**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that all residents received treatment and care for peripherally inserted central catheters in accordance with professional standards of practice by failing to provide central venous dressing changes for 3 of 4 reviewed residents with central venous access devices, Residents #71, #289 and #297. The lack of appropriate dressing changes to assess the insertion site for signs and symptoms of infection, fluid leaking, redness, pain, tenderness, and swelling can result in an increased risk of infection at the insertion site, sepsis (a life-threatening infection in the blood), damage to the vein, phlebitis or blood clots, which can result in the likelihood of increased risk of serious harm and/or death. Findings include: 1. Review of Resident #71's admission records revealed the resident was admitted to the facility on [DATE] with diagnoses including infection of right lower extremity amputation stump, chronic obstructive pulmonary disease, hyperlipidemia (high cholesterol), personal history of transient ischemic attack (a brief stroke like attack) and cerebral infraction (a stroke) without residual deficits, peripheral vascular disease (a disorder that causes narrowing, blockage or spasms in the blood vessels), essential hypertension (high blood pressure), acquired absence of right leg above knee, unspecific atrial fibrillation (an irregular heartbeat), pleural effusion (fluid around the lungs due to poor pumping of the heart), infective myositis (inflammation of the muscles), and unspecified diastolic heart failure (a chronic condition in which the heart doesn't pump blood as well as it should). Review of Resident #71's New admission Data Collection and Observation dated 11/23/2022 at 6:53 PM revealed, 1. Initial Data Intake: 1b. admission Date/Time: 11/23/2022 at 1800 [6:00 PM]. Section 9a. Hydration/Port of Medication Entry: 3. PICC, 9c. Comments: IV antibiotic therapy. Review of a physician order dated 11/24/2022 for Resident #71 revealed, Change PICC [Peripherally Inserted Central Line] Line Dressing Every 7 Days and prn [as needed] if soiled or dislodged every night shift every 7 days for picc care. During an observation on 12/12/2022 at 9:45 AM, Resident #71 was sitting up in a wheelchair at her bed side with a single lumen PICC line in her right upper arm, covered with white tubular netting. The dressing had a dressing change date of 11/18 written in black marker and covered with a transparent dressing. During an interview on 12/12/2022 at 9:47 AM, Resident #71 stated, They have not changed my dressing at all since I got here. During an observation on 12/13/2022 at 11:09 AM, Resident #71 was sitting up in a wheelchair with a single lumen PICC line in her right upper arm covered with a white tubular netting dressing. The transparent dressing under the white tubular netting had a dressing change sticker dated 11/18 in black marker. During an interview on 12/13/2022 at 11:09 AM, Resident #71 stated, I have never refused a dressing change. Nurses just come in and flush the PICC line and give me my medication. Review of the progress notes from 11/23/2022 to 12/13/2022 for Resident #71 revealed no documentation of peripherally inserted central catheter care being refused. During an interview on 12/13/2022 at 11:42 AM, the Director of Nursing (DON) confirmed Resident #71's transparent dressing had the date of 11/18 written on it stating, All PICC line dressings should have been done on a weekly basis. This dressing is way out of date, and I will look into this. During an interview on 12/13/2022 at 11:58 AM, the Advanced Practice Registered Nurse (APRN) #1 stated, Oh wow, no way. There is a risk for infection, line infection, which would enter to the body eventually. Any kind of septic infection, there would be a risk for any kind of organ in the body. Review of Resident #71's Treatment Administration Record (TAR) revealed, Change PICC Line Dressing Every 7 Days and prn if soiled or dislodged every night shift every 7 day(s) for picc care. The TAR documented staff initials for the treatment being completed on 11/24/2022, 12/01/2022, and 12/08/2022. During an interview on 12/14/2022 at 6:53 AM, Staff A, Registered Nurse (RN), stated, I don't understand how that happened, how the dressing didn't get changed. The dressing order was popping up every day. In my mind, the dressing change was every 7 days, but it was coming up in the system every day. I will look at the site every day to make sure there is no infiltration and look at the date on dressing. I can't really say what happened that night that I signed it. It was a mistake to sign it and not do it. It must have been a busy night. Sometimes you might mark off something and it gets busy. I should change dressing if it is compromised or it needs to be changed, it's time for it to be changed. I only remember working with [Resident #71's name] one time. Not to my knowledge has she ever refused. She was always pleasant and did not refuse treatment. During an interview on 12/14/2022 at 9:04 AM, the Infection Preventionist RN stated, Central venous lines are assigned to another nurse to keep track of and monitor, the ADON [Assistant Director of Nursing]. I will look at them for general issues or signs of concerns such as infections. But the regular maintenance, training, and education fall under Assistant Director of Nursing. During an interview on 12/14/2022 at 9:29 AM, the APRN #2 stated, Central venous lines standards for dressing changes are every 7 days, and if soiled, or compromised. It really should be covered, and the insertion site not exposed. There is always a possibility for infections, that is the reason why we change them. I expect all orders to be followed. Nursing staff should be assessing, flushing and all appropriate things. Looking for abnormalities. I assess PICC's or midlines when a resident is initially admitted , but it is not my role any longer, my role has changed. This is delegated on nursing staff to do and to follow physician orders. There is always a possibility for infection when dressings are not changed. During an interview on 12/14/2022 at 10:26 AM, the Medical Doctor (MD) #1 stated, I do not know what protocol the facility has for central line dressing changes, but that is unacceptable, not to change dressings for that long. It can result in a localized infection or any kind of infection. I did not receive a call from the facility to notify me of the occurrence. During an interview on 12/14/2022 at 11:41 AM, the Assistant Director of Nursing stated, Nursing staff should be following physician orders for dressing changes. Nurses should be looking at dressings, dates and assessing site and change it if needed. During an interview on 12/15/2022 at 11:25 AM, the Medical Director stated, I am not involved in that resident's care. I am not in a place to give my medical opinion on that resident. I do not know all the details. You should speak to her attending physician. My opinion will not be much different than his. Maybe a localized infection and it is a breach in protocol. My expectations are for nurses and facilities to follow orders placed for dressing changes. During an interview on 12/15/2022 at 12:53 PM, Staff E, Licensed Practical Nurse (LPN), stated, I don't always look at the dressing site if I am not administering medication. If I see the dressing out of date, I would have changed it. I did not notice the dressing of [Resident #71's name] was out of date. I do not remember if I removed the netting or not. During an interview on 12/15/2022 at 1:28 PM, Staff F, Registered Nurse (RN), stated, I should have changed the dressing since it was out of date. I can't tell you why I didn't. During an interview on 12/15/2022 at 1:47 PM, Staff G, RN, stated, I do remember [Resident #71's name] had a sleeve on. Absolutely yes, should have changed the dressing. I don't know why I didn't. During an interview on 12/15/2022 at 2:59 PM, Staff M, LPN, stated, I don't remember seeing the dressing for her [Resident #71] I would absolutely have changed the dressing if I saw that it was dated 11/18. I did not see the date clearly. 2. Review of Resident #289's admission records revealed the resident was admitted to the facility on [DATE] with diagnoses including right knee septic MSSA (Methicillin-Susceptible Staphylococcus Aureus), arthritis with cellulitis (infection of the skin), infection and inflammatory reaction due to internal right knee prosthesis, unspecified atrial fibrillation (irregular heartbeat), chronic obstructive pulmonary disease, type 2 diabetes mellitus, presence of right artificial knee joint, essential (primary) hypertension (high blood pressure), and depression, unspecified. During an observation on 12/12/2022 at 12:35 PM, Resident #289 was sitting up in a wheelchair at bedside with a right upper arm single lumen PICC line, with the transparent dressing rolled up at the edges, and the insertion site exposed and opened to air. The dressing was dated 12/6/2022. There was white tubular dressing retainer net covering the PICC line and in contact with the insertion site. The white tubular dressing retainer net had several brownish stained areas noted on it. During an observation on 12/13/2022 at 8:45 AM, Resident #289 was observed sitting at bedside with a right upper arm PICC line with the transparent dressing rolled up and exposing the insertion site. The dressing was dated 12/6/2022. The white tubular dressing retainer net was covering the PICC line and in contact with the insertion site. The white tubular dressing retainer net had several brownish stained areas noted on it. During an interview on 12/13/2022 at 8:45 AM, Resident #289 stated, That has been rolled up like that for a few days now. The nurses don't really ask to have a look at the catheter, they just give me my antibiotics. Review of Resident #289's NSG New admission (Only) Data Collection and Observation Form dated 12/6/2022 revealed, Section 18. Diagnosis Generalized Category Nutrition/Hydration/Port of medication entry: Section 9b. Hydration/Port of medication entry 3. PICC 9c. comments right upper arm. Review of a physician order dated 12/6/2022 for Resident #289 revealed, Change PICC line dressing every 7 days and PRN if soiled or dislodged. Every night shift for PICC care. During an interview on 12/13/2022 at 11:00 AM, the DON stated, The dressing was exposing his insertion site and we will need that changed. It is a risk to have this open to air, maybe this just happened. The dressing date was 12/6/2022. During a telephone interview on 12/15/2022 at 12:01 PM, Staff C, Licensed Practical Nurse (LPN), stated, Well, no I did not pull back the netting and look at the site when I gave the 2 o'clock medication. When it's under netting, I don't always check. I probably should check the site before and after I give the medication. I don't know why I didn't. During an interview on 12/16/2022 at 8:23 AM, Staff D, LPN, stated, I don't think that I actually looked at the site of the PICC line when I gave medications. I usually just pull down the netting enough to get to the connector. 3. Review of Resident #297's admission record revealed the resident was admitted to the facility on [DATE] with diagnoses including endocarditis (an infection of the inner lining of the heart), atherosclerosis of coronary artery bypass graft(s) (coronary artery disease) with angina pectoris (chest pain), essential (primary) hypertension (high blood pressure), chronic kidney disease, type II diabetes mellitus, venous insufficiency (chronic) (peripheral), and right lower limb cellulitis, left lower limb cellulitis (infection in the legs). Review of a physician order dated 12/7/2022 for Resident #297 revealed, Change PICC line dressing every 7 days and PRN if soiled or dislodged every night shift every 7 days for PICC line care. During an observation on 12/12/2022 at 10:00 AM, Resident #297 was sitting up in a wheelchair with a right arm single lumen PICC line with a dressing date of 12/6/2022. There was a transparent dressing with a gauze under the transparent dressing covering the insertion site. During an interview on 12/12/2022 at 10:05 AM, Resident #297 stated, No, they haven't changed this dressing since I got here. During an observation on 12/13/2022 at 8:49 AM, Resident #297 had a right arm single lumen PICC line with gauze under the transparent dressing. The dressing was dated 12/6/2022. Review of the facility policy and procedure titled Central Venous Catheter Dressing Changes reads, Policy: Central Venous catheter dressings will be changed at specific intervals, or when needed, to prevent catheter infections that are associated with contaminated, loosened, soiled or wet dressings. Preparation: 2. A physician's order is not needed for this procedure. General Guidelines: 1. Apply and maintain sterile dressing on intravenous access devices. Dressing must stay clean, dry, and intact. Explain to the resident that the dressing should not get wet. 2. Change all dressings if any suspicion of contamination is suspected. 4. After original insertion of CVAD, the dressing will consist of gauze and TSM. This will change within 24 hours. Replace with sterile transparent dressing. 5. Change transparent semi-permeable membrane (TSM) dressing every 5-7 days and PRN (when wet, soiled, or not intact). 6. Change gauze dressing, or TSM over gauze dressing every 48 hours. 