**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure a central venous line site was maintained consistent with professional standards of practice for 1 of 1 residents reviewed for central venous lines (a thin, flexible tube that's inserted into a large vein to provide access to the circulatory system). (Resident #18) The facility failed to change a midline catheter (a type of central venous line) dressing according to facility protocol causing Resident #18 to miss one dressing change. The area was observed to be red and warm to the touch. The resident developed a localized midline infection at the site that was confirmed by the Nurse Practitioner. Resident #18 was sent to the hospital for replacement of the midline catheter. This failure resulted in the identification of an Immediate Jeopardy (IJ) on 11/05/24 at 1:15 p.m. The IJ template was provided to the facility on [DATE] at 1:22 p.m. While the IJ was removed on 11/06/24 at 10:48 a.m., the facility remained out of compliance at a scope of isolated and a severity level at potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents with central venous lines at risk of a systemic infection that could lead to serious illness and/or death. Findings included: Record review of a face sheet dated 11/04/2024 revealed Resident #18 was a [AGE] year-old male and was re-admitted on [DATE] with diagnoses including urinary tract infection, carrier of carpenium-resistant enterobacterales (a group of bacteria that are resistant to antibiotics and can cause serious infections), and pneumonia (a lung infection that causes the air sacs in the lungs to fill with fluid or pus, making it difficult to breathe). Record review of an annual MDS dated [DATE] revealed Resident #18 was understood and understood others. The MDS revealed a BIMS score of 12, indicating moderate cognitive impairment. The MDS indicated Resident #18 required partial to moderate assistance with ADL's. The MDS indicated Resident #18 received IV (intravenous medications) while a resident. Record review of a care plan last revised on 10/28/24 revealed Resident #18 on the intravenous medication Avycaz related to carpenium-resistant enterobacterales. There was an intervention of PICC LINE (a type of central venous line) DRESSING: Left upper, are, observe dressing daily and change per orders. Record review of a hospital Physician Discharge summary dated [DATE] at 8:31 a.m. indicated Resident #18 had been admitted to the hospital on [DATE] and was discharged on 10/24/24. There was a diagnosis of Sepsis (a life-threatening condition that occurs when the body has an extreme response to an infection or injury) secondary to UTI (urinary tract infection). Record review of Resident #18 electronic medical record from 10/24/24 - 11/03/24 did not indicate documentation of a central venous line dressing change or assessment of the site to Resident #18's left upper arm. Record review of a physician's order summary report for Resident #18 dated 11/04/24 did not indicate a physician's order for central venous line care, including dressing changes. There was an order for Avycaz Intravenous Solution Reconstituted 2.5 (2-0.5) grams (an antibiotic medication used to treat a wide variety of bacterial infections), use 2.5 gram intravenously three times a day for CRE until 11/06/2024. During an observation on 11/04/24 at 10:04 a.m., revealed Resident #18 had a single lumen (a single catheter) central venous line to the resident's left upper arm. The transparent dressing was dated 10/24/24. Record review of a nursing progress note for Resident #18 dated 11/04/24 at 6:45 p.m., indicated .Nurse was called to elder room @ 1300 (1:00 p.m.) Elder sitter informed nurse of some warm redness to left arm elder denies any pain, discomfort, or itching, (Nurse Practitioner) was informed and gave orders to have midline removed and a new one replaced and to start Bactrim DS po BID (by mouth twice a day) x 7 days. Elder informed and [family member] was informed also elder refused to have removal done this evening time 3-4 offers. Elder claims he was not mentally prepared and would like to wait until morning once sent to ER (emergency room) . Record review of a nursing progress note for Resident #18 dated 11/04/24 at 6:56 p.m., indicated Elder currently has IV ABT (intravenous antibiotic on hold until order given to resume with current or new midline. Record review of a Nurse Medication Administration Record dated 11/01/24 - 11/06/24 indicated Resident #18 did not receive Avycaz Intravenous Solution 2.5 grams for three scheduled doses for 11/05/24 due to the medication being on hold. During an observation and interview on 11/05/24 at 7:50 a.m., revealed Resident #18 had a single lumen (a single catheter) central venous line to the resident's left upper arm. The transparent dressing was dated 10/24/24. There site was red, and the redness extended under Resident #18's arm outside of the dressing. RN E said Resident #18 was being sent to the hospital due to redness and the site being warm to the touch. She said he was not going to the emergency room. She said the Nurse Practitioner had been notified