**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive assessment of a resident for 1 of 5 residents (Resident #1) reviewed for quality of care. The facility failed to ensure Resident #1's catheter/catheter balloon remained in place in the bladder. On 08/04/25, the resident had a change in condition, and the NP ordered bloodwork, a UA, and a catheter change. During the catheter change, Resident #1 began to bleed from the catheter site and a few hours later, labs from the bloodwork came back critical and was sent to the hospital. Resident #1 was diagnosed with acute kidney failure and trauma to the urethra due to the catheter balloon not being in the right location. An Immediate Jeopardy (IJ) was identified on 08/21/25 at 4:55 PM. The IJ template was provided to the facility on [DATE] at 5:10 PM. While the IJ was removed on 08/22/25, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place residents at risk for an adverse outcome to resident care or services and may also include the potential for physical and psychosocial harm.Findings included: Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included stroke (occurs when blood flow to the brain is blocked or a blood vessel inside or on the surface of the brain bursts), quadriplegia (partial or complete paralysis of both the arms and legs that is usually due to injury or disease of the spinal cord in the region of the neck), and nontraumatic subarachnoid hemorrhage (bleeding in the space surrounding the brain often caused by a ruptured brain aneurysm). Resident #1 had a BIMS score of 12 which indicated his cognition was moderately impaired. The MDS further reflected Resident #1 had an indwelling catheter and had impairment on both sides of his upper and lower extremities. Record review of Resident #1's care plan revised on 07/18/25 reflected he had a Foley catheter (a thin flexible catheter used especially to drain urine from the bladder) related to a neurogenic bladder (when a person lacks bladder control due to brain, spinal, or nerve problems). The goal was that Resident #1 would remain free from catheter-related trauma and interventions included change the catheter as needed and monitor/record/report signs and symptoms of UTI (an infection of any part of the urinary system), pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, altered mental status, change in behavior, and change in eating patterns. Record review of Resident #1's monthly orders for August 2025 reflected the following: Foley Catheter: 18 Fr 10cc bulb [a type of Foley catheter where the French scale indicates the size of the catheter, and the 10 cc designation indicates the size of the balloon that holds the fluid] as needed for occlusion [blockage or closing of an opening, blood vessel, or hollow organ] or leakage as needed Record review of Resident #1's May 2025, June 2025, and July 2025 TAR (a document in healthcare that tracks the administration of treatments and medications to patients) reflected the resident's catheter had not been changed. Record review of Resident #1's progress note documented by the NP reflected the following: .08/04/25 Seen at request of staff d/t AMS [a disruption in how the brain works that causes a change in behavior]. Pt is acting paranoid, thinks his food is being contaminated. Says his penis is swollen and tender.1. Altered mental status, unspecified altered mental status type STAT CBC [a blood test that measures the amounts and sizes of your red blood cells, hemoglobin, white blood cells, and platelets], BMP [a blood test that measures eight different substances in the blood], UA [a blood test that analyzes urine].await results .2. Swollen PenisSwitch out catheterGentle pericare [hygiene practice involving cleansing of the genital and anal area]Monitor closely. Record review of Resident #1's progress noted dated 08/04/25 documented by RN A reflected the following: This nurse received a new order for CBC, BMP, and UA in [lab system] and to change the Foley catheter, immediately this nurse deflated the balloon, patient began to bleed. This nurse notified the [physician], ordered not to remove the catheter but inflate it and leave in place and monitor patient and call if bleeding continues. Informed the incoming nurse to follow up. Further review of Resident #1's progress notes dated 08/05/25 documented by LVN B reflected the following: Critical lab results received. MD on-call notified. New order received to send patient to the hospital for evaluation.911 called, patient transported to the ER at [hospital]. Patient in stable condition at the time of leaving the facility. Record review of Resident #1 lab results report dated 08/04/25 reflected the following: BMP Results Reference Range Potassium 6.4 mmol/L 3.5 - 5.1BUN 103 mg/dL 6 - 25Creatinine 6.01 mg/dL 0.70 - 1.30 Potassium - (high potassium levels occur when blood potassium is too high, often caused by kidney problems, certain medications, or severe illness) BUN - (Blood Urea Nitrogen test which measures a waste product in the blood to assess kidney function) Creatinine - (a waste product from normal muscle breakdown that healthy kidneys filter from the blood and excrete in urine and measures this waste product to assess kidney function) Record review of Resident #1's hospital records dated 08/05/25 reflected the following: Assessment and Plan(Principal) Hyperkalemia [high potassium]Acute kidney injury.Gross hematuria [visible blood in the urine, making it appear pink, red, or brown] Due to Foley trauma. Balloon was noted to be in urethra. Catheter was removed. NP reports significant bleeding after catheter removed. Foley was reinserted. Patient with continued gross hematuria. No urology is available at this facility. House supervisor asked to assist with transfer to a higher level of care for urology evaluation. Hospital Labs Potassium - 5.9BUN - 94Creatinine - 4.88 Interview on 08/20/25 at 1:46 PM with RN A revealed during her shift on 08/04/25, Resident #1 refused his medications and refused to eat. She stated this was not Resident #1's baseline. She stated the NP happened to be doing her rounds that day, so she asked the NP to assess the resident. RN A said the NP ordered blood work and a UA to be done via straight catheterization. RN A said the Treatment Nurse was in the room when she (RN A) was going to remove Resident #1's catheter. RN A stated when she deflated the resident's catheter balloon, fresh blood came out on the drape under the resident and appeared to be mixed with urine. At that time, RN A said she stopped, left the catheter in place, and called the physician. The physician gave orders to leave the catheter in place, reinflate the catheter balloon, and monitor