 had 7 weekly skin assessments from 1/13/24 to 2/28/24. None of the assessments documented the PICC line on his left upper arm nor any actions taken regarding the PICC. The assessments indicated there were no new areas of skin impairment and no mention of the PICC line. One assessment documented a refusal by resident #72. Review of the Treatment Administration Record dated January 2024, revealed a physician's order to monitor bruise to left inner forearm and notify the physician of any changes every shift that started on 1/11/24. During the month of January, 23 different nurses documented they had looked at resident #72's left arm and did not notify the physician about his undated/unlabeled PICC line. Review of the Treatment Administration Record dated February 2024, revealed the same physician's order to monitor the bruise to resident #72's left inner forearm and notify the physician of any changes every shift. For February 2024, 22 different nurses documented they had looked at resident #72's left arm and did not notify the physician about his undated/unlabeled PICC line. Review of the Treatment Administration Record for March 2024 revealed 6 nurses documented they had looked at resident #72's left arm per the physician order to monitor the bruise to his left forearm and failed to notify the physician about his undated/unlabeled PICC line that had no orders for care or maintenance. In total, 33 different nurses including three UM's and the first floor Director of Nursing (DON) documented they had looked at resident #72's left arm and failed to notice the PICC line and notify the physician for orders. On 3/03/24 at 3:06 PM, LPN AA stated she had cared for resident #72 since January when he was readmitted to the facility with the PICC line. She could not recall how long he had the PICC line or why he had it but said it had been awhile. LPN AA explained if a resident came to the facility with a PICC line, the nurse needed to obtain orders from the doctor to care for it. She stated she never realized he didn't have orders to care or maintain his PICC. She described a PICC line as needing to be flushed and the site assessed every shift, yet she did not know why she never questioned the lack of physician orders for care of resident #72's PICC line. On 3/04/24 at 12:28 PM, the admitting nurse, LPN BB in a telephone interview stated she was IV certified and recalled caring for resident #72 over the past several months. She stated when she admitted or readmitted a resident she did a head-to-toe skin assessment and often the supervisor or UM submitted the orders for medications and other care needs. LPN BB described the hospital transfer form was sometimes incorrect, so it was important to do your own assessment of the resident. She explained if she saw a wound or other skin impairment she would let the physician know, and she would document it in the skin assessment. LPN BB stated she could not recall resident #72's PICC, could not recall notifying the physician, nor could she recall assessing resident #72 at all. She explained a PICC line needed orders for care like flushes and if there were no medications ordered for it, the physician would often discontinue the line. LPN BB stated if she saw that a new or readmitted resident had a PICC line, she would notify the supervisor as they would call the physician for orders. She explained she would also look at a resident from head to toe during weekly skin checks and document if there was an IV and notify the physician. LPN BB could not recall ever discussing the PICC line with his primary physician or Advanced Practice Registered Nurse (APRN) CC and could not say why she had not notified them herself. On 3/04/24 at 1:13 PM, the Staff Development Coordinator (SDC) stated on admission the admitting nurse should put in the required batch orders for the PICC line. These orders included flushes every shift and as needed, change of the administration set every 4 days for any IV medications, documentation of site appearance every shift, dressing changes every 7 days and as needed, change the cap every 7 days, change the dressing within 24 hours of admit/insertion, flush each lumen with 10 milliliters of normal saline after each intermittent infusion, for blood draws flush with 10 milliliters of normal saline and to measure the arm circumference. She stated nurses had received education on what they were expected to do on admission and there was a class in their electronic learning modules they would take during onboarding. She described the admitting nurse was supposed to admit the resident in the electronic health record, observe the resident, do a hands-on head to toe assessment, then verify the medications with the physician including any batch orders as needed. The SDC explained the UM also did a second skin assessment on each resident on admission/readmission and documented any skin impairment in the health record. She acknowledged the C wing UM documented bruises to resident #72's upper left arm and left and right hands but failed to document the PICC line to his upper left arm upon admission or obtain orders. The SDC acknowledged subsequent assigned nurses failed to document the PICC line in the skin assessments including the first skin assessment on 1/13/24. She stated nurses were aware of the batch orders for PICCs and should have called the physician. On 3/08/24 at 11:52 AM, the Regional Clinical Reimbursement Specialist stated the facility Clinical Reimbursement Specialists participated in clinical meeting and discussed care plans for new admissions, readmissions and any other residents with changes in their plan of care. She described the Clinical Reimbursement Specialists did an order listing review every morning, and looked at the physician orders. The Regional Clinical Reimbursement Specialist stated when they did the Minimum Data Set Assessment they were supposed to look at the resident for their assessment. She said they should have physically assessed resident #72 and noted he had a PICC line and documented it on the Annual MDS assessment on 1/13/24. The Regional Clinical Reimbursement Specialist explained the facility Clinical Reimbursement Specialist would have looked at him on 1/10/24 and he should have had a care plan for the PICC. The Regional Clinical Reimbursement Specialist said there was obviously some kind of a problem. On 3/08/24 at 8:49 AM, the Risk Manager (RM) stated she was told about the concerns regarding resident #72's PICC line on Monday, 3/04/24. She explained staff usually gave her a call, before they did a risk report. The RM said a risk report was done for any falls, treatment or medication variance, skin impairments, abuse/neglect allegations, unexpected hospitalizations, or deaths. She described the concerns for resident #72 having not received care or services for his PICC as the risk for infection. The RM stated the PICC line should have been removed due to risk it lead to infection or damage to major vessel in the heart. She stated her expectation was the nurse would notify the physician of the PICC not getting treatment when it was discovered and document this in the medical record. On 3/04/24 at 10:24 AM, in a telephone interview APRN CC stated she saw resident #72 frequently at the facility and described herself as the primary provider besides his attending physician. APRN CC stated she had not known resident #72 had a PICC line, nor had she known he had not had any orders for care or maintenance of the line since he arrived at the facility on 1/10/24. She described having seen resident #72 just a few days previously for some concerns about constipation. She stated she was not aware resident #72 had the PICC line and was surprised as he had no reason to have it as he did not have antibiotics or any other medication that needed a PICC. APRN CC described the physician ZZ having seen resident #72 on the previous Thursday as well and was adamant she was unaware of the PICC in his left upper arm as well. She explained they had not ordered any antibiotics and stated there was no justification for resident #72 to still have the PICC. She stated 7 weeks and 4 days was a very long time for resident #72 to not have any care for the PICC. She explained the nurses should have called to obtain orders to either discontinue the line or orders for care and maintenance. She stated no one from the facility had notified her or physician WW about resident #72's PICC not having any care or orders since the facility was made aware the day before on 3/03/24. APRN CC then called physician ZZ to clarify what she knew about resident #72's PICC. APRN CC continued the telephone interview and stated she spoke with physician WW, who told her she also did not know about resident #72's PICC. APRN CC stated if they had known, they would have discontinued the PICC line. APRN CC indicated nurses should have observed the PICC line during their weekly skin checks and noticed there were no orders for care and notified her or the physician. Review of resident #72's medical record revealed resident #72 was assessed 9 times by the APRN between his admission on [DATE] and 3/03/24. The progress notes on 1/12/24, 1/13/24, 1/23/24, 1/24/24, 1/26/24, 1/30/24, 2/02/24, 2/07/24, and 2/20/24 did not mention resident #72's PICC line even though cardiac, skin and extremities were documented as assessed. On 3/04/24 at 12:50 PM, in a telephone interview, physician WW stated when APRN CC first called her she did not recall resident #72 having the PICC line, but now she remembered he had one. She stated she had spoken with the nurse about the line needing to be changed but wanted to deal with resident #72's abdominal pain first. Physician WW was asked if she knew resident #72 had gone for 7 weeks without any care for his PICC and she said she was not aware he didn't have any orders for the PICC since he came to the facility with it in January. Physician WW