Health inspection·May 1, 2023

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 observations, record reviews, and interviews, the facility failed to provide treatment and care in accordance with professional standards for two (Residents #3 and #4) of three sampled residents related to the maintenance of intravenous access devices and the provision of wound care as ordered by the physician. Residents Affected - Few Findings included: 1. On 5/1/23 at 10:37 a.m., an observation was conducted of Resident #3 sitting in a wheelchair in his room. The observation revealed a triple lumen peripherally inserted central catheter (PICC) line in his right upper arm with an inclusive dressing dated 4/21. A medication pole was observed at the head of his bed opposite of where he was sitting. An empty clear intravenous bag was hanging from the pole. The resident said he was receiving an antibiotic. Resident #3 was also observed with an undated pink foam dressing near the left antecubital area. An observation and interview was conducted with Staff A, Licensed Practical Nurse (LPN) on 5/1/23 at 10:42 a.m. She said the resident was on intravenous antibiotics and the PICC line dressing should be changed one time a day. Staff A confirmed the dressing date was 4/21 and said it should have been changed over the weekend. Staff A removed the foam dressing from the left arm of the resident with her bare hands, folded the dressing up, and confirmed the dressing should have been dated. The white foam of the dressing contained dried dark red/brown substance, the area under the dressing was a raw and wet-looking area approximately two centimeters length and width. The resident stated that it (the wound) happened about week and half ago, the nurse did it when attempting to lift the resident. A review of the admission Record indicated that Resident #3 was initially admitted on [DATE] and re-admitted on [DATE]. The record included diagnoses not limited to unspecified organism pneumonia, chronic obstructive pulmonary disease with (acute) exacerbation, and unspecified diastolic (congestive) heart failure. The Admission/readmission progress note, dated 4/26/23 at 10:52 p.m., identified that Resident #3 had a skin tear on the left forearm. A review of Resident #3's April 2023 Medication Administration Record (MAR) identified the following administrations: - Nafcillin Sodium in Dextrose Intravenous Solution 2 gram (GM)/100 milliliter (mL) - Use 100 mL intravenously (IV) six times a day for sepsis, started 4/26 and discontinued 4/28/23. The MAR identified that this antibiotic was administered on 4/26 - 4/28/23. Page 1 of 5 105636 105636 05/01/2023 Belleair Health Care Center 1150 Ponce DE Leon Blvd Clearwater, FL 33756

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few - Nafcillin Sodium Intravenous Solution Reconstituted 2 GM - Use 100 mL intravenously every 4 hours for sepsis until 5/21/23, started on 4/29/23. The MAR indicated that the medication was administered as ordered. - Flush PICC with normal saline 10 mL prior to administration of IV medication, then flush with normal saline 10 mL followed by 5 mL of Heparin 10 units/mL post IV medication administration, started 4/27/23. A review of Resident #3's April 2023 Treatment Administration Record (TAR) identified the following physician orders: - Dressing change every week and as needed (prn). Measure length of line and circumference of arm upon admission/insertion then weekly. To measure length start from hub of PICC line to insertion site of forearm. To measure arm circumference measure at the insertion site around the forearm. Continue weekly until line discontinued. Document the length of line & circumference of arm upon admission/insertion below. PICC line length: (blank) centimeter (cm). Arm Circumference: (blank) cm as needed for IV maintenance. Report signs/symptoms (s/s) of infections/infiltration/dislodgement to MD. Change dressing prn and document measurement of line, started on 4/27/23 and discontinued at 9:23 a.m. on 4/27/23. The TAR identified that the order was scheduled as needed (prn) and did not indicate a dressing change had been completed as needed on 4/27/23. - Dressing change every week and as needed (prn). Measure length of line and circumference of arm upon admission/insertion then weekly. To measure length start from hub of PICC line to insertion site of forearm. To measure arm circumference measure at the insertion site around the forearm. Continue weekly until line discontinued. Document the length of line & circumference of arm upon admission/insertion below. PICC line length: (blank) centimeter (cm). Arm Circumference: (blank) cm every shift every 7 day(s) for IV maintenance. Report signs/symptoms (s/s) of infections/infiltration/dislodgement to MD. Change dressing weekly and document measurement of line, started on 4/27/23 and discontinued on 4/27/23. The TAR indicated that this order was to be completed every shift and was not completed prior to its discontinuation at 9:23 a.m. on 4/27/23. - Dressing change every week and as needed (prn), Right Upper Extremity (RUE). Measure length of line and circumference of arm upon admission/insertion then weekly. To measure length start from hub of PICC line to insertion site of forearm. To measure arm circumference measure at the insertion site around the forearm. Continue weekly until line discontinued. Document the length of line & circumference of arm upon admission/insertion below. PICC line length: (blank) centimeter (cm). Arm Circumference: (blank) cm as needed for IV maintenance. Report signs/symptoms (s/s) of infections/infiltration/dislodgement to MD. Change dressing prn and document measurement of line, started t 9:30 a.m. on 4/27/23. The TAR indicated this order was scheduled as needed and allowed for daily completion starting on 4/27/23. The TAR did not indicate a dressing change to Resident #3's PICC line had been completed in April. A further review of Resident #3's April TAR did not include a physician order for the care of the 105636 Page 2 of 5 105636 05/01/2023 Belleair Health Care Center 1150 Ponce DE Leon Blvd Clearwater, FL 33756