9. Change needless connection device, extension tubing, and stabilization device at the time of routine dressing changes. During an interview on 12/13/2022 at 11:42 AM, the DON stated, The dressing does have gauze over the insertion site and those per policy required changing in 48 hours. The Immediate Jeopardy was removed on site on December 16, 2022 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 the following: On 12/13/2022, the facility assessed the residents involved in the IJ situation and conducted a facility-wide audit of all current residents with a PICC line and receiving IV medications to identify possible harm, side effects, and injury to the resident due to IV administration. On 12/15/2022, the facility conducted an Ad Hoc QAPI (Quality Assurance and Performance Improvement) meeting and a root cause analysis. On 12/15-16/2022, the facility educated all nursing staff related to PICC line dressing changes and maintenance and documentation. On 12/16/2022, the [NAME] President of Clinical Services provided training to the facility administration on QAPI/QAA (Quality Assurance and Performance Improvement/ Quality Assurance and Assessment) policy and abuse/neglect policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure all residents were free from medical neglect. The facility failed to provide central venous catheter dressing changes and failed to ensure licensed practical nurses had the appropriate skills and competencies to administer intravenous medications via central venous access devices for 3 of 4 reviewed residents with central venous access devices, Residents #71, #289 and #297. The lack of appropriate dressing changes to assess the insertion site for signs and symptoms of infection, fluid leaking, redness, pain, tenderness, and swelling can result in an increased risk of infection at the insertion site, sepsis (a life-threatening infection in the blood), damage to the vein, phlebitis (inflammation of a vein) or blood clots. The lack of IV certification and validation of competency for IV infusion can result in an increased risk of infection, damage to veins and injection sites, an air embolism, phlebitis, and blood clots. Phlebitis can cause blood clots, which can block important blood vessels, causing tissue damage or even be life threatening. Lack of 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 and can result in the likelihood of increased risk of serious harm and/or death. Findings include: 1. Review of Resident #71's admission records revealed the resident was admitted to the facility on [DATE] with diagnoses including infection of right lower extremity amputation stump, chronic obstructive pulmonary disease, hyperlipidemia (high cholesterol), personal history of transient ischemic attack (a brief stroke like attack) and cerebral infraction (a stroke) without residual deficits, peripheral vascular disease (a disorder that causes narrowing, blockage or spasms in the blood vessels), essential hypertension (high blood pressure), acquired absence of right leg above knee, unspecific atrial fibrillation (an irregular heartbeat), pleural effusion (fluid around the lungs due to poor pumping of the heart), infective myositis (inflammation of the muscles), and unspecified diastolic heart failure (a chronic condition in which the heart doesn't pump blood as well as it should). Review of Resident #71's New admission Data Collection and Observation dated [DATE] at 6:53 PM revealed, 1. Initial Data Intake: 1b. admission Date/Time: [DATE] at 1800 [6:00 PM]. Section 9a. Hydration/Port of Medication Entry: 3. PICC, 9c. Comments: IV antibiotic therapy. Review of a physician order dated [DATE] for Resident #71 revealed, Change PICC [Peripherally Inserted Central Line] Line Dressing Every 7 Days and prn [as needed] if soiled or dislodged every night shift every 7 days for picc care. During an observation on [DATE] at 9:45 AM, Resident #71 was sitting up in a wheelchair at her bed side with a single lumen PICC line in her right upper arm, covered with white tubular netting. The dressing had a dressing change date of 11/18 written in black marker and covered with a transparent dressing. During an interview on [DATE] at 9:47 AM, Resident #71 stated, They have not changed my dressing at all since I got here. During an observation on [DATE] at 11:09 AM, Resident #71 was sitting up in a wheelchair with a single lumen PICC line in her right upper arm covered with a white tubular netting dressing. The transparent dressing under the white tubular netting had a dressing change sticker dated 11/18 in black marker. During an interview on [DATE] at 11:09 AM, Resident #71 stated, I have never refused a dressing change. Nurses just come in and flush the PICC line and give me my medication. Review of the progress notes from [DATE] to [DATE] for Resident #71 revealed no documentation of peripherally inserted central catheter care being refused. During an interview on [DATE] at 11:42 AM, the Director of Nursing (DON) confirmed Resident #71's transparent dressing had the date of 11/18 written on it stating, All PICC line dressings should have been done on a weekly basis. This dressing is way out of date, and I will look into this. During an interview on [DATE] at 11:58 AM, the Advanced Practice Registered Nurse (APRN) #1 stated, Oh wow, no way. There is a risk for infection, line infection, which would enter to the body eventually. Any kind of septic infection, there would be a risk for any kind of organ in the body. Review of Resident #71's Treatment Administration Record (TAR) revealed, Change PICC Line Dressing Every 7 Days and prn if soiled or dislodged every night shift every 7 day(s) for picc care. The TAR documented staff initials for the treatment being completed on [DATE], [DATE], and [DATE]. During an interview on [DATE] at 6:53 AM, Staff A, Registered Nurse (RN), stated, I don't understand how that happened, how the dressing didn't get changed. The dressing order was popping up every day. In my mind, the dressing change was every 7 days, but it was coming up in the system every day. I will look at the site every day to make sure there is no infiltration and look at the date on dressing. I can't really say what happened that night that I signed it. It was a mistake to sign it and not do it. It must have been a busy night. Sometimes you might mark off something and it gets busy. I should change dressing if it is compromised or it needs to be changed, it's time for it to be changed. I only remember working with [Resident #71's name] one time. Not to my knowledge has she ever refused. She was always pleasant and did not refuse treatment. During an interview on [DATE] at 9:04 AM, the Infection Preventionist RN stated, Central venous lines are assigned to another nurse to keep track of and monitor, the ADON [Assistant Director of Nursing]. I will look at them for general issues or signs of concerns such as infections. But the regular maintenance, training, and education fall under Assistant Director of Nursing. During an interview on [DATE] at 9:29 AM, the APRN #2 stated, Central venous lines standards for dressing changes are every 7 days, and if soiled, or compromised. It really should be covered, and the insertion site not exposed. There is always a possibility for infections, that is the reason why we change them. I expect all orders to be followed. Nursing staff should be assessing, flushing and all appropriate things. Looking for abnormalities. I assess PICC's or midlines when a resident is initially admitted , but it is not my role any longer, my role has changed. This is delegated on nursing staff to do and to follow physician orders. There is always a possibility for infection when dressings are not changed. During an interview on [DATE] at 10:26 AM, the Medical Doctor (MD) #1 stated, I do not know what protocol the facility has for central line dressing changes, but that is unacceptable, not to change dressings for that long. It can result in a localized infection or any kind of infection. I did not receive a call from the facility to notify me of the occurrence. During an interview on [DATE] at 11:41 AM, the Assistant Director of Nursing stated, Nursing staff should be following physician orders for dressing changes. Nurses should be looking at dressings, dates and assessing site and change it if needed. During an interview on [DATE] at 11:25 AM, the Medical Director stated, I am not involved in that resident's care. I am not in a place to give my medical opinion on that resident. I do not know all the details. You should speak to her attending physician. My opinion will not be much different than his. Maybe a localized infection and it is a breach in protocol. My expectations are for nurses and facilities to follow orders placed for dressing changes. During an interview on [DATE] at 12:53 PM, Staff E, Licensed Practical Nurse (LPN), stated, I don't always look at the dressing site if I am not administering medication. If I see the dressing out of date, I would have changed it. I did not notice the dressing of [Resident #71's name] was out of date. I do not remember if I removed the netting or not. During an interview on [DATE] at 1:28 PM, Staff F, Registered Nurse (RN), stated, I should have changed the dressing since it was out of date. I can't tell you why I didn't. During an interview on [DATE] at 1:47 PM, Staff G, RN, stated, I do remember [Resident #71's name] had a sleeve on. Absolutely yes, should have changed the dressing. I don't know why I didn't. During an interview on [DATE] at 2:59 PM, Staff M, LPN, stated, I don't remember seeing the dressing for her [Resident #71] I would absolutely have changed the dressing if I saw that it was dated 11/18. I did not see the date clearly. Review of a physician order dated [DATE] for Resident #71 revealed, Sodium Chloride solution 0.9% use 10 milliliters intravenously every shift for flush every shift and before and after each use. Review of a physician order dated [DATE] for Resident #71 revealed, Aztreonam in dextrose solution 1 GM [gram]/50 ml [milliliters], use 1 gram intravenously two times a day for RLE [right lower extremity] stump infection until [DATE]. Review of [DATE] Medication Administration Record (MAR) for Resident #71 revealed Staff D, Licensed Practical Nurse (LPN), administered sodium chloride solution 0.9% intravenously right arm on [DATE] at 1:53 AM, and administered Aztreonam 1 gm/50 ml intravenously right arm on [DATE] at 5:19 AM. 2. Review of Resident #289's admission records revealed the resident was admitted to the facility on [DATE] with diagnoses including right knee septic MSSA (Methicillin-Susceptible Staphylococcus Aureus), arthritis with cellulitis (infection of the skin), infection and inflammatory reaction due to internal right knee prosthesis, unspecified atrial fibrillation (irregular heartbeat), chronic obstructive pulmonary disease, type 2 diabetes mellitus, presence of right artificial knee joint, essential (primary) hypertension (high blood pressure), and depression, unspecified. During an observation on [DATE] at 12:35 PM, Resident #289 was sitting up in a wheelchair at bedside with a right upper arm single lumen PICC line, with the transparent dressing rolled up at the edges, and the insertion site exposed and opened to air. The dressing was dated [DATE]. There was white tubular dressing retainer net covering the PICC line and in contact with the insertion site. The white tubular dressing retainer net had several brownish stained areas noted on it. During an observation on [DATE] at 8:45 AM, Resident #289 was observed sitting at bedside with a right upper arm PICC line with the transparent dressing rolled up and exposing the insertion site. The dressing was dated [DATE]. The white tubular dressing retainer net was covering the PICC line and in contact with the insertion site. The white tubular dressing retainer net had several brownish stained areas noted on it. During an interview on [DATE] at 8:45 AM, Resident #289 stated, That has been rolled up like that for a few days now. The nurses don't really ask to have a look at the catheter, they just give me my antibiotics. Review of Resident #289's NSG New admission (Only) Data Collection and Observation Form dated [DATE] revealed, Section 18. Diagnosis Generalized Category Nutrition/Hydration/Port of medication entry: Section 9b. Hydration/Port of medication entry 3. PICC 9c. comments right upper arm. Review of a physician order dated [DATE] for Resident #289 revealed, Change PICC line dressing every 7 days and PRN if soiled or dislodged. Every night shift for PICC care. Review of a physician order dated [DATE] for Resident #289 revealed, Cefazolin sodium solution reconstituted 2 GM (grams) use 2 gram intravenously three times a day for infected right knee prosthesis for 33 days. Review of a physician order dated [DATE] for Resident #289 revealed, Sodium Chloride solution 0.9% use 10 milliliters intravenously three times per day for flush before and after each use of PICC line. Review of a physician order dated [DATE] for Resident #289 revealed, Heparin Lock Flush solution 100 unit/ml use 200 unit intravenously every 12 hours as needed for maintain patency before and after each use and use 200 unit intravenously three times a day for flush picc line using the sash method before and after each use. Review of [DATE] MAR for Resident #289 documented on [DATE] at 2:02 PM, Staff C, LPN, administered Cefazolin Sodium Solution 2-gram IV right arm, on [DATE] at 2:02 PM, Staff C, LPN, administered 10 milliliters of Sodium Chloride solution 0.9% intravenously right arm, on [DATE] at 1:56 PM, Staff C, LPN, administered Cefazolin Sodium Solution 2 gram IV right arm, on [DATE] at 1:56 PM, Staff C, LPN, administered 10 milliliters of Sodium Chloride solution 0.9% intravenously right arm, on [DATE] at 10:05 PM, Staff D, LPN, administered Cefazolin Sodium Solution 2 gram IV right arm, on [DATE] at 10:05 PM, Staff D, LPN, administered 10 milliliters of Sodium Chloride solution 0.9% intravenously right arm, on [DATE] at 5:02 AM, Staff D, LPN, administered Cefazolin Sodium Solution 2 gram IV right arm, on [DATE] at 5:02 AM, Staff D, LPN, administered 10 milliliters of Sodium Chloride solution 0.9% intravenously right arm, on [DATE] at 3:54 PM, Staff C, LPN, administered Cefazolin Sodium Solution 2 gram IV right arm, on [DATE] at 3:54 PM, Staff C, LPN, administered 10 milliliters of Sodium Chloride solution 0.9% intravenously right arm, on [DATE] at 9:19 PM, Staff D, LPN, administered Cefazolin Sodium Solution 2 gram IV right arm, on[DATE] at 9:19 PM, Staff D, LPN, administered 10 milliliters of Sodium Chloride solution 0.9% intravenously right arm, on [DATE] at 5:34 AM, Staff D, LPN, administered Cefazolin Sodium Solution 2 gram IV right arm, on[DATE] at 5:34 AM, Staff D, LPN, administered 10 milliliters of Sodium Chloride solution 0.9% intravenously right arm, on [DATE] at 3:10 PM, Staff C, LPN, administered Cefazolin Sodium Solution 2 gram IV right arm, on [DATE] at 3:10 PM, Staff C, LPN, administered 10 milliliters of Sodium Chloride solution 0.9% intravenously right arm, and on [DATE] at 3:10 PM, Staff C, LPN administered Heparin Lock Flush solution 100 units/ml. During an interview on [DATE] at 11:00 AM, the DON stated, The dressing was exposing his insertion site and we will need that changed. It is a risk to have this open to air, maybe this just happened. The dressing date was [DATE]. During a telephone interview on [DATE] at 12:01 PM, Staff C, Licensed Practical Nurse (LPN), stated, Well, no I did not pull back the netting and look at the site when I gave the 2 o'clock medication. When it's under netting, I don't always check. I probably should check the site before and after I give the medication. I don't know why I didn't. During an interview on [DATE] at 8:23 AM, Staff D, LPN, stated, I don't think that I actually looked at the site of the PICC line when I gave medications. I usually just pull down the netting enough to get to the connector. 