explained APRN CC saw resident #72 frequently, confirmed APRN CC was supposed to perform and document a complete hands-on assessment of the resident. She stated none of the facility staff had called to inform her or ask for orders for the PICC. Physician WW stated she did not know how it happened that resident #72 went for that long without anyone knowing he did not have any orders to care for the PICC. She said she had looked at the on call list and there was nothing that showed there were any issues with resident #72's PICC from 3/03/24 when the facility was made aware of the concerns about lack of care. She stated it was important for the PICC to get care because it could cause serious complications. On 3/08/24 at 2:21 PM, the Medical Director stated he was made aware of the issue with resident #72's PICC not having care since his readmission on [DATE]. He stated he expected facility nurses to obtain orders for care and notify the physician. The Medical Director stated PICCs were associated with complications like infections and said it was very lucky that resident #72 did not get a Central line associated infection or other complication due to this lack of care or maintenance for his PICC. The undated job description Unit Manager summary of position detailed the UM was responsible for overseeing direct nursing care to assigned residents by assuming responsibility and accountability for the nursing care and services provided on the unit. The UM was responsible for and adhered to the standards of care for the assigned residents and assisted with monitoring and implementation of physician orders based on individual resident needs. The UM was also responsible to supervise the resident care activity performance by licensed nurses. Essential duties and responsibilities included ensuring proper nursing care was provided, overseeing the assessments of the resident admission process and participation in the clinical admission process. Review of immediate actions to remove the Immediate Jeopardy implemented by the facility revealed the following, which were verified by the survey team: * A registered nurse removed the PICC line from resident #72 on 3/04/24. The site was assessed by the RN and no signs of infection were present upon removal. Resident #72 remained in the facility with no change in condition or signs of distress. *The DON, Assistant DON (ADON) and UMs assessed all 381 residents for intravenous lines including central lines on 3/05/24. There were 6 residents with intravenous lines, including central lines with appropriate orders in place, proper fluids running as ordered and dressings appropriately dated. Each intravenous linesite was assessed by an RN with no signs of symptoms of infection present. * The Nurse Consultant educated the DON on the proper assessment of intravenous lines, including central lines on 3/05/24. The DON educated RNs who participated in the resident assessment referenced in bullet point #2 on the proper assessment of intravenous lines, including central lines. The DON or designee-initiated education on notification of physicians related to obtaining orders for care, maintenance or discontinuance of intravenous lines, including central lines. Education was initiated with licensed nurses related to neglect with obtaining and following physician orders related to intravenous lines including central lines. As of 3/05/24 24 of 114 licensed nurses had received education related to abuse and neglect training. They had a goal to complete an additional 25 nurses by 3/06/24 with the remaining nurses to be completed prior to starting their next work shift. * The DON or designee will compare the admission data collection to the physician order to validate notification to the physician occurred and orders for maintenance or discontinuance of the line were obtained. The DON or designee will visually inspect every resident with an intravenous line including central lines to validate care, maintenance or discontinuance orders were followed. Review of in-service education sign in sheets and reconciliation with staff roster validated education was completed according to the facility's plan. 98 of the total 102 nurses at the facility were educated on neglect; assessment, documentation, and monitoring of IV site and dressing; midline/central line dressing change and flushing of vascular device. Additionally, 76 RNs were educated on PICC catheter removal. Interview with the Nursing Home Administrator on 3/08/24 at 12:32 PM, revealed he was the abuse coordinator and reported the allegation of neglect on 3/05/24 to the State Agency, Department of Children and Families and to local law enforcement. An ad hoc Quality Assurance Performance Improvement (QAPI) was held on 3/06/24 that included the Medical Director. On 3/05/24 a venous doppler of resident #72's left upper arm, an Xray of the left arm and labs were ordered by the physician to ensure no complications such as retained objects or infection after the removal of the PICC. Per interview with the Executive DON these tests resulted as within normal limits. On 3/06/24, 3/07/24 and 3/08/24 interviews were conducted with 30 of the nursing staff, including 24 RNs and 6 LPNs, including 6 second shift nurses. All verbalized understanding of the education provided by the facility including neglect, assessment, documentation, and monitoring of IV site and dressing; midline/central line dressing change and flushing a vascular device. The sample was expanded to include 4 other residents identified with IV lines. No concerns were found regarding these residents including resident #354 who had a tunneled central line in his right chest.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide adequate care and services in accordance with accepted professional standards to identify, obtain and implement physician orders for a peripherally inserted intravenous central line catheter (PICC) for 1 of 1 resident reviewed for PICC lines, (#72), failed to change intravenous line dressings as per orders for 1 of 6 residents reviewed for medication administration (#435), and failed to monitor blood glucose levels as per physician orders for 1 of 3 residents reviewed for (#584) insulin use out of a total sample of 109 residents, (#72). Resident #72 was readmitted to the facility from the hospital on 1/10/24 with a peripherally inserted central line catheter in his left upper arm. The 3008 Agency for Healthcare Administration Transfer and Discharge form dated 1/10/24 detailed the double lumen PICC, but the form did not give the date it was inserted, the date the dressing was last changed or the location. The admitting nurse at the facility documented the presence of a double lumen device under the skin assessment portion of the readmission documentation, but failed to mention it was a PICC. She documented the wrong location and did not obtain orders for discontinuance or maintenance/care of the intravenous central line. Resident #72 went for a short stay to the emergency room on 2/26/24, but otherwise remained at the facility for 7 weeks and 4 days without receiving care and services to maintain the PICC line or prevent infection. On 3/03/24 the PICC was brought to the attention of facility staff by the surveyor and was ordered removed on 3/04/24. Resident #72 required an ultrasound, an X-ray of his left arm and blood work to ensure he had no complications from the facility's neglect of the PICC line The facility's failure to identify and provide necessary care and services for maintenance and use of a peripherally inserted central line catheter placed resident #72 and all residents who were admitted /readmitted with medical devices including PICCs at risk for serious injury/impairment/death. Without appropriate central line catheter care, there was high likelihood resident #72 could have developed severe infection, blood clots, vascular damage or even death. This failure resulted in Immediate Jeopardy (IJ) starting on 1/10/24. The IJ was removed on 3/06/24. Findings: Cross reference to F600 and F726 1. Resident #72, a [AGE] year-old was admitted to the facility on [DATE] with diagnoses of pneumonia of unknown origin, acute respiratory failure with low oxygen, chronic lung disease, feeding tube to his stomach, low white blood cell count, heart failure, skin cancer, lung cancer and tongue cancer. Review of the Minimum Data Set (MDS) admission assessment dated [DATE] revealed resident #72 was cognitively intact, had clear speech, adequate vision, and had clear comprehension of others. The assessment indicated resident #72 required moderate assistance with most transfers and required supervision for bed mobility. The assessment also revealed resident #72 had no refusal of care, no intravenous medications, nor did it indicate any IV access including central lines during the look back period. On 3/03/24 at 2:25 PM, resident #72 was awake and alert, seated upright in bed. On his left upper arm, the double lumens of a PICC catheter were seen hanging down from his sleeve. Resident #72 stated he received the intravenous line (IV) in the hospital, but he could not recall how long he had it, nor why it was still there. Resident #72 lifted his sleeve to reveal a piece of worn white, tube-type gauze covering most of the IV site. He moved the gauze over to reveal the PICC dressing underneath was undated, unlabeled, and gaping open at the bottom where the double lumens hung out. He stated he could not recall receiving care for the PICC line while at the facility. Review of Florida Agency for Health Care Administration 5000-3008 Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated 1/10/24 revealed resident #72 was readmitted to the facility on [DATE] for vomiting blood. The Treatment Devices section of the form indicated for type, a double lumen PICC. The form did not indicate when it was inserted, when the device was last changed or where it was located. There were