and the resident had been placed on oral antibiotics. She said central venous line dressings were to be changed every 7 days. During an interview on 11/05/24 at 8:53 a.m., the Nurse Practitioner said Resident #18 had a localized midline (central venous line) infection. She said staff attempted to remove the central venous line on 11/04/24 and he refused to have it pulled. She said he was scheduled to have it replaced at 1:30 p.m. on 11/05/24. She said the site around the central venous line was red and warm to the touch. She said she expected the facility to follow central venous line dressing protocol on dressing changes. She said typically the dressing change order would be put in the admission orders. She said she would have expected the dressing to have been changed before now. She said the dressing not being changed could contribute to an infection. She said Resident #18 did pick at his dressing and the site. During an observation and interview on 11/05/24 at 10:20 a.m., revealed Resident #18 had a single lumen (a single catheter) central venous line to the resident's left upper arm. The transparent dressing was dated 10/24/24. The site was red, and the redness extended under Resident #18's left arm outside of the dressing. Resident #18 said the area was tender. Record review of physician's orders dated 11/05/24 indicated, .may have PICC (a type of central venous line) line removed per (Nurse Practitioner). PICC appears warm to touch with redness noted and Remove midline from Left upper extremity. Send out for replacement midline. Record review of a nursing progress note for Resident #18 dated 11/05/24 at 10:36 a.m. indicated, Midline removed per (Nurse Practitioner). Removal of midline was guided by CDC recommendations. Elder tolerated well .Elder will be seen today at (hospital) for replacement. Record review of a Vascular Access Team - Report of Procedure dated 11/05/24 at 2:00 p.m. indicated, Procedure orders - Insert Midline . The report indicated a midline was inserted on 11/05/24 at 3:33 p.m. to right basilic (vein in upper right arm). Record review of a physician's order summary report for Resident #18 dated 11/06/24 indicated an order with a start date of 11/05/24 for Bactrim DS Oral Tablet (antibiotic used to treat infection) 800-160 milligrams, give 1 tablet by mouth two times a day for possible phlebitis (a condition where a vein becomes inflamed and could be caused by infection, injury, or irritation) for 7 days. The order for Avycaz Intravenous Solution was on hold. During an interview on 11/05/24 at 11:08 a.m., the DON said the central venous line site should have been observed with every encounter and dressing changed every 7 days. She said there should be documentation of the dressing change. She said Resident #18's central venous line dressing change should have been done on 10/31/24 . She said a central venous line dressing not being changed could lead to infection. During an interview on 11/05/24 at 12:06 p.m., the DON said the nurse admitting a resident should get an order for dressing changes. She said there should be an order so that everyone knew there should be a dressing change and when it is due to be changed. She said the nurse that admitted Resident #18 should have put in orders for central line dressing changes. During an interview on 11/05/24 at 12:10 p.m., RN E said the admitting nurse should obtain an order for a dressing changes. She said that then placeds an order on the nursing medication administration record or the treatment administration record. During an interview on 11/06/24 on 8:47 a.m., RN F She said she was the admitting nurse for Resident #18 on 10/24/24. She said if a resident was admitted with a central venous line the admitting nurse was supposed to put the order in for dressing changes and care. She said she overlooked putting in an order for Resident #18's central venous line care. She said there were a lot of things with that admission that got her sidetracked. She said Resident #18 got antibiotics three times a day and she said she did not understand why other nurses did not notice his dressing needed to be changed. She said a dressing not being changed could lead to infection. During an interview on 11/06/24 at 10:09 a.m., the ADON said she would have expected for orders to have been placed for the central venous line dressing change and care for Resident #18. She said this was the responsibility of the admitting nurse. She said the dressing should have been changed on 10/31/24. She said there was always potential for infection if the central venous line dressing change was not done. During an interview on 11/06/24 at 1:27 p.m., the Administrator said the admission nurse should have put an order in for a central venous line dressing change for the appropriate time per their policy. She said a dressing not being changed in a timely manner could cause an infection. Record review of a Central Venous Catheter Care and Dressing Changes facility policy dated March 2022 indicated, .