for further bleeding. RN A stated when she re-inflated the catheter balloon she did not feel resistance and the bleeding stopped. During the procedure, she said she did not notice any redness or swelling to Resident #1's penis. RN A further stated it was the end of her shift, and Resident #1's bloodwork results had not come back during her shift. She stated Resident #1 did not have issues with his catheter prior to that day. RN A said she had been trained on the insertion and removal of Foley catheters, but she did not give a date of the training. Interview on 08/20/25 at 2:40 PM with the Treatment Nurse revealed RN A got orders to change out Resident #1's catheter on 08/04/25, and she went in to assist. The Treatment Nurse said RN A deflated the catheter balloon and pulled out 10 cc of fluid via syringe. She stated blood began to come out from around the catheter on to the drape under the resident. The Treatment Nurse said she told RN A not to pull the catheter out and to leave it in place because the blood could indicate possible urethral trauma. The Treatment Nurse said RN A immediately called the physician and the physician gave orders to leave the catheter in place and re-inflate the balloon. The Treatment Nurse said there did not appear to be any resistance when RN A reinflated the balloon, and Resident #1 did not appear to be in any distress. The Treatment Nurse stated Resident #1 had urine in his bag after the attempted catheter removal. The Treatment Nurse stated she did not recall the resident having any issues with his catheter prior to that day they tried to change it. Interview on 08/20/25 at 3:57 PM with LVN B revealed he worked the night shift of 08/04/25 and Resident #1 had not been eating. He stated Resident #1 reported feeling tired which was not Resident #1's normal baseline. LVN B said he was given report to monitor the resident but had not been told blood had come out during an attempted catheter change. During his shift, he stated Resident #1's bloodwork results came back with some critical labs. He stated the physician was consulted and gave orders for Resident #1 to be sent to the hospital for further evaluation. When Resident #1 was sent to the hospital, the resident's vitals were within normal range. Prior to 08/04/05, LVN B stated Resident #1 had not had any catheter-related issues. Interview on 08/21/25 at 2:27 PM with CNA C revealed she had worked with Resident #1 around the time he had been sent to the hospital (08/05/25), but did not recall which day. CNA C said she provided care to the resident and noticed his penis was swollen, and there was blood coming from his penis around the catheter line, which she reported to LVN D. She stated LVN D was already aware of the resident's condition, and LVN D was checking on the resident. CNA C stated Resident #1 complained about discomfort to this catheter, and the resident wanted to make sure someone was checking on him during her shift. Interview on 08/21/25 at 2:35 PM with CNA E revealed she worked with Resident #1 the day he was sent to the hospital on [DATE] during the morning shift (6:00 AM to 2:00 PM), and had given the resident a bed bath. CNA E said when she changed the resident, she noticed his penis was swollen and had some dried drainage around his penis. CNA E said Resident #1 did not express he was in pain or discomfort. CNA A said she reported the drainage to RN A, who went to assess Resident #1. She stated later she saw the NP go into the resident's room. Interview on 08/21/25 at 3:16 PM with LVN D revealed he worked with Resident #1 on 08/04/25 during the 2:00 PM to 10:00 PM shift. He stated RN A reported to him that the NP ordered a UA and for Resident #1's catheter to be changed. RN A told LVN D she and another nurse (Treatment Nurse) tried to change the resident's catheter but when they had deflated the balloon and before they pulled the catheter out, blood was noted to be coming out from around the catheter. LVN D said RN A told him she had contacted the physician and he had given the orders to leave the catheter in and monitor. LVN D said he went in to see Resident #1 after getting report and there was some blood around the tip of the resident's penis, the collection bag had some urine in it but he did not see any blood in the bag. LVN D stated he did not notice any swelling to the resident's penis and there was nothing out of the ordinary during the resident of shift and the resident continued to have urine output in the bag with no blood in it. LVN D further stated Resident #1 did not have any issues with his catheter in the past. Interview on 08/21/25 at 3:45 PM with Resident #1 revealed, during his bed bath on 08/04/25, one of the aides (CNA E) told him his penis was infected and looked like it had some kind of drainage/puss to the area. The resident said the NP went in to see him and told the nurse his catheter needed to be changed. The Treatment Nurse assisted RN A and during the process, he stated he felt some pain, and it appeared something went wrong because it bled. Resident #1 said, sometime later, he was sent to the hospital, and the staff there told him something had ruptured in his urethra when they tried to change the catheter. Interview on 08/21/25 at 12:45 PM with the DON revealed the weekend of Saturday 08/02/25 and Sunday 08/03/25 Resident #1 did not want to eat and refused his medications. She stated RN A called her on Monday, 08/04/25 because said she and the Treatment Nurse tried to change the resident's catheter. RN A told her when they deflated the balloon, blood came out. RN A also told her the physician was called, and he gave orders to monitor the resident. The DON said they had ordered bloodwork and when those results came in, some of labs were critical so the resident was sent to the hospital. The DON further stated the nursing staff reported to her that Resident #1 continued to have urine output that afternoon before he was sent to the hospital. The DON said RN A had been trained on catheter insertion and removal upon hire and the training was a part of the Infection Control section. Record review of RN A's new hire training dated 09/16/25 reflected she took the Infection Control Portion. There were no other details to the training. Interview on 08/21/25 at 4:07 PM with the NP revealed she assessed the resident on 08/04/25 after staff told her Resident #1 had been acting confused and paranoid. The NP said when she assessed the resident she noticed his penis was slightly swollen so she ordered blood work, (CBC and CMP), a UA and a catheter change in case he had developed an infection (UTI). The NP said the resident's vitals were stable at the time, there was no bleeding to