no antibiotics or IV medications listed on the form. A PICC line is a thin, flexible tube inserted into an upper arm vein and guided into the large vein on the right side of the heart. It is used for intravenous delivery of antibiotics or chemotherapy drugs. Delayed complications such as infection and device dysfunction are more gradual in onset and occur over weeks or sometimes months. The most common complication is infection which can lead to sepsis, shock, and death. The reported patient mortality rate was between 12% and 25% for central line related blood stream infections. Device dysfunctions occurred more often in central lines that have been in place for extended times and include catheter fracture and venous clots. Furthermore, cancer patients have amongst the highest risk of thrombosis at 41%. Current research showed no difference between PICCs and standard central lines for rates of complications (retrieved from www.ncbi.nlm.nih.gov on 3/11/24). On 3/03/24 at 2:34 PM, Licensed Practical Nurse (LPN) Z was at resident #72's bedside, and acknowledged she was aware of the PICC IV in his arm. LPN Z verified the PICC dressing had no date or initials on it and was loose at the bottom where the lumens emerged. She stated she did not know how long he had the line and was unable to say by looking at the unlabeled IV dressing. LPN Z explained she was not IV certified and would have to notify the supervisor if it needed to be assessed or needed care. She stated she was supposed to look at the dressing to check if it was intact, clean and for the date of the last dressing change, but said she was at the end of her shift and had not done that. LPN Z stated she did not know when the last time resident #72's PICC dressing had been changed. She reviewed the resident's medical record and stated she could not find any physician orders for resident #72's PICC line. She said she was not aware there were no physician orders for resident #72's PICC. LPN Z stated care and maintenance of a PICC line was important because it was a central line and could get infected without proper care. On 3/03/24 at 2:53 PM, the C wing Unit Manager (UM) said she was told by LPN Z of resident #72's PICC line having no orders. The C wing UM stated she was not aware of the PICC line. She verified there were no orders to care for the IV, no care plan, nor was it on the Medication Administration or Treatment Administration record for February 2024. The C wing UM explained the line needed to be flushed every shift, before and after any medications going into it along with regular dressing changes and assessments. On 3/03/24 at 3:06 PM, LPN AA stated she had cared for resident #72 since January when he was readmitted to the facility with the PICC line. She could not recall how long he had the PICC line or why he had it but said it had been awhile. LPN AA explained if a resident came to the facility with a PICC line, the nurse needed to obtain orders from the doctor to care for it. She stated she never realized he didn't have orders to care or maintain his PICC. She described a PICC line as needing to be flushed and the site assessed every shift, yet she did not know why she never questioned the lack of physician orders for care of resident #72's PICC line. Review of the Admission/readmit: Data Collection and Baseline Care Plan dated 1/10/24 at 3:45 PM, revealed LPN BB documented resident #72 was admitted with skin issues of right arm- multiple bruises and incorrectly documented right double lumen instead of left. The box for subsection i3 to Obtain physician orders for care instructions and monitoring, was checked by LPN BB. Section E, Drug Regimen Review detailed the drug regimen was reviewed by the practitioner on admission completed to include medication reconciliation completed upon admission/readmission, PCC order entry warnings and any applicable pharmacy recommendations and found, No clinically significant findings. The subsections for date and time of follow up and follow up information/see new orders were left blank. Review of the Medication Review Report dated 3/03/24 at 3:12 PM, revealed no physician orders for IV medications nor for care or maintenance of resident #72's PICC line. Review of resident #72's medical record revealed no care plan was ever created for his PICC line until 3/04/24, when it was brought to the facility's attention by the State Agency Surveyor. The facility had a policy and procedure for weekly skin check to document the skin condition throughout the resident's stay in the facility. The policy with effective date October 2021 described the nurse would conduct a weekly skin check to identify impairment or suspected impairment timely to reduce the risk for further decline in skin integrity. The policy further described the nurse should document on the weekly skin check and on the appropriate corresponding skin grid any new areas of impairment weekly, as needed and on admission or readmission to the facility. The procedure section described the nurse to document actions taken based on the skin check, to update the care plan as appropriate and to make a notation on the 24-hour report so the Interdisciplinary Team (IDT) would be informed. Review of the medical record revealed resident #72 had 7 weekly skin assessments completed during the 8-week period from 1/13/24 to 2/28/24, none of which documented the PICC line on his left upper arm nor were any actions taken documented on the assessments. Seven different nurses checked resident #72's skin each week and all of the assessments indicated there were no new areas of skin impairment and had no mention of the PICC. Review of the Treatment Administration Record dated January 2024, revealed a physician's order to monitor bruise to left inner forearm and notify the physician of any changes every shift that started on 1/11/24. Twenty three different nurses documented they had looked at resident #72's left arm and did not notify the physician about his undated/unlabeled PICC line in January 2024. Review of the Treatment Administration Record dated February 2024, revealed the same physician's order to monitor the bruise to resident #72's left inner forearm and notify the physician of any changes every shift. For February 2024, 22 different nurses documented they had looked at resident #72's left arm and did not notify the physician about the PICC line. Review of the Treatment Administration Record for March 2024 revealed 6 nurses documented they had looked at resident #72's left arm per the physician order to monitor the bruise to his left forearm and failed to notify the physician about his PICC line that had no orders for care or maintenance. In total 33 different nurses including three UM's and the first floor Director of Nursing (DON) documented they had looked at resident #72's left arm and all of them failed to notice the PICC line and notify the physician for orders. On 3/04/24 at 10:03 AM, the B wing UM stated a clinical meeting was held every weekday morning to discuss all new admissions and readmissions. She stated the UMs discussed the admissions and readmissions to their unit using the information from the hospital paperwork, baseline care plan and the admission audit. She explained the admission audit was completed by the nurse managers after the admission was completed by the assigned nurse. The B wing UM described the process included checks to verify physician orders were in place for devices such as IV lines. She explained this was a check to ensure orders were complete on admission. If orders were incomplete, the UM would contact the physician to obtain the orders. The B wing UM was unsure if the DON or anyone else looked at the audits once they were completed by the managers. On 3/04/24 at 10:47 AM, the C wing UM described the admission process for the assigned nurse. She stated the nurse should do a full body head to toe assessment of the resident and note any devices or skin impairments. She explained the nurse looked at all the hospital paperwork including the hospital transfer form in order to transcribe the orders needed for the resident at the facility to determine if there were any changes, new medications or devices when a resident returned to the facility from the hospital. She stated it was important for the nurse to read all of the hospital forms to determine if there were any changes in the resident's care. She explained the assigned nurse would then call the physician to verify the orders. The C wing UM stated the next day, the UM would perform a chart audit using the admission checklist on all newly admitted and readmitted residents along with performing a second head to toe skin assessment. She described the chart audit would include the UM checking the paperwork from the hospital for anything pertinent relating to the care of the resident including skin, devices like an IV or catheter or even follow up appointments. The C wing UM detailed that on the skin assessment they were to document anything that was not normally found on the skin or going into the skin/body. She stated there were batch orders for IVs that allowed the nurse to place all the needed orders to care and maintain an IV including a PICC. The C wing UM detailed the UMs then handed the audits to the DON. The C wing UM explained the UMs would then summarize information about the newly admitted or readmitted resident during the clinical meeting every morning. The C wing UM explained the nurse should call the doctor for orders if a resident had a PICC line to determine whether the line should be discontinued or obtain care orders for maintenance. She acknowledged she documented the second skin assessment for resident #72 which was inaccurate and stated she did not recall seeing the PICC line on his left arm when she did the second head to toe skin assessment. The C wing UM stated LPN BB should have called the physician about resident #72's PICC line when