Health inspection·October 12, 2023

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 administer parenteral fluids consistent with professional standards of practice and in accordance with physician orders for two (Resident #1 and Resident #2) of two residents reviewed for parenteral fluids. Residents Affected - Few 1. The facility failed to ensure RN A and LVN B stopped administration of TPN (nutrition administered intravenously through a large vein near the heart) which could cause tissue damage, while performing a sterile dressing change for Resident #1. 2. The facility failed to ensure Resident #1 and Resident #2 had their central lines maintained per professional standards, physician's order, or facility policy. These failures could place the residents with central lines at risk for serious infection, impaired nutrition, and hospitalization. Findings included: 1) Review of Resident #1's undated face sheet reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included hypomagnesemia (low magnesium level in the blood) , unspecified protein-calorie malnutrition (lack of sufficient nutrients), essential hypertension (high blood pressure), malignant neoplasm of cervix uteri (cancer), unspecified intestinal obstruction, fistula of the intestine (an abnormal connection of two body cavities) and gastroparesis (delay in stomach emptying). Review of Resident #1's admission MDS dated [DATE] reflected a BIMS of 15 indicating intact cognition. Section K reflected the resident received parenteral/IV feeding while not a resident at the facility and while a resident at the facility. Review of Resident #1's comprehensive care plan dated 8/23/23, reflected only a urinary tract infection and she preferred not to attend group activities. The care plan did not address the central line or the total parenteral nutrition. Page 1 of 17 675536 675536 10/12/2023 Hill Country Heights 810 Industrial Ave Copperas Cove, TX 76522

F 0694 Level of Harm - Minimal harm or potential for actual harm Review of Resident #1's physician order dated 8/25/2023 reflected, TPN 3-1. Infuse via central line at 133.3 ml/hr x 12 hrs at night. Mix vial 1 and vial 2 vitamins prior to infusion. Start 1400, stop 0200. Review of Resident #1's physician order dated 8/29/2023 reflected, Central line dressing and cap change weekly using sterile technique per protocol every day shift every Tuesday. Residents Affected - Few Review of Resident #1's Medication/Treatment Administration Record for 10/1/23 through 10/31/23 reflected the central line dressing was changed on 10/3/23 by RN C. There was no documentation of a dressing change on 10/7/23 as written on the dressing. Review of Resident #1's progress noted dated 10/10/23 at 4:09 PM written by LVN B reflected, During PICC line dressing change, PICC line migrated from original site. Attempt made to locate original measurements of line, but unable to locate any documentation. TPN fluid began seeping through insertion site. On call NP notified. Received orders to discontinue existing PICC and the send resident to emergency department to receive new PICC. PICC line ended up coming all the way out of insertions site before having chance to pull it out. No bleeding noted. Remained at resident for approximately 5 minutes and applied intermittent pressure to site to ensure bleeding would not start. Afterward EMS was notified. Resident left with EMS at approximately 5:30 PM. Observation on 10/10/23 at 10:04 AM, revealed Resident #1 in her room lying in bed with the presence of a double lumen central line in her right, upper chest. Neither lumen was observed marked specifically for TPN. The transparent dressing was curled around the edges and about one third of the dressing was lifted away from her body. Resident #1 pressed on the dressing to make it flat. The dressing was labeled with initials KG and the date 10/7/23. The time of the dressing change was not on the label. Three small black dots to indicate 1cm measurements were visible on the central line. During an observation on 10/10/23 at 4:00 PM, Resident #1 was sitting up on the edge of the bed. The TPN bag was connected to the central line with IV tubing. The IV pump indicated the TPN was infusing at 133 ml/hr. The IV tubing was not taped or secured to the resident. RN A assisted Resident #1 to lay down on the bed. LVN B requested permission to move items off the table in order to use the table for her sterile field. Resident #1 consented. LVN B moved the items, performed hand hygiene, donned a face mask then sterile gloves then prepared her sterile work area. RN A stated to LVN B, I'll remove the old dressing while you do that. Wearing non-sterile gloves, RN A removed the dressing from the chest then stepped back which left the central line and IV tubing unsecured. RN A was not observed wearing a mask. Resident #1 was not observed wearing a mask. Neither RN A nor LVN B were observed to have offered Resident #1 a mask nor instructed her to look away from the procedure. Resident #1 was observed watching the dressing being removed. Resident #1 repositioned herself slightly then as she crossed her arms across her abdomen/chest which placed pressure on the IV tubing which caused the central to protrude further from the insertion site than previously observed. LVN B measured the length of the central line. LVN B stated to RN A, 14 cm or 5.5 inches. RN A was observed leaving the room to verify the length of the previously charted. LVN B was observed cleaning the skin around the insertion site with alcohol swabs from the dressing kit. A white fluid, consistent with the TPN fluid in the bag was observed as it leaked and pooled around the insertion site. LVN B walked around the bed and pushed the pause button on the IV pump. LVN B held gauze on the insertion site. Resident observed the procedure and told LVN B the central line tubing looked different than it had earlier in the day. The alarm on the pump sounded and Resident #1 asked LVN B if she should push the pause button again. LVN B replied, No, we can wait for her to come back in and push the button to stop it. 675536 Page 2 of 17 675536 10/12/2023 Hill Country Heights 810 Industrial Ave Copperas Cove, TX 76522