catheter site at the time, and there was yellow urine in the catheter bag. The NP stated she was not certain how the catheter balloon had gotten in Resident #1's urethra unless the catheter was tugged causing it to go into the urethra. Interview on 08/21/25 at 10:40 AM with the Physician revealed he cared for Resident #1, and there had not been any issues with the resident's catheter other than a couple UTIs. The last time the Physician had seen Resident #1 was on 07/30/25 for medication adjustments, and there were no issues with the resident's catheter. The Physician said, according to Resident #1's progress notes, Resident #1 had been seen by the NP on 08/04/25. He stated the NP documented that Resident #1's catheter was to be switched out because his penis was swollen. The Physician read Resident #1's hospital records and they said if it was documented that his catheter balloon was inflated in the urethra then it probably was causing bleeding from the trauma it caused the urethra. If the balloon was indeed in the urethra, the Physician stated it would explain why his BUN and Creatinine labs were critical which would indicate the resident was in acute renal failure because it would block the urine from flowing causing it to go back up into the kidneys. The Physician continued to read Resident #1's hospital records and said it appeared once the catheter was replaced his labs (Potassium, BUN, and Creatinine) began to decrease. The Physician said if the catheter balloon was in the urethra it was possibly inflated wrong or it was tugged on which would cause trauma and bleeding. Record review of the facility's policy titled Indwelling Catheter-Male and Female (Insertion and Removal of) reviewed on 06/2006 reflected the following: PurposeTo provide continuous drainage of the urinary bladder; to prevent contact of urine with open areas on the body; to obtain accurate measurement of urinary output; to obtain a sterile specimen for diagnostic purposes; and to instill medication into the bladder. Insertion of Indwelling Catheter .Procedure - .advance catheter one to one and one-half inches beyond the point of free flow or urine. - Check size of balloon; draw up sterile water to his amount (if not using pre-filled syringe), attach the syringe to the balloon port of the catheter. - Do not force water into balloon. If resistance is encountered or the patient complains of pain, deflated balloon, advance farther into the bladder and inflated. - Tug gently on catheter until you feel resistance. Removal of Indwelling Catheter.Procedure- Attach syringe to balloon port of catheter and aspirate entire amount of sterile water in balloon.- Pinch catheter and withdraw gently and slowly. Record review of the facility's policy titled Catheter Care, Urinary revised on September 2014 reflected the following: .Complications1. Observe the resident for complications associated with urinary catheters.b. Check the urine for unusual appearance (i.e., color, blood, etc.)c. Notify the physician or supervisor in the event of bleeding, or if the catheter is accidently removed. d. Report any complaints the resident may have of burning, tenderness, or pain in the urethral area. An Immediate Jeopardy was identified on 08/21/25. The Administrator, DON and the Regional Nurse Consultant were notified of the Immediate Jeopardy on 08/21/25 at 4:55 PM. The IJ template was provided to the facility on [DATE] at 5:10 PM. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The facility's Plan of Removal for the Immediate Jeopardy was accepted on 08/22/25 at 8:30 AM and reflected the following: Concern:F684J - Quality of Care F684 - The facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person -entered care plan, and the residents' choices based upon the comprehensive assessment of a resident. On 08/04/25, a [AGE] year-old male resident, who had a diagnosis of quadriplegia and who had a urinary catheter, experienced a change in condition resulting in loss of appetite and tiredness. The facility notified the Nurse Practitioner about the change in condition, and orders were given perform a straight catheter to obtain a sample for a urinalysis and for blood work to be done. When the nurse deflated the catheter balloon to remove the urinary catheter, she noticed blood coming out around the catheter. The physician was immediately notified and instructed the nurse to re-inflate the balloon and monitor for further bleeding. A few hours after this the resident's lab results arrived and showed that the resident had critical labs. The physician gave orders for the resident to be sent to the hospital. At the hospital, the hospital discovered that the catheter balloon had been inflated in the urethra causing trauma and bleeding. The resident was transferred to a higher level of care for a urology consultation. The facility failed to properly insert a urinary catheter which resulted in the resident experiencing urethral trauma and bleeding. Immediate Actions Resident #1 is no longer in the building. The Medical Director was assigned this resident. 1 The Ombudsman was notified of the content of the immediate jeopardy via email on 08/21/2025. 2 On 08/21/2025 The RDCS in-serviced the DON and the Unit Managers with test for competency on: - Following physicians' orders - Effective Documentation - Recognizing Changes in Condition - Urethral Catheter Placement with competency of test and with skill assessment checked off by nurse leadership/designee 3 On 08/21/2025 The RDCS and DON completed a 100% audit of all residents who are on catheters , who have the potential to be affected. The results of the audit yielded that no other residents were affected and were at their normal baseline. The Foley catheters were all appropriately placed and draining appropriately. Staff Training and Education Mandatory Training: Starting 08/21/2025 All licensed and registered nursing staff will undergo mandatory training on proper urinary catheter insertion and re-insertion techniques, including recognizing complications and responding appropriately. Training will be conducted by the DON/Clinical Designee. Competency Assessment: Each licensed or registered nursing staff member will be required to demonstrate competency in catheter insertion and re-insertion through hands-on evaluations. Staff who fail to demonstrate competency will not be allowed to work or perform catheter-related procedures until retraining and reassessment are completed. 