she did the admission. She admitted she should have documented the PICC on the second skin assessment she performed and must have overlooked it. The C wing UM stated she also did not catch it on the hospital transfer form therefore she did not call the physician for the necessary orders. The C wing UM explained she was aware of resident #72's PICC and had even spoken to the physician about the PICC the previous week in regard to some labs that were needed but could not explain why she did not ask for orders for its care and maintenance, nor did she document the conversation. She reiterated a PICC needed to be kept clean, with an intact dressing, needed dressing changes and care because it could cause infections like sepsis or an infection in your heart. Review of the admission Checklist (Clinical Leadership) updated December 2023, revealed the hospital transfer form was checked to verify physician orders were complete, confirmed with the physician and matched the orders in the electronic medical record. Another section of the audit detailed for the manager to review the admission nurse chart audit and to read the admission Data Collection to verify its accuracy. Further in the document a section described a second skin check was completed and compared to the initial skin check along with notification to the physician, documentation and appropriate orders in place. Another section of the audit form detailed IV fluids/meds, dressing (check date), pump, to be checked with the care plan, physician orders, computer and at bedside. On 3/04/24 at 11:23 PM, the Executive DON stated the UMs turned the audits in to either the 1st floor or 2nd floor DON. She explained the DONs only ensured the audits were completed but did not check the information on the audits for accuracy. She stated they discussed the new admissions and readmissions at the clinical meeting by talking about the diagnoses and the plan. She then explained they did not review the audits in the meeting. The Executive DON stated it was her expectation the nurse would call the physician about the PICC line and document the conversation. On 3/04/24 at 12:28 PM, the admitting nurse, LPN BB in a telephone interview stated she was IV certified and recalled caring for resident #72 in the past several months. She stated when she admitted or readmitted a resident she did a head-to-toe skin assessment and often the supervisor or UM submitted the orders for medications, and other care needs. LPN BB described the hospital transfer form was sometimes incorrect, so it was important to do an assessment of the resident. She explained if she saw a wound or other skin impairment she would inform the physician, and document the skin assessment. LPN BB stated she could not recall resident #72's PICC, could not recall notifying the physician, nor could she recall assessing resident #72 at all. She explained a PICC needed orders for care like flushes and if there were no medications ordered for it, the physician would often discontinue the line. LPN BB stated if she saw that a new or readmitted resident had a PICC, she would notify the supervisor since they would be the one to call the physician for orders. LPN BB could not recall ever discussing the PICC with the resident's primary physician or Advanced Practice Registered Nurse (APRN) CC and could not say why she had not notified them. On 3/04/24 at 10:24 AM, in a telephone interview, APRN CC stated she saw resident #72 frequently at the facility and described herself as the primary provider besides the resident's attending physician. APRN CC stated she had not known resident #72 had a PICC line, nor had she known he had not had any orders for care or maintenance of the line since he arrived at the facility on 1/10/24. She described having seen resident #72 just a few days previously for some concerns about constipation. She stated she was not aware resident #72 had the PICC line and was surprised as he had no reason to have it as he did not have antibiotics or any other medication that needed a PICC. APRN CC described the physician ZZ having seen resident #72 on the previous Thursday as well and was adamant she was unaware of the PICC in his left upper arm as well. She explained they had not ordered any antibiotics and stated there was no justification for resident #72 to still have the PICC. She stated 7 weeks and 4 days was a very long time for resident #72 to not have any care for the PICC. She explained the nurses should have called to obtain orders to either discontinue the line or orders for care and maintenance. She stated no one from the facility had notified her or physician WW about resident #72's PICC not having any care or orders since the facility was made aware the day before on 3/03/24. APRN CC then called physician ZZ to clarify what she knew about resident #72's PICC. APRN CC continued the telephone interview and stated she spoke with physician WW, who told her she also did not know about resident #72's PICC. APRN CC stated if they had known, they would have discontinued the PICC line. APRN CC indicated nurses should have observed the PICC line during their weekly skin checks and noticed there were no orders for care and notified her or the physician. On 3/04/24 at 12:50 PM, in a telephone interview, physician WW stated when APRN CC first called her she did not recall resident #72 having the PICC line, but now she remembered he had one. She stated she had spoken with the nurse about the line needing to be changed but wanted to deal with resident #72's abdominal pain first. Physician WW was asked if she knew resident #72 had gone for 7 weeks without any care for his PICC and she said she was not aware he didn't have any orders for the PICC since he came to the facility with it in January. Physician WW explained APRN CC saw resident #72 frequently, confirmed APRN CC was supposed to perform and document a complete hands-on assessment of the resident. She stated none of the facility staff had called to inform her or ask for orders for the PICC. Physician WW stated she did not know how it happened that resident #72 went for that long without anyone knowing he did not have any orders to care for the PICC. She said she had looked at the on call list and there was nothing that showed there were any issues with resident #72's PICC from 3/03/24 when the facility was made aware of the concerns about lack of care. She stated it was important for the PICC to get care because it could cause serious complications. Further review of resident #72's medical record revealed resident #72 was assessed 9 times by APRN CC between his admission on [DATE] and 3/03/24. These progress notes on 1/12/24, 1/13/24, 1/23/24, 1/24/24, 1/26/24, 1/30/24, 2/02/24, 2/07/24, and 2/20/24 had no mention of resident #72's PICC even though cardiac, skin and extremities were documented as assessed. On 3/04/24 at 1:13 PM, the Staff Development Coordinator (SDC) stated on admission the admitting nurse should put in the required batch orders for the PICC line. These orders included flushes every shift and as needed, change of the administration set every 4 days for any IV medications, documentation of site appearance every shift, dressing changes every 7 days and as needed, change the cap every 7 days, change the dressing within 24 hours of admit/insertion, flush each lumen with 10 milliliters of normal saline after each intermittent infusion, for blood draws flush with 10 milliliters of normal saline and to measure the arm circumference. She stated nurses had received education on what they were expected to do on admission and there was a class in their electronic learning modules they would take during onboarding. She described the admitting nurse was supposed to admit the resident in the electronic health record, observe the resident, do a hands-on head to toe assessment, then verify the medications with the physician including any batch orders as needed. The SDC explained the UM also did a second skin assessment on each resident on admission/readmission and documented any skin impairment in the health record. She acknowledged the C wing UM documented bruises to resident #72's upper left arm and left and right hands but failed to document the PICC line to his upper left arm upon admission or obtain orders. The SDC acknowledged subsequent assigned nurses failed to document the PICC line in the skin assessments including the first skin assessment on 1/13/24. She stated nurses were aware of the batch orders for PICCs and should have called the physician. On 3/06/24 at 5:32 PM, Registered Nurse (RN) E recalled seeing resident #72 with the PICC in his arm. She described that a PICC line would usually have an order to flush it and to change the dressing. She acknowledged she had documented resident #72's left arm per the physician orders and could only say it slipped her mind to check if the PICC line had any orders for care or maintenance. On 3/06/24 at 5:45 PM, RN B also recalled caring for resident #72 since January. She remembered seeing the PICC in his arm and said in the evenings with two nurses on the unit it was very busy. She explained if she saw an order to do something she would do it but might not notice if there was no order for something. RN B said if the PICC dressing did not have a date on the dressing the nurse should look at the orders and call the physician if there weren't any orders. She was unable to say why she did not notice resident #72 did not have a date on his PICC dressing. On 3/08/24 at 2:21 PM, the Medical Director stated he was made aware of the issue with resident #72's PICC line with no care orders since his readmission on [DATE]. He stated he expected nurses to obtain orders for care and to notify the physician. The Medical Director stated PICCs were associated with complications like infections and said it was very lucky resident #72 did not get a central line associated infection or other complication