F 0694 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 10/10/23 at 10:04 AM, Resident #1 stated her central line dressing needed to be changed because it was not sticking to her skin. She then stated, This is missing the round thing that they usually put on there. When asked if she was referring to an antimicrobial patch she stated, Yes. Resident #1 stated the staff had changed her dressing, Every other week or so. Resident #1 stated, Last time the state was here, a week or two ago, the central line got pulled out a little, but they got right on it. Resident stated the facility got an order for an x-ray. She stated waiting for the x-ray caused a delay in the TPN being administered but, They got it back on schedule. During an interview on 10/10/23 at 3:18 PM with RN A, she stated, she had worked at the facility for about seven years, but most recently working as an agency nurse through the company's agency. She stated central line dressings were checked every shift. She stated dressings were changed every seven days and as needed. She stated she did not have any central line dressing changes scheduled on her shift. She stated she did not know when Resident #1 had been scheduled for a dressing change. RN A checked in the computer and reported the change had been scheduled for 6:00 AM today but it was not signed off as completed. She then stated the pharmacy had been notified by the day shift nurse and they were waiting for the dressing kit to be delivered as they did not have any in stock. She stated on a double lumen central line, the red lumen was used for TPN, and the purple was used for meds and things. She stated she did not know if the facility marked a lumen specifically for TPN and stated she did not know if there was a policy and procedure about the lumen being marked. RN A stated she did not remember any training at this facility regarding central line use and maintenance. She stated she had worked with central lines in the past and was familiar with maintaining central lines. During an interview on 10/10/23 at 3:35 PM with LVN B, she stated she was the treatment nurse and she occasionally changed central line dressings but usually it was done by the floor nurses. She stated she has maintained her IV certification throughout her career, and she completed the on-line course provided by the facility prior to the facility accepting residents requiring TPN. She stated dressing changes should be completed weekly. She stated an adverse outcome for a central line not properly maintained could be infection or death. During an interview on 10/10/23 at 4:38 PM with the ADON, he stated, he had been trained on central lines. His competency had been verified by the DON. He stated for central line dressing changes, he maintained sterile at the start and throughout. He stated the site was assessed prior to changing anything and abnormal findings were reported to the provider. He stated after the old dressing was removed, hand hygiene was performed, and sterile gloves applied. He stated, Use what is in the kit to change the dressing. He stated the label was marked with the date, time, and initials. He stated a mask for the nurse completing the procedure, the resident, and any others in the room during the procedure is required to prevent the spreading of droplets. He stated he expected staff to follow the policies when they changed central line dressings. He stated central line dressings should be changed every seven days unless otherwise ordered. He stated residents were at risk for infection and infections associated with lines if the central line is not properly maintained. During an interview on 10/10/23 at 4:40 PM with RN A, she stated Resident #1 would be sent out to the hospital for placement of a new central line. She stated they had received orders to remove the current central line. During a telephone interview on 10/11/23 at 12:39 PM with PHARM, when asked if TPN solution could be caustic or cause damage to tissue if the central line became dislodged, he stated, it depended on the pH, osmolarity, and the ingredients, but TPN could potentially be caustic if it got in the tissues. 675536 Page 3 of 17 675536 10/12/2023 Hill Country Heights 810 Industrial Ave Copperas Cove, TX 76522

F 0694 Review of the facility's policy titled Parenteral Nutrition, revised March 2022, reflected the following: Level of Harm - Minimal harm or potential for actual harm Preparation 1. Residents Affected - Few A physician's order is necessary for this treatment. The PN order should include the formula or a list of all individual ingredients/nutrients in the base solution, total volume and rate of administration as well as orders for monitoring laboratory results on a routine basis. Safety Precautions 1. Parenteral nutrition orders will include an order for dextrose 10% IV to run at the same rate as PN, in case the PN has to be stopped or discontinued suddenly. 4. Administer PN via an electronic pump. The solution must be filtered. 8. For multi-lumen catheters, specify/label one lumen for PN use only. Do not use this lumen for other infusions or blood sampling. Steps in the procedure 18. Check connections. Secure tubing to resident with tape. Documentation The following should be documented in the resident's medical record. 3. Rate and volume infused. Review of the policy titled Central Venous Catheter Care and Dressing Changes, revised March 2022, reflected the following: General Guidelines 1. Perform site care and dressing change at established intervals or immediately if the integrity of the dressing is compromised (e.g., damp, loosened, or visibly soiled). 675536 Page 4 of 17 675536 10/12/2023 Hill Country Heights 810 Industrial Ave Copperas Cove, TX 76522

