Health inspection·May 28, 2025

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a physician's order was documented for insertion of a size 20 French urinary catheter for 1 (Resident #3) of 3 residents reviewed for urinary catheters (tube inserted in the bladder to drain urine). The findings included: Review of the facility policy for Standards and Guidelines: Physician Orders, revised 1/2024: 5.) Verbal orders should be recorded in the resident's chart by the authorized person receiving the order and should include the prescriber's name, credentials, the date and the time of the order. Review of the admission Minimum Data Set (MDS) assessment with a target date of 3/12/25 revealed Resident #3 was admitted on [DATE]. Diagnoses included neurogenic bladder (Bladder dysfunction). Resident #3 had an indwelling urinary catheter Review of the hospital discharge record form 3008 dated 3/5/25 revealed Resident #3 had an indwelling urinary catheter size 16 French (fr). Review of the progress notes revealed on 3/14/25 at 8:58 a.m., a Change in Condition note revealed Resident #3 had new abdominal pain and bleeding. The attending physician was notified and ordered a STAT (immediate) KUB (Kidney, ureter, and bladder X-ray), flushing, irrigation of the urinary catheter, and an ultrasound of the abdomen. Review of the nursing progress note effective 3/14/25 at 10:11 a.m., revealed Resident #3 presented this morning with a gross amount of clots in his urinary catheter drainage bag and severe spasm at his supra pubic area. The resident stated he was experiencing pain (10 out of 10). The progress note documented, A 16 fr. Foley (urinary catheter) was replaced with a size 20 fr. On 5/28/25, a review of the physician's orders failed to reveal an order to replace the 16 fr. urinary catheter with the 20 fr. urinary catheter. On 5/28/25 at 4:27 p.m., in an interview Registered Nurse (RN) Staff A said on 3/14/25 he replaced the 16 fr. catheter with the 20 fr. catheter. He said he thought he texted or called the physician to request the order for the 20 fr. urinary catheter. RN Staff A verified there was no order for the 20 fr. urinary catheter he inserted on 3/14/25. Page 1 of 2 105421 105421 05/28/2025 Woodside Health and Rehabilitation Center 3601 Lakewood Blvd Naples, FL 34112

F 0842 On 5/28/25 at 5:46 p.m., in an interview the Director of Nursing said there should be an order from the physician for the 20 fr. catheter. The DON verified there was no order for the 20 fr. catheter. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 105421 Page 2 of 2