The findings of the complaint health survey (Intake # 26374) conducted 9/14/20 through 9/24/20 are documented in this report. The survey was conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities.
The sample was comprised of 8 current residents. The facility had a census of 40 residents.
Abbreviations possibly used in this document:
ADL: activities of daily living
bid: twice a day
BIMS: Brief Interview for Mental Status
CAA: Care Area Assessment
CBG: capillary blood glucose or
blood sugar
cm: centimeter
CMA: Certified Medication Aide
CNA: Certified Nursing Assistant
CPR: Cardiopulmonary Resuscitation
DNS: Director of Nursing Services
F: Fahrenheit
FRI: Facility Reported Incident
HS or hs: hour of sleep
LPN: Licensed Practical Nurse
MAR: Medication Administration
Record
mcg: microgram
MDS: Minimum Data Set
mg: milligram
ml: milliliters
O2 sats: oxygen saturation in the
blood
OT: Occupational Therapist
PCP: Primary Care Physician
PO: by mouth, orally
PRN: as needed
PT: Physical Therapist
RA: Restorative Aide
RAI: Resident Assessment
Instrument
RD: Registered Dietician
ROM: range of motion
RN: Registered Nurse
RNCM: Registered Nurse Care
Manager
SLP: Speech Language
Pathologist
TAR: Treatment Administration
Record
tid: three times a day
UA: Urinary Analysis
UTI: urinary tract infection
The findings of the revisit complaint (Intake# 26374) health survey conducted 11/4/20 through 11/6/20 are documented in this report. The facility was found to be in substantial compliance with 42 CFR Part ยง483 Requirements for Long Term Care Facilities.
Based on observation, interview and record review it was determined the facility failed to provide adequate catheter care for 2 of 3 (#s 1 and 4) residents reviewed for catheterization. This placed residents at risk for unmet catheter needs.
Catheter Care, Urinary Level III dated 10/2010 Policies and Procedures revealed to document the following in the resident's medical record.
1. The date and time catheter care was given.
2. The name and title of the individual giving catheter care.
3. All assessment data obtained while giving catheter care.
4. Character of urine such as color, clarity, and odor.
5. Any noted problems at catheter-urethral junction during care such as drainage, redness, bleeding, irritation, crusting or pain.
6. Problems or complaints made by the resident related to the procedure.
7. How the resident tolerated the procedure.
8. If the resident refused the procedure.
9. Signature and title of the person recording the data.
1. Records indicated Resident 1 admitted to the facility in 8/2020 with a diagnosis including urethral obstruction (a blockage in one or both of the tubes which carry urine from your kidneys to your bladder) and kidney failure.
An 8/6/20 care plan revealed Resident 1 had an indwelling catheter with interventions including catheter care, change foley catheter PRN for obstruction/occlusion, and contact hospice for catheter related concerns.
An 8/12/20 Urinary Indwelling Catheter CAA revealed Resident 1 was at risk for infection, due to indwelling catheter, the goal of the care plan was to maintain urine flow, avoid UTIs, and catheter related trauma.
a. The 8/2020 Documentation Survey Report revealed on the following days catheter care was not completed:
-8/7/20 evening shift
-8/11/20 day shift
-8/18/20 day shift
-8/20/20 day shift
-8/22/20 evening shift
-8/27/20 day shift
An 8/6/20 Nursing Care Note revealed Resident 1's Foley catheter was patent, draining amber colored urine.
8/8/20 and 8/14/20 Progress Notes revealed Resident 1's indwelling catheter was draining to gravity.
No additional documentation was found for Resident 1's catheter care in clinical records for 8/2020.
The 9/2020 Documentation Survey Report revealed on the following days catheter care was not completed:
-9/12/20 day shift
-9/13/20, day shift
-9/14/20 day shift.
No additional documentation was found for Resident 1's catheter care in clinical records for 9/1/20 through 9/9/20.
An observation on 9/18/20 at 10:23 AM revealed Resident 1 lying in her/his bed with the catheter bag uncovered attached to the side of the bed; the privacy curtain was drawn.
On 9/24/20 at 10:26 AM Staff 1 (Administrator) and Staff 2 (DNS) stated they expected staff to complete catheter care every shift and document in Resident 1's clinical records.
b. An 8/2020 TAR instructed staff to change the catheter bag PRN for leakage or drainage, and to change the Foley catheter to prevent obstruction or occlusion. Neither the catheter or bag was changed in 8/2020.
On 9/17/20 at 8:23 AM Witness 1 (Hospice) stated on 9/10/20 she observed Resident 1's catheter and it was completely clogged and draining around the sides. Witness 1 stated the catheter bag was dated 7/27/20 and she changed the bag.
On 9/17/20 Staff 3 (Charge Nurse) stated there was no order to change Resident 1's catheter and the last time it was changed was in 7/2020. Staff 3 stated the orders for the catheter were not clarified with hospice regarding who was responsible.
An observation on 9/18/20 at 10:23 AM revealed Resident 1 lying in her/his bed with the catheter bag uncovered attached to the side of the bed; the privacy curtain was drawn.
On 9/21/20 Witness 2 (Hospice) stated she was late on completing the catheter bag change which was dated 7/27/20 for Resident 1.