F 0694 3 Level of Harm - Minimal harm or potential for actual harm Change the dressing if it becomes damp, loosened or visibly soiled and: c. immediately if the dressing or cite appear compromised. Residents Affected - Few 5. d. palpate and inspect the skin, dressing and securement device for signs of complications including: dislodgement, redness, tenderness, swelling, infiltration, induration, elevated body temperature or drainage. e. Ask the resident if he or she is experiencing pain, tingling, or numbness. 6. Measure the length of the external central vascular access device with each dressing change or if catheter dislodgement is suspected. Compare with the length documented at insertion. Assessment Observe insertion site and surrounding area for complications. Steps in the Procedure 1. Clean over the bed table with soap and water, or alcohol. 4. Resident should be lying on bed, with head facing opposite direction from dressing site 5. Ask resident to keep arms at side of body or have someone help him or her to do this. 7. e. Label with initials, date and time. Review of the National Library of Medicine website Chapter 4 Manage Central Lines - Nursing Advanced Skills - NCBI Bookshelf (nih.gov) accessed on 10/16/23 read, High osmolarity solutions refer to a highly concentrated solution expressed as the total number of solute particles per liter. High osmolarity solutions, such as total parenteral nutrition and hypertonic IV fluids, are irritating to peripheral vessels and increase the client's risk for phlebitis, thrombosis, and occlusion. Additionally, vesicant medications (such as certain antineoplastic drugs, antibiotics, electrolytes, and vasopressors) can cause severe tissue injury or destruction if they extravasate. Extravasation refers to leakage of fluid into the tissues around the IV site, causing tissue injury when the catheter has dislodged from the blood vessel but is still in the nearby tissue. For this reason, infusions of high osmolarity solutions and vesicant medications are administered through a CVAD into a large vein such as the superior vena cava. When these solutions enter this larger vessel, the solution is hemodiluted, thus minimizing the risk of these complications from occurring. 675536 Page 5 of 17 675536 10/12/2023 Hill Country Heights 810 Industrial Ave Copperas Cove, TX 76522

F 0694 Infiltration or extravasation Level of Harm - Minimal harm or potential for actual harm Palpate over the catheter insertion site dressing and around the surrounding area for sponginess and observe for redness or swelling. Note any labored breathing exhibited by the client or complaints of pain with infusions. Observe IV flow rate for free-flowing fluid. Aspirate for blood return. Residents Affected - Few Stop the infusion and/or administration of the vesicant solution. If extravasation occurs, aspirate any remaining medication from the catheter after disconnection to prevent further damage to vessels. To maintain skin integrity, administer antidote or therapeutic medication as appropriate per protocol.[20] Discontinue IV solutions. Apply warm/cold compresses as recommended by agency policy. Notify the provider and anticipate an order for a chest X-ray to evaluate catheter integrity and placement. 2.) Review of Resident #1's physician order dated 10/11/23 reflected Dextrose Intravenous solution 10% (dextrose) Use 133 ml/hr intravenously as needed for TPN DC or must be stopped Start Dextrose 10% @ 126 ml/hr if suddenly discontinued or TPN must be stopped. Review of Resident #1's Medication Administration Record for 10/1/23 through 10/31/23 did not reflect administration of IV dextrose after the TPN had been stopped. Review of Resident #1's progress notes dated 9/29/23 reflected, Resident reported that during dressing reinforcement yesterday PICC line came out a little bit and was pushed back in by nurse. The dressing was changed and NP notified. Orders received for chest x-ray to verify placement. Review of Resident #1's Medication Administration Record for 9/1/23 through 9/30/23 reflected the central line dressing was changed on 9/26/23. There was no documentation of a dressing change on 9/29/23. Review of Resident #2's undated face sheet reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included postsurgical malabsorption not elsewhere classified, decreased white blood cell count, compression of the first, second, and fifth lumbar vertebra, chronic heart failure, and chronic obstructive pulmonary disease. Review of Resident #2's admission MDS dated [DATE] reflected a BIMS of 14 reflecting intact cognition. Section K reflected the resident received parenteral/IV feeding while not a resident at the facility and while a resident at the facility. Review of Resident #2's comprehensive care plan initiated 8/17/23 reflected the problem The resident requires TPN r/t short gut syndrome. The goal reflected, The resident will remain free of side effects or complications related to TPN through review date. The Intervention reflected, Obtain and monitor lab/diagnostic work as ordered, Report results to MD and follow up as indicated. Another care plan problem reflected, I am on a regular diet, regular texture, regular liquids. I also receive nutrition via TPN. The goal and interventions for this problem did not address the TPN or central line. No other entries on the care plan addressed the TPN or central line. Review of Resident #2's physician order dated 8/20/23 reflected, TPN electrolytes Intravenous 675536 Page 6 of 17 675536 10/12/2023 Hill Country Heights 810 Industrial Ave Copperas Cove, TX 76522

