Health inspection·July 12, 2023

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to provide monitoring and care according to professional standards of practice related to urinary catheter care for one resident (#1) out of 3 residents sampled for catheter care. Findings included: Resident #1 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] after a hospitalization. Resident #1 diagnoses include but are not limited to, Bacteremia, Stage 3 Chronic Kidney Disease, candidiasis, need for assistance with personal care, obstructive and reflux uropathy, dementia without behavioral disturbances, and dysphagia. A review of Resident #1's Minimum Data Set (MDS), dated [DATE], revealed in Section H: Bladder and Bowel, Resident #1 had a urinary catheter. Section C: Cognitive Patterns, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 5 out of 15, indicating severe cognitive impairment. A review of Resident #1's Certified Nursing Assistant (CNA) documentation from 7/3/23-7/12/23 revealed documentation that identified Resident #1 as having an indwelling urinary catheter. An observation was conducted of Resident #1 on 7/12/23 at 3:00 p.m. The resident was observed to be in bed sitting upright with the head of the bed elevated, watching television. A urinary catheter bag was observed to be hanging on her bed frame, empty and off of the floor. A review of Resident #1's Physician orders did not reveal any orders related to Resident #1 having a urinary catheter, care of a urinary catheter, or monitoring of a urinary catheter. A review of Resident #1's July 2023 Medication Administration Record (MAR) and Treatment Administration Record (TAR) did not reveal any documentation a urinary catheter was being monitored or cared for by nursing. A further MAR and TAR review from June 2023, revealed Resident #1 had not had a urinary catheter monitored or cared for by nursing since June 12th, 2023. An interview was conducted on 7/12/23 at 2:00 p.m. with the facility's Director of Nursing (DON). She confirmed there were no urinary catheter orders in place for Resident #1 and she stated, The resident has been in and out of the hospital so the orders must not have been reordered when she came back. Page 1 of 2 105271 105271 07/12/2023 Boca Ciega Center 1414 59th St S Gulfport, FL 33707

F 0690 On 7/12/23 at 2:35 p.m. The DON stated the facility does not have a urinary catheter policy for review, they only have a catheter competency list. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 105271 Page 2 of 2