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few skin tear on the left forearm that was noted on the residents Admission/readmission evaluation or as observed on 5/1/23. The review of Resident #3's May MAR indicated that the resident continued to receive the antibiotic Nafcillin every 4 hours and the PICC line was flushed with normal saline and Heparin every shift. The order for flushing identified that the residents PICC line was to be flushed with normal saline prior to the administration of IV medication (ordered every 4 hours) and flushed after the administration with normal saline followed by heparin every shift. The documentation indicated that flushing was done one time per shift and did not document the administration of Heparin. A review of Resident #3's physician orders identified an order that was obtained on 5/1/23 at 11:29 a.m. (37 minutes after the observation was made with Staff A) that instructed staff to clean skin tear to left arm with normal saline, apply oil emulsion, and to cover until healed, every day shift every 3 day(s) for skin tear. The May TAR indicated that the order was to start on 5/3/23. The review of Resident #3's physician orders indicated the following dressing changes related to the residents' PICC line: - Dressing change every week and as needed (prn), Right Upper Extremity (RUE). Measure length of line and circumference of arm upon admission/insertion then weekly. To measure length start from hub of PICC line to insertion site of forearm. To measure arm circumference measure at the insertion site around the forearm. Continue weekly until line discontinued. Document the length of line & circumference of arm upon admission/insertion below. PICC line length: (blank) centimeter (cm). Arm Circumference: (blank) cm every day shift every Monday (Mon) for IV maintenance. Report signs/symptoms (s/s) of infections/infiltration/dislodgement to MD. Change dressing weekly and document measurement of line, started on 5/1/23. The Director of Nursing (DON) stated, on 5/1/23 at 3:23 p.m., that Resident #3 had come back from the hospital on Nafcillin every 4 hours and that the PICC line dressing should be changed every 7 days and (any) dressings should be dated. The DON reported that the nurse put in the order (PICC dressing) to be changed every 7 days with the incorrect start date. The DON stated, in regards to the skin tear, Oh it just happened. The policy - Central Venous Catheter Dressing Changes, dated 2009 and revised July 2011, identified Central venous catheter dressings will be changed at specific intervals, or when needed, to prevent catheter-related infections that are associated with contaminated, loosened, soiled, or wet dressings. The guidelines instructed that Registered and Licensed Practical Nurses were to: - Apply an maintain sterile dressing on intravenous access devices. Dressings must stay clean, dry, and intact. - Catheter site care and dressing changes will include: removal of the old dressing, observation, and evaluation of the catheter-skin junction and surrounding tissue, cleansing with an approved antiseptic solution (e.g. chlorhexidine solution), replacement of any stabilization device and application of a sterile dressing. - Change transparent semi-permeable membrane (TSM)dressings every 5 to 7 days and prn (when wet, soiled, or not intact). 105636 Page 3 of 5 105636 05/01/2023 Belleair Health Care Center 1150 Ponce DE Leon Blvd Clearwater, FL 33756