F 0694 Level of Harm - Minimal harm or potential for actual harm Concentrate Use 126.2 ml/hr intravenously one time a day for Nutrition Inject with Vial 1 and 2 of vitamins and infuse over 14 hours. Review of Resident #2's physician order dated 9/6/23 reflected, PICC line dressing and cap change weekly using sterile technique per protocol every day shift every Wednesday. Residents Affected - Few Review of Resident #2's Medication Administration Record for 9/1/23 through 9/30/23 reflected PICC line dressing and cap change weekly using sterile technique per protocol. There was no check mark or initials for Wednesday 9/20/23, indicating the dressing was not changed. The previous dressing change was documented 9/13/23 and the subsequent dressing change was documented on 9/27/23. Review of Resident #2's Medication Administration Record for 10/1/23 through 10/31/23 reflected PICC line dressing and cap change weekly using sterile technique per protocol. A check mark and initials indicated the dressing was last changed on 10/4/23. Observation on 10/10/23 at 10:11 AM revealed Resident #2 lying in bed. A double lumen peripherally inserted central catheter (PICC) was observed in her left upper arm. Neither lumen was marked specifically for TPN. The dressing was not dated, timed, or initialed. Observation on 10/10/23 at 2:55 PM revealed Resident #2 lying in bed. A double lumen PICC was observed in her left upper arm. TPN was connected and infusing. The dressing was dated for 10/7/23 and initialed by RN C. The dressing was not timed. During an observation and interview on 10/11/23 at 11:12 AM, Resident #1 was lying in her bed. She stated she went out to the hospital yesterday, but the hospital wanted to wait a couple of days before replacing the central line. She stated someone was supposed to come out to the facility to insert a new line. She stated she did not get her TPN last night because she did not have a central line in place. No central lines or IV access observed on arms or chest. During an observation and interview on 10/12/23 at 10:10 AM, Resident #1 was observed lying in bed. A PICC line was observed in her left upper arm. The dressing was clean, dry, and intact. An antimicrobial patch was in place at the insertion site. Resident #1 stated she did not get her TPN last night because the x-ray had to be rescheduled. No other IV access observed. During an interview on 10/10/23 at 10:42 AM with RN C, she stated, she did not have any central line dressings scheduled to be changed on her shift. During an interview on 10/10/23 at 10:52 AM with the ADON, he stated central line dressing changes could be changed by LVNs or RNs if they had been trained or checked out first. Central line competencies were requested. During an interview on 10/10/23 at 1:38 with RN C, she stated she had received training on how to change central line dressings, flush and hook up TPN. She stated when she changed a central line dressing, she removed the old dressing, changed gloves, put a mask on herself then one on the resident. She stated she would use the supplies in the dressing kit. Once covered, she wrote her initials and date on the label. She stated they were supposed to put filters on TPN lines then added, Sometimes the filters don't work with the machines. She verified the machine was the electronic IV pump. She stated she looked at the physician orders and the care plan to determine the care needed. She stated if a central line got pulled out, she would flush the line and look at the site. She stated an 675536 Page 7 of 17 675536 10/12/2023 Hill Country Heights 810 Industrial Ave Copperas Cove, TX 76522

F 0694 adverse outcome for a resident if a central line is not properly maintained could be an infection. Level of Harm - Minimal harm or potential for actual harm During an interview on 10/10/23 at 2:11 PM with the MDS nurse, she stated, she expected to find a care plan for TPN that included monitoring the PICC line, dressing changes, flushes, and weight monitoring. She stated if TPN was not care planned, the resident could be at risk for dehydration, heart failure, staff not following up or checking on the resident. Residents Affected - Few During an interview on 10/10/23 at 3:40 PM with RN A, she stated, I think I may have told you wrong, it is the purple line for TPN. During an interview on 10/11/23 at 2:10 PM with the DON, she stated Central line dressings were labeled with the date of the change. She stated she was familiar with the PN policy and stated the facility does follow the policy. She stated the facility did not mark a lumen specific for TPN on double lumen lines, We just use the red one. She stated the facility did not have orders for dextrose should the TPN be stopped unexpectedly. She stated both the DON and ADON were responsible for ensuring staff were trained. 675536 Page 8 of 17 675536 10/12/2023 Hill Country Heights 810 Industrial Ave Copperas Cove, TX 76522

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record revies, the facility failed to have sufficient nursing staff with appropriate competencies and skills sets to provide nursing services to assure resident safety and maintain the highest practicable, physical, well-being of the resident for two (Resident #1 and Resident #2) of two residents and three (RN A, RN C, and LVN D) of four staff reviewed for competent nursing. 1. The facility failed to ensure RN A and LVN B stopped administration of TPN (nutrition administered intravenously through a large vein near the heart) which could cause tissue damage while performing a sterile dressing change for Resident #1. 2. The facility failed to ensure nursing staff (RN A, RN C, and LVN D) who cared for residents with central lines (Resident #1 and Resident #2) were competent in providing care following physician orders and facility policy. These failures could place the residents with central lines at risk for serious infection, impaired nutrition, and hospitalization. Findings included: 1.) Review of Resident #1's undated face sheet reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included hypomagnesemia (low magnesium level in the blood), unspecified protein-calorie malnutrition (lack of sufficient nutrients), essential hypertension (high blood pressure), malignant neoplasm of cervix uteri (cancer), unspecified intestinal obstruction, fistula of the intestine (an abnormal connection of two body cavities) and gastroparesis (delay in stomach emptying). Review of Resident #1's admission MDS dated [DATE] reflected a BIMS of 15 indicating intact cognition. Section K reflected the resident received parenteral/IV feeding while not a resident at the facility and while a resident at the facility. Review of Resident #1's comprehensive care plan dated 8/23/23, reflected only a urinary tract infection and she preferred not to attend group activities. The care plan did not address the central line or the total parenteral nutrition. Review of Resident #1's physician order dated 8/25/2023 reflected, TPN 3-1. Infuse via central line at 133.3 ml/hr x 12 hrs at night. Mix vial 1 and vial 2 vitamins prior to infusion. Start 1400, stop 0200. Review of Resident #1's physician order dated 8/29/2023 reflected, Central line dressing and cap change weekly using sterile technique per protocol every day shift every Tuesday. 675536 Page 9 of 17 675536 10/12/2023 Hill Country Heights 810 Industrial Ave Copperas Cove, TX 76522