due to the lack of care or maintenance for his PICC. Review of the Clinical Guidelines Manual- admission Orders presented by the facility with effective date of October 2021 revealed the policy admission orders would be obtained/approved through the attending physician following or prior to the resident's admission to the facility. The procedure section described the procedure if returned from the hospital to contact the attending physician if the order read to resume all previous orders, and to assure at minimum the orders contained diet, medication, routine care to maintain or improve functional ability, and code status. The return from the hospital procedure did not give direction specifically to review the orders that came with the transfer. The admitted from the hospital/ER section detailed the procedure to review the transfer orders, contact the attending physician immediately upon admission to review the transfer orders and obtain approval and to obtain further orders as appropriate. Review of both the undated job descriptions, Licensed Practical Nurse and Registered Nurse revealed both the LPN and RN were responsible for delivering care to residents using the nursing process of assessment, planning, intervention, implementation, and evaluation to maintain standards of professional nursing. The document further described the responsibilities of the LPN and RN which included assess, plan, direct, and evaluate total nursing care as determined by the resident's needs in accordance with established standards, policies, and procedures. Another responsibility was to monitor, record and report changes in resident's condition in a timely manner, and to perform physical exams to determine the resident's status and develop a treatment plan. Also to complete and review the admission Data record and to assess the needs of residents to identify potential health or safety problems. The undated job description Unit Manager summary of position detailed the UM was responsible for overseeing direct nursing care to assigned residents by assuming responsibility and accountability for the nursing care and services provided on the unit. The UM was responsible for and adhered to the standards of care for the assigned residents and assisted with monitoring and implementation of physician orders based on individual resident needs. The UM was also responsible to supervise the resident care activity performance by licensed nurses. Essential duties and responsibilities included ensuring proper nursing care was provided, overseeing the assessments of the resident admission process and participation in the clinical admission process. Review of immediate actions to remove the Immediate Jeopardy implemented by the facility revealed the following, which were verified by the survey team: * A registered nurse removed the PICC line from resident #72 on 3/04/24. The site was assessed by the RN and no signs of infection were present upon removal. Resident #72 remained in the facility with no change in condition or signs of distress. *The DON, Assistant DON (ADON) and UMs assessed all 381 residents for intravenous lines including central lines on 3/05/24. There were 6 residents with intravenous lines, including central lines with appropriate orders in place, proper fluids running as ordered and dressings appropriately dated. Each intravenous linesite was assessed by an RN with no signs of symptoms of infection present. * The Nurse Consultant educated the DON on the proper assessment of intravenous lines, including central lines on 3/05/24. The DON educated RNs who participated in the resident assessment referenced in bullet point #2 on the proper assessment of intravenous lines, including central lines. The DON or designee-initiated education on notification of physicians related to obtaining orders for care, maintenance or discontinuance of intravenous lines, including central lines. Education was initiated with licensed nurses related to neglect with obtaining and following physician orders related to intravenous lines including central lines. As of 3/05/24 24 of 114 licensed nurses had received education related to abuse and neglect training. They had a goal to complete an additional 25 nurses by 3/06/24 with the remaining nurses to be completed prior to starting their next work shift. * The DON or designee will compare the admission data collection to the physician order to validate notification to the physician occurred and orders for maintenance or discontinuance of the line were obtained. The DON or designee will visually inspect every resident with an intravenous line including central lines to validate care, maintenance or discontinuance orders were followed. Review of in-service education sign in sheets and reconciliation with staff roster validated education was completed according to the facility's plan. 98 of the total 102 nurses at the facility were educated on neglect; assessment, documentation, and monitoring of IV site and dressing; midline/central line dressing change and flushing of vascular device. Additionally, 76 RNs were educated on PICC catheter removal. Interview with the Nursing Home Administrator on 3/08/24 at 12:32 PM, revealed he was the abuse coordinator and reported the allegation of neglect on 3/05/24 to the State Agency, Department of Children and Families and to local law enforcement. An ad hoc Quality Assurance Performance Improvement (QAPI) was held on 3/06/24 that included the Medical Director. On 3/05/24 a venous doppler of resident #72's left upper arm, an Xray of the left arm and labs were ordered by the physician to ensure no complications such as retained objects or infection after the removal of the PICC. Per interview with the Executive DON these tests resulted as within normal limits. On 3/06/24, 3/07/24 and 3/08/24 interviews were conducted with 30 of the nursing staff, including 24 RNs and 6 LPNs, including 6 second shift nurses. All verbalized understanding of the education provided by the facility including neglect, assessment, documentation, and monitoring of IV site and dressing; midline/central line dressing change and flushing a vascular device. The sample was expanded to include 4 other residents identified with IV lines. No concerns were found regarding these residents including resident #354 who had a tunneled central line in his right chest. 2. Review of resident #435's medical record revealed he was admitted to the facility on [DATE] from an acute care hospital with diagnoses that included sepsis (infection of the blood stream), methicillin-resistant Staphylococcus aureus (a bacteria resistant to certain antibiotics), and extended spectrum beta-lactamase (enzymes that break down and destroy some commonly used antibiotics). Review of the Florida Agency for Health Care Administration 5000-3008 Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form signed by the hospital's physician on 2/28/24 revealed resident #435 had a Midline IV line inserted on 2/21/24 for administration of IV antibiotics. A midline catheter is a small, thin tube that is inserted into a vein in the upper arm or at the bend in the elbow. A midline catheter is a type of IV access.may be used to: . give medicines. (Retrieved from www.elsevier.com on 3/13/24). Review of resident #435's care plan for IV medications initiated on 2/29/24 included an intervention to check dressing at site daily. Change per facility policy/MD (physician) orders. Review of resident #435's physician orders revealed he received Meropenem (IV antibiotic) three times a day for sepsis until 3/05/24. He had additional orders dated 2/29/24 for nurses to change the IV dressing every 7 days or as needed (PRN) for soiling and/or disl[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 were knowledgeable and demonstrated competency to provide care and services per standards of care for a peripherally inserted intravenous central line catheter (PICC) for 1 of 1 resident reviewed for PICC lines, out of a total sample of 109 residents (#72) and failed to ensure licensed nurses were competent to follow physician orders for medication parameters, topical ointments and diabetes management for 4 of 102 licensed nurses, (Registered Nurses D, K, E and GG). Resident #72 was readmitted to the facility from the hospital on 1/10/24 with a peripherally inserted central line catheter in his left upper arm. The 3008 Agency for Healthcare Administration Transfer and Discharge form dated 1/10/24 detailed the double lumen PICC, but the form did not give the date it was inserted, the date the dressing was last changed or the location. The admitting nurse at the facility documented the presence of a double lumen device under the skin assessment portion of the readmission documentation, but failed to mention it was a PICC. She documented the wrong location and did not obtain orders for discontinuance or maintenance/care of the intravenous central line. Resident #72 went for a short stay to the emergency room on 2/26/24, but otherwise remained at the facility for 7 weeks and 4 days without receiving care and services to maintain the PICC line or prevent infection. On 3/03/24 the PICC was brought to the attention of facility staff by the surveyor and was ordered removed on 3/04/24. Resident #72 required an ultrasound, an X-ray of his left arm and blood work to ensure he had no complications from the facility's neglect of the PICC line. The facility's failure to ensure licensed nurses were knowledgeable and competent to assess central line catheters including PICCs, obtain appropriate admission orders, and provide care and services for peripherally inserted central line catheters placed resident #72 and all residents admitted to the facility with a central line catheter or other intravenous (IV) catheter device at risk. Without appropriate central line catheter care, there was high likelihood resident #72 could have developed severe infection, blood