4 On 08/21/2025 initiation of all in-house licensed and registered nurses and were re-inserviced with a test to validate competency on: Following physicians' orders Effective Documentation Recognizing Changes in Condition Urethral Catheter Placement with competency of test and with skill assessment checked off by nurse leadership/designee Systematic Approach 1. On 08/21/2025 A QAPI meeting was held, in attendance were the Medical Director (via TEAMS), Executive Director, DON, and the Regional Director of Clinical Services. Policy and Procedures on Physician Notification, Documentation and Changes in Condition were reviewed and found to be sufficient and met state and federal requirements. QAPI discussed the components and the interventions of this plan of removal. 2. The facility will incorporate catheter-related procedures into its annual staff training program and QAPI initiatives to ensure ongoing compliance and resident safety. Monitoring 1 DON, UMs were educated on 08/21/25 in the daily process of: a. The DON and Unit manager(s) were educated by the RDCS on 08/21/25 and will use the Grand Rounds process and 24-hour Summary to identify any and all residents who were may have been admitted with or given orders to insert a urethral catheter to ensure appropriate placement and flow. This will occur daily for 2 weeks, weekly for 2 weeks and then monthly. On the weekends and holidays, the Nurse Supervisor/Designee will complete the audit/review. The DON/ Designee will monitor daily, M-F, on the weekends and holidays, the Nurse Supervisor/Designee will complete the review. The DON/Designee will monitor this process. ******Any staff who are not present to complete the in-service by 8/21/2025 will be required to complete the in-service at the start of their next shift before beginning work. New Hires, PRN and any agency staff will also be in-serviced prior to the start of their shift. The education will be conducted and monitored by the DON/Designee. Quality Assurance: Results of all monitoring by DON and Unit Manager shall be brought to the Quality Assessment and Assurance Committee for review and any committee recommendations will be acted upon. The DON will be responsible for bringing the results of the monitoring to the QA committee. Completion Date: 08/21/2025 Monitoring the facility's Plan of Removal included the following: Observation on 08/20/25 at 9:45 AM revealed Resident #1 was no longer at the facility. Record review of the In-service Training Report dated 08/21/25 reflected 12 charge nurses were educated on Foley insertion, verify placement, documentation, physician orders, change of condition, complete transfer form. Further review of the training revealed each charge nurse was given a competency test and a skills assessment checked off by nursing management. Interviews on 08/22/25 from 11:26 AM to 3:29 PM from nurses from various shifts were the DON, ADON, Treatment Nurse, RN A, LVN B, LVN D, LVN F, LVN G, LVN H, LVN I, LVN J, RN K, RN L, and LVN M. All staff were able to identify the following: - What type of documentation is required with resident that have Foleys; (i.e. color, odor, urine output, urine retention, discomfort to area and size of catheter and balloon inflation)- How to insert a catheter using sterile technique in males and females. (insert until there is urine return and go farther if resistance is felt) - What to do if they feel resistance when inflating the catheter balloon. - How to remove a catheter (pull the same amount of fluid that was inserted in the balloon, and gently pull out)- What to do if the is blood noted upon removal (do not remove and call the physician for orders)Each charge nurse had a competency test and skill assessment as part of their in-service. Review of the audits dated 08/21/25 revealed there were 5 residents with catheters and there were no issues identified with the resident's catheters. Observation on 08/22/25 of catheter care for Residents #2, #3, and #4 from 10:15 AM to 11:06 AM revealed appropriate technique was used, clear urine was flowing in the output bags, and there were no issued noted. There were no residents that required catheter insertion or changing. The Regional Nurse Consultant and DON were notified on 08/22/25 at 3:45 PM, the Immediate Jeopardy was removed. While the IJ was removed on 08/22/25, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to administer parenteral fluids consistent with professional standards of practice and in accordance with physician orders for one (Resident #1) of one resident reviewed for parenteral fluids. The facility failed to obtain physician orders to manage, provide care, and change Resident #1's CVC dressing at least every 7 days and as needed if the dressing or site appeared compromised (damp, loosened or visibly soiled). The facility failed to change Resident #1's CVC dressing at least every 7 days and ensure Resident #1's central line was maintained per professional standards and facility policy. On 10/04/23 Resident #1 was transferred to the ER and admitted for a medical emergency - Sepsis (the body's extreme response to an infection) and Septic Shock (a life-threatening condition that happens when blood pressure drops to a dangerously low level after an infection). An Immediate Jeopardy (IJ) was identified on 10/18/23. The IJ template was provided to the facility on [DATE] at 1:51 PM. While the IJ was removed on 10/19/23, the facility remained out of compliance at a scope of isolated and severity level of actual harm that is not immediate due to the facility continuing to monitor the implementation and effectiveness of the corrective systems. This deficient practice place residents at high risk or the likelihood of, serious injury, harm, impairment, or death by not having their needs met, or receiving treatment in a timely manner in accordance with professional standards of practice. Findings included: Record review of Resident #1's Face Sheet, printed on 10/12/23, revealed the resident was a [AGE] year-old male, who admitted to the facility on [DATE] with the following diagnoses: HTN (a condition in which the blood vessels have persistently raised pressure);T2DM (a chronic condition that affects the way the body processes glucose [blood sugar]) with hyperglycemia (high blood glucose [blood sugar]); DVT (when a blood clot forms in a deep vein); and CKD (kidneys have mild to moderate damage). Record review of Resident #1's undated Five-Day PPS Assessment, signed by RN J on 09/06/23, verifying assessment completion, revealed a reentry from an acute hospital on [DATE]. Resident #1 readmission diagnoses included Severe sepsis with septic shock (septicemia). Other health conditions reflected in the Five-Day PPS Assessment were fever and vomiting. Resident #1 had a BIMS Summary Score of 15 which suggested intact cognition. Resident #1's functional status required one-person physical assist with ADLs. Resident #1 had an urostomy (an opening in the abdominal wall that re-directs urine away from the bladder) and colostomy (an opening formed in the abdominal wall to bypass a damaged part of the colon). Resident #1 receive parenteral/IV feeding, TPN (via right subclavian CVC). Resident #1 returned to SNF on 10/16/23 from an acute hospital stay (10/04/23 - 10/16/23). A record review on 10/12/23 of hospital medical records (visit: 08/08/23 - 08/16/23) revealed Resident #1's CVC was placed on 08/10/2023 during hospitalization in August 2023 for admission diagnosis of severe sepsis when PICC line was the source of sepsis. Record review on 10/12/23 at 2:19 PM of Resident #1's October 2023 physician order sheet reflected: -Order date 08/25/23: Take vital signs. Frequency: By shift starting 08/25/2023 Record review of Resident #1's September [09/01/23 - 09/30/23] and October [10/01/23 - 10/31/23] TARs, print date 10/17/23 at 4:36 PM, reflected the following orders did not have assigned administration times in the Date Range Specified: - IV - Flush SASH Method by shift starting 07/11/2023 - COMPLETED - IV - Site Check by shift starting 07/11/23 - COMPLETED - IV - Tubing Change every 24-hours starting 07/11/23 - COMPLETED - PICC - Dressing Change one time weekly starting 07/11/23 - COMPLETED - IV - Dressing Change every one week starting 07/12/23 - COMPLETED CVC dressing changes were not documented as completed on the August 2023, September 2023, or October 2023 TARs following the resident's return from the hospital on [DATE]. The TARs did not reflect CVC (placed 08/10/23) dressing changes at least every 7 days beginning 08/17/23, 08/24/23, 08/31/23, 09/07/23, 09/14/23, 09/21/23, or 09/28/23. The next CVC dressing changed would have been scheduled for 10/05/23. Review of Resident #1's progress notes reflected: - On 10/03/23 at 11:49 PM, RN D entered, Dressing on the IV site changed, patient tolerated well, IV line flushing well, patient alert and oriented, able to verbalize needs, TPN running well, V/S within normal saline. continue to monitor. Record review on 10/12/23 at 2:05 PM, Resident #1's care plan (Effective: 06/06/23; Created: 06/19/23), date range: 06/06/23 - Present, did not reflect interventions for the care of CVC that included routine inspection and dressing changes at least every 7 days and as needed. Record review on 10/13/23 at 2:07 PM of Resident #1's hospital medical records, admission date 10/04/23 (still IP, no D/C date), reflected Resident #1 arrived at the ER on [DATE] at 6:51 PM. Record review of the ER Provider Note dated 10/04/23 at 7:02 PM reflected, per EMS, [Resident #1] with fever of 103 ( F), chills and diaphoresis (unusual sweating) . nausea and vomiting as well. Resident #1's vital signs revealed: BP: 100/55; HR: 127; Temp: 100.6 F; Resp: 15. The ER provider physical exam revealed Resident #1 with AMS, tachycardic (heart rate over 100 beats a minute), sleepy; drowsy, but followed commands. The ER provider assessment/plan indicated (Resident #1) with indwelling subclavian catheter for TPN, urostomy and colostomy, presented with AMS, high fever, and very likely sepsis. sepsis IVF (Resident #1) with consistent low blood pressure. A consultation with ICU provider agreed with plan to admit Resident #1 to the ICU for constant monitoring and treatment of severe sepsis. Review of Resident #1's blood labs collected in the ER on [DATE] at 7:02 PM revealed: Glucose: 163 mg/dL [Range 70 - 100] (measures the level of glucose (blood sugar) in the blood) BUN: 38 mg/dL [Range: 8 - 23] (measures the amount of urea nitrogen, a waste product, in the blood) RBC: 3.49 per mcL [Range: 4.7 - 6.1] (measures how many red blood cells circulating in the blood) HGB: 10.0 g/dL [Range: 13.8 - 17.2] (measures the amount of hemoglobin [Hgb] in the blood) HCT: 31.8% [Range: 40.7 - 50.3] (blood test that measures how much blood is made up of red blood cells) Lymphocyte, absolute: 0.35 cells/µL [Range: 0.95 - 3.07] (measures the levels of lymphocytes in an entire sample of whole blood as an absolute number instead of as a percentage) Lactate: 3.1 mmol/L [Range: 0.5 - 2.2] (blood test that measures the level of lactic acid made in the body at a given point in time) Record review of Septic Shock. (2023), accessed on 10/23/23 at https://www.ncbi.nlm.nih.gov/books/NBK430939/ revealed the presence of two of the four early clinical signs (fever [100.4 F]; HR more than 90 bpm; respirations more than 20 bpm; and SBP less than 100 mmHg) and laboratory findings of hyperglycemia (glucose more than 120 mg/dL), Thrombocytopenia (low platelet count), increased BUN, and/or lactic acidosis (more than 2 mmol/L) suggest severe sepsis. Severe sepsis with hypotension development progress to septic shock. A review of a hospital provider assessment and physical exam dated 10/04/23 at 11:35 PM revealed Sepsis Reperfusion Exam (a focused exam withing 6 hours of severe sepsis or septic shock presentation) was performed. Labs were notable for glucose 163 mg/dL . BUN 38 mg/dL, lactate 3.1 mmol/L . Hgb 10.0 g/dL/Hct 31.8% . CXR suggestive of early pneumonia . Repeat lactate on 10/04/23 at 9:39 PM was 2.7 mmol/L. IVF bolus of 30 mL/kg and broad spectrum abx were given. Record review of Resident #1's hospital medical records, admission date 10/04/23 (still IP, no D/C date), reflected a final diagnosis on 10/05/23 at 1:58 AM of Sepsis and Septic shock. A review of a hospital provider clinical notes dated 10/06/23 at 2:14 PM reflected fever overnight, acetaminophen x 1 . fever trending down. Blood cultures (drawn on 10/04/23 at 7:20 PM) noted positive for Staphylococcus epidermidis (bacteria cause infections), suspected source is central line . Bilateral lung infiltrates likely due to pneumonia . Plan: Repeat blood culture tomorrow (10/07/23) if (Resident #1) remains unstable or blood cultures are repeatedly positive then remove the tunneled Internal Jugular (a CVC surgically inserted into a vein in the neck). A review of a hospital provider clinical notes dated 10/09/23 at 9:27 AM reflected, Repeat blood cultures still positive for Staphylococcus epidermidis, orders placed to remove CVC . A review of a hospital provider clinical notes dated 10/09/23 at 9:34 AM reflected, tunneled catheter removal (inserted in August 2023) . tip sent for culture. A review of a hospital provider clinical notes dated 10/11/23 at 6:30 PM reflected, . Staphylococcus epidermidis bacteremia, sepsis source is central line. Record review of Resident #1's hospital medical records, admission date 10/04/23 (still IP, no D/C date), reflected CVC tunneled placement was performed 10/13/23 at 9:48 AM - 10:05 AM. During a phone interview on 10/12/23 at 12:51 PM, a family member stated concerns