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #1's Medication/Treatment Administration Record for 10/1/23 through 10/31/23 reflected the central line dressing was changed on 10/3/23 by RN C. There was no documentation of a dressing change on 10/7/23 as written on the dressing. Review of Resident #1's Medication Administration Record for 10/1/23 through 10/31/23 reflected the central line dressing was changed on 10/3/23 by RN C. There was no documentation of a dressing change on 10/7/23. Review of Resident #1's progress noted dated 10/10/23 at 4:09 PM written by LVN B reflected, During PICC line dressing change, PICC line migrated from original site. Attempt made to locate original measurements of line, but unable to locate any documentation. TPN fluid began seeping through insertion site. On call NP notified. Received orders to discontinue existing PICC and the send resident to emergency department to receive new PICC. PICC line ended up coming all the way out of insertions site before having chance to pull it out. No bleeding noted. Remained at resident for approximately 5 minutes and applied intermittent pressure to site to ensure bleeding would not start. Afterward EMS was notified. Resident left with EMS at approximately 5:30 PM. Observation on 10/10/23 at 10:04 AM, revealed Resident #1 in her room lying in bed with the presence of a double lumen central line in her right, upper chest. Neither lumen was observed marked specifically for TPN. The transparent dressing was curled around the edges and about one third of the dressing was lifted away from her body. Resident #1 pressed on the dressing to make it flat. The dressing was labeled with initials KG and the date 10/7/23. The time of the dressing change was not on the label. Three small black dots to indicate 1cm measurements were visible on the central line. During an observation on 10/10/23 at 4:00 PM, Resident #1 was sitting up on the edge of the bed. The TPN bag was connected to the central line with IV tubing. The IV pump indicated the TPN was infusing at 133 ml/hr. The IV tubing was not taped or secured to the resident. RN A assisted Resident #1 to lay down on the bed. LVN B requested permission to move items off the table in order to use the table for her sterile field. Resident #1 consented. LVN B moved the items, performed hand hygiene, donned a face mask then sterile gloves then prepared her sterile work area. RN A stated to LVN B, I'll remove the old dressing while you do that. Wearing non-sterile gloves, RN A removed the dressing from the chest then stepped back which left the central line and IV tubing unsecured. RN A was not observed wearing a mask. Resident #1 was not observed wearing a mask. Neither RN A nor LVN B were observed to have offered Resident #1 a mask nor instructed her to look away from the procedure. Resident #1 was observed watching the dressing being removed. Resident #1 repositioned herself slightly then was observed as she crossed her arms across her abdomen/chest which placed pressure on the IV tubing which caused the central to protrude further from the insertion site than previously observed. LVN B was observed as she measured the length of the central line. LVN B stated to RN A, 14 cm or 5.5 inches. RN A was observed leaving the room to verify the length of the previously charted. LVN B was observed cleaning the skin around the insertion site with alcohol swabs from the dressing kit. A white fluid, consistent with the TPN fluid in the bag was observed as it leaked and pooled around the insertion site. LVN B walked around the bed and pushed the pause button on the IV pump. LVN B held gauze on the insertion site. Resident observed the procedure and told LVN B the central line tubing looked different than it had earlier in the day. The alarm on the pump sounded and Resident #1 asked LVN B if she should push the pause button again. LVN B replied, No, we can wait for her to come back in and push the button to stop it. During an interview on 10/10/23 at 3:18 PM with RN A, she stated, she had worked at the facility for about seven years, but most recently working as an agency nurse though the company's agency. She 675536 Page 10 of 17 675536 10/12/2023 Hill Country Heights 810 Industrial Ave Copperas Cove, TX 76522

