Health inspection·July 26, 2022

CLASS A CITATION-PATIENT CARE #1100-2923-17082 REVIST Date: 8/23/22 Complaint(s) CA00654972 T22 - 72315(f)(7) The facility was found not to be in substantial compliance with Title 22, Chapter 3, Article 3, Section 72315(f)(7), when the facility's Plan of Correction was not fully implemented. Facility census on the day of the Revisit was 81. Findings: An onsite Revisit was conducted on 8/23/2022 at 1 p.m., and included interviews and record review with the Director of Nursing (DON) and the Infection Preventionist (IP). The following items on the facility's Plan of Correction were not completed by 8/9/2022, the completion date identified by the facility: a) Onetime baseline hands-on assessment and documentation of all residents in-house with Foley catheters (flexible tube placed in the bladder to drain urine), including assessment of the urinary drainage for signs of infection, urine volume, and skin breakdown at the site of the catheter's insertion. b) A whole house audit by the DON, to ensure that catheter care is being conducted and assessments are being performed and documented. 1 of 3 resident record reviews revealed Resident 1's medical record did not contain documentation that catheter care was conducted, and assessments were performed on 8/16/22, 8/17/22, and 8/18/22. c) The Interdisciplinary Team (IDT) will conduct a daily review during morning stand up to ensure the policy and procedure on Foley catheter care was followed - the IDT did not identify that Resident 1 was missing documentation in his record regarding catheter care/assessments/documentation, from 8/16/22 through 8/18/22. d) Documentation would be added to the Licensed Nurses Medication Administration Record (MAR) to include urine output for all residents with a Foley catheter. The documentation was added to the Treatment Administration Record (not the MAR) and subsequently missed by nursing staff. e) The Medical Records Director will conduct a weekly audit of all weekly skin checks to ensure documentation is complete and the skin check has been completed - this was not done, per the DON. f) All licensed nurses will be in-serviced (educated) on urinary tract infection prevention, per the Center for Disease Control and Prevention guidelines - approximately 50% were educated, per the DON. g) The Activity of Daily Living (ADLs) documentation (by CNA's - Certified Nursing Assistants) will be audited weekly by the Medical Records Director for completeness and the results will be given to the IP for further education as needed. Per the IP, the ADL sheets have been incomplete, but not all the CNA's had been reeducated. h) Medical Records Director will bring the ADL sheet audits to the QAA (Quality Assessment and Assurance) committee for review - not done per the DON. i) The DON will bring a running list of residents with Foley catheters and proof of review to the QAA committee - per the DON, the QAA reviews issues from the previous month so this review will occur at a later meeting.