3. Review of Resident #297's admission record revealed the resident was admitted to the facility on [DATE] with diagnoses including endocarditis (an infection of the inner lining of the heart), atherosclerosis of coronary artery bypass graft(s) (coronary artery disease) with angina pectoris (chest pain), essential (primary) hypertension (high blood pressure), chronic kidney disease, type II diabetes mellitus, venous insufficiency (chronic) (peripheral), and right lower limb cellulitis, left lower limb cellulitis (infection in the legs). Review of a physician order dated [DATE] for Resident #297 revealed, Change PICC line dressing every 7 days and PRN if soiled or dislodged every night shift every 7 days for PICC line care. During an observation on [DATE] at 10:00 AM, Resident #297 was sitting up in a wheelchair with a right arm single lumen PICC line with a dressing date of [DATE]. There was a transparent dressing with a gauze under the transparent dressing covering the insertion site. During an interview on [DATE] at 10:05 AM, Resident #297 stated, No, they haven't changed this dressing since I got here. During an observation on [DATE] at 8:49 AM, Resident #297 had a right arm single lumen PICC line with gauze under the transparent dressing. The dressing was dated [DATE]. Review of the facility policy and procedure titled Central Venous Catheter Dressing Changes reads, Policy: Central Venous catheter dressings will be changed at specific intervals, or when needed, to prevent catheter infections that are associated with contaminated, loosened, soiled or wet dressings. Preparation: 2. A physician's order is not needed for this procedure. General Guidelines: 1. Apply and maintain sterile dressing on intravenous access devices. Dressing must stay clean, dry, and intact. Explain to the resident that the dressing should not get wet. 2. Change all dressings if any suspicion of contamination is suspected. 4. After original insertion of CVAD, the dressing will consist of gauze and TSM. This will change within 24 hours. Replace with sterile transparent dressing. 5. Change transparent semi-permeable membrane (TSM) dressing every 5-7 days and PRN (when wet, soiled, or not intact). 6. Change gauze dressing, or TSM over gauze dressing every 48 hours. 9. Change needless connection device, extension tubing, and stabilization device at the time of routine dressing changes. During an interview on [DATE] at 11:42 AM, the DON stated, The dressing does have gauze over the insertion site and those per policy required changing in 48 hours. Review of a physician order dated [DATE] for Resident #297 revealed, Cefazolin sodium solution reconstituted 1 Gm [gram] use 100 mg intravenously every 12 hours for endocarditis for 42 days. Review of a physician order dated [DATE] for Resident #297 revealed, Sodium Chloride Solution 0.9% use 10 milliliters intravenously every 12 hours for flush. Review of a physician order dated [DATE] for Resident #297 revealed, Heparin lock flush solution 100 Unit/ml [milliliter] use 200 unit intravenously every 12 hours as needed for flush, use SASH [Saline, Administer Medication, Saline, H] method before and after each use of IV. Review of [DATE] MAR for Resident #297 revealed on [DATE] at 7:36 PM, Staff C, LPN, administered Cefazolin Sodium Solution 1 gram IV right arm, on [DATE] at 7:35 AM, Staff C, LPN, administered 10 milliliters of Sodium Chloride solution 0.9% intravenously right arm, on [DATE] at 7:36 PM, Staff C, LPN, administered Cefazolin Sodium Solution 1 gram IV right arm, on [DATE] at 7:36 PM, Staff C, LPN, administered 10 milliliters of Sodium Chloride solution 0.9% intravenously right arm, on [DATE] at 6:04 AM, Staff D, LPN, administered Cefazolin Sodium Solution 1 gram IV right arm, on [DATE] at 6:05 AM, Staff D, LPN, administered 10 milliliters of Sodium Chloride solution 0.9% intravenously right arm, on [DATE] at 6:02 PM, Staff C, LPN, administered Cefazolin Sodium Solution 1 gram IV right arm, on [DATE] at 6:02 PM, Staff C, LPN, administered 10 milliliters of Sodium Chloride solution 0.9% intravenously right arm, and on [DATE] at 6:02 PM, Staff C, LPN, administered Heparin lock flush solution intravenously right arm. Review of IV Certification for Staff D, LPN, dated [DATE], from [College Name] Community College Center for workforce development reads, This is to certify that [Staff D's [NAME] name] has successfully completed an 8 hour course (.8 ceus) [Continuing Education Units] in I.V. Infusion Therapy on the twenty-sixth day of October in the year 2022. Review of the Certificate from [Technical Center name] reads, Recognizes the attendance of [Staff C's [NAME] name] at the IV therapy/phlebotomy course dated [DATE] to [DATE]. There is no documentation of additional CEUs provided to Staff D, LPN. During an interview on [DATE] at 7:02 AM, the Administrator stated, We do not have IV certification for [Staff D, LPN's name] and there are some other staff that have not completed the 30 hours. I don't know how this happened. I have [the DON's name] working on that. During an interview on [DATE] at 7:15 AM, the Director of Nursing (DON) stated, We reached out to [Staff D's name] and she does not have more than 8 hours of IV training. She does not have the required 30 hours in order to give IV medications. Yes, she should have that. I can't tell you why we did not know this before now. It has been HR's (human resources) responsibility to get the certification. We have also found that a few other nurses do not have the required 30 hours, just 24 hours. I asked if they are certified. I do not get a copy or keep a copy. No, the ADON [Assistant Director of Nursing] who is responsible for training does not keep a copy. We don't have any system in place to help identify whether a staff has IV certification if they are an LPN. I am responsible to know who is competent and what those competencies are. It really is the nurses' responsibility to not give medications if they are not qualified. We have had them tell someone they can't do the IV's. Well, they wouldn't know if they were asking another uncertified nurse unless they were asking an RN to do it for them. I was not aware that this was a problem until now. During a telephone interview on [DATE] at 7:24 AM, Staff D, LPN, stated, I was IV certified a long time ago in Virginia and wasn't aware that I needed anything different. I would never deliberately practice outside my scope. I did administer IV medications to [Resident #71's name, Resident #289's name and Resident #297's name]. I have not been asked to provide my IV certification until Wednesday and yesterday they asked if I had any other certifications. I do not have any more than 8 hours of training that met the requirement at that time. I didn't know that it wasn't the same in Florida. During an interview on [DATE] at 8:14 AM, the Medical Director stated, I expect that all nurses will practice within their scope of practice. We should take notice and put a stop to it immediately. The facility should be asking for verification of IV certification before they administer any medications. During an interview on [DATE] at 8:19 AM, the Assistant Director of Nursing stated, There are several staff who don't have the required 30-hour course and we did not know this. The staffing coordinator will usually ask the agency if the LPNs are IV certified. The staffing coordinator will ask them to provide the IV certification and the staffing coordinator will let the manager know if someone is not IV certified. With regular full or part time staff, HR is responsible for obtaining certifications and maintaining them in the files. I do not keep any files on staff for competence. I was not aware that staff were not IV certified. I have not had any system in place to identify who is certified. We do not have any competencies that are specific to PICC lines or midlines. When nurses are oriented, they pass medications with the person training them. During an interview on [DATE] at 8:28 AM, the Director of Nursing stated, Typically, I interview the nurses. I will ask them if they are IV certified and will get any certification if they bring them to the interview. If they are hired, I send them to HR and HR would get copies of their IV certification, CPR [Cardiopulmonary Resuscitation] or any other certifications and that is where they are kept. I don't know if HR obtained a copy of [Staff D's name] IV certification. I am ultimately responsible for all clinical staff and their competency. I was not aware that there were staff who did not meet the requirements and they have been administering IV medications. We should have had a process in place to ensure all staff are competent. Review of Chapter 64B9-12 Administration of Intravenous Therapy by Licensed Practical Nurses revealed, 64B9-12.005 Competency and Knowledge requirements necessary to qualify the LPN to administer IV therapy. (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: (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 0022, F.A. C. Appropriate education and training requires a minimum of four (4) hours of instruction. This required 4 hours of instruction may be included as part of the 30 hours required for intravenous therapy education specified in subsection (4) of this rule. The education and training requirement 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 (central venous line) site assessment; (c) CVL dressing and cap changes; (d) CVL flushing;(e) CVL medications 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 witnessed by a Registered Nurse who shall file a proficiency statement regarding the licensed practical nurses ability to perform intravenous therapy via central lines. The proficiency statement shall be kept in the Licensed Practical Nurses personnel file. (5) Clinical Competence. The course must be followed by supervised clinical practice in intravenous therapy as needed to demonstrate clinical competence. Verification of clinical competence shall be the responsibility of each institution employing a licensed practical nurse based on institutional protocol. Such verification shall be given through a signed statement of a Florida licensed Registered Nurse. Review of Subsection (4) revealed, 4) Educational Alternatives. The cognitive training shall include one or more of the following: a) Post-graduate Level Course. In recognition that the curriculum requirements mandated by Sections 464.019(1)(b), 464.019(1)(f), and 464.019(1)(g), F.S., for practical nursing programs are extensive and that every licensed practical nurse will not administer IV Therapy, the course necessary to qualify a licensed practical nurse or graduate practical nurse to administer IV therapy shall be not less than a thirty (30) hour post-graduate level course teaching aspects of IV therapy containing the components enumerated in subsection 64B9-12.005(1), F.A.C. Review of the facility policy and procedure titled Abuse, Neglect and Exploitation with an approval date of [DATE] reads, Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Definitions: Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Policy explanation and compliance guidelines: 1. The facility will develop and implement written policies and procedures that: a. prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property b. established policies and procedures to investigate any such allegations and d. establish coordination with the QAPI program. 3. The facility will provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written. III. Prevention of Abuse, Neglect, and Exploitation: the facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: D. The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect. IV. Identification of Abuse, Neglect and Exploitation: B. Potential indicators of abuse include, but are not limited to: 8. Failure to provide care needs such as comfort, safety, feeding, bathing, dressing, turning. The Immediate Jeopardy (IJ) was removed on site on [DATE] 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 the following: On [DATE], the facility assessed the residents involved in the IJ situation and conducted a facility-wide audit of all current residents with a PICC line and receiving IV medications to identify possible harm, side effects, and injury to the resident due to IV administration. On [DATE], the facility conducted an Ad Hoc QAPI (Quality Assurance and Performance Improvement) meeting and a root cause analysis. On 12/15-16/2022, the facility educated all nursing staff related to PICC line dressing changes and maintenance, documentation, and the 30-hour IV certification requirement for LPNs prior to PICC line handling. On [DATE], the [NAME] President of Clinical Services provided training to the facility administration on QAPI/QAA (Quality Assurance and Performance Improvement/ Quality Assurance and Assessment) policy and abuse/neglect policy. On [DATE], an audit was conducted to verify all IV medications, dressing changes and line maintenance are performed by competent nursing staff. On [DATE], education was provided by the Regional Nurse to the Director of Nursing, the Assistant Director of Nursing and nursing supervisors related to the requirement of 30-hour IV LPN Certification. A list of LPNs with IV certification competency was placed at each nurses' station to ensure that nurses are aware of who is qualified to perform IV tasks.