Health inspection·March 21, 2024

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 observation, interview, and record review, the facility failed to ensure nurses administered Intravenous (IV) medications according to physician's orders for 1 of 4 residents reviewed for Quality of Care and Treatment, of a total sample of 10 residents, (#1). Residents Affected - Few Findings: A review of the medical record revealed resident #1, a [AGE] year old female was admitted to the facility on [DATE] from an acute care hospital with diagnoses of fractures of the right arm and shoulder, severe aortic (main heart artery) valve stenosis (narrowing), severe malnutrition, need for assistance with personal care, and osteoporosis. On 2/09/24, she was diagnosed with a stage four pressure wound to her sacrum (tailbone), sacral osteomyelitis (infection of bone), deep tissue pressure wounds to her left and right heels and ankles, and a non-pressure wound to her right elbow. The Minimum Data Set (MDS) Modified admission assessment with Assessment Reference Date (ARD) 1/19/24 noted resident #1 scored 15 out of 15 for the Brief Interview for Mental Status (BIMS) which indicated she was cognitively intact, and did not reject evaluations or care. The assessment showed the resident required staff assistance to complete Activities of Daily Living (ADLs), was incontinent, and she had one stage three pressure ulcer documented as present upon admission during the look-back period. The MDS Discharge Return Anticipated assessment with ARD 2/18/24 showed the resident had one stage four, and four deep tissue pressure ulcers that were not present upon admission during the look-back period. The Comprehensive Care Plan included focuses for osteomyelitis infection with interventions to administer physician ordered IV medications and treatments, pressure wounds to sacrum, both heels and ankles, and right elbow with interventions to administer physician ordered medications and a wound vacuum (negative-pressure therapy). The Order Summary Report noted physicians' orders for antibiotic (infection) medications included Doxycycline 100 Milligrams (MG) every 12 hours for osteomyelitis on 2/02/24, Cefdinir 300 MG every 12 hours on 2/09/24 for infection, Peripherally Inserted Central Catheter (PICC) line insertion for IV medications, Vancomycin HCI 750 MG IV solution every morning for osteomyelitis on 2/09/24, and Levaquin 500 MG once daily for osteomyelitis on 2/16/24. On 3/20/24 at 11:19 AM, Licensed Practical Nurse (LPN) A explained nurses had 24/7 access to certain medications that included IV solutions and supplies from the Pyxis(automated dispenser). She showed the surveyor where the machine was located and demonstrated how nurses accessed it with written laminated administration instructions secured to the machine. Page 1 of 3 105904 105904 03/21/2024 Atlantic Shores Nursing and Rehab Center 4251 Stack Blvd Melbourne, FL 32901

F 0694 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 3/20/24 at 11:29 AM, the North Unit Manager accessed the Pyxis and printed an Inventory Report that showed there were several vials of Vancomycin IV solution. She explained nurses could access the machine for medications if needed. She said she was not aware the IV form was there, and nurses, Usually wait for the pharmacy. Review of the February 2024 Medication Administration Report (MAR) showed IV Vancomycin HCI Solution was signed as administered on 2/12/24, 2/13/24, and 2/18/24 at 6:00 AM. The report did not show any documentation that nurses administered the IV Vancomycin HCl Solution on 2/10/24, 2/11/24 or 2/17/24. A Nurse Progress Note completed by LPN B on 2/09/24 at 4:48 PM read, IV not ready yet. A Nurse Progress Note completed by the North Unit Manager on 2/09/24 at 2:38 PM read, Patient will be on IV Vanco (Vancomycin) after PICC line insertion. Another Nurse Progress Note documented by LPN B on 2/10/24 at 7:43 AM read, Awaiting pharmacy delivery. The Physician/Practitioner Progress Note completed on 2/13/24 at 6:15 AM by the Infectious Disease Advanced Practice Registered Nurse (APRN) read, Wound culture has been obtained and grew MRSA (Methicillin-resistant Staphylococcus aureus) (bacteria) . Another Physician's Progress Note completed by the Medical Director on 2/10/24 at 3:30 PM, read, . worsening leukocytosis (excess white blood cells that fight infections) starting IV Vancomycin and omnicef . consult ID (Infectious Disease) . On 3/20/24 at 12:00 PM, the Director of Nursing (DON) reviewed the medical record and explained pharmacy delivery records showed resident #1's IV medication was delivered on 2/10/24 at 7:48 AM which was after the night nurse had given report to the oncoming day shift nurse at 6:00 AM. She said if the medication was not delivered, nurses would pass it on and let the oncoming shift know so they administered it after delivery. She could not explain why nurses had not accessed the Pyxis (automated dispensary). She stated the first dose was administered 2/11/24 at 6:00 AM and could not explain why the MAR showed nurses had not signed the medication was administered on 2/11/24. She said the 2/10/24 day shift nurse should have administered the medication. On 3/20/24 at 11:48 AM, the North Unit Manager said IV medications should be started immediately after they were obtained from the pharmacy who delivered routinely twice daily with emergency deliveries in between if needed. The IV Services progress note documented on 2/09/24 at 4:45 PM, read the Registered Nurse placed a PICC in the resident's left arm. In an interview with the Medical Director on 3/20/24 at 12:27 PM, he recalled resident #1 and explained he had ordered IV antibiotic medication to treat her sacral (tailbone) osteomyelitis (infection of bone) on 2/09/24. He said he was not aware the resident's treatment was delayed when nurses had not administered the medication until 2/11/24 at 6:00 AM as reported by the DON, or that the MAR was not signed for 2/11/24. He acknowledged at best; the delay was 37 hours after the IV catheter access was placed. He said the facility had emergency kit medication resources, and nurses were expected to administer critical medications as soon as possible and no later than within a few hours. He said 105904 Page 2 of 3 105904 03/21/2024 Atlantic Shores Nursing and Rehab Center 4251 Stack Blvd Melbourne, FL 32901

F 0694 Level of Harm - Minimal harm or potential for actual harm if problems arose with obtaining medications, nurses needed to let him know and stated, They should've contacted me. The facility's standards and guidelines titled Intravenous Therapy Policy SHCRC30005.01 read, . 3. Record in the progress notes: . results of interventions, care provided, adjustments in the interventions . Residents Affected - Few Review of the facility's standards and guidelines dated 12/13/23 titled LTC (Long Term Care) Facility's Pharmacy Services and Procedures Manual revealed that facilities may use an Automatic Medication Dispensing System to access emergency medications, first dose medications, or scheduled medications, per applicable laws. Review of the Center Assessment Tool dated 10/27/23 revealed the facility was able to care for residents who required Special Treatments including IV Medications. 105904 Page 3 of 3