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. An observation was made at 10:25 a.m. on 5/1/23 of Resident #4 sitting at the nursing station in a wheelchair. The resident had a large greenish-purple bruise on the left side of her face and an undated pink foam dressing on her left elbow. Staff A, LPN, said the resident had fallen prior to admission to the facility. Staff A reviewed the resident's record and indicated Resident #4 had been admitted on [DATE]. Staff A said she did not know when the dressing was put on. On 5/1/23 at 10:31 a.m., Staff A observed Resident #4's left elbow dressing and confirmed the dressing was not dated. She said dressings were to be dated when applied. Staff A removed the resident's elbow dressing with her bare hands. The dressing had dark red and bright red drainage and the area underneath was raw-looking. A review of the admission Record identified that Resident #4 was admitted on [DATE] and with diagnoses not limited to subsequent encounter (of) diffuse traumatic brain injury with loss of consciousness status unknown and history of falling. The Admission/readmission evaluation, dated 4/25/23, revealed the resident was admitted with discoloration to left-side of face, skin tear, brace, and discoloration to left arm, scab to left knee, and discoloration to right hand/arm. The intervention implemented was skin protectant/off loading. A review of Resident #4's April and May Medication Administration Records (MAR) did not include any physician order for a dressing change to the resident's left elbow. A review of Resident #4's April Treatment Administration Record (TAR) did not include a physician order for the skin tear to the resident's left elbow. A physician order was obtained on 5/1/23 at 11:28 a.m., instructing staff to Clean skin tear left (lt) arm with normal saline (ns), apply oil emulsion, and cover every 3 days (q 3 days) until healed. This order was to be completed every day shift, every 3 day(s) for skin tear. The order was created 1 hour and 3 minutes after the observation was made with Staff A of Resident #4's left elbow wound. The review of Resident #4's May TAR included physician orders for the wound care to the residents' left elbow: - Clean skin tear left (lt) arm with normal saline (ns), apply oil emulsion, and cover every (q) 3 days until healed. One time a day every 3 day(s) for skin tear, started 5/2/23 at 9:00 a.m., and discontinued at 11:27 a.m. on 5/1/23. - Clean skin tear lt arm with ns, apply oil emulsion, and cover q 3 days until healed. Every day shift every 3 day(s) for skin tear, started on 5/3/23. The care plan for Resident #4 indicated the resident had an actual impairment to skin integrity of the (specify location) related to (r/t), initiated on 4/26/23. The interventions included: Administer treatments as ordered and monitor for effectiveness. The May TAR did not indicate wound care had been provided to the skin tear on Resident #4's left elbow. During an interview with the Director of Nursing (DON), on 5/1/23 at 3:23 p.m., the DON stated you know the answer to that regarding Staff A removing dressings from Resident #3 and Resident #4 with 105636 Page 4 of 5 105636 05/01/2023 Belleair Health Care Center 1150 Ponce DE Leon Blvd Clearwater, FL 33756

F 0684 her bare hands. Level of Harm - Minimal harm or potential for actual harm The policy - Dressing Change - Non Sterile and Sterile, dated 2008, identified that the purpose was To perform dressing changes according to Physician's orders. The procedure indicated: Residents Affected - Few - 1. Verify physician order for most current order. - 7. Wash hands, don gloves, and open dressing packs and leave on bottom half of wrapper if possible. - 8. Write date, time, and initials on cover dressing or pre-cut tape. - 9. Position patient. - 10. Remove soil dressings, discard. - 11. Remove gloves, wash hands, swab scissors with alcohol wipe if used. The policy indicated that documentation should include condition of wound site and surrounding area, dressing change, and tolerance to procedure. The dressing change should be recorded in the treatment record. 105636 Page 5 of 5