clots, vascular damage or even death. These failures resulted in Immediate Jeopardy starting on 1/10/24. The Immediate Jeopardy was removed on 3/06/24. Findings: Cross reference F600 and F684 1. Resident #72, was admitted to the facility on [DATE] with diagnoses of pneumonia, acute respiratory failure with low oxygen, chronic lung disease, feeding tube to his stomach, low white blood cell count, heart failure, skin cancer, lung cancer and tongue cancer. The Florida Agency for Health Care Administration 5000-3008 Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated 1/10/24 revealed resident #72 was readmitted to the facility on [DATE] with a double lumen PICC line. The form did not indicate when it was inserted, when the device was last changed or where it was located. The Admission/readmit: Data Collection and Baseline Care Plan with effective date 1/10/24 at 3:45 PM, indicated Licensed Practical Nurse (LPN) BB documented resident #72 was admitted with the following skin issues, right arm- multiple bruises and she incorrectly documented and failed to identify the type of line. She recorded only, right double lumen instead of indicating the PICC in his left upper arm. LPN BB checked the box which directed the nurse to, Obtain physician orders for care instructions and monitoring, and she later documented the drug regimen was reviewed by the practitioner on admission. She indicated on the form there were no clinically significant findings. Review of the Medication Review Report dated 3/03/24 at 3:12 PM, revealed no current physician orders for IV medications nor for care or maintenance of resident #72's PICC line. Review of resident #72's Medication and Treatment Administration Records for January 2024, February 2024 and March 2024 revealed no physician orders for care, maintenance, or assessment of resident #72's PICC line. Further review of resident #72's medical record revealed no care plan was created for his PICC line until 3/04/24, when concerns about the PICC were brought to the facility's attention by the State Agency Surveyor. On 3/03/24 at 2:25 PM, resident #72 was awake and alert, seated upright in bed. On his left upper arm, the double lumens of a PICC catheter were hanging down from his sleeve. Resident #72 stated he received the intravenous line (IV) in the hospital, but he could not recall how long he had it, nor why it was still there. Resident #72 lifted his sleeve to reveal a piece of worn white, tube-type gauze covering most of the IV site. He moved the gauze over to reveal the PICC dressing underneath was undated, unlabeled, and gaping open at the bottom where the double lumens hung down. He stated he could not recall receiving care for the PICC line while at the facility. On 3/03/24 at 2:34 PM, Licensed Practical Nurse (LPN) Z was at resident #72's bedside, and acknowledged she was aware of the PICC IV in his arm. LPN Z verified the PICC dressing had no date or initials on it and was loose at the bottom where the lumens emerged. She stated she did not know how long he had the line and was unable to say by looking at the unlabeled IV dressing. LPN Z explained she was not IV certified and would have to notify the supervisor if it needed to be assessed or needed care. She stated she was supposed to look at the dressing to check if it was intact, clean and for the date of the last dressing change, but said she was at the end of her shift and had not done that. LPN Z stated she did not know when the last time resident #72's PICC dressing had been changed. She reviewed the resident's medical record and stated she could not find any physician orders for resident #72's PICC line. She said she was not aware there were no physician orders for resident #72's PICC. LPN Z stated care and maintenance of a PICC line was important because it was a central line and could get infected without proper care. During interviews on 3/03/24 at 2:53 PM and 3/04/24 at 10:47 AM, the C wing Unit Manager (UM) said she was told by LPN Z of resident #72's PICC line having no orders. She was unable to say how long he had had the IV, when it was inserted, why he had had it or why it was still in place. She stated she thought resident #72's IV was a midline he received at the hospital but was not sure when. She verified there were no orders to care for the IV, no care plan for it, nor was it on the Medication Administration or Treatment Administration record for February 2024. The C wing UM explained the line needed to be flushed every shift, before and after any medications going into it along with dressing changes and assessment. She described the admission process for the assigned nurse who should do a full body head to toe assessment of the resident and note any devices or skin impairments on the resident. The C wing UM explained the nurse looked at all of the hospital paperwork including the hospital transfer form in order to transcribe the orders needed for the resident at the facility to determine if there were any changes, new medications or devices when a resident returned to the facility from the hospital. She stated it was important for the nurse to read all of the hospital papers to determine if there were any changes that happened since the resident went to the hospital. The C wing UM indicated the assigned nurse would call the physician to verify the orders. She stated the next day the UM would perform a chart audit using the admission checklist on all newly admitted or readmitted residents along with performing a second head to toe skin assessment. She described the chart audit would include the UM again checking the paperwork from the hospital for anything pertinent related to the care of the resident including skin, devices like an IV or catheter or even follow up appointments. The C wing UM detailed that on the skin assessment they were to document anything that was not normally found on the skin or going into the skin/body. She stated there were batch orders for IVs and other things that allowed the nurse to place all the needed orders to care and maintain an IV including a PICC. The C wing UM detailed the UMs would hand the audits to the DON and said she assumed they were checking it as well. The C wing UM explained the UMs would then summarize information about the newly admitted or readmitted resident during the clinical meeting every morning. The C wing UM explained the nurse should call the doctor for orders if a resident had a PICC line to determine if the line should be discontinued or implement orders for its care and maintenance. She acknowledged the second skin assessment she documented for resident #72 was inaccurate and stated she did not recall seeing his PICC line on his left arm when she did the second head to toe skin assessment. The C wing UM stated the LPN BB should have called the physician about resident #72's PICC line when she did the admission. She admitted she should have documented the PICC on the second skin assessment she performed and must have overlooked it. She stated she also did not catch it when she reviewed the hospital transfer form and therefore did not call the physician for the necessary orders. The C wing UM explained she was aware of resident #72's PICC and had even spoken to the physician about the PICC the previous week in regard to some labs that were needed but could not explain why she did not ask for orders for its care and maintenance at that time. She admitted she notified the on-call physician on 3/03/24 after being made aware by the State Surveyor there was a resident with an IV that she needed orders for. She acknowledged she did not inform the on-call physician of the details that resident #72 had a PICC that had not received care and services since January. The C wing UM instead received approval to put in the batch orders for resident #72's PICC without the physician knowing all of the circumstances concerning his PICC not receiving care. The C wing UM acknowledged she was aware that resident neglect meant not receiving care and services that were required for a resident's health and wellbeing. She reiterated a PICC needed to be kept clean, with an intact dressing, needed dressing changes and care because it could cause infections like sepsis or an infection in your heart. Review of the Job Description- Unit Manager-RN undated, revealed the UM was responsible for overseeing direct nursing care to assigned residents. The UM assumed responsibility and accountability for the nursing care and services provided on the assigned unit. The UM was also responsible for and adhered to the standards of care for assigned residents and assisted with data collection, monitoring and implementation of physician orders based on individual resident needs. The UM was also responsible for supervising the resident care activity performance by licensed nurses. Essential duties and responsibilities included observing staff and visiting residents to ensure proper nursing care was provided and oversaw the assessments of the resident admission process. On 3/04/24 at 10:03 AM, the B wing UM stated a clinical meeting was held every weekday morning to discuss all new admissions and readmissions. She stated the UMs reviewed the admissions and readmissions to their unit using the information from the hospital paperwork, baseline care plan and the admission audit. She explained the admission audit was completed by the nurse managers after the admission was completed by the assigned nurse. The B wing UM described she checked to verify the physician orders for devices such as IV lines were in place. She explained this was to ensure orders were complete on admission and if they were not she would call the physician to obtain the orders. The B wing UM was unsure if the DON or anyone else looked at the audits once they were completed by the managers. In interviews on 3/04/23 at 11:23 AM and 4:55 PM, the Executive DON stated the UMs submitted the audits to