Health inspection·April 11, 2024

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 Based on observation, interview, and record review, the facility failed to ensure central venous catheter dressing was changed in accordance with professional standards of practice for 2 of 2 residents with central venous catheters, Residents #3 and #4. Residents Affected - Few Findings include: 1. Review of Resident #3's admission record showed the resident was admitted to the facility with the diagnoses including unspecified fracture of left forearm, acute respiratory failure with hypoxia, chronic obstructive pulmonary disease, arthritis due to other bacteria left elbow, atrial fibrillation, and pneumonia. During an observation on 4/11/2024 at 9:10 AM, Resident #3 was in bed with a right upper extremity peripherally inserted central catheter (PICC) line with a net stocking over the insertion site. The resident rolled down the netting. There was a gauze under a transparent dressing that was covering the insertion site. The transparent dressing was dated 4/1/2024. The dressing was curling up at the edges and the insertion site remained covered. During an interview on 4/11/2024 at 9:12 AM, Resident #3 stated, I'm in here for antibiotics because I have an infection after I broke my arm. It is an MRSA [Methicillin Resistant Staphylococcus Aureus] infection, so I needed a PICC line and antibiotics for a long time, another 6 weeks. They changed this about 10 days ago I guess. Review of Resident #3's physician order dated 3/26/2024 read, Change PICC line dressing q [every] week every day shift every Sat [Saturday] for PICC line. Review of Resident #3's Physician Orders dated 3/26/2024 reads, Monitor PICC line Q shift, inform MD ( Medical Doctor) of any abnormal findings every shift for PICC line. Review of Resident #3's Treatment Administration Record (TAR) for April 2024 showed dressing change on 4/6/2024 by Staff A, Registered Nurse (RN). Review of Resident #3's TAR for April 2024 showed that Staff B, Licensed Practical Nurse (LPN), monitored the PICC line on 4/11/2024 at 9:00 AM. 2. Review of Resident #4's admission record showed the resident was admitted to the facility with the diagnoses including discitis (an infection of the discs between the bones of the spine) in lumbosacral area, low back pain, type 2 diabetes mellitus with diabetic neuropathy unspecified, essential primary hypertension, and chronic obstructive pulmonary disease. Page 1 of 2 105705 105705 04/11/2024 Lake Port Square Health Center 701 Lake Port Blvd Leesburg, FL 34748

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation on 4/11/2024 at 11:15 AM, Resident #4 was resting in bed with a left upper arm single lumen PICC line with transparent dressing over a gauze dressing. The transparent dressing was dated 4/6/2024. During an interview on 4/11/2024 at 11:15 AM, Resident #4 stated, Oh, they changed that a few days ago now, maybe a week. I am getting antibiotics every day. I am going to be on antibiotics for about another month. Review of Resident #4's physician order dated 4/5/2024 read, Change PICC dressing and measure external catheter length and document every seven days and PRN [as needed]. Note any complications. Every day shift every Saturday for IV [Intravenous] abt [antibiotic] tx [treatment]. Change PICC dressing and measure external catheter length and document every seven days and PRN. Note any complications. If any discrepancy in length from any previous measure, stop using line and notify provider immediately. Obtain f/u [follow up] instructions. During an interview on 4/11/2024 at 12:07 PM, Staff A, RN, stated, I did observe the PICC lines for [Resident #3 and #4's names] and didn't realize that they had gauze under them. I should have changed it when I saw that. We should only have gauze in the initial dressings. After that, it should be a transparent dressing. We should assess the sites every shift and when we give an IV meds [medications]. During an interview on 4/11/2024 at 12:37, Staff B, LPN, stated, I did administer both patients [Resident #3 and #4's] normal saline flush this morning and I should observe the dressing and the site when I do that. I didn't notice they had the gauze under the transparent dressing. I just didn't realize it. We should assess the insertion site when we administer the medication. I should have looked at the date of the dressing and the insertion site when I gave the normal saline. It is outdated. The dressing was dated 4/1/2024 for [Resident #3's name]. [Resident #4's name] dressing is in date it was done on 4/6, but it does have gauze under it, so it should have been changed on 4/8. During an interview on 4/11/2024 at 1:30 PM, the Director of Nursing stated, I can't say why the staff put gauze under the dressings for the PICC lines. The dressings should have been changed after 2 days because of the gauze under them. It is our policy to do that. Review of the facility policy and procedure titled Central Venous Catheter Dressing Changes read, Policy: 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. General Guidelines . 2. Change transparent semi-permeable membrane (TSM) dressings at least every 5-7 days and PRN (when wet, soiled, or not intact). 3. If gauze is used, it must be changed every 2 days. 105705 Page 2 of 2