Health inspection·May 28, 2021

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices related to skin care for one of 43 residents. (Resident #28) Residents Affected - Few The findings include: Record review for Resident #28 revealed he was admitted to the facility on [DATE] with his most recent readmission on [DATE]. A review of the care plan, revised on 5/20/2021, revealed the following: Focus: Resident is at risk for alteration in skin integrity related to hygiene issues, incontinence, dementia, diabetes, dandruff on scalp, boil on abdomen. Goal: Will receive appropriate services and treatments to minimize potential skin breakdown, and will implement interventions to minimize the risk of skin impairment through next review, and facial rash will continue to improve within two weeks. Interventions: apply moisture, observe skin with ADLs (activities of daily living) and report abnormalities. Report localized skin problems (dryness, redness, pustules, inflammation, etc). Triamcinolone cream .5% (can be used to treat topical inflammatory skin lesions), apply to face topically, daily, every evening shift for facial rash. Weekly skin check by licensed nurse. On 05/26/2021 at 11:28 AM, Resident #28 was observed sitting in the open lounge area in the center of the facility. Multiple staff members were also present in the area. Other aides and a nurse were observed passing by the resident, and some stopped to greet the resident. During this observation, small scaly white flakes were observed on the resident's shoulders, collar and the chest area of his dark blue shirt. The scaly white flakes were also observed on areas of the resident's forehead, eyebrows and in his hair. The resident also had multiple dry, white skin spots on his right hand and forehead. The resident acknowledged that he had dry skin, and advised that he used to have a cream for his skin, but he hadn't received it in some time. On 05/27/2021 at 8:31 AM, an observation was made of Resident #28 seated in the lounge area with multiple areas on his shirt covered with scaly, white flakes. Various staff members were in the area at the time of the observation. On 05/27/2021 at 10:25 AM, Resident #28 was observed in the facility lounge watching television. There were noticeable scaly, white flakes on his chest, collar and the sleeves of his shirt. There were also visible scaly white flakes on his forehead and eyebrows. During an interview with Employee H, Licensed Practical Nurse (LPN), on 5/27/2021 at 3:34 PM, she Page 1 of 4 105402 105402 05/28/2021 Bridgeview Center 350 S Ridgewood Avenue Ormond Beach, FL 32174

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few acknowledged that she was familiar with Resident #28. She confirmed he had a rash and dry skin. He was ordered Triamcinolone cream, but that was discontinued some time in February 2021. She stated the skin assessments were not assigned, and the skin check orders were not being completed as they should be. She acknowledged the presence of the scaly white flakes in the resident's hair and on his face. She stated the certified nursing assistants (CNAs) were responsible for providing ADL care and the nurses were responsible for providing treatments. On 05/28/2021 at 9:47 AM, Resident #28 was observed seated in the lounge area in the center of the facility. White, scaly flakes were on the resident's dark blue shirt. During an interview with Employee F, Registered Nurse (RN), on 5/28/2021 at 12:36 PM, she stated she was familiar with Resident #28 and was responsible for completing and reviewing the Minimum Data Set (MDS) assessments, including the section for skin assessments. She reviewed the treatment records and a licensed nurse completed the skin assessment weekly. A CNA was expected to evaluate the resident's skin while providing care, and the nurses were responsible for looking for dry skin, boils etc. when they did the skin checks. Employee F stated there were currently no orders for skin treatments for Resident #28, although the care plan was revised on 5/20/21 and indicated the use of Triamcinolone cream. She stated there had been an order in the past, but she could not provide any information as to why it was discontinued. Review of the Skin Sheet for Resident #28, dated 05/27/2021, documented no concerns. Employee F was asked if she had observed the condition of the resident's skin and the scaly white flakes. She responded yes, stating the nurse who completed the skin check should have documented the observation of dry skin and the scaly white flakes on the resident's shirt. She stated if the nurse had indicated the skin issues, orders could have been put in for treatments. On 05/28/2021 at 12:59 PM, Employee J, RN/Unit Manager, stated she was familiar with Resident #28. She acknowledged that she observed the resident covered in scaly white flakes. She stated he had received a shower and the CNAs should have been applying lotion to the resident after his showers. She confirmed that the care plan was revised on 05/20/2021. She stated that the cream was discontinued and was not re-started, but that it should have been. She confirmed that the Care Plan could not have been followed if the cream was not present. She stated that it should have been updated and/or the cream should have been re-ordered. During an interview with Employee K, RN, on 5/28/2021 at 3:28 PM, she stated she was familiar with Resident #28, and acknowledged that she completed the skin check dated 5/27/2021. She stated the process for performing a skin check was new, and she was not very familiar with it. She confirmed that she had observed dry skin and scaly white flakes on the resident' skin, and stated she gave him some over-the-counter lotion for the dryness. She acknowledged that she could have documented her observations on the skin sheet. A review of the physician's orders revealed a new order for Triamcinolone Acetonide 0.5%, one application topically twice a day (day and evening shift), effective 05/28/2021 at 3:00 PM. . 105402 Page 2 of 4 105402 05/28/2021 Bridgeview Center 350 S Ridgewood Avenue Ormond Beach, FL 32174