about Resident #1's hospitalization (on 10/04/23) for sepsis. The family member stated that they did not feel staff responded as quickly as should when Resident #1 had a change in condition. The family member stated they did not have notes in front of them to discuss the recurring issues. During an observation and interview (at the hospital) on 10/13/23 beginning at 10:49 AM, Resident #1 appeared clean, groomed, and dressed in a hospital gown. Resident #1 was observed in a full upright sitting position in bed. Resident #1 received a standard TPN solution administered through a CVC line (bandage strips and a few stitches noted at entry site) that was covered by a transparent drsg dated 10/13/23) at the right upper chest. Resident #1 had a midline abdominal colostomy with drainable ostomy pouch that drained dark brown liquid stool by gravity to a drainage bag that hung on left bed frame; and a right lower abdominal urostomy with urostomy pouch that drained pale yellow urine by gravity to a drainage bag that hung on right bed frame. Resident #1 appeared comfortable. Resident #1 was Alert, attentive, and oriented to level of awareness of self, place, time, and situation. Resident #1 was calm and cooperative. Resident #1 was reasonably responsive with purposeful movements, appropriate gestures and answered questions directly, accurately, and with relevance. Resident #1 had fair recall of immediate and past events. Resident #1 said that he was in the hospital for sepsis and the [hospital doctor(s)] said the central line was the source. Resident #1 said that he knew the CVC dressing should be changed every 7 days and he tried to stay on top of the due date to remind the nurses. Resident #1 said that there were times the CVC dressing was not changed weekly or was changed after 7 days had passed. Resident #1 said the CVC line that was currently in place was inserted that morning (10/13/23). Resident #1 said he was usually awake and alert but started feeling sluggish and slept most of the day (10/03/23). Resident #1 said he asked the nurse [later identified as LVN A] to check his temperature because he felt feverish (on 10/04/23 could not state the time for sure, but said it was sometime around 4:00 PM). Resident #1 said it took the nurse a while (described a while as 20 - 30 minutes) to return and check temperature. Resident #1 said he was told his temperature was high. Resident #1 said that [LVN A] returned after 15-20 minutes and performed a COVID test. Resident #1 said that [DNP L] was in his room around the same time LVN A informed that the COVID test was negative. Resident #1 said he did not recall exactly what happened, only remembered he was sent to the hospital. During an interview on 10/13/23 at 2:42 PM, LVN A said that she worked the 6A - 2P shift. LVN A said she was familiar with Resident #1's care needs. LVN A stated Resident #1 required staff assistance with ADLs, had a urostomy and colostomy drainage bags . received TPN via a PICC (LVN A could not recall if the central catheter line was placed in Resident #1's arm [PICC] or chest [CVC]). LVN A defined a change in condition in a resident is when their normal status changed from being alert, ability to walk, have a decline or when vital signs are outside of [physician ordered] parameters or different from measurements compared to baseline. LVN A said a CVC or PICC line dressing should be changed every seven days. LVN A said that LVNs could change the dressing if they were IV certified. LVN A said that she was IV certified and changed Resident #1's sterile dressing before, but did not know the exact date. LVN A said she worked and was assigned to Resident #1 the day he was sent to the ER [DATE]). LVN A said the cause was a fever. A record review of an email received 10/16/23 at 11:50 AM, a family member wrote, .there are a few other things not mentioned during the initial contact (10/12/23 at 12:51 PM). After [Resident #1] first round of sepsis from the PICC line on [DATE] thru [DATE] (2023) . [Resident #1] did not receive TPN until Saturday morning, August 19 (2023). They [SNF] have told [family member] that the pharmacy was so far away and if they don't get the order in early enough . delay in delivery of the order. This was not the first time had to wait several days to receive TPN. Record review on 10/18/23 at 10:44 AM of Resident #1's October 2023 physician order sheet reflected hospital discharge orders (written 10/16/23), antibiotic therapy via the CVC, vital sign measurement every shift (BP/Pain/Pulse/Pulse Oximeter/Respiration/Temperature); monitor for s/sx of complications related to TPN administration including air embolism (occurs when air is admitted into the vascular system), hypervolemia (too much fluid volume in the body), hyperglycemia (high blood sugar), hypoglycemia (low blood sugar), infections, and Pneumothorax (collection of air outside the lung but within the pleural cavity [fluid filled space that surrounds the lungs]) each shift, and CVC site check, management, and dressing change one time weekly. During record review and interview on 10/18/23 beginning at 1:35 PM, RN D said that she worked evening shifts, 2P - 10P and was familiar with Resident #1 and his care needs as the primary assigned nurse. RN D said that she recalled working on 10/04/23 and Resident #1 did not have a decline in ADLs or a change in condition. RN D defined a change in condition as anything about a resident that was different from a resident normal clinical status. RN D said that she was required to complete a Daily Skilled Assessment for Resident #1 to provide information that [Resident #1] needed daily skilled (nursing) interventions. Review of Resident #1's progress notes and a note entered by RN D on 10/03/23 at 11:49 PM revealed dressing on the IV site changed, patient tolerated well, IV line flushing well . RN D said that she did not recall the date on the old IV dressing because she did not change the dressing. RN D said that she asked LVN E (WCN) to change the IV dressing because she [RN D] was too busy. RN D said that the task to change the IV dressing did not pop up on the TAR, that she knew it needed to be changed PRN because the bottom edge of the dressing was pulled away from the skin. RN D made a hand gesture, touching her chest, to suggest the area of the IV dressing was pulled away from [Resident #1's chest]. RN D said that sterile dressings to IV/PICC/CVC sites should be changed every 7 days and was reflected on the TAR. RN D said that there should always be an order to perform care or administer medication to a resident. Review of a Daily Skilled Assessment completed by RN D on 10/03/23 at 11:56 PM indicated Resident #1 level of consciousness was Alert-Responds readily but may be confused and had new or increased confusion. RN D said that she did not recall working 2P - 10P and probably selected the wrong item when charting and did not mean to select new or increased confusion. Record review of Resident #1's Daily Skilled Nurse Assessments [Date range: 09/01/23 - 10/04/23], printed 10/18/23 at 2:31 PM, provided by the NFA to support documentation by nurses that Resident #1's CVC dressing was changed every 7 days revealed in the section Describe any other services, education or training provided: 09/05/23 at 3:09 PM, completed by LVN N, reflected the response Central line drsg patent, clean dry and intact. The Daily Skilled Nurse Assessment did not indicate the dressing was changed. 