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure licensed practical nurses had the appropriate skills and competencies to administer intravenous (IV) medications via central venous access devices for 3 of 4 reviewed residents with central venous access devices, Residents #71, #289 and #297. The lack of IV certification and validation of competency for IV infusion can result in an increased risk of infection, damage to veins and injection sites, an air embolism, phlebitis, and blood clots. Phlebitis can cause blood clots, which can block important blood vessels, causing tissue damage or even be life threatening. Lack of 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 and can result in the likelihood of increased risk of serious harm and/or death. Findings include: 1. Review of Resident #71's admission records revealed the resident was admitted to the facility on [DATE] with diagnoses including infection of right lower extremity amputation stump, chronic obstructive pulmonary disease, hyperlipidemia (high cholesterol), personal history of transient ischemic attack (a brief stroke like attack) and cerebral infraction (a stroke) without residual deficits, peripheral vascular disease (a disorder that causes narrowing, blockage or spasms in the blood vessels), essential hypertension (high blood pressure), acquired absence of right leg above knee, unspecific atrial fibrillation (an irregular heartbeat), pleural effusion (fluid around the lungs due to poor pumping of the heart), infective myositis (inflammation of the muscles), and unspecified diastolic heart failure (a chronic condition in which the heart doesn't pump blood as well as it should). Review of a physician order dated [DATE] for Resident #71 revealed, Sodium Chloride solution 0.9% use 10 milliliters intravenously every shift for flush every shift and before and after each use. Review of a physician order dated [DATE] for Resident #71 revealed, Aztreonam in dextrose solution 1 GM [gram]/50 ml [milliliters], use 1 gram intravenously two times a day for RLE [right lower extremity] stump infection until [DATE]. Review of [DATE] Medication Administration Record (MAR) for Resident #71 documented Staff D, Licensed Practical Nurse (LPN), administered sodium chloride solution 0.9% intravenously right arm on [DATE] at 1:53 AM, and administered Aztreonam 1 gm/50 ml intravenously right arm on [DATE] at 5:19 AM. 2. Review of Resident #289's admission records revealed the resident was admitted to the facility on [DATE] with diagnoses including right knee septic MSSA (Methicillin-Susceptible Staphylococcus Aureus), arthritis with cellulitis (infection of the skin), infection and inflammatory reaction due to internal right knee prosthesis, unspecified atrial fibrillation (irregular heartbeat), chronic obstructive pulmonary disease, type 2 diabetes mellitus, presence of right artificial knee joint, essential (primary) hypertension (high blood pressure), and depression, unspecified. Review of Resident #289's NSG New admission (Only) Data Collection and Observation Form dated [DATE] revealed, Section 18. Diagnosis Generalized Category Nutrition/Hydration/Port of medication entry: Section 9b. Hydration/Port of medication entry 3. PICC 9c. comments right upper arm. Review of a physician order dated [DATE] for Resident #289 revealed, Cefazolin sodium solution reconstituted 2 GM (grams) use 2 gram intravenously three times a day for infected right knee prosthesis for 33 days. Review of a physician order dated [DATE] for Resident #289 revealed, Sodium Chloride solution 0.9% use 10 milliliters intravenously three times per day for flush before and after each use of PICC line. Review of a physician order dated [DATE] for Resident #289 revealed, Heparin Lock Flush solution 100 unit/ml use 200 unit intravenously every 12 hours as needed for maintain patency before and after each use and use 200 unit intravenously three times a day for flush picc line using the sash method before and after each use. Review of [DATE] MAR for Resident #289 documented on [DATE] at 2:02 PM, Staff C, LPN (date of hire: [DATE]), administered Cefazolin Sodium Solution 2-gram IV right arm, on [DATE] at 2:02 PM, Staff C, LPN, administered 10 milliliters of Sodium Chloride solution 0.9% intravenously right arm, on [DATE] at 1:56 PM, Staff C, LPN, administered Cefazolin Sodium Solution 2 gram IV right arm, on [DATE] at 1:56 PM, Staff C, LPN, administered 10 milliliters of Sodium Chloride solution 0.9% intravenously right arm, on [DATE] at 10:05 PM, Staff D, LPN (date of hire: [DATE]), administered Cefazolin Sodium Solution 2 gram IV right arm, on [DATE] at 10:05 PM, Staff D, LPN, administered 10 milliliters of Sodium Chloride solution 0.9% intravenously right arm, on [DATE] at 5:02 AM, Staff D, LPN, administered Cefazolin Sodium Solution 2 gram IV right arm, on [DATE] at 5:02 AM, Staff D, LPN, administered 10 milliliters of Sodium Chloride solution 0.9% intravenously right arm, on [DATE] at 3:54 PM, Staff C, LPN, administered Cefazolin Sodium Solution 2 gram IV right arm, on [DATE] at 3:54 PM, Staff C, LPN, administered 10 milliliters of Sodium Chloride solution 0.9% intravenously right arm, on [DATE] at 9:19 PM, Staff D, LPN, administered Cefazolin Sodium Solution 2 gram IV right arm, on[DATE] at 9:19 PM, Staff D, LPN, administered 10 milliliters of Sodium Chloride solution 0.9% intravenously right arm, on [DATE] at 5:34 AM, Staff D, LPN, administered Cefazolin Sodium Solution 2 gram IV right arm, on[DATE] at 5:34 AM, Staff D, LPN, administered 10 milliliters of Sodium Chloride solution 0.9% intravenously right arm, on [DATE] at 3:10 PM, Staff C, LPN, administered Cefazolin Sodium Solution 2 gram IV right arm, on [DATE] at 3:10 PM, Staff C, LPN, administered 10 milliliters of Sodium Chloride solution 0.9% intravenously right arm, and on [DATE] at 3:10 PM, Staff C, LPN administered Heparin Lock Flush solution 100 units/ml. 3. Review of Resident #297's admission record revealed the resident was admitted to the facility on [DATE] with diagnoses including endocarditis (an infection of the inner lining of the heart), atherosclerosis of coronary artery bypass graft(s) (coronary artery disease) with angina pectoris (chest pain), essential (primary) hypertension (high blood pressure), chronic kidney disease, type II diabetes mellitus, venous insufficiency (chronic) (peripheral), and right lower limb cellulitis, left lower limb cellulitis (infection in the legs). Review of a physician order dated [DATE] for Resident #297 revealed, Cefazolin sodium solution reconstituted 1 Gm [gram] use 100 mg intravenously every 12 hours for endocarditis for 42 days. Review of a physician order dated [DATE] for Resident #297 revealed, Sodium Chloride Solution 0.9% use 10 milliliters intravenously every 12 hours for flush. Review of a physician order dated [DATE] for Resident #297 revealed, Heparin lock flush solution 100 Unit/ml [milliliter] use 200 unit intravenously every 12 hours as needed for flush, use SASH [Saline, Administer Medication, Saline, H] method before and after each use of IV. Review of [DATE] MAR for Resident #297 revealed on [DATE] at 7:36 PM, Staff C, LPN, administered Cefazolin Sodium Solution 1 gram IV right arm, on [DATE] at 7:35 AM, Staff C, LPN, administered 10 milliliters of Sodium Chloride solution 0.9% intravenously right arm, on [DATE] at 7:36 PM, Staff C, LPN, administered Cefazolin Sodium Solution 1 gram IV right arm, on [DATE] at 7:36 PM, Staff C, LPN, administered 10 milliliters of Sodium Chloride solution 0.9% intravenously right arm, on [DATE] at 6:04 AM, Staff D, LPN, administered Cefazolin Sodium Solution 1 gram IV right arm, on [DATE] at 6:05 AM, Staff D, LPN, administered 10 milliliters of Sodium Chloride solution 0.9% intravenously right arm, on [DATE] at 6:02 PM, Staff C, LPN, administered Cefazolin Sodium Solution 1 gram IV right arm, on [DATE] at 6:02 PM, Staff C, LPN, administered 10 milliliters of Sodium Chloride solution 0.9% intravenously right arm, and on [DATE] at 6:02 PM, Staff C, LPN, administered Heparin lock flush solution intravenously right arm. Review of IV Certification for Staff D, LPN, dated [DATE], from [College Name] Community College Center for workforce development reads, This is to certify that [Staff D's [NAME] name] has successfully completed an 8 hour course (.8 ceus) [Continuing Education Units] in I.V. Infusion Therapy on the twenty-sixth day of October in the year 2022. Review of the Certificate from [Technical Center name] reads, Recognizes the attendance of [Staff C's [NAME] name] at the IV therapy/phlebotomy course dated [DATE] to [DATE]. There is no documentation of additional CEUs provided to Staff D, LPN. During an interview on [DATE] at 7:02 AM, the Administrator stated, We do not have IV certification for [Staff D, LPN's name] and there are some other staff that have not completed the 30 hours. I don't know how this happened. I have [the DON's name] working on that. During an interview on [DATE] at 7:15 AM, the Director of Nursing (DON) stated, We reached out to [Staff D's name] and she does not have more than 8 hours of IV training. She does not have the required 30 hours in order to give IV medications. Yes, she should have that. I can't tell you why we did not know this before now. It has been HR's responsibility to get the certification. We have also found that a few other nurses do not have the required 30 hours, just 24 hours. I asked if they are certified. I do not get a copy or keep a copy. No, the ADON [Assistant Director of Nursing] who is responsible for training does not keep a copy. We don't have any system in place to help identify whether a staff has IV certification if they are an LPN. I am responsible to know who is competent and what those competencies are. It really is the nurses' responsibility to not give medications if they are not qualified. We have had them tell someone they can't do the IV's. Well, they wouldn't know if they were asking another uncertified nurse unless they were asking an RN to do it for them. I was not aware that this was a problem until now. During a telephone interview on [DATE] at 7:24 AM, Staff D, LPN, stated, I was IV certified a long time ago in Virginia and wasn't aware that I needed anything different. I would never deliberately practice outside my scope. I did administer IV medications to [Resident #71's name, Resident #289's name and Resident #297's name]. I have not been asked to provide my IV certification until Wednesday and yesterday they asked if I had any other certifications. I do not have any more than 8 hours of training that met the requirement at that time. I didn't know that it wasn't the same in Florida. During an interview on [DATE] at 8:14 AM, the Medical Director stated, I expect that all nurses will practice within their scope of practice. We should take notice and put a stop to it immediately. The facility should be asking for verification of IV certification before they administer any medications. During an interview on [DATE] at 8:19 AM, the Assistant Director of Nursing stated, There are several staff who don't have the required 30-hour course and we did not know this. The staffing coordinator will usually ask the agency if the LPNs are IV certified. The staffing coordinator will ask them to provide the IV certification and the staffing coordinator will let the manager know if someone is not IV certified. With regular full or part time staff, HR is responsible for obtaining certifications and maintaining them in the files. I do not keep any files on staff for competence. I was not aware that staff were not IV certified. I have not had any system in place to identify who is certified. We do not have any competencies that are specific to PICC lines or midlines. When nurses are oriented, they pass medications with the person training them. During an interview on [DATE] at 8:28 AM, the Director of Nursing stated, Typically, I interview the nurses. I will ask them if they are IV certified and will get any certification if they bring them to the interview. If they are hired, I send them to HR and HR would get copies of their IV certification, CPR [Cardiopulmonary Resuscitation] or any other certifications and that is where they are kept. I don't know if HR obtained a copy of [Staff D's name] IV certification. I am ultimately responsible for all clinical staff and their competency. I was not aware that there were staff who did not meet the requirements and they have been administering IV medications. We should have had a process in place to ensure all staff are competent. Review of Chapter 64B9-12 Administration of Intravenous Therapy by Licensed Practical Nurses revealed, 64B9-12.005 Competency and Knowledge requirements necessary to qualify the LPN to administer IV therapy. (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: (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 0022, F.A. C. Appropriate education and training requires a minimum of four (4) hours of instruction. This required 4 hours of instruction may be included as part of the 30 hours required for intravenous therapy education specified in subsection (4) of this rule. The education and training requirement 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 (central venous line) site assessment; (c) CVL dressing and cap changes; (d) CVL flushing;(e) CVL medications 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 witnessed by a Registered Nurse who shall file a proficiency statement regarding the licensed practical nurses ability to perform intravenous therapy via central lines. The proficiency statement shall be kept in the Licensed Practical Nurses personnel file. (5) Clinical Competence. The course must be followed by supervised clinical practice in intravenous therapy as needed to demonstrate clinical competence. Verification of clinical competence shall be the responsibility of each institution employing a licensed practical nurse based on institutional protocol. Such verification shall be given through a signed statement of a Florida licensed Registered Nurse. Review of Subsection (4) revealed, 4) Educational Alternatives. The cognitive training shall include one or more of the following: a) Post-graduate Level Course. In recognition that the curriculum requirements mandated by Sections 464.019(1)(b), 464.019(1)(f), and 464.019(1)(g), F.S., for practical nursing programs are extensive and that every licensed practical nurse will not administer IV Therapy, the course necessary to qualify a licensed practical nurse or graduate practical nurse to administer IV therapy shall be not less than a thirty (30) hour post-graduate level course teaching aspects of IV therapy containing the components enumerated in subsection 64B9-12.005(1), F.A.C. The Immediate Jeopardy was removed on site on [DATE] 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 the following: On [DATE], the facility assessed the residents involved in the IJ situation and conducted a facility-wide audit of all current residents with a PICC line and receiving IV medications