Health inspection·May 30, 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 interview and record review the facility failed to change a resident's PICC (Peripherally inserted central) line transparent sterile dressing as ordered by the physician. Residents Affected - Few This applies to 1 of 3 residents (R1) reviewed for PICC line care in the sample of 4. The findings include: R1 was admitted to the facility from the acute care hospital on April 25, 2024. R1 had multiple diagnoses including, mechanical complication of internal right knee prosthesis, infection, and inflammatory reaction due to internal right knee prosthesis, presence of right artificial knee joint and right knee arthritis due to other bacteria, based on the face sheet. R1's initial nursing assessment dated [DATE] showed that the resident was admitted to the facility with a PICC line. R1's IV (intravenous) administration site showed that the resident's PICC line was located on her right arm. R1's order recap report showed an order dated April 25, 2024 to change the PICC line transparent sterile dressing within 24 hours of admission every day shift for 1 day. This order had an end date of April 26, 2024. The order recap report showed an order dated April 26, 2024 to change the PICC line transparent sterile dressing within 24 hours of admission every night shift for 1 day. This order had an end date of April 27, 2024. The same order recap report showed an order dated May 2, 2024 to change the transparent sterile dressing weekly and as needed every Thursday during the night shift. R1's TAR (treatment administration record) dated April 25 showed no documentation that the PICC line transparent sterile dressing was changed on admission. The TAR dated April 26, 2024 with regards to PICC line transparent sterile dressing change within 24 hours of admission showed a 9 code with the initials of V3 (RN/Registered Nurse) in the initial box. The TAR chart code for 9 indicated other-see progress notes. The MAR (medication administration record) for the month of April 2024 showed no documentation that R1's PICC line transparent sterile dressing was changed on admission and/or as needed from April 25 through April 30, 2024. R1's progress notes dated April 27, 2024 at 6:33 AM created by V3 showed, IV PICC: Transparent sterile dressing change within 24 hours of admission every night shift for 1 Day, On order from pharmacy. Further review of R1's progress notes from April 25 through April 30, 2024 showed no documentation that the PICC line transparent sterile dressing was changed as ordered. R1's MAR for the month of May 2024 showed that the PICC line transparent sterile dressing was Page 1 of 2 146153 146153 05/30/2024 Alden Estates of Shorewood 710 W Black Road Shorewood, IL 60404

F 0694 Level of Harm - Minimal harm or potential for actual harm scheduled for the weekly change during the night shift on May 9, 2024. The MAR dated May 9, 2024 for the said scheduled weekly change showed a 9 code with the initials of V4 (RN) in the initial box. The MAR chart code for 9 indicated other-see progress notes. R1's May 2024 MAR and TAR showed no documentation that the resident's PICC line transparent sterile dressing was changed as ordered from May 9, 2024 through May 14, 2024 (day of discharge). Residents Affected - Few R1's progress notes dated May 10, 2024 at 4:42 AM created by V4 showed, IV PICC: Transparent sterile dressing change weekly and PRN (as needed), every night shift every [Thursday], will change when receive. Further review of R1's progress notes from May 9, 2024 through May 14, 2024 showed no documentation that the PICC line transparent sterile dressing was changed as ordered. On May 29, 2024 at 9:50 AM, V2 (Director of Nursing) stated that she had reviewed R1's medical records including the physician's order, MAR, TAR, and progress notes. According to V2, based on her review, R1's PICC line transparent sterile dressing was not changed within 24 hours of admission as ordered. V2 further stated that R1's PICC line transparent sterile dressing was also not changed on May 9, 2024 for the scheduled weekly change and that there was no documentation to indicate that the PICC line dressing was changed between May 10 and May 14, 2024. V2 stated that if the PICC line dressing changes were not documented in R1's medical records, then the procedure was not performed as ordered by the physician. According to V2, she expects the nurses to follow the physician's orders with regards to PICC line dressing changes, because it is important to change the resident's PICC line dressing to assess and maintain the integrity of the insertion site and to prevent infection. On May 29, 2024 at 11:21 AM, V3 (RN/Registered Nurse) stated that on April 26 and April 27, 2024, she was not able to change R1's PICC line transparent dressing because there were no available supplies in the facility. According to V3, she had placed the order to the pharmacy to deliver the supplies to change R1's PICC line transparent sterile dressing. V3 added that she was not aware if the supplies were delivered, and she does not know who changed R1's PICC line dressing from April 26 through May 1, 2024. On May 29, 2024 at 2:15 PM, V4 (RN) stated that she did not change the transparent sterile dressing on R1's PICC line on May 9 and May 10, 2024, because there were no available supplies in the facility. According to V4, she ordered the supplies from the pharmacy and was waiting for delivery. V4 stated that she does not know who changed R1's PICC line transparent sterile dressing after she had ordered the supplies on May 10, 2024. 146153 Page 2 of 2