09/11/23 at 1:41 PM (6 days later), completed by LVN A, reflected the response Central line dressing changed using sterile procedure, resident tolerated the procedure no signs of infection noted. Remains intact and flushable. 09/19/23 at 1:57 AM (8 days later), completed by LVN I, reflected the response Central Line dressing change. The first and the last Daily Skilled Nurse Assessment provided with the Assessments listed above, were not dated, or signed by a nurse. The CVC (placed 08/10/23) dressing changes were expected to be changed at least every 7 days beginning 08/17/23 then, 08/24/23, 08/31/23, 09/07/23, 09/14/23, 09/21/23, and 09/28/23. The next CVC dressing change would be scheduled on 10/05/23. During Record review and interview with the RDCS and Sr. E.D. on 10/18/23 beginning at 3:42 PM, the Sr. E.D. indicated nurses documented IV/CVC dressing changes in Resident #1's Daily skilled Nurse Assessments. The RDCS stated the task to change an IV/CVC dressing did not have to reflect on the TAR and the nurse did not have to document in a progress note. Attempted phone interview with LVN E on 10/18/23 at 4:18 PM was unanswered. No return call received before exit conference on 10/19/23. During a telephone interview on 10/19/23 at 3:26 PM, the MD said that he was also the Medical Director. The MD said that he was familiar with Resident #1. The MD said that CVC central line care and maintenance was important to minimize the risk of infection. The MD said that orders were written to provide central line care and dressing changes every 7 days for every resident that has a central line in place. The MD said if a resident had a CVC/PICC line and there were no orders, it was the nurse staff/nurse manager responsibility to ensure orders were obtained and reflected in the chart. The MD said that nurses should closely monitor the CVC site, flush the line every day (or as ordered) to prevent clotting. The MD said that handling of the CVC should be minimal to reduce the risk of contamination. Record review of Maintenance and Removal of Central Venous Catheters (n.d.), accessed on 10/23/23 at https://www.cdc.gov/infectioncontrol/pdf/strive/CLABSI104-508.pdf revealed CVC dressing status should be assessed at least daily, transparent dressings changed every 7 days and whenever dressing becomes damp, loosened or soiled. Record Review of the facility policy and procedure titled Central Venous Catheter Care and Dressing Changes, revised March 2022, read in part: The purpose of this procedure is to prevent complications associated with intravenous therapy, including catheter-related infections that are associated with contaminated, loosened, soiled, or wet dressings. General Guidelines included: 1. Perform site care and dressing change at established intervals or immediately if the integrity of the dressing is compromised. 2. Maintain sterile dressing for all central vascular access devices. 3. Change the dressing if it becomes damp, loosened or visibly soiled, at least every 7 days, and immediately if the dressing or site appear compromised. 5. Assess central venous access devices with each infusion and at least daily. Assessment guideline indicated to observe insertion site and surrounding area for complications. Documentation guidelines indicated to: 1. The following information should be recorded in the resident's medical record: a. Date and time dressing was changed. b. Location and objective description of insertion site. c. Any complication, interventions that were done. d. Condition of sutures (if present). e. Any questions, education given to resident, resident's statement regarding IV therapy and response to procedure. f. Signature and title of the person recording the data. Reporting guidelines indicated to report any signs and symptoms of complications to physician, supervisor and oncoming shift; intervene as necessary. The NFA was notified of an Immediate Jeopardy (IJ) on 10/18/23 at 1:18 PM, due to the above failures and the IJ template was provided. The facility's Plan of Removal (POR) was accepted on 10/19/23 at 12:05 PM and included: Impact Statement: On 10/18/2023, the facility was provided notification that the survey agency has determined that the conditions at the center constitute an Immediate Jeopardy to resident health. The facility failed to change Resident #1's central line dressing every 7 days as ordered. Immediate Action: Please accept this as a Plan of Removal for the alleged Immediate Jeopardy related to Parenteral/IV Fluids on 10/18/2023 at 1:51 pm. The facility failed to change Resident #1's central line dressing every 7 days as ordered. Residents that can be affected are those with central lines. Systematic Approach: 1. Assessment - Resident #1 with signs and symptoms of sepsis was transferred to the hospital on [DATE] per the order of the Nurse Practitioner and was admitted to the hospital for sepsis, septic shock, and pneumonia. -The Executive Director notified the facility Medical Director of the Immediate Jeopardy on 10/18/2023 at 3:20 pm. -An emergency QAPI meeting was held on 10/16/2023. -All residents will have any central line dressings observed by Director of Nurses or Assistant Director of Nurses on 10/18/2023 to identify any current patients that are at imminent risk related to not having the dressing changed per physician orders. The observations were completed on 10/18/23 by 6:00 pm. After completion of observations, no other residents were found to be at imminent risk of central line dressing changes not having been completed. Who will be responsible: Director of Nursing/Nurse Managers Who Will monitor: Executive Director and RDCS All nursing staff were educated to notify the DON/Nurse Managers immediately upon any central line dressing changes that had not been completed per physician orders. This education was provided on 10/18/2023. This education was provided by the DON and RDCS. Staff will not be allowed to begin their shift until the education has been completed. Treatments that are physician ordered will reflect on the MAR/TAR. This will include all CVC/PICC line care including sterile dressing changes per physician orders. 