Health inspection·April 2, 2024

F 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. 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 properly collect and document for one of 3 sampled residents (Resident 1) a 24-hour urinalysis specimen. Residents Affected - Few This failure contributed to a clinically compromised Resident 1 not completing a physician ordered laboratory test. Findings: During review of Residents 1 ' s admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses to include: malignant poorly differentiated neuroendocrine tumors (highly aggressive cancer of pancreas), secondary malignant neoplasm of bone (bone cancer), spinal stenosis (narrowing inside the bones of the spine), palliative care (medical care focuses on providing relief from pain and other symptoms of serious illness). During a concurrent interview and record review of Resident 1 ' s Medical Record with the Assistant Director of Nurses (ADON), reviewed and verified the following: 1. Nurse Note dated February 11, 2024, at 08:50, Note Text states, Resident 1 sister called to collect 24-hour urine to resident start 5am Sunday until 5am Monday and she will pick up the urine collection 24 hours and will bring it to [acute hospital]. Placed a call [doctor] for order of Foley catheter (used to drain urine from the bladder by way of urethra) for insertion to collect 24-hour urine collections since the resident is confused not able to express needs and cannot follow command. Obtained new order to insert foley catheter for urine 24-hour urine collection carried out and noted. Foley catheter, insert used F14(size of catheter) catheter aseptically no urine obtained yet since the resident just had urinated diaper fully soaked with urine. Foley Catheter in a basin with ice. Will continue to monitor. 2. No Documentation in electronic medical record of a date, time start, end time, and no assessment of urine collection (color, quantity, etc.) for a 24-hour urine collection ordered February 11, 2024. 3. No laboratory results for the 24- hour urine collection ordered from February 11, 2024. During an interview on March 19, 2024, with the Case Manager (CM), CM stated, Resident 1 did go out to Oncology, he came back with order for Endocrinology. I don ' t see an order from his consults an order for UA 24-hour collection. If the family would have told us about any 24-hour urine collection we would call to get an order, the family doesn ' t usually know the details, so we call and Page 1 of 2 055565 055565 04/02/2024 Waterman Canyon Post Acute 1850 N. Waterman Ave. San Bernardino, CA 92404

F 0770 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few document in the system. I was not made aware of the Nurse progress note from February 11, 2024. This nurse (RN1) should have notified us on this 24-hour urine collection order. During an interview on March 19, 2024, with the Social Service (SS), SS stated, R1 sister called on February 13, 2024, about the urine sample, she said she brought the Urine Container and gave it to the nurse and the facility lost it. I told her over the phone I forward it to Assistant Director of Nursing (ADON) and he will look into it. During an interview on March 19, 2024, with the Assistant Director of Nursing (ADON), ADON stated, There were no orders from his February 08, 2024, from Oncology, he came back with No orders to collect urine. The sister came in and told the nurse about the collection. There a note from the Registered Nurse (RN1) about called our doctor and got order for foley catheter and urine collection. In the note there is nothing about a collection container, just the 24-hour urine collection order, but the order time don ' t coincide with the collection times. We would not have sent out the foley bag as the collection container, it would be placed in our container. If we had the order for a 24-hour urine collection, we contact the other doctor or facility if they have a container, or question how they want this collected. We do not take containers from family stating that urine needs to be collected, we need to follow up with who is ordering the test. During a review of the facility ' s policy and procedure titled, 24-hour Urine Specimen revised October 2010, the policy and procedure indicated: The purpose of this procedure is to collect a 24-hour urine specimen for laboratory analysis .Preparation 1. Verify that there is a physician's order for this procedure .Equipment and Supplies 9. 24-Hour Urine Specimen container and tag .Steps in the Procedure 11.Observe the urine for color, sediments, blood, odor, etc. 15.Save all the urine during the 24-hour period . Documentation: The following information should be recorded in the resident's medical record: 1.The date and time that the specimen was collected.2.The name and title of the individual(s) who performed the procedure.3.The character, clarity and color of urine.4.All assessment data obtained during the procedure.5.The date and time the 24-hour period began and ended.6.The time each specimen was collected.7.The date and time the specimen was sent to the lab.8.How the resident tolerated the procedure.9.If the resident refused the procedure, the reason(s) why and the intervention taken.10.The signature and title of the person recording the data. 055565 Page 2 of 2