On 9/24/20 at 10:26 AM Staff 1 (Administrator) and Staff 2 (DNS) stated there was a communication concern between hospice and the facility which they needed to correct.
2. Resident 4 was admitted to the facility in 5/2020 with a diagnosis including dementia and kidney failure.
A 5/13/20 Admission Nursing Database revealed Resident 4's Foley catheter was patent and draining
A 5/20/20 Urinary Incontinence and Indwelling Catheter CAA revealed Resident 4 was at risk for infection, injury and loss of dignity due to the indwelling catheter. The Foley catheter was placed prior to admission by Hospice for comfort.
A 5/26/20 care plan revealed Resident 4 had an indwelling catheter with the goal to show no signs of UTI and trauma. Interventions included catheter care and catheter placement per physician orders.
No Physcian orders were found in clinical records for Resident 4's Foley catheter for 5/2020 or 6/2020
A 7/2020 TAR instructed staff to change Resident 4's catheter bag PRN for leakage and drainage and to change the Foley catheter PRN for blockage with a start date of 7/16/20.
An 8/27/20 Hospice care plan revealed starting 5/14/20 Resident 4 had a urinary catheter due to urinary retention with goals of managing the urinary catheter within two weeks, to perform a urethral catheter change every eight weeks and to change PRN for dysfunction or dislodgment.
A 9/18/20 draft progress note revealed Hospice's care plan and physician orders for catheter care the catheter was to be changed every eight weeks and PRN. The facility did not know if the catheter was changed by the Hospice nurse or by the facility nurse.
On 9/24/20 Staff 1 (Administrator) and Staff 2 (DNS) stated they were aware of the issue of lack of communication between Hospice and the facility in regard to catheters. Staff 1 stated the standard of practice was every time there was communication between Hospice and the facility it was documented. Staff 1 stated there was no documentation in 5/2020 or 6/2020 Hospice was providing daily catheter care for Resident 4.
F690-Bowel/Bladder/Incontinence, Catheter, UTIImmediate ActionResident #1 has discharged from the facilityResident #4 Was assessed by the RN on 9/24/2020, Tx plan, and Care plan were revised to meet the care needs on the resident and policies and procedures.ON-GOING ACTION AND PREVENTION.Other resident who have catheters are at potential risk of repeat incidents if policies and procedures are not adhered to R/T catheters. Tx plans for residents with catheters have been audited and corrected to be in compliance with policy and procedures. Nursing staff has been in-serviced on Catheter policies and procedures including: Documentation requirements R/T Foley catheter changes or any changes. Obtaining Physician Orders for all Foley Catheters including size, Bulb, irrigation, and date to be changed (if recommended) along with the requirement that all catheter bags must be covered.DNS/RCM will audit Nursing documentation R/T catheters to ensure compliance. 1X per week for 4 Weeds and Monthly for an additional 2 months.DNS/RCM will audit Resident with Catheters for documentation on Change and change frequency, Complete Physician's orders R/T catheters and catheter bags being covered. 1X per week for 4 weeks and monthly for an additional 2 months. DNS/RCM will Audit communication between hospice and facility. Ensure communication between facility and hospice upon each visit using progress notes/hospice notes. 1X per week for 4 weeds and monthly for and additional 2 months.All finding will be brought to monthly QAPI for follow-up and review until resolved.
The findings of the licensure and complaint survey (Intake #26374) conducted 9/14/20 through 9/24/20 are documented in this report. The survey was conducted to determine compliance with OAR 411 Divisions 85 through 89. For additional information refer to the Form CMS 2567 dated 9/24/20.
The sample was comprised of 8 current residents. The facility had a census of 40 residents.
Abbreviations possibly used in this document:
ADL: activities of daily living
bid: twice a day
BIMS: Brief Interview for Mental Status
CAA: Care Area Assessment
CBG: capillary blood glucose or
blood sugar
cm: centimeter
CMA: Certified Medication Aide
CNA: Certified Nursing Assistant
CPR: Cardiopulmonary Resuscitation
DNS: Director of Nursing Services
F: Fahrenheit
FRI: Facility Reported Incident
HS or hs: hour of sleep
LPN: Licensed Practical Nurse
MAR: Medication Administration
Record
mcg: microgram
MDS: Minimum Data Set
mg: milligram
ml: milliliters
O2 sats: oxygen saturation in the
blood
OT: Occupational Therapist
PCP: Primary Care Physician
PO: by mouth, orally
PRN: as needed
PT: Physical Therapist
RA: Restorative Aide
RAI: Resident Assessment
Instrument
RD: Registered Dietician
ROM: range of motion
RN: Registered Nurse
RNCM: Registered Nurse Care
Manager
SLP: Speech Language
Pathologist
TAR: Treatment Administration
Record
tid: three times a day
UA: Urinary Analysis
UTI: urinary tract infection
The findings of the revisit complaint (intake# 26374) health survey conducted 11/4/20 through 11/6/20 are documented in this report. The facility was found to be in substantial compliance with OAR 411 - 85 through 89.
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OAR 411-086-0140 Nursing Services: Problem Resolution & Preventive Care
Refer to F690
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