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 .A physician's order is not needed for this procedure .Change the dressing if it becomes damp, loosened or visibly soiled and .at least every 7 days for TSM dressing (a transparent semi-permeable membrane dressing) .Assess central venous access devices with each infusion and at least daily .check expiration dates of the infusion, dressing, and administration set .the following information should be recorded in the resident's medical record .Date and time dressing was changed . Record review of https://www.registerednursern.com/picc-line-care-picc-line-dressing-change-clinical-nursing-skills/ accessed on 11/12/24 PICC Line Care PICC Line Dressing Change Clinical Nursing Skills indicated .A peripherally inserted central catheter or PICC line is a soft plastic tube that is inserted into a large vein right above the patient's heart. The PICC line must always remain sterile so that the patient does not run the risk of getting an infection. PICC lines should be changed at least once per week. If the dressing becomes loose, wet, or dirty, the dressing must be changed more often to prevent infection. PICC line dressings must be inspected on a daily basis. Moist dressings are breeding grounds for infections . The Administrator was notified of an IJ on 11/05/24 at 1:22 p.m. and was given a copy of the IJ template and a Plan of Removal (POR) was requested. The Plan of Removal was accepted on 11/05/24 at 5:55 p.m. and included the following: Please accept this Plan of Removal as a credible allegation of compliance for immediate jeopardy initiated on November 5, 2024, for failing to follow the central venous catheter care and dressing change policy by assessing, monitoring and documenting the IV daily. One resident of the facility had the potential to be affected by this alleged deficient practice. A. Corrective Action Notified PCP. Removed Resident #18's PICC line on 11/5/2024. Resident #18 went to a hospital for a PICC line replacement for 11/5/2024. Ad Hoc QAPI meeting was held in Administrator's office on 11/05/2024 around 4:15PM with the following in attendance: Administrator, Medical Director, Nurse Practitioner, DON, ADON and Executive Director. Community Plan for Removal developed and initiated from this meeting. In-Service initiated on 11/5/2024 regarding Central Venous Catheter Dressing Changes. Registered Nurses will be in-serviced prior to working their next shift by the DON/ADON and/or designee. o The in-service covers the frequency of dressing changes, or when needed, to prevent catheter-related infections that are associated with contaminated, loosened, soiled, or wet dressings. o Corporate Nurse, via Teams Conference call with video and audio, and Nurse Practitioner, in person, in-serviced DON and ADON on 11/5/2024. DON began in-servicing Registered Nurses via in-person and Teams Conference call via video and audio on 11/5/2024. In-service initiated on 11/5/2024 regarding admission Check List and Documentation Guidelines for Infusion Therapy. Nurses will be in-serviced prior to working their next shift by the DON/ADON and/or designee. o The Documentation Guidelines for Infusion Therapy covers assessing, monitoring, and documenting regarding infusion therapy. o The admission Checklist includes skin assessment, pictures of the skin and IV dressing orders. admission Nurse will use admission Checklist to ensure admission is correct. o Corporate Nurse, via Teams Conference call with video and audio, and Nurse Practitioner, in person, in-serviced DON and ADON on 11/5/2024. DON will begin in-servicing Nurses via in-person and Teams Conference call via video and audio on 11/5/2024. B. Identification: There is no other resident at risk, as there are no other intravenous lines at this time. C. Preventative Measures: admission audit sheet created. admission Nurse will use admission Checklist to ensure admission is correct. Quality Assurance Nurse, ADON, will check behind this admission Nurse by the next weekday morning. A Triple Check will be completed by the MDS Nurse by third weekday. D. Monitoring: DON and/or designee will monitor admissions daily for two weeks beginning on 11/6/2024 to ensure compliance. DON and/or designee will monitor admissions weekly beginning on 11/20/2024 to ensure compliance and report to the Community QAPI Committee meetings for six months unless otherwise determined by the QAPI committee. Medical Director informed of the Immediate Jeopardy on 11/5/2024. DON and/or designee will monitor Central Venous dressings biweekly beginning on 11/5/2024 to ensure dressing is clean, dry, intact and changed timely and report to community QAPI Committee meetings for six months unless otherwise determined by QAPI committee. The surveyor verification of the Plan of Removal from 11/05/24 was as follows: Record review of a QAPI Sign in Sheet dated 11/05/24 indicated a QAPI meeting was held on 11/05/24 and was attended by the ADON, DON, Administrator, the Nurse Practitioner, Executive Director, and Medical Director. Record review of a Resident Matrix dated 11/04/24 indicated Resident #18 was the only resident receiving intravenous therapy. Record review of a blank admission Checklist indicated information concerning the resident being admitted