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated central line dressings were checked every shift. She stated dressings were changed every seven days and as needed. She stated she did not have any central line dressing changes scheduled on her shift. She stated she was the nurse assigned to Resident #1 but she did not know when Resident #1 had been scheduled for a dressing change. RN A checked in the computer and reported the change had been scheduled for 6:00 AM today but it was not signed off as completed. She then stated the pharmacy had been notified and they were waiting for the dressing kit to be delivered as they did not have any in stock. She stated on a double lumen central line, the red lumen was used for TPN, and the purple was used for meds and things. She stated she did not know if the facility marked a lumen specifically for TPN and stated she did not know if there was a policy and procedure about the lumen being marked. RN A stated she did not remember any training at this facility regarding central line use and maintenance. She stated she had worked with central lines in the past. During an interview on 10/10/23 at 3:35 PM with LVN B, she stated she was the treatment nurse and she occasionally changed central line dressings but usually it was done by the floor nurses. She stated she has maintained her IV certification throughout her career, and she completed the on-line course provided by the facility prior to the facility accepting residents requiring TPN. She stated dressing changes should be completed weekly. She stated an adverse outcome for a central line not properly maintained could be infection or death. During an interview on 10/10/23 at 4:38 PM with the ADON, he stated, he had been trained on central lines. His competency had been verified by the DON. He stated for central line dressing changes, he maintained sterile at the start and throughout. He stated the site was assessed prior to changing anything and abnormal findings were reported to the provider. He stated after the old dressing was removed, hand hygiene was performed, and sterile gloves applied. He stated, Use what is in the kit to change the dressing. He stated the label was marked with the date, time, and initials. He stated a mask for the nurse completing the procedure, the resident, and any others in the room during the procedure was required to prevent the spreading of droplets. He stated it did not meet his expectations if the resident and a nurse did not wear a mask during a central line dressing change. He stated if a nurse had not taken the IV class they would not participate in that practice. He stated he and the DON were responsible for monitoring the completion of training. He stated, to his knowledge, the IV Mastery course was not required. During an interview on 10/10/23 at 4:40 PM with RN A, she stated Resident #1 would be sent out to the hospital for placement of a new central line. She stated they had received orders to remove the current central line. During a telephone interview on 10/11/23 at 12:39 AM with PHARM, he stated, it depended on the pH, osmolarity, and the ingredients, but TPN could potentially be caustic if it got in the tissues. Review of the facility's policy titled Parenteral Nutrition, revised March 2022, reflected the following: Preparation 2. A physician's order is necessary for this treatment. The PN order should include the formula or a list of all individual ingredients/nutrients in the base solution, total volume and rate of administration as well as orders for monitoring laboratory results on a routine basis. 675536 Page 11 of 17 675536 10/12/2023 Hill Country Heights 810 Industrial Ave Copperas Cove, TX 76522

F 0726 Safety Precautions Level of Harm - Minimal harm or potential for actual harm 2. Residents Affected - Few Parenteral nutrition orders will include an order for dextrose 10% IV to run at the same rate as PN, in case the PN has to be stopped or discontinued suddenly. 5. Administer PN via an electronic pump. The solution must be filtered. 9. For multi-lumen catheters, specify/label one lumen for PN use only. Do not use this lumen for other infusions or blood sampling. Steps in the procedure 18. Check connections. Secure tubing to resident with tape. Documentation The following should be documented in the resident's medical record. 6. Rate and volume infused. Review of the policy titled Central Venous Catheter Care and Dressing Changes, revised March 2022, reflected the following: General Guidelines 2. Perform site care and dressing change at established intervals or immediately if the integrity of the dressing is compromised (e.g., damp, loosened, or visibly soiled). 4 Change the dressing if it becomes damp, loosened or visibly soiled and: c. immediately if the dressing or cite appear compromised. 5. d. palpate and inspect the skin, dressing and securement device for signs of complications including: dislodgement, redness, tenderness, swelling, infiltration, induration, elevated body temperature or drainage. e. Ask the resident if he or she is experiencing pain, tingling, or numbness. 675536 Page 12 of 17 675536 10/12/2023 Hill Country Heights 810 Industrial Ave Copperas Cove, TX 76522

F 0726 6. Measure the length of the external central vascular access device with each dressing change or if catheter dislodgement is suspected. Compare with the length documented at insertion. Level of Harm - Minimal harm or potential for actual harm Assessment Residents Affected - Few Observe insertion site and surrounding area for complications. Steps in the Procedure 2. Clean over the bed table with soap and water, or alcohol. 7. Resident should be lying on bed, with head facing opposite direction from dressing site . 8. Ask resident to keep arms at side of body or have someone help him or her to do this. 8. e. Label with initials, date and time. Documentation 1. The following information should be recorded in the resident's medical record: a. Date and time dressing was changed. b. location and objective description of insertion site. e. any questions, education given to resident, resident's statement regarding IV therapy and response to procedure. Review of the National Library of Medicine website Chapter 4 Manage Central Lines - Nursing Advanced Skills - NCBI Bookshelf (nih.gov) accessed on 10/16/23, High osmolarity solutions refer to a highly concentrated solution expressed as the total number of solute particles per liter. High osmolarity solutions, such as total parenteral nutrition and hypertonic IV fluids, are irritating to peripheral vessels and increase the client's risk for phlebitis, thrombosis, and occlusion. Additionally, vesicant medications (such as certain antineoplastic drugs, antibiotics, electrolytes, and vasopressors) can cause severe tissue injury or destruction if they extravasate. Extravasation refers to leakage of fluid into the tissues around the IV site, causing tissue injury when the catheter has dislodged from the blood vessel but is still in the nearby tissue. For this reason, infusions of high osmolarity solutions and vesicant medications are administered through a CVAD into a large vein such as the superior vena cava. When these solutions enter this larger vessel, the solution is hemodiluted, thus minimizing the risk of these complications from occurring. 2.) Review of Resident #1's physician order dated 10/11/23 at reflected Dextrose Intravenous solution 675536 Page 13 of 17 675536 10/12/2023 Hill Country Heights 810 Industrial Ave Copperas Cove, TX 76522