to identify possible harm, side effects, and injury to the resident due to IV administration. On [DATE], the facility conducted an Ad Hoc QAPI (Quality Assurance and Performance Improvement) meeting and a root cause analysis. On 12/15-16/2022, the facility educated all nursing staff on the 30-hour IV certification requirement for LPNs prior to PICC line handling. On [DATE], an audit was conducted to verify all IV medications, dressing changes and line maintenance are performed by competent nursing staff. On [DATE], education was provided by the Regional Nurse to Director of Nursing, the Assistant Director of Nursing and nursing supervisors related to the requirement of 30-hour IV LPN Certification. A list of LPNs with IV certification competency was placed at each nurses' station to ensure that nurses are aware of who is qualified to perform IV tasks. `

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility administration failed to ensure the highest practicable physical wellbeing of each resident by not assuming full responsibility for the day-to-day operations of the facility. The facility failed to provide central venous catheter dressing changes and failed to ensure licensed practical nurses had the appropriate skills and competencies to administer intravenous medications via central venous access devices for 3 of 4 reviewed residents with central venous access devices, Residents #71, #289 and #297. The lack of appropriate dressing changes to assess the insertion site for signs and symptoms of infection, fluid leaking, redness, pain, tenderness, and swelling can result in an increased risk of infection at the insertion site, sepsis (a life-threatening infection in the blood), damage to the vein, phlebitis or blood clots. The lack of IV certification and validation of competency for IV infusion can result in an increased risk of infection, damage to veins and injection sites, an air embolism, phlebitis, and blood clots. Phlebitis can cause blood clots, which can block important blood vessels, causing tissue damage or even be life threatening. Lack of 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 and can result in the likelihood of increased risk of serious harm and/or death. Findings include: 1. Review of the job description for the Administrator dated [DATE] reads, General Purpose of Job: The administrator is responsible for the overall day-to-day operations of the facility . Essential Duties and Responsibilities: Oversee and manage individual departments to develop an overview of the facility and its operating condition . Implement company personnel policies and procedures with Human Resources to ensure federal, state, and local compliance. Assure quality patient care is provided consistent with company policies and budget objectives . Responsible for staff performance, recruitment, retention, and development. Review of the job description for the Director of Nursing (DON) dated [DATE] reads, General Purpose of Job: The DON participates as a member of the management team in planning, policy formulation, and administrative decision making for the Nursing Services Department in accordance with current existing federal, state, and local standards. This position is responsible for patient care, management, resource management, and fiscal management in the nursing home. Standard Requirements: Supports and cooperates with specific procedures and programs for . Quality Improvement and compliance with all regulatory requirements . Essential Duties and Responsibilities: Plan, develop, organize, implement, evaluate and direct the Nursing Services Department according to federal, state, local and facility guidelines, as well as regulated programs and activities, including: Physician orders . In-services/Training, Utilization review . Assess the quality of care rendered . Initiates the development of policies and procedures that govern nursing services and other services under his or her position control. Responsible for verifying employee credentials under his or her position control. Responsible for staff performance, recruitment, retention, and development . Audit documentation for errors or inconsistencies, correct and document as necessary. Review of Resident #71's admission records revealed the resident was admitted to the facility on [DATE] with diagnoses including infection of right lower extremity amputation stump, chronic obstructive pulmonary disease, hyperlipidemia (high cholesterol), personal history of transient ischemic attack (a brief stroke like attack) and cerebral infraction (a stroke) without residual deficits, peripheral vascular disease (a disorder that causes narrowing, blockage or spasms in the blood vessels), essential hypertension (high blood pressure), acquired absence of right leg above knee, unspecific atrial fibrillation (an irregular heartbeat), pleural effusion (fluid around the lungs due to poor pumping of the heart), infective myositis (inflammation of the muscles), and unspecified diastolic heart failure (a chronic condition in which the heart doesn't pump blood as well as it should). Review of Resident #71's New admission Data Collection and Observation dated [DATE] at 6:53 PM revealed, 1. Initial Data Intake: 1b. admission Date/Time: [DATE] at 1800 [6:00 PM]. Section 9a. Hydration/Port of Medication Entry: 3. PICC, 9c. Comments: IV antibiotic therapy. Review of a physician order dated [DATE] for Resident #71 revealed, Change PICC [Peripherally Inserted Central Line] Line Dressing Every 7 Days and prn [as needed] if soiled or dislodged every night shift every 7 days for picc care. During an observation on [DATE] at 9:45 AM, Resident #71 was sitting up in a wheelchair at her bed side with a single lumen PICC line in her right upper arm, covered with white tubular netting. The dressing had a dressing change date of 11/18 written in black marker and covered with a transparent dressing. During an interview on [DATE] at 9:47 AM, Resident #71 stated, They have not changed my dressing at all since I got here. During an observation on [DATE] at 11:09 AM, Resident #71 was sitting up in a wheelchair with a single lumen PICC line in her right upper arm covered with a white tubular netting dressing. The transparent dressing under the white tubular netting had a dressing change sticker dated 11/18 in black marker. During an interview on [DATE] at 11:09 AM, Resident #71 stated, I have never refused a dressing change. Nurses just come in and flush the PICC line and give me my medication. Review of the progress notes from [DATE] to [DATE] for Resident #71 revealed no documentation of peripherally inserted central catheter care being refused. During an interview on [DATE] at 11:42 AM, the Director of Nursing (DON) confirmed Resident #71's transparent dressing had the date of 11/18 written on it stating, All PICC line dressings should have been done on a weekly basis. This dressing is way out of date, and I will look into this. During an interview on [DATE] at 11:58 AM, the Advanced Practice Registered Nurse (APRN) #1 stated, Oh wow, no way. There is a risk for infection, line infection, which would enter to the body eventually. Any kind of septic infection, there would be a risk for any kind of organ in the body. During an interview on [DATE] at 6:53 AM, Staff A, Registered Nurse (RN), stated, I don't understand how that happened, how the dressing didn't get changed. The dressing order was popping up every day. In my mind, the dressing change was every 7 days, but it was coming up in the system every day. I will look at the site every day to make sure there is no infiltration and look at the date on dressing. I can't really say what happened that night that I signed it. It was a mistake to sign it and not do it. It must have been a busy night. Sometimes you might mark off something and it gets busy. I should change dressing if it is compromised or it needs to be changed, it's time for it to be changed. I only remember working with [Resident #71's name] one time. Not to my knowledge has she ever refused. She was always pleasant and did not refuse treatment. During an interview on [DATE] at 9:04 AM, the Infection Preventionist RN stated, Central venous lines are assigned to another nurse to keep track of and monitor, the ADON [Assistant Director of Nursing]. I will look at them for general issues or signs of concerns such as infections. But the regular maintenance, training, and education fall under Assistant Director of Nursing. During an interview on [DATE] at 9:29 AM, the APRN #2 stated, Central venous lines standards for dressing changes are every 7 days, and if soiled, or compromised. It really should be covered, and the insertion site not exposed. There is always a possibility for infections, that is the reason why we change them. I expect all orders to be followed. Nursing staff should be assessing, flushing and all appropriate things. Looking for abnormalities. I assess PICC's or midlines when a resident is initially admitted , but it is not my role any longer, my role has changed. This is delegated on nursing staff to do and to follow physician orders. There is always a possibility for infection when dressings are not changed. During an interview on [DATE] at 10:26 AM, the Medical Doctor (MD) #1 stated, I do not know what protocol the facility has for central line dressing changes, but that is unacceptable, not to change dressings for that long. It can result in a localized infection or any kind of infection. I did not receive a call from the facility to notify me of the occurrence. During an interview on [DATE] at 11:41 AM, the Assistant Director of Nursing stated, Nursing staff should be following physician orders for dressing changes. Nurses should be looking at dressings, dates and assessing site and change it if needed. During an interview on [DATE] at 11:25 AM, the Medical Director stated, I am not involved in that resident's care. I am not in a place to give my medical opinion on that resident. I do not know all the details. You should speak to her attending physician. My opinion will not be much different than his. Maybe a localized infection and it is a breach in protocol. My expectations are for nurses and facilities to follow orders placed for dressing changes. During an interview on [DATE] at 12:53 PM, Staff E, Licensed Practical Nurse (LPN), stated, I don't always look at the dressing site if I am not administering medication. If I see the dressing out of date, I would have changed it. I did not notice the dressing of [Resident #71's name] was out of date. I do not remember if I removed the netting or not. During an interview on [DATE] at 1:28 PM, Staff F, Registered Nurse (RN), stated, I should have changed the dressing since it was out of date. I can't tell you why I didn't. During an interview on [DATE] at 1:47 PM, Staff G, RN, stated, I do remember [Resident #71's name] had a sleeve on. Absolutely yes, should have been changed the dressing. I don't know why I didn't. During an interview on [DATE] at 2:59 PM, Staff M, LPN, stated, I don't remember seeing the dressing for her [Resident #71] I would absolutely have changed the dressing if I saw that it was dated 11/18. I did not see the date clearly. Review of a physician order dated [DATE] for Resident #71 revealed, Sodium Chloride solution 0.9% use 10 milliliters intravenously every shift for flush every shift and before and after each use. Review of a physician order dated [DATE] for Resident #71 revealed, Aztreonam in dextrose solution 1 GM [gram]/50 ml [milliliters], use 1 gram intravenously two times a day for RLE [right lower extremity] stump infection until [DATE]. Review of [DATE] Medication Administration Record (MAR) for Resident #71 revealed Staff D, Licensed Practical Nurse (LPN), administered sodium chloride solution 0.9% intravenously right arm on [DATE] at 1:53 AM, and administered Aztreonam 1 gm/50 ml intravenously right arm on [DATE] at 5:19 AM. 2. Review of Resident #289's admission records revealed the resident was admitted to the facility on [DATE] with diagnoses including right knee septic MSSA (Methicillin-Susceptible Staphylococcus Aureus), arthritis with cellulitis (infection of the skin), infection and inflammatory reaction due to internal right knee prosthesis, unspecified atrial fibrillation (irregular heartbeat), chronic obstructive pulmonary disease, type 2 diabetes mellitus, presence of right artificial knee joint, essential (primary) hypertension (high blood pressure), and depression, unspecified. During an observation on [DATE] at 12:35 PM, Resident #289 was sitting up in a wheelchair at bedside with a right upper arm single lumen PICC line, with the transparent dressing rolled up at the edges, and the insertion site exposed and opened to air. The dressing was dated [DATE]. There was white tubular dressing retainer net covering the PICC line and in contact with the insertion site. The white tubular dressing retainer net had several brownish stained areas noted on it. During an observation on [DATE] at 8:45 AM, Resident #289 was observed sitting at bedside with a right upper arm PICC line with the transparent dressing rolled up and exposing the insertion site. The dressing was dated [DATE]. The white tubular dressing retainer net was covering the PICC line and in contact with the insertion site. The white tubular dressing retainer net had several brownish stained areas noted on it. During an interview on [DATE] at 8:45 AM, Resident #289 stated, That has been rolled up like that for a few days now. The nurses don't really ask to have a look at the catheter, they just give me my antibiotics. Review of Resident #289's NSG New admission (Only) Data Collection and Observation Form dated [DATE] revealed, Section 18. Diagnosis Generalized Category Nutrition/Hydration/Port of medication entry: Section 9b. Hydration/Port of medication entry 3. PICC 9c. comments right upper arm. Review of a physician order dated [DATE] for Resident #289 revealed, Change PICC line dressing every 7 days and PRN if soiled or dislodged. every night shift for PICC care. Review of a physician order dated [DATE] for Resident #289 revealed, Cefazolin sodium solution reconstituted 2 GM (grams) use 2 gram intravenously three times a day for infected right knee prosthesis for 33 days. Review of a physician order dated [DATE] for Resident #289 revealed, Sodium Chloride solution 0.9% use 10 milliliters intravenously three times per day for flush before and after each use