either the 1st floor or 2nd floor DON. She explained the DONs only ensured the audits were completed but did not check the information on the audits for accuracy. She stated they discussed the new admissions and readmissions at the clinical meeting by reviewing their diagnoses and the plan of care. The Executive DON stated the facility did not have a policy and procedure for PICC lines and stated only an RN could draw blood by PICC line but acknowledged a physician order was needed. She noted it was her expectation the nurse would call the physician about the PICC line and document the conversation. Review of the Clinical Guidelines Manual- admission Orders presented by the facility with effective date of October 2021 revealed the policy admission orders would be obtained/approved through the attending physician following or prior to the resident's admission to the facility. The procedure section described the procedure if returned from the hospital to contact the attending physician if the order read to resume all previous orders, and to assure at minimum the orders contained diet, medication, routine care to maintain or improve functional ability, and code status. The return from the hospital procedure did not give direction specifically to review the orders that came with the transfer. The admitted from the hospital/ER section detailed the procedure to review the transfer orders, contact the attending physician immediately upon admission to review the transfer orders and obtain approval and to obtain further orders as appropriate. In a telephone interview on 3/04/24 at 12:28 PM, the admitting nurse, LPN BB stated she was previously certified to care for intravenous lines and recalled caring for resident #72 in the past several months. She stated when she admitted or readmitted a resident she did a head-to-toe skin assessment and often the supervisor or UM submitted the orders for medications and other treatments. LPN BB described the hospital transfer form was sometimes incorrect, so it was important to do your own assessment of the resident. She explained if you saw a wound or other skin impairment you would let the physician know, and you would document it in the skin assessment. LPN BB acknowledged she had documented the double lumen was present on resident #72 when she completed the Admission/readmit: Data Collection and Baseline Care Plan on 1/10/24 but documented incorrectly the location of the line and failed to document what type of line it was. Although she documented the presence of resident #72's IV she also acknowledged she did not obtain orders from the physician per the batch orders available for the PICC. She stated she could not recall resident #72's PICC, could not recall notifying the physician, nor could she recall assessing resident #72 at all. LPN BB explained a PICC needed orders for care like flushes and if there were no medications ordered for it, the physician would often discontinue the line. LPN BB stated if the nurse saw that a new or readmitted resident had a PICC they were supposed to notify the supervisor since they would be the one to call the physician for orders. LPN BB could not recall ever discussing the PICC with his primary physician or Advanced Practice Registered Nurse (APRN) CC and could not say why she had not notified them herself as she was aware of what type of care the IV required. LPN BB next explained weekly skin checks were completed by the assigned nurse as it was scheduled. She described the process was to look at the resident head to toe and note any new impairments or anything that did not normally belong on their skin. LPN BB stated the nurse should document what they found and complete an incident report for any newly found impairments. On 3/06/24 at 5:32 PM, Registered Nurse (RN) E recalled seeing resident #72 with the PICC in his arm and she acknowledged she had documented having looked at resident #72's left arm per the physician orders. She described that a PICC line should at the minimum have orders to flush it and to change the dressing but could only say it may have slipped her mind that the PICC did not have any orders for care or maintenance. On 3/06/24 at 5:45 PM, RN B also recalled caring for resident #72 since January. She remembered seeing the PICC in his arm and said in the evenings with two nurses on the unit it was very busy. She explained if she saw an order to do something she would do it but said she might not notice if there was no order for something. RN B said if the PICC dressing did not have a date on the dressing you should look at the orders and call the physician if there weren't any orders. She was unable to say why she did not notice resident #72 did not have a date on his PICC dressing. RN B stated care for the PICC line was important because you would want to treat the resident like you would want someone to care for yourself. Review of the Treatment Administration Record dated January 2024, revealed a physician's order to monitor bruise to left inner forearm and notify the physician of any changes every shift that started on 1/11/24. During the month of January, 23 different nurses documented they had looked at resident #72's left arm and did not notify the physician about his undated/unlabeled PICC line. Review of the Treatment Administration Record dated February 2024, revealed the same physician's order to monitor the bruise to resident #72's left inner forearm and notify the physician of any changes every shift. For February 2024, 22 different nurses documented they had looked at resident #72's left arm and did not notify the physician about his undated/unlabeled PICC line. Review of the Treatment Administration Record for March 2024 revealed 6 nurses documented they had looked at resident #72's left arm per the physician order to monitor the bruise to his left forearm and failed to notify the physician about his undated/unlabeled PICC line that had no orders for care or maintenance. In total 33 different nurses including three UM's and the first floor Director of Nursing (DON) documented they had looked at resident #72's left arm and failed to notice the unlabeled PICC line and notify the physician for orders. On 3/08/24 at 11:52 AM, the Regional Clinical Reimbursement Specialist stated that the facility Clinical Reimbursement Specialists go to the clinical meeting and participate in it to discuss the care plans for new admissions, readmissions, and any other residents with changes in their plan of care. She described that the Clinical Reimbursement Specialists did an order listing review every morning, and they should look at the orders. The Regional Clinical Reimbursement Specialist stated when they did the Minimum Data Set Assessment they were supposed to go and look at the resident for their assessment. She said they should have also assessed resident #72 and it should have been on his Annual MDS on 1/13/24 that he had the PICC. The Regional Clinical Reimbursement Specialist explained the facility Clinical Reimbursement Specialist would have looked at him on 1/10/24 and he should have had a care plan for the PICC. She said they should have seen it then and made a care plan for it. Absolutely, she said. The Regional Clinical Reimbursement Specialist said there was obviously some kind of a problem. In interviews on 3/04/24 at 12:23PM and 1:13 PM, the Staff Development Coordinator (SDC) stated on admission the admitting nurse should put in batch orders for the PICC line. These orders would include flushes every shift and as needed, change of the administration set every 4 days for any IV medications, documentation of site appearance every shift, dressing changes every 7 days and as needed, change the cap every 7 days, change the dressing within 24 hours of admit/insertion, flush each lumen with 10 milliliters of normal saline after each intermittent infusion, for blood draws flush with 10 milliliters of normal saline and to measure the arm circumference. She stated nurses got education on what they were expected to do on admission and there was a class in their electronic learning modules. She described the admitting nurse was supposed to admit the resident in the computer, look at the resident as they meet them, do a hands-on head to toe assessment, then verify the medications with the physician including any batch orders as needed. The SDC explained the UM also did a second skin assessment on each resident on admission/readmission and documented any skin impairment in the computer. She acknowledged the C wing UM documented bruises to resident #72's upper left arm and left and right hands but failed to document the PICC in his upper left arm. The SDC acknowledged nurses had said they had drawn labs from the PICC line without any physician orders. She explained, IV certified nurses could draw blood from a PICC line but confirmed they needed a physician order to do so. The SDC also acknowledged subsequent assigned nurses failed to document the PICC in the skin assessments including the first skin assessment on 1/13/24. She stated nurses were aware of the batch orders for PICCs and should have called the physician. On 3/04/24 at 10:24 AM, in a telephone interview APRN CC stated she saw resident #72 frequently at the facility and described herself as the primary provider besides his attending physician. APRN CC stated she had not known resident #72 had a PICC line, nor had she known he had not had any orders for care or maintenance of the line since he arrived at the facility with it on 1/10/24. She described having seen resident #72 just a few days previously for some concerns about constipation. She stated she was not aware resident #72 had the PICC line and was surprised as he had no reason to have it because he did not have antibiotics or any other medication that needed to go through a PICC. APRN CC described the physician ZZ having seen resident #72 on the previous Thursday as well and was