F 0726 Level of Harm - Minimal harm or potential for actual harm 10% (dextrose) Use 133 ml/hr intravenously as needed for TPN DC or must be stopped Start Dextrose 10% @ 126ml/hr if suddenly discontinued or TPN must be stopped. Review of Resident #1's Medication Administration Record for 10/1/23 through 10/31/23 did not reflect administration of IV dextrose after the TPN had been stopped. Residents Affected - Few Review of Resident #1's progress notes dated 9/29/23 reflected, Resident reported that during dressing reinforcement yesterday PICC line came out a little bit and was pushed back in by nurse. The dressing was changed and NP notified. Orders received for chest x-ray to verify placement. Review of Resident #1's Medication Administration Record for 9/1/23 through 9/30/23 reflected the central line dressing was changed on 9/26/23. There was no documentation of a dressing change on 9/29/23. Review of Resident #2's undated face sheet reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included postsurgical malabsorption not elsewhere classified, decreased white blood cell count, compression of the first, second, and fifth lumbar vertebra, chronic heart failure, and chronic obstructive pulmonary disease. Review of Resident #2's admission MDS dated [DATE] reflected a BIMS of 14 reflecting intact cognition. Section K reflected the resident received parenteral/IV feeding while not a resident at the facility and while a resident at the facility. Review of Resident #2's comprehensive care plan initiated 8/17/23 reflected the problem The resident requires TPN r/t short gut syndrome. The goal reflected, The resident will remain free of side effects or complications related to TPN through review date. The Intervention reflected, Obtain and monitor lab/diagnostic work as ordered, Report results to MD and follow up as indicated. Another care plan problem reflected, I am on a regular diet, regular texture, regular liquids. I also receive nutrition via TPN. The goal and interventions for this problem did not address the TPN or central line. No other entries on the care plan addressed the TPN or central line. Review of Resident #2's physician order dated 8/20/23 reflected, TPN electrolytes Intravenous Concentrate Use 126.2 ml/hr intravenously one time a day for Nutrition Inject with Vial 1 and 2 of vitamins and infuse over 14 hours. Review of Resident #2's physician order dated 9/6/23 reflected, PICC line dressing and cap change weekly using sterile technique per protocol every day shift every Wednesday. Review of Resident #2's Medication Administration Record for 9/1/23 through 9/30/23 reflected PICC line dressing and cap change weekly using sterile technique per protocol. There was no check mark or initials for Wednesday 9/20/23, indicating the dressing was not changed. The previous dressing change was documented 9/13/23 and the subsequent dressing change was documented on 9/27/23. Review of Resident #2's Medication Administration Record for 10/1/23 through 10/31/23 reflected PICC line dressing and cap change weekly using sterile technique per protocol. A check mark and initials indicated the dressing was last changed on 10/4/23. Observation on 10/10/23 at 10:11 AM revealed Resident #2 lying in bed. A double lumen peripherally inserted central catheter (PICC) was observed in her left upper arm. Neither lumen was marked 675536 Page 14 of 17 675536 10/12/2023 Hill Country Heights 810 Industrial Ave Copperas Cove, TX 76522