of PICC line. Review of a physician order dated [DATE] for Resident #289 revealed, Heparin Lock Flush solution 100 unit/ml use 200 unit intravenously every 12 hours as needed for maintain patency before and after each use and use 200 unit intravenously three times a day for flush picc line using the sash method before and after each use. Review of [DATE] MAR for Resident #289 documented on [DATE] at 2:02 PM, Staff C, LPN, administered Cefazolin Sodium Solution 2-gram IV right arm, on [DATE] at 2:02 PM, Staff C, LPN, administered 10 milliliters of Sodium Chloride solution 0.9% intravenously right arm, on [DATE] at 1:56 PM, Staff C, LPN, administered Cefazolin Sodium Solution 2 gram IV right arm, on [DATE] at 1:56 PM, Staff C, LPN, administered 10 milliliters of Sodium Chloride solution 0.9% intravenously right arm, on [DATE] at 10:05 PM, Staff D, LPN, administered Cefazolin Sodium Solution 2 gram IV right arm, on [DATE] at 10:05 PM, Staff D, LPN, administered 10 milliliters of Sodium Chloride solution 0.9% intravenously right arm, on [DATE] at 5:02 AM, Staff D, LPN, administered Cefazolin Sodium Solution 2 gram IV right arm, on [DATE] at 5:02 AM, Staff D, LPN, administered 10 milliliters of Sodium Chloride solution 0.9% intravenously right arm, on [DATE] at 3:54 PM, Staff C, LPN, administered Cefazolin Sodium Solution 2 gram IV right arm, on [DATE] at 3:54 PM, Staff C, LPN, administered 10 milliliters of Sodium Chloride solution 0.9% intravenously right arm, on [DATE] at 9:19 PM, Staff D, LPN, administered Cefazolin Sodium Solution 2 gram IV right arm, on[DATE] at 9:19 PM, Staff D, LPN, administered 10 milliliters of Sodium Chloride solution 0.9% intravenously right arm, on [DATE] at 5:34 AM, Staff D, LPN, administered Cefazolin Sodium Solution 2 gram IV right arm, on[DATE] at 5:34 AM, Staff D, LPN, administered 10 milliliters of Sodium Chloride solution 0.9% intravenously right arm, on [DATE] at 3:10 PM, Staff C, LPN, administered Cefazolin Sodium Solution 2 gram IV right arm, on [DATE] at 3:10 PM, Staff C, LPN, administered 10 milliliters of Sodium Chloride solution 0.9% intravenously right arm, and on [DATE] at 3:10 PM, Staff C, LPN administered Heparin Lock Flush solution 100 units/ml. During an interview on [DATE] at 11:00 AM, the DON stated, The dressing was exposing his insertion site and we will need that changed. It is a risk to have this open to air, maybe this just happened. The dressing date was [DATE]. During a telephone interview on [DATE] at 12:01 PM, Staff C, Licensed Practical Nurse (LPN), stated, Well, no I did not pull back the netting and look at the site when I gave the 2 o'clock medication. When it's under netting, I don't always check. I probably should check the site before and after I give the medication. I don't know why I didn't. During an interview conducted on [DATE] at 8:23 AM, Staff D, LPN, stated, I don't think that I actually looked at the site of the PICC line when I gave medications. I usually just pull down the netting enough to get to the connector. 3. Review of Resident #297's admission record revealed the resident was admitted to the facility on [DATE] with diagnoses including endocarditis (an infection of the inner lining of the heart), atherosclerosis of coronary artery bypass graft(s) (coronary artery disease) with angina pectoris (chest pain), essential (primary) hypertension (high blood pressure), chronic kidney disease, type II diabetes mellitus, venous insufficiency (chronic) (peripheral), and right lower limb cellulitis, left lower limb cellulitis (infection in the legs). During an observation on [DATE] at 10:00 AM, Resident #297 was sitting up in a wheelchair with a right arm single lumen PICC line with a dressing date of [DATE]. There was a transparent dressing with a gauze under the transparent dressing covering the insertion site. During an interview on [DATE] at 10:05 AM, Resident #297 stated, No, they haven't changed this dressing since I got here. During an observation on [DATE] at 8:49 AM, Resident #297 with a right arm single lumen PICC line with gauze under the transparent dressing. The dressing was dated [DATE]. Review of the facility policy and procedure titled Central Venous Catheter Dressing Changes reads, Policy: Central Venous catheter dressings will be changed at specific intervals, or when needed, to prevent catheter infections that are associated with contaminated, loosened, soiled or wet dressings. Preparation: 2. A physician's order is not needed for this procedure. General Guidelines: 1. Apply and maintain sterile dressing on intravenous access devices. Dressing must stay clean, dry, and intact. Explain to the resident that the dressing should not get wet. 2. Change all dressings if any suspicion of contamination is suspected. 4. After original insertion of CVAD, the dressing will consist of gauze and TSM. This will change within 24 hours. Replace with sterile transparent dressing. 5. Change transparent semi-permeable membrane (TSM) dressing every 5-7 days and PRN (when wet, soiled, or not intact). 6. Change gauze dressing, or TSM over gauze dressing every 48 hours. 9. Change needless connection device, extension tubing, and stabilization device at the time of routine dressing changes. During an interview on [DATE] at 11:42 AM, the DON stated, The dressing does have gauze over the insertion site and those per policy required changing in 48 hours. Review of a physician order dated [DATE] for Resident #297 revealed, Change PICC line dressing every 7 days and PRN if soiled or dislodged every night shift every 7 days for PICC line care. Review of a physician order dated [DATE] for Resident #297 revealed, Cefazolin sodium solution reconstituted 1 Gm [gram] use 100 mg intravenously every 12 hours for endocarditis for 42 days. Review of a physician order dated [DATE] for Resident #297 revealed, Sodium Chloride Solution 0.9% use 10 milliliters intravenously every 12 hours for flush. Review of a physician order dated [DATE] for Resident #297 revealed, Heparin lock flush solution 100 Unit/ml [milliliter] use 200 unit intravenously every 12 hours as needed for flush, use SASH [Saline, Administer Medication, Saline, H] method before and after each use of IV. Review of [DATE] MAR for Resident #297 revealed on [DATE] at 7:36 PM, Staff C, LPN, administered Cefazolin Sodium Solution 1 gram IV right arm, on [DATE] at 7:35 AM, Staff C, LPN, administered 10 milliliters of Sodium Chloride solution 0.9% intravenously right arm, on [DATE] at 7:36 PM, Staff C, LPN, administered Cefazolin Sodium Solution 1 gram IV right arm, on [DATE] at 7:36 PM, Staff C, LPN, administered 10 milliliters of Sodium Chloride solution 0.9% intravenously right arm, on [DATE] at 6:04 AM, Staff D, LPN, administered Cefazolin Sodium Solution 1 gram IV right arm, on [DATE] at 6:05 AM, Staff D, LPN, administered 10 milliliters of Sodium Chloride solution 0.9% intravenously right arm, on [DATE] at 6:02 PM, Staff C, LPN, administered Cefazolin Sodium Solution 1 gram IV right arm, on [DATE] at 6:02 PM, Staff C, LPN, administered 10 milliliters of Sodium Chloride solution 0.9% intravenously right arm, and on [DATE] at 6:02 PM, Staff C, LPN, administered Heparin lock flush solution intravenously right arm. Review of IV Certification for Staff D, LPN, dated [DATE], from [College Name] Community College Center for workforce development reads, This is to certify that [Staff D's [NAME] name] has successfully completed an 8 hour course (.8 ceus) [Continuing Education Units] in I.V. Infusion Therapy on the twenty-sixth day of October in the year 2022. Review of the Certificate from [Technical Center name] reads, Recognizes the attendance of [Staff C's [NAME] name] at the IV therapy/phlebotomy course dated [DATE] to [DATE]. There is no documentation of additional CEUs provided to Staff D, LPN. During an interview on [DATE] at 7:02 AM, the Administrator stated, We do not have IV certification for [Staff D, LPN's name] and there are some other staff that have not completed the 30 hours. I don't know how this happened. I have [the DON's name] working on that. During an interview on [DATE] at 7:15 AM, the Director of Nursing (DON) stated, We reached out to [Staff D's name] and she does not have more than 8 hours of IV training. She does not have the required 30 hours in order to give IV medications. Yes, she should have that. I can't tell you why we did not know this before now. It has been HR's responsibility to get the certification. We have also found that a few other nurses do not have the required 30 hours, just 24 hours. I asked if they are certified. I do not get a copy or keep a copy. No, the ADON [Assistant Director of Nursing] who is responsible for training does not keep a copy. We don't have any system in place to help identify whether a staff has IV certification if they are an LPN. I am responsible to know who is competent and what those competencies are. It really is the nurses' responsibility to not give medications if they are not qualified. We have had them tell someone they can't do the IV's. Well, they wouldn't know if they were asking another uncertified nurse unless they were asking an RN to do it for them. I was not aware that this was a problem until now. During a telephone interview on [DATE] at 7:24 AM, Staff D, LPN, stated, I was IV certified a long time ago in Virginia and wasn't aware that I needed anything different. I would never deliberately practice outside my scope. I did administer IV medications to [Resident #71's name, Resident #289's name and Resident #297's name]. I have not been asked to provide my IV certification until Wednesday and yesterday they asked if I had any other certifications. I do not have any more than 8 hours of training that met the requirement at that time. I didn't know that it wasn't the same in Florida. During an interview on [DATE] at 8:14 AM, the Medical Director stated, I expect that all nurses will practice within their scope of practice. We should take notice and put a stop to it immediately. The facility should be asking for verification of IV certification before they administer any medications. During an interview on [DATE] at 8:19 AM, the Assistant Director of Nursing stated, There are several staff who don't have the required 30-hour course and we did not know this. The staffing coordinator will usually ask the agency if they LPNs are IV certified. The staffing coordinator will ask them to provide the IV certification and the staffing coordinator will let the manager know if someone is not IV certified. With regular full or part time staff, HR is responsible for obtaining certifications and maintaining them in the files. I do not keep any files on staff for competence. I was not aware that staff were not IV certified. I have not had any system in place to identify who is certified. We do not have any competencies that are specific to PICC lines or midlines. When nurses are oriented, they pass medications with the person training them. During an interview on [DATE] at 8:28 AM, the Director of Nursing stated, Typically, I interview the nurses. I will ask them if they are IV certified and will get any certification if they bring them to the interview. If they are hired, I send them to HR and HR would get copies of their IV certification, CPR or any other certifications and that is where they are kept. I don't know if HR obtained a copy of [Staff D's name] IV certification. I am ultimately responsible for all clinical staff and their competency. I was not aware that there were staff who did not meet the requirements and they have been administering IV medications. We should have had a process in place to ensure all staff are competent. Review of Chapter 64B9-12 Administration of Intravenous Therapy by Licensed Practical Nurses revealed, 64B9-12.005 Competency and Knowledge requirements necessary to qualify the LPN to administer IV therapy. (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: (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 0022, F.A. C. Appropriate education and training requires a minimum of four (4) hours of instruction. This required 4 hours of instruction may be included as part of the 30 hours required for intravenous therapy education specified in subsection (4) of this rule. The education and training requirement 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 (central venous line) site assessment; (c) CVL dressing and cap changes; (d) CVL flushing;(e) CVL medications 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 witnessed by a Registered Nurse who shall file a proficiency statement regarding the licensed practical nurses ability to perform intravenous therapy via central lines. The proficiency statement shall be kept in the Licensed Practical Nurses personnel file. (5) Clinical Competence. The course must be followed by supervised clinical practice in intravenous therapy as needed to demonstrate clinical competence. Verification of clinical competence shall be the responsibility of each institution employing a licensed practical nurse based on institutional protocol. Such verification shall be given through a signed statement of a Florida licensed Registered Nurse. Review of Subsection (4) revealed, 4) Educational Alternatives. The cognitive training shall include one or more of the following: a) Post-graduate Level Course. In recognition that the curriculum requirements mandated by Sections 464.019(1)(b), 464.019(1)(f), and 464.019(1)(g), F.S., for practical nursing programs are extensive and that every licensed practical nurse will not administer IV Therapy, the course necessary to qualify a licensed practical nurse or graduate practical nurse to administer IV therapy shall be not less than a thirty (30) hour post-graduate level course teaching aspects of IV therapy containing the components enumerated in subsection 64B9-12.005(1), F.A.C. The Immediate Jeopardy (IJ) was removed on site on [DATE] 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 the following: On [DATE], the facility assessed the residents involved in the IJ situation and conducted a facility-wide audit of all current residents with a PICC line and receiving IV medications to identify possible harm, side effects, and injury to the resident due to IV administration. On [DATE], the facility conducted an Ad Hoc QAPI (Quality Assurance and Performance Improvement) meeting and a root cause analysis. On 12/15-16/2022, the facility educated all nursing staff related to PICC line dressing changes and maintenance, documentation, and the 30-hour IV certification requirement for LPNs prior to PICC line handling. On [DATE], the [NAME] President of Clinical Services provided training to the facility administration on QAPI/QAA (Quality Assurance and Performance Improvement/ Quality Assurance and Assessment) policy and abuse/neglect policy. On [DATE], an audit was conducted to verify all IV medications, dressing changes and line maintenance are performed by competent nursing staff. On [DATE], education was provided by the Regional Nurse to the Director of Nursing, the Assistant Director of Nursing and nursing supervisors related to the requirement of 30-hour IV LPN Certification. A list of LPNs with IV certification competency was placed at each nurses' station to ensure that nurses are aware of who is qualified to perform IV tasks.