F 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and staff interviews, the facility failed to follow physician orders for the administration of intravenous therapy (IV) for 1 of 1 residents sampled for IV administration from a total sample of 43. (Resident #2) Residents Affected - Few The findings include: A record review for Resident #2 revealed a [AGE] year-old female admitted on [DATE] with diagnoses including a fractured right femur and a urinary tract infection (UTI). The admission nursing note revealed she had a peripherally inserted central catheter (PICC line) to the mid-right arm for administration of intravenous (IV) antibiotics. A review of a 5/10/2021 physician's order revealed: Ceftriaxone (antibiotic) 2 grams IV every 24 hours via the PICC line, infuse over 30 minutes; Vancomycin (antibiotic) 1 gram every 12 hours IV, infuse over 60 minutes; flush PICC line with normal saline 0.9% solution 10 ml (milliliters) IV every shift. Also change the PICC line dressing every 5-7 days. A review of the May 2021 Medication Administration Record (MAR) revealed there was no PICC line dressing change documented until 5/21/2021. Further review of the MAR found that the PICC line dressing change order, dated 5/10/2021, had not been entered into the the record until 5/21/21. There were no further entries for the PICC line dressing change. An observation was made of the PICC line dressing for Resident #2 with Employee I, Licensed Practical Nurse (LPN), on 5/28/21 at 12:45 p.m. When the nurse was asked who was responsible for changing the PICC line dressing, she said a Registered Nurse (RN). She was asked when it was last changed, and she did not know. She said the dressing should be dated when changed. When asked how often did the nurses observe the PICC line site, she said every time you hang an IV medication. She was asked if there was a date on the dressing, but she did not see a date. When asked if the dressing was clean and intact, she said it wasn't dirty, but had loosened and needed to be secured. Also observed was IV Vancomycin, 1 gm at 250 ml hanging on IV pole. The tubing was running through an IV pump. The pump was set at 250 cc/hr. Observation of the IV bag containing the antibiotic Vancomycin was found to have solution remaining in the bag and the pump was still running. An interview was conducted with Employee I on 5/28/21 at 1:20 pm. Regarding the time she hung the Vancomycin for Resident #2, she said it was scheduled for 8:00 am, but not hung until 10:00 am due to a lab drawn this morning and the need to call the pharmacy to get authorization to hang. She said the Vancomycin trough had been running high and had to be held for 2 days. She received the ok from the pharmacy and hung the bag at 10 am. When asked how long it usually takes for Vancomycin to infuse, she said if the pump is working right, about an hour. She was asked if there was a reason why it had not completed infusing, and she said the pump kept occluding and had to keep resetting. She also said she used the gravity flow the other day and it too was very slow. An interview was conducted with Employee H, LPN, on 5/28/21 at 1:30pm. When asked how often the PICC line dressings were changed, she said weekly but only the RN can change. Regarding the duration for the IV antibiotics for Resident #2 to infuse from the time hung, she said it should only take about 30 minutes, but it often takes several hours when the tubing becomes occluded and the pump needs to be reset. She said perhaps the PICC line itself may need to be changed. When asked if the 105402 Page 3 of 4 105402 05/28/2021 Bridgeview Center 350 S Ridgewood Avenue Ormond Beach, FL 32174

F 0694 physician had been notified, she said she would call today. Level of Harm - Minimal harm or potential for actual harm On 5/28/21 at 1:50 pm, the Director of Nursing was asked where the nurses document the PICC line dressing changes. She would need to review the record as they had a change in their computer system and some information did not come over. When she reviewed the records, she confirmed the original order for PICC line dressing changes on 5/10/21, did not appear on the MAR or Treatment record (TAR). She said the order was entered on 5/21/21 and the RN documented PICC line dressing change occurred. She confirmed that no dressing changes had been performed prior to 5/21/21 or after. When asked if she was aware of a problem with the IV pumps infusing slowly and delaying optimal effect of antibiotics, she said the pharmacy supplies the pumps and they are outdated. The pharmacy has purchased new pumps; however, the new pumps are not yet available to the facility. Residents Affected - Few 105402 Page 4 of 4