F 0726 specifically for TPN. The dressing was not dated, timed, or initialed. Level of Harm - Minimal harm or potential for actual harm Observation on 10/10/23 at 2:55 PM revealed Resident #2 lying in bed. A double lumen PICC was observed in her left upper arm. TPN was connected and infusing. The dressing was dated for 10/7/23 and initialed by RN C. The dressing was not timed. Residents Affected - Few During an observation and interview on 10/11/23 at 11:12 AM, Resident #1 was lying in her bed. She stated she went out to the hospital yesterday, but the hospital wanted to wait a couple of days before replacing the central line. She stated someone was supposed to come out to the facility to insert a new line. She stated she did not get her TPN last night because she did not have a central line in place. No central lines or IV access observed on arms or chest. During an observation and interview on 10/12/23 at 10:10 AM, Resident #1 was observed lying in bed. A PICC line was observed in her left upper arm. The dressing was clean, dry, and intact. An antimicrobial patch was in place at the insertion site. Resident #1 stated she did not get her TPN last night because the x-ray had to be rescheduled. No other IV access observed. During an interview on 10/10/23 at 10:04 AM, Resident #1 stated her central line dressing needed to be changed because it was not sticking to her skin. She then stated, This is missing the round thing that they usually put on there. When asked if she was referring to an antimicrobial patch she stated, Yes. Resident #1 stated the staff had changed her dressing, Every other week or so. Resident #1 stated, Last time the state was here, a week or two ago, the central line got pulled out a little, but they got right on it. Resident stated the facility got an order for an x-ray. She stated waiting for the x-ray caused a delay in the TPN being administered but, They got it back on schedule. During an interview on 10/10/23 at 10:42 AM with RN C, she stated, she was the nurse for Resident #1 and Resident #2 and she did not have any central line dressings scheduled to be changed on her shift. During an interview on 10/10/23 at 10:52 AM with the ADON, he stated central line dressing changes could be changed by LVNs or RNs if they had been trained or checked out first. Central line competencies were requested. During an interview on 10/10/23 at 1:38 with RN C, she stated she had received training on how to change central line dressings, flush and hook up TPN. She stated when she changed a central line dressing, she removed the old dressing, changed gloves, put a mask on herself then one on the resident. She stated she would use the supplies in the dressing kit. Once covered, she wrote her initials and date on the label. She stated they were supposed to put filters on TPN lines then added, Sometimes the filters don't work with the machines. She verified the machine was the electronic IV pump. She stated she looked at the physician orders and the care plan to determine the care needed. She stated if a central line got pulled out, she would flush the line and look at the site. She stated an adverse outcome for a resident if a central line is not properly maintained could be an infection. During an interview on 10/10/23 at 2:11 PM with the MDS nurse, she stated, she expected to find a care plan for TPN that included monitoring the PICC line, dressing changes, flushes, and weight monitoring. She stated if TPN was not care planned, the resident could be at risk for dehydration, heart failure, staff not following up or checking on the resident. During an interview on 10/10/23 at 3:40 PM with RN A, she stated, I think I may have told you 675536 Page 15 of 17 675536 10/12/2023 Hill Country Heights 810 Industrial Ave Copperas Cove, TX 76522

F 0726 wrong, it is the purple line for TPN. Level of Harm - Minimal harm or potential for actual harm During an interview on 10/11/23 at 10:51 AM with the ADON, he stated staffing was determined by the complexity, acuity, and skills required for each resident. The resident needs were determined by their assessment and care plan. He stated they were currently reviewing the process to determine how agency staff competencies were assessed. He stated there were monthly CEU requirements and they give in-services as needed. He stated about once a year they get everyone together for skills, corporate provides the checklist for those skills. Requested training records. Residents Affected - Few During an interview on 10/11/23 at 1:35 PM with the DON, she stated the DON, ADON, or designee were responsible to ensure training was complete for new employees. She stated agency staff should be trained by the facility they orient at so the facility should have a file for RN A. She stated staffing was not different because of the TPN, RNs hang the TPN and LVNs maintain it. She stated LVNs were trained with IV certification. She stated it did not meet her expectations that a dressing was observed with no date in the morning then in the afternoon the dressing was observed with a date three days prior to the observation. Requested policy and procedure for staff training and competencies. Requested training records. During an interview on 10/11/23 at 2:10 PM with the DON, she stated Central line dressings were labeled with the date of the change. She stated she was familiar with the PN policy and stated the facility does follow the policy. She stated the facility did not mark a lumen specific for TPN on double lumen lines, We just use the red one. She stated the facility did not have orders for dextrose should the TPN be stopped unexpectedly. During an interview on 10/12/23 at 10:12 AM with LVN D, she stated prior to this week, she had not had any training on central lines since working at this facility. She stated she did receive IV and central line training in nursing school. She stated she has been an LVN for two years and started working at this facility at the end of July this year. She stated she was not sure if a particular line was marked for TPN since she was an LVN, she does not hang the TPN but she can flush the lines and change the dressings. She stated she has changed central line dressings at this facility. She stated clots or infections could be a possible negative outcome if central lines were not properly maintained. During an interview on 10/12/23 at 11:09 AM with the DON, she stated, they do not really have a policy about training but provided a policy about On-the-Job Training. She stated there was a list of trainings that must be completed by newly hired employees. Requested the training files for three staff members including LVN D. Review of the facility's policy titled On-the-Job Training, revised January 2008, reflected the following: 2. Department directors will be responsible for on-the-job training to assure that our established training schedules are followed. 7. Training records will be filed in the employee's personnel file or may be maintained by the 675536 Page 16 of 17 675536 10/12/2023 Hill Country Heights 810 Industrial Ave Copperas Cove, TX 76522

F 0726 department supervisor. Level of Harm - Minimal harm or potential for actual harm Review of the IV-Central Vascular Access and Midline- Dressing Change Skill Assessments provided for currently employed RNs and LVNs reflected a completed skill assessment for LVN B dated 5/9/23. There was no skill assessment for RN A, RN C, or LVN D. Residents Affected - Few Review of the IV Mastery Certificate of Completions provided reflected no certificate for RN A, RN C, or LVN D. No other training records were provided prior to the survey exit. 675536 Page 17 of 17