Health inspection·April 13, 2023

F 0690 Level of Harm - Minimal harm or potential for actual harm Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on interview, record review, and observation the facility failed to perform urinary catheter care to professional standards for 1 of 1 sampled residents (Resident #201). Residents Affected - Few Findings included: The policy, subtitled Prevention of Catheter-Associated Urinary Tract Infections (CAUTI) (2019) has a list of instructions on preventing CAUTI. Item #17 states: Do not clean the periurethral area with antiseptic to prevent CAUTI while the catheter is in place. Routine hygiene (e.g., cleansing of the meatal surface during daily bathing or showering) is sufficient. The policy titled Catheter Care, Urinary (revised 2014) has a subparagraph titled Steps in the Procedure with the following steps: 7. Wash the resident's genitalia and perineum thoroughly with soap and water. Rinse the area well and towel dry. 16. For a male resident: Use a washcloth with warm water and soap to cleanse around the meatus. Cleanse the glans using circular strokes from the meatus outward. Change the position of the washcloth with each cleansing stroke. With a clean washcloth, rinse with warm water using the above technique. Return the foreskin [when present] to normal position. 17. Use a clean washcloth with warm water and soap to cleanse and rinse the catheter from the insertion site to approximately four inches outward. 18. Secure catheter utilizing a leg band. On 04/12/23 at 10:57 AM, an observation