2. In-Services All staff were in-serviced on CVC/PICC line care including sterile dressing changes per physician orders by the RDCS/Director of Nursing and/or Nurse Managers. All new staff will receive the education as part of the onboarding orientation process prior to being assigned tasks and providing care to residents. No licensed staff member will be allowed to work in the facility until the above required in-services are completed. The in-service with all licensed clinical staff will be completed by 10/18/2023. All staff were in-serviced by 8:00pm on 10/18/2023. Who will be responsible: DON/Nurse Managers Who Will monitor: Executive Director/RDCS A staff roster was utilized to ensure 100% of licensed nursing staff were in-serviced and tested. In-services were deemed to be effective by the in-services signatures and verbalization of understanding by all licensed facility staff. The Executive Director, DON and ADON were in-serviced by the RDCS on sterile dressing changes per physician orders on 10/18/23 by 4:00 pm. Who will be responsible: DON/Nurse Managers Who Will monitor: Executive Director/RDCS 3. Monitoring Starting 10/18/23 the Executive Director, Director of nursing and/or Nurse Managers will review all central line orders to ensure dressing changes are completed per the orders. Observations will be made to ensure dressings have been changed. The Regional Director of Clinical Services will review the documentation each week for compliance. On 10/19/23 the surveyor began monitoring for implementation of the facility's plan of removal by: During a phone interview on 10/19/23 at 3:26 PM, the medical director acknowledged notification of the Immediate Jeopardy. Record review of the QAPI meeting minutes dated 10/16/23 at 12:30 PM reflected the following members in attendance: NFA, RDCS, DON B, DON C, ADON, RVP, and the medical director was notified by phone. The special discussion items reflected CVC Dressing Change. The QAPI Plan for CVC Dressing Change reflected a systematic approach, education, monitoring, and QA beginning 10/16/23 and education will continue through the first 30 days. During an interview on 10/19/23 at 4:22 PM, DON C indicated her first day as the full-time DON at the SNF was 10/13/23. DON C said that she participated in a QAPI meeting on 10/16/23 and the topic of discussion was change of condition, physician notification, and IV/CVC management and care (included dressing change). DON C said that she and the ADON reviewed all residents for any change of condition on 10/18/23 to identify abnormal vital signs or change of condition. DON C said on 10/18/23, in collaboration with nurse managers, provided in-services and training to nursing staff (CNAs, MAs, and LVNs/RNs) that included education about what is considered a change in condition (All nursing staff), action to take (LVNs/RNs), and physician notification (LVNs/RNs), the earlier the better. DON C stated that the nurse should call the physician immediately after assessment and document in the medical record. DON C said the in-services and training was on-going. DON C said that central line care and maintenance training was scheduled for all nurses (10/20/23 or to be determined) and IV dressing change skills check off would be completed. DON C said that she expected nurses to notify the ADON/DON, MD, NP (if delegated when MD was unavailable), and RP as soon as possible after assessment of the resident. DON C said if a resident change of condition was not reported, or within a timely manner, could lead to serious outcome, medical complications, hospitalization, or death. During an interview on 10/19/23 at 4:35 PM, the NFA stated that she assumed the role of administrator in August 2023. The NFA stated the facility and nurse management were responsible for ensuring staff could access, were educated, and followed policies and procedures. The NFA was not able to speak to the process of physician notification and could not produce related policies. The NFA was not able to speak to the procedure, the necessary steps, per the facility policy, to comply with central line management. The NFA stated steps discussed in a QAPI meeting to develop a list of changes, concerns, criteria that required physician notification and that it should be comprehensive. The NFA stated there should always be a clear understanding by all staff what is considered an acceptable timeframe for physician notification. Record review of an undated in-service titled Sterile dressing changes per physician orders conducted by the RDCS was presented to the NFA, DON, and ADON. In-services conducted by the DON and ADON beginning 10/18/23 and on-going, on the topic of IV/PICC line must be changed weekly and PRN revealed a summary of training that CVC/PICC line care included sterile dressing changes per physician orders. The sign in sheet reflected the following staff participated in the in-service: LVN F, LVN N, RN D, LVN I, LVN O, LVN P, LVN Q, ADON, and RN R. Record review of the In-Service Training Sheet, dated 10/18/23 on the topic of IV/PICC line must be changed weekly and PRN revealed the following staff were notified by DON C via phone call: LVN S, LVN T, LVN U (left message), LVN V (left message), LVN W (left message), RN X, LVN A, LVN G, LVN Y, RN Z, LVN H (left message), LVN AA (left message), RN R, RN AB, LVN AC (left message), and LVN AD. Interviews conducted on 10/19/23 with nurses scheduled on the 6A - 2P shift (LVN G [at 1:09 PM], LVN F [at 1:00 PM], LVN N [at 1:51 PM], and LVN A [at 2:29 PM]); 2P - 10P shift (RN D [at 2:15 PM], LVN H [at 2:36 PM weekend double LVN], and LVN I [at 2:43 PM])indicated they participated in an in-service training about recognizing change in condition, physician notification, and monitoring and changing an IV/CVC dressing. Each nurse stated in their own words the procedure was to notify the physician about the resident's change in condition as soon as possible - after vital signs were measured and an assessment performed. Each nurse verbalized the steps of procedure to change a sterile IV/CVC dressing every 7 days and there should be an order that reflected on the TAR. On 10/18/23, an Immediate Jeopardy was identified. The NFA was notified and provided an IJ template on 10/18/23 at 1:51 PM. While the IJ was lowered on 10/19/23, the facility remained out of compliance at a scope of isolated and severity level of actual harm that is not IJ due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.