including allergies, vitals, diet, completion of all evaluations due on admission, medications, skin assessment, and any customized standing orders. The customized standing orders included dressing changes, wound care or treatment orders, and pictures of skin issues. Notifying the Nurse Practitioner, ADON, and DON were part of the checklist. There was a section for the signature of the admitting nurse and the ADON. Record review of a Training In-Service form dated 11/05/24 indicated the Corporate Nurse and the Nurse Practitioner in-serviced the DON and the ADON on central venous dressing changes and the process for the admission Checklist. Record review of Admit Checklist Training In-Service forms dated 11/05/24 indicated 9 nurses across all shifts were educated on all nurses completing an admission will be required to complete the new Admit Checklist by the end of the shift and turn into ADON for Follow up. Record review of PICC line care & dressing change Training In-service forms dated 11/05/04 indicated 17 nurses across all shifts were educated on Central Venous Catheter Dressing Changes. The in-service indicated, Change dressing if any suspicion of contamination is suspected .change transparent semi-permeable membrane (TSM) dressings at least every 7 days and PRN (as needed, when wet, soiled, or not intact). The in-service indicated the nurses were educated on documentation including date and the time the care was provided. During an interview on 11/06/24 at 10:05 a.m., the MDS Nurse said she was in-serviced by the DON concerning PICC line care & dressing changes including documentation and assessment. She said a dressing to PICC lines should be changed every 7 days and as needed if soiled or loose. She said a resident being admitted with a PICC line should be assessed by the admitting nurse. The admitting nurse should document the assessment and check to make sure all orders were in. She said she was in-serviced on new admission Checklist. She said the ADON in-serviced her on the check list. She said the charge or admitting would complete a check list on admission. Then it would be passed to the ADON. The ADON will make sure everything has been done. She said she was then the third check. Then it would be passed to the DON. She said that would be the procedure for all new admissions. During an interview on 11/06/24 at 10:09 a.m., the ADON said she was in-serviced by the Nurse Practitioner, in house, and the Corporate Nurse via video call. She said she was in-serviced on documentation, dressing changes, and the admission checklist. She said the check list, once completed, would be brought to her so she could make sure everything was done. She said that would be on the next weekday. She said the checklist would then be passed off to the MDS nurse so that she could do an audit on the third day. She said that would be on every admission. She said there had been no admission since the form was implemented on 11/05/24. During an interview on 11/06/24 at 10:23 a.m., the DON said she was in-serviced by the Corporate Nurse and the Nurse Practitioner on 11/5/24. She said she was in-serviced on the policy of PICC line dressing changes and documentation, including assessment. She said she was also in-serviced on the new Admissions Checklist. She said there had been no new admissions since 11/05/24. She said the admission nurse/charge nurse would complete the check list saying they addressed those areas. The next business day the ADON would review the check list and make sure the areas were completed. The following day the MDS Nurse would do a third check. She said then the check list would be passed on to her for a 4th check. During interviews conducted on 11/06/24 beginning at 10:02 a.m. through 10:45 a.m., 15 of 21 of nurses in-serviced (the ADON, the DON, the MDS Nurse, LVN J, LVN K, RN L, RN E, RN M, LVN N, LVN P, LVN Q, LVN R, LVN S, RN T, and LVN U) were interviewed. All staff said they were educated on the newly implemented admission Checklist. Each staff member was able to verbalize what the checklist consisted of including allergies, vitals, diet, completion of all evaluations due on admission, medications, skin assessment, and any customized standing orders, including dressing changes, wound care or treatment orders, and pictures of skin issues, notifying the Nurse Practitioner, ADON, and DON. Each nurse verbalized passing the check list off to the ADON for review and that the form would also be reviewed by the MDS Nurse. During interviews conducted on 11/06/24 beginning at 10:02 a.m. through 10:45 a.m., 17 of 21 of nurses in-serviced (the ADON, the DON, the MDS Nurse, LVN J, LVN K, RN L, RN E, RN F, RN M, LVN N, LVN O, LVN P, LVN Q, LVN R, LVN S, RN T, and LVN U) were interviewed. All staff said they were educated on central line venous care, including dressing changes every 7 days and correct documentation of the care provided. On 11/06/24 at 10:48 a.m., the Administrator was notified the IJ was removed. However, the facility remained out of compliance at a scope of isolated and a severity level at potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.