adamant she was unaware of the PICC in his left upper arm as well. She explained they had not ordered any antibiotics and stated there was no justification for resident #72 to still have the PICC. She stated 7 weeks and 4 days was a very long time for resident #72 to not have had any care for his PICC, and commented facility staff should have called and gotten orders to either discontinue or care for it. She then explained her, and the physician WW were the primary point of contact for the facility staff and said they primarily called her but could text her as well. She stated no one from the facility had notified her or physician WW about resident #72's PICC not having any care or orders since the facility was made aware the day before on 3/03/24. The APRN CC then asked to stop the conversation and call back later until after she could call physician ZZ to clarify what she knew about resident #72's PICC. A few minutes later APRN CC continued the telephone interview and stated she spoke with physician WW, who told her she also did not know about resident #72's PICC. APRN CC stated if they had known he had a PICC they would have discontinued it. She stated they were going to discontinue it now. APRN CC explained normally she expected facility nurses to notify the physician of the PICC line. APRN CC stated the nurses also did weekly skin checks and should have noticed the PICC and noticed there were no orders for care and notified her or the physician. Further review of resident #72's medical record revealed resident #72 was assessed 9 times by the APRN between his admission on [DATE] and 3/03/24. These progress notes on 1/12/24, 1/13/24, 1/23/24, 1/24/24, 1/26/24, 1/30/24, 2/02/24, 2/07/24, and 2/20/24 had no mention of resident #72's PICC even though cardiac, skin and extremities were documented as assessed. On 3/04/24 at 12:50 PM, in a telephone interview physician WW stated when APRN CC first called her she did not recall resident #72 having the PICC line, but now she remembered he had one. She stated she had talked with the nurse about the line needing to be changed but wanted to deal with resident #72's abdominal pain first. Physician WW was asked if she knew resident #72 had gone for 7 weeks without any care for his PICC and she said she was not aware he didn't have any orders for the PICC since he came into the facility with it in January. Physician WW explained APRN CC saw resident #72 frequently, confirmed APRN CC was supposed to perform and document a complete hands-on assessment of the residents. She stated none of the facility staff had called to inform her or ask for orders for the PICC and also confirmed a physician order was needed for IV certified nurses to use the PICC for blood draws. Physician WW stated she did not know how it happened that resident #72 went for that long without anyone knowing he did not have any orders to care for the PICC. Physician WW said she had looked at the on-call list and there was nothing that showed there were any issues with resident #72's PICC from 3/03/24 when the facility was made aware of the concerns about lack of care. She stated it was important for the PICC to get care because it could cause serious complications. On 3/08/24 at 2:21 PM, the Medical Director stated he was made aware of the issue with resident #72's PICC not having care since his readmission on [DATE]. He stated he expected nurses to obtain orders for care and to notify the physician. The Medical Director stated PICCs were associated with complications like infections and said it was very lucky that resident #72 did not get a central line associated infection or other complication due to this lack of care or maintenance for his PICC. Review of both the undated job descriptions, Licensed Practical Nurse and Registered Nurse revealed both the LPN and RN were responsible for delivering care to residents using the nursing process of assessment, planning, intervention, implementation, and evaluation to maintain standards of professional nursing. The document further described the responsibilities of the LPN and RN which included assess, plan direct, and evaluate total nursing care as determined by the resident's needs in accordance with established standards, policies, and procedures. Another responsibility was to monitor, record and report changes in resident's condition in a timely manner, and to perform physical exams to determine the resident's status and develop a treatment plan. Also to complete and review the admission Data record and to assess the needs of residents to identify potential health or safety problems. Review of immediate actions to remove the Immediate Jeopardy implemented by the facility revealed the following, which were verified by the survey team: * A registered nurse removed the PICC from resident #72 on 3/04/24. The site was assessed by the RN and no signs of infection were present upon removal. Resident #72 remained in the facility with no change in condition or signs of distress. *The DON, Assistant DON (ADON) and UMs assessed all 381 residents for intravenous lines including central lines on 3/05/24. There were 6 residents with intravenous lines, including central lines with appropriate orders in place, proper fluids running as ordered and dressings appropriately dated. Each intravenous line site was assessed by an RN with no signs of symptoms of infection present. * The Nurse Consultant educated the DON on 1) clinical care related to intravenous line, including central line, 2) accurately documenting site location, 3) notification to the physician to clarify and obtain orders for the care, maintenance or discontinuance of the line, and 4) initiating the care plan. As of 3/05/24, the DON or designee has provided education to 24 of 114 nurses on 1) clinical care related to intravenous line, including central line, 2) accurately documenting site location, 3) notification to the physician to clarify and obtain orders for the care, maintenance or discontinuance of the line, and 4) initiating the care plan. As of 3/05/24 24 out of 104 registered nurses and LPNs with IV certification have completed competencies related to 1) PICC Catheter removal, 2) Flushing of Vascular Access Device, and 3) Midline/Central Line Dressing Changes. We have a goal of completing education and competencies on an additional 25 nurses by 3/05/24, with the remaining nurses being completed prior to the start of their next shift worked. * The DON or designee will observe each patient with an intravenous line including central line to validate that care, maintenance, or discontinuance has occurred. Any variance identified will result in the immediate reeducation of the licensed nurse. Review of in-service education sign in sheets and reconciliation with staff roster validated education was completed according to the facility's plan. 98 of the total 102 nurses at the facility were educated on neglect; assessment, documentation, and monitoring of IV site and dressing; midline/central line dressing change and flushing a vascular device. Additionally, 76 RNs were educated on PICC catheter removal. An ad hoc QAPI was held on 3/06/24 that included the Medical Director. On 3/05/24 a venous doppler to resident #72's left upper arm, an Xray to the left arm and labs were ordered by the physician to ensure no complications such as retained objects or infection after the removal of the PICC. Per interview with the Executive DON these tests resulted as within normal limits. On 3/05/24 through 3/08/24 interviews were conducted with 30 of the nursing staff, including 24 RNs and 6 LPNs, including 6 second shift nurses. All verbalized understanding of the education provided by the facility including neglect; assessment, documentation, and monitoring of IV site and dressing; midline/central line dressing change and flushing a vascular device. The sample was expanded to include all 4 other residents identified with IV lines. No concerns were found regarding these residents including resident #354 who had a tunneled central line in his right chest. 2. On 3/03/24 at 5:34 PM and 3/05/24 at 10:05 AM, RN K stated there were residents on her assignment who had physician orders for blood glucose checks and insulin administration scheduled at 4:00 PM. She confirmed she had not done the task and she did not always do so before dinner as the residents left the unit to eat in the dining room. RN K stated she checked some residents' blood glucose levels after they returned from dinner in the dining room. On 3/04/24 at 1:07 PM, RN GG confirmed he had not checked scheduled pre-lunch blood glucose levels for his assigned diabetic residents and explained he was busy doing other things. RN GG acknowledged blood glucose monitoring and insulin administration were to be completed prior to meals. When asked if he reported he was running late to the Unit Manager, RN GG stated the manager was aware. On 3/06/24 at 11:01 AM, RN E acknowledged she performed blood glucose monitoring after her assigned resident consumed breakfast. She explained blood glucose could be checked and insulin administered either 20 minutes before or after meals. When asked if there would be a difference in the readings, RN E said, .the after meal reading would be higher, but not a really big difference. She was asked to review the physician order for insulin that read, with meals. RN E confirmed the order meant insulin should be given while eating but she reiterated, I know I can do it 20 minutes before or after meals. I have had him before. On 3/06/24 at 12:31 PM, the B Wing UM stated she expected all nurses to know blood glucose monitoring was to be done before mealtime. She stated if residents ate in the dining room, it was the nurse's responsibility to ensure blood glucose was checked before they left the unit. The B Wing UM explained the nurse could remind the resident to see her before going to the dining room. She stated her off[TRUNCATED]