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement their Quality Assessment and Process Improvement (QAPI) policy and procedure to identify and correct quality deficiencies related to the following: ensuring residents with central venous catheters received dressing changes as ordered and ensuring licensed practical nurses had the appropriate skills and competencies to administer intravenous medications via central venous access devices for 3 of 4 reviewed residents with central venous access devices, Residents #71, #289 and #297. The lack of appropriate dressing changes to assess the insertion site for signs and symptoms of infection, fluid leaking, redness, pain, tenderness, and swelling can result in an increased risk of infection at the insertion site, sepsis (a life-threatening infection in the blood), damage to the vein, phlebitis or blood clots. The Lack of IV certification and validation of competency for IV infusion can result in an increased risk of infection, damage to veins and injection sites, an air embolism, phlebitis, and blood clots. Phlebitis can cause blood clots, which can block important blood vessels, causing tissue damage or even be life threatening. Lack of 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 and can result in the likelihood of increased risk of serious harm and/or death. Findings include: 1. Review of Resident #71's admission records revealed the resident was admitted to the facility on [DATE] with diagnoses including infection of right lower extremity amputation stump, chronic obstructive pulmonary disease, hyperlipidemia (high cholesterol), personal history of transient ischemic attack (a brief stroke like attack) and cerebral infraction (a stroke) without residual deficits, peripheral vascular disease (a disorder that causes narrowing, blockage or spasms in the blood vessels), essential hypertension (high blood pressure), acquired absence of right leg above knee, unspecific atrial fibrillation (an irregular heartbeat), pleural effusion (fluid around the lungs due to poor pumping of the heart), infective myositis (inflammation of the muscles), and unspecified diastolic heart failure (a chronic condition in which the heart doesn't pump blood as well as it should). Review of Resident #71's New admission Data Collection and Observation dated [DATE] at 6:53 PM revealed, 1. Initial Data Intake: 1b. admission Date/Time: [DATE] at 1800 [6:00 PM]. Section 9a. Hydration/Port of Medication Entry: 3. PICC, 9c. Comments: IV antibiotic therapy. Review of a physician order dated [DATE] for Resident #71 revealed, Change PICC [Peripherally Inserted Central Line] Line Dressing Every 7 Days and prn [as needed] if soiled or dislodged every night shift every 7 days for picc care. During an observation on [DATE] at 9:45 AM, Resident #71 was sitting up in a wheelchair at her bed side with a single lumen PICC line in her right upper arm, covered with white tubular netting. The dressing had a dressing change date of 11/18 written in black marker and covered with a transparent dressing. During an interview on [DATE] at 9:47 AM, Resident #71 stated, They have not changed my dressing at all since I got here. During an observation on [DATE] at 11:09 AM, Resident #71 was sitting up in a wheelchair with a single lumen PICC line in her right upper arm covered with a white tubular netting dressing. The transparent dressing under the white tubular netting had a dressing change sticker dated 11/18 in black marker. During an interview on [DATE] at 11:09 AM, Resident #71 stated, I have never refused a dressing change. Nurses just come in and flush the PICC line and give me my medication. Review of the progress notes from [DATE] to [DATE] for Resident #71 revealed no documentation of peripherally inserted central catheter care being refused. During an interview on [DATE] at 11:42 AM, the Director of Nursing (DON) confirmed Resident #71's transparent dressing had the date of 11/18 written on it, stating, All PICC line dressings should have been done on a weekly basis. This dressing is way out of date, and I will look into this. During an interview on [DATE] at 11:58 AM, the Advanced Practice Registered Nurse (APRN) #1 stated, Oh wow, no way. There is a risk for infection, line infection, which would enter to the body eventually. Any kind of septic infection, there would be a risk for any kind of organ in the body. During an interview conducted on [DATE] at 7:00 AM, the DON stated, Well, it is a very high risk, and we probably should have identified that there might be concerns with this. I do not know if there have been problems before this. I have not provided training to staff related to PICC line care or assessment. I don't think we do a specific competency related to central lines. We have not provided any type of special training. All nurses should be competent if they are an RN or are IV certified. We have not established way to determine if agency staff are IV certified. I guess we should as we use them. I expect nurses to let us know if they are not IV certified. During an interview on [DATE] at 7:10 AM, the Administrator stated, We have not completed a QAPI related to PICC lines. I know that we did last night and have begun a plan of correction. QAPI is a process that we look at to identify any possible concerns. This is a high-risk area and I guess we should have done a QAPI. We were really not aware that we had any concerns related to PICC lines. During an interview on [DATE] at 9:04 AM, the Infection Preventionist RN stated, Central venous lines are assigned to another nurse to keep track of and monitor, the ADON [Assistant Director of Nursing]. I will look at them for general issues or signs of concerns such as infections. But the regular maintenance, training, and education fall under Assistant Director of Nursing. During an interview on [DATE] at 11:41 AM, the Assistant Director of Nursing stated, Nursing staff should be following physician orders for dressing changes. Staff will show me IV certification. I do not necessarily do IV competencies. If not IV certified, nurses are expected to ask supervisors or another nurse who is certified. We do not have a system in place for verification to determine IV competencies for nursing staff. Nurses should be looking at dressing, dates and assessing site and change it if needed. I have not done skills fair. Random audits have been done for central venous lines. I physically go into resident rooms and look at dressing including dates and if dressing is peeling. Last audit was done last week. I did not have [Resident #71's name] in my pool. I select them randomly. During an interview on [DATE] at 7:22 AM, the DON stated, We do the audit when we are in survey window not because there is a problem. In June, when we identified deficient practice for two residents, I don't know why we didn't do a QAPI. I do not look at all audits done that is not my responsibility. During an interview on [DATE] at 9:16 AM, the ADON stated, They did not have a problem with dressing dates, and I corrected that. I did not do a root cause analysis and no education or training was provided to the nursing staff, just the two staff involved were educated and orders were placed. I gave all audits to the Director of Nursing. During an interview on [DATE] at 10:53 AM, the DON stated, I did not feel the missing orders for PICC lines were a high risk to put it through QAPI. During an interview on [DATE] at 11:25 AM, the Medical Director stated, I spoke to the administrator we will bring up in next Quality meeting. We updated policies this month, don't remember central venous catheter devices mentioned in past QAPI meetings. Review of a physician order dated [DATE] for Resident #71 revealed, Sodium Chloride solution 0.9% use 10 milliliters intravenously every shift for flush every shift and before and after each use. Review of a physician order dated [DATE] for Resident #71 revealed, Aztreonam in dextrose solution 1 GM [gram]/50 ml [milliliters], use 1 gram intravenously two times a day for RLE [right lower extremity] stump infection until [DATE]. Review of [DATE] Medication Administration Record (MAR) for Resident #71 revealed Staff D, Licensed Practical Nurse (LPN), administered sodium chloride solution 0.9% intravenously right arm on [DATE] at 1:53 AM, and administered Aztreonam 1 gm/50 ml intravenously right arm on [DATE] at 5:19 AM. 2. Review of Resident #289's admission records revealed the resident was admitted to the facility on [DATE] with diagnoses including right knee septic MSSA (Methicillin-Susceptible Staphylococcus Aureus), arthritis with cellulitis (infection of the skin), infection and inflammatory reaction due to internal right knee prosthesis, unspecified atrial fibrillation (irregular heartbeat), chronic obstructive pulmonary disease, type 2 diabetes mellitus, presence of right artificial knee joint, essential (primary) hypertension (high blood pressure), and depression, unspecified. During an observation on [DATE] at 12:35 PM, Resident #289 was sitting up in a wheelchair at bedside with a right upper arm single lumen PICC line, with the transparent dressing rolled up at the edges, and the insertion site exposed and opened to air. The dressing was dated [DATE]. There was white tubular dressing retainer net covering the PICC line and in contact with the insertion site. The white tubular dressing retainer net had several brownish stained areas noted on it. During an observation on [DATE] at 8:45 AM, Resident #289 was observed sitting at bedside with a right upper arm PICC line with the transparent dressing rolled up and exposing the insertion site. The dressing was dated [DATE]. The white tubular dressing retainer net was covering the PICC line and in contact with the insertion site. The white tubular dressing retainer net had several brownish stained areas noted on it. During an interview on [DATE] at 8:45 AM, Resident #289 stated, That has been rolled up like that for a few days now. The nurses don't really ask to have a look at the catheter, they just give me my antibiotics. Review of Resident #289's NSG New admission (Only) Data Collection and Observation Form dated [DATE] revealed, Section 18. Diagnosis Generalized Category Nutrition/Hydration/Port of medication entry: Section 9b. Hydration/Port of medication entry 3. PICC 9c. comments right upper arm. Review of a physician order dated [DATE] for Resident #289 revealed, Change PICC line dressing every 7 days and PRN if soiled or dislodged. Every night shift for PICC care. Review of a physician order dated [DATE] for Resident #289 revealed, Cefazolin sodium solution reconstituted 2 GM (grams) use 2 gram intravenously three times a day for infected right knee prosthesis for 33 days. Review of a physician order dated [DATE] for Resident #289 revealed, Sodium Chloride solution 0.9% use 10 milliliters intravenously three times per day for flush before and after each use of PICC line. Review of a physician order dated [DATE] for Resident #289 revealed, Heparin Lock Flush solution 100 unit/ml use 200 unit intravenously every 12 hours as needed for maintain patency before and after each use and use 200 unit intravenously three times a day for flush picc line using the sash method before and after each use. Review of [DATE] MAR for Resident #289 documented on [DATE] at 2:02 PM, Staff C, LPN, administered Cefazolin Sodium Solution 2-gram IV right arm, on [DATE] at 2:02 PM, Staff C, LPN, administered 10 milliliters of Sodium Chloride solution 0.9% intravenously right arm, on [DATE] at 1:56 PM, Staff C, LPN, administered Cefazolin Sodium Solution 2 gram IV right arm, on [DATE] at 1:56 PM, Staff C, LPN, administered 10 milliliters of Sodium Chloride solution 0.9% intravenously right arm, on [DATE] at 10:05 PM, Staff D, LPN, administered Cefazolin Sodium Solution 2 gram IV right arm, on [DATE] at 10:05 PM, Staff D, LPN, administered 10 milliliters of Sodium Chloride solution 0.9% intravenously right arm, on [DATE] at 5:02 AM, Staff D, LPN, administered Cefazolin Sodium Solution 2 gram IV right arm, on [DATE] at 5:02 AM, Staff D, LPN, administered 10 milliliters of Sodium Chloride solution 0.9% intravenously right arm, on [DATE] at 3:54 PM, Staff C, LPN, administered Cefazolin Sodium Solution 2 gram IV right arm, on [DATE] at 3:54 PM, Staff C, LPN, administered 10 milliliters of Sodium Chloride solution 0.9% intravenously right arm, on [DATE] at 9:19 PM, Staff D, LPN, administered Cefazolin Sodium Solution 2 gram IV right arm, on[DATE] at 9:19 PM, Staff D, LPN, administered 10 milliliters of Sodium Chloride solution 0.9% intravenously right arm, on [DATE] at 5:34 AM, Staff D, LPN, administered Cefazolin Sodium Solution 2 gram IV right arm, on[DATE] at 5:34 AM, Staff D, LPN, administered 10 milliliters of Sodium Chloride solution 0.9% intravenously right arm, on [DATE] at 3:10 PM, Staff C, LPN, administered Cefazolin Sodium Solution 2 gram IV right arm, on [DATE] at 3:10 PM, Staff C, LPN, administered 10 milliliters of Sodium Chloride solution 0.9% intravenously right arm, and on [DATE] at 3:10 PM, Staff C, LPN administered Heparin Lock Flush solution 100 units/ml. During an interview on [DATE] at 11:00 AM, the DON stated, The dressing was exposing his insertion site and we will need that changed. It is a risk to have this open to air, maybe this just happened. The dressing date was [DATE]. During a telephone interview on [DATE] at 12:01 PM, Staff C, Licensed Practical Nurse (LPN) stated, Well, no I did not pull back the netting and look at the site when I gave the 2 o'clock medication. When it's under netting, I don't always check. I probably should check the site before and after I give the medication. I don't know why I didn't. During an interview conducted on [DATE] at 8:23 AM, Staff D, LPN, stated, I don't think that I actually looked at the site of the PICC line when I gave medications. I usually just pull down the netting enough to get to the connector. 3. Review of Resident #297's admission record revealed the resident was admitted to the facility on [DATE] with diagnoses including endocarditis (an infection of the inner lining of the heart), atherosclerosis of coronary artery bypass graft(s) (coronary artery disease) with angina pectoris (chest pain), essential (primary) hypertension (high blood pressure), chronic kidney disease, type II diabetes mellitus, venous insufficiency (chronic) (peripheral), and right lower limb cellulitis, left lower limb cellulitis (infection in the legs). Review of a physician order dated [DATE] for Resident #297 revealed, Change PICC line dressing every 7 days and PRN if soiled or dislodged every night shift every 7 days for PICC line care. During an observation on [DATE] at 10:00 AM, Resident #297 was sitting up in a wheelchair with a right arm single lumen PICC line with a dressing date of [DATE]. There was a transparent dressing with a gauze under the transparent dressing covering the insertion site. During an interview on [DATE] at 10:05 AM, Resident #297 stated, No, they haven't changed this dressing since I got here. During an observation on [DATE] at 8:49 AM, Resident #297 had a right arm single lumen PICC line with gauze under the transparent dressing. The dressing was dated [DATE]. Review of the facility policy and procedure titled Central Venous Catheter Dressing Changes reads, Policy: Central Venous catheter dressings will be changed at specific intervals, or when needed, to prevent catheter infections that are associated with contaminated, loosened, soiled or wet dressings. Preparation: 2. A physician's order is not needed for this procedure. General Guidelines: 1. Apply and maintain sterile dressing on intravenous access devices. Dressing must stay clean, dry, and intact. Explain to the resident that the dressing should not get wet. 2. Change all dressings if any suspicion of contamination is suspected. 4. After original insertion of CVAD, the dressing will consist of gauze and TSM. This will change within 24 hours. Replace with sterile transparent dressing. 5. Change transparent semi-permeable membrane (TSM) dressing every 5-7 days and PRN (when wet, soiled, or not intact). 6. Change gauze dressing, or TSM over gauze dressing every 48 hours. 9. Change needless connection device, extension tubing, and stabilization device at the time of routine dressing changes. During an interview on [DATE] at 11:42 AM, the DON stated, The dressing does have gauze over the insertion site and those per policy required changing in 48 hours. Review of a physician order dated [DATE] for Resident #297 revealed, Cefazolin sodium solution reconstituted 1 Gm [gram] use 100 mg intravenously every 12 hours for endocarditis for 42 days. Review of a physician order dated [DATE] for Resident #297 revealed, Sodium Chloride Solution 0.9% use 10 milliliters intravenously every 12 hours for flush. Review of a physician order dated [DATE] for Resident #297 revealed, Heparin lock flush solution 100 Unit/ml [milliliter] use 200 unit intravenously every 12 hours as needed for flush, use SASH [Saline, Administer Medication, Saline, H] method before and after each use of IV. Review of [DATE] MAR for Resident #297 revealed on [DATE] at 7:36 PM, Staff C, LPN, administered Cefazolin Sodium Solution 1 gram IV right arm, on [DATE] at 7:35 AM, Staff C, LPN, administered 10 milliliters of Sodium Chloride solution 0.9% intravenously right arm, on [DATE] at 7:36 PM, Staff C, LPN, administered Cefazolin Sodium Solution 1 gram IV right arm, on [DATE] at 7:36 PM, Staff C, LPN, administered 10 milliliters of Sodium Chloride solution 0.9% intravenously right arm, on [DATE] at 6:04 AM, Staff D, LPN, administered Cefazolin Sodium Solution 1 gram IV right arm, on [DATE] at 6:05 AM, Staff D, LPN, administered 10 milliliters of Sodium Chloride solution 0.9% intravenously right arm, on [DATE] at 6:02 PM, Staff C, LPN, administered Cefazolin Sodium Solution 1 gram IV right arm, on [DATE] at 6:02 PM, Staff C, LPN, administered 10 milliliters of Sodium Chloride solution 0.9% intravenously right arm, and on [DATE] at 6:02 PM, Staff C, LPN, administered Heparin lock flush solution intravenously right arm. Review of IV Certification for Staff D, LPN, dated [DATE], from [College Name] Community College Center for workforce development reads, This is to certify that [Staff D's [NAME] name] has successfully completed an 8 hour course (.8 ceus) [Continuing Education Units] in I.V. Infusion Therapy on the twenty-sixth day of October in the year 2022. Review of the Certificate from [Technical Center name] reads, Recognizes the attendance of [Staff C's [NAME] name] at the IV therapy/phlebotomy course dated [DATE] to [DATE]. There is no documentation of additional CEUs provided to Staff D, LPN. During an interview on [DATE] at 7:02 AM, the Administrator stated, We do not have IV certification for [Staff D, LPN's name] and there are some other staff that have not completed the 30 hours. I don't know how this happened. I have [the DON's name] working on that. During an interview on [DATE] at 7:15 AM, the Director of Nursing (DON) stated, We reached out to [Staff D's name] and she does not have more than 8 hours of IV training. She does not have the required 30 hours in order to give IV medications. Yes, she should have that. I can't tell you why we did not know this before now. It has been HR's responsibility to get the certification. We have also found that a few other nurses do not have the required 30 hours, just 24 hours. I asked if they are certified. I do not get a copy or keep a copy. No, the ADON [Assistant Director of Nursing] who is responsible for training does not keep a copy. We don't have any system in place to help identify whether a staff has IV certification if they are an LPN. I am responsible to know who is competent and what those competencies are. It really is the nurses' responsibility to not give medications if they are not qualified. We have had them tell someone they can't do the IV's. Well, they wouldn't know if they were asking another uncertified nurse unless they were asking an RN to do it for them. I was not aware that this was a problem until now. During a telephone interview on [DATE] at 7:24 AM, Staff D, LPN, stated, I was IV certified a long time ago in Virginia and wasn't aware that I needed anything different. I would never deliberately practice outside my scope. I did administer IV medications to [Resident #71's name, Resident #289's name and Resident #297's name]. I have not been asked to provide my IV certification until Wednesday and yesterday they asked if I had any other certifications. I do not have any more than 8 hours of training that met the requirement at that time. I didn't know that it wasn't the same in Florida. During an interview on [DATE] at 8:14 AM, the Medical Director stated, I expect that all nurses will practice within their scope of practice. We should take notice and put a stop to it immediately. The facility should be asking for verification of IV certification before they administer any medications. During an interview on [DATE] at 8:19 AM, the Assistant Director of Nursing stated, There are several staff who don't have the required 30-hour course and we did not know this. The staffing coordinator will usually ask the agency if they LPNs are IV certified. The staffing coordinator will ask them to provide the IV certification and the staffing coordinator will let the manager know if someone is not IV certified. With regular full or part time staff, HR is responsible for obtaining certifications and maintaining them in the files. I do not keep any files on staff for competence. I was not aware that staff were not IV certified. I have not had any system in place to identify who is certified. We do not have any competencies that are specific to PICC lines or midlines. When nurses are oriented, they pass medications with the person training them. During an interview on [DATE] at 8:28 AM, the Director of Nursing stated, Typically, I interview the nurses. I will ask them if they are IV certified and will get any certification if they bring them to the interview. If they are hired, I send them to HR and HR would get copies of their IV certification, CPR [Cardiopulmonary Resuscitation] or any other certifications and that is where they are kept. I don't know if HR obtained a copy of [Staff D's name] IV certification. I am ultimately responsible for all clinical staff and their competency. I was not aware that there were staff who did not meet the requirements and they have been administering IV medications. We should have had a process in place to ensure all staff are competent. Review of Chapter 64B9-12 Administration of Intravenous Therapy by Licensed Practical Nurses revealed, 64B9-12.005 Competency and Knowledge requirements necessary to qualify the LPN to administer IV therapy. (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: (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 0022, F.A. C. Appropriate education and training requires a minimum of four (4) hours of instruction. This required 4 hours of instruction may be included as part of the 30 hours required for intravenous therapy education specified in subsection (4) of this rule. The education and training requirement 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 (central venous line) site assessment; (c) CVL dressing and cap changes; (d) CVL flushing;(e) CVL medications 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 witnessed by a Registered Nurse who shall file a proficiency statement regarding the licensed practical nurses ability to perform intravenous therapy via central lines. The proficiency statement shall be kept in the Licensed Practical Nurses personnel file. (5) Clinical Competence. The course must be followed by supervised clinical practice in intravenous therapy as needed to demonstrate clinical competence. Verification of clinical competence shall be the responsibility of each institution employing a licensed practical nurse based on institutional protocol. Such verification shall be given through a signed statement of a Florida licensed Registered Nurse. Review of Subsection (4) revealed, 4) Educational Alternatives. The cognitive training shall include one or more of the following: a) Post-graduate Level Course. In recognition that the curriculum requirements mandated by Sections 464.019(1)(b), 464.019(1)(f), and 464.019(1)(g), F.S., for practical nursing programs are extensive and that every licensed practical nurse will not administer IV Therapy, the course necessary to qualify a licensed practical nurse or graduate practical nurse to administer IV therapy shall be not less than a thirty (30) hour post-graduate level course teaching aspects of IV therapy containing the components enumerated in subsection 64B9-12.005(1), F.A.C. Review of Risk Management/Quality Improvement Data Collection Form dated [DATE] revealed two out of six residents who had PICC/midline did not have order to change dressing every 7 days. The facility's action was placing orders for dressing. The form did not indicate a plan to evaluate the effectiveness of the actions taken. Review of the facility policy and procedure titled Quality Assessment and Performance Improvement (QAPI) with an approval date of [DATE] reads, Policy: It is the policy of this facility to develop, implement and maintain an effective, comprehensive, data driven QAPI program that focuses on indicators of the outcomes of care and quality of life and addresses all the care and unique services the facility provides . Policy Explanation and Compliance Guideline . 2. The QAA [Quality Assurance and Assessment] Committee shall be interdisciplinary and shall . c. Develop and implement appropriate plans of action to correct identified quality deficiencies. d. Regularly review and analyze data, including data collected under the QAPI program and data resulting from drug regimen reviews, and act on available data to make improvements . Program Development Guidelines . 2. Governance and Leadership: a. The governing body and/or executive leadership is responsible and accountable for the QAPI program. b. Governing oversight responsibilities include, but are not limited to the following . v. Ensuring the program identifies and prioritizes problems and opportunities that reflect organizational processes, functions, and services provided to residents based on performance indicator data, and resident and staff input, and other information. vi. Ensuring that corrective actions address gaps in systems and are evaluated for effectiveness . 4. Program activities: a. All identified problems will be addressed and prioritized, whether by frequency of data collection/monitoring or by the establishment of sub-committees. The Immediate Jeopardy (IJ) was removed on site on [DATE] 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 the following: On [DATE], the facility assessed the residents involved in the IJ situation and conducted a facility-wide audit of all current residents with a PICC line and receiving IV medications to identify possible harm, side effects, and injury to the resident due to IV administration. On [DATE], the facility conducted an Ad Hoc QAPI meeting and a root cause analysis. On 12/15-16/2022, the facility educated all nursing staff related to PICC line dressing changes and maintenance, documentation, and the 30-hour IV certification requirement for LPNs prior to PICC line handling. On [DATE], the [NAME] President of Clinical Services provided training to the facility administration on QAPI/QAA policy and abuse/neglect policy. On [DATE], an audit was conducted to verify all IV medications, dressing changes, and line maintenance are performed by competent nursing staff. On [DATE], education was provided by the Regional Nurse to the Director of Nursing, the Assistant Director of Nursing and nursing supervisors related to the requirement of 30-hour IV LPN Certification. A list of LPNs with IV certification competency was placed at each nurses' station to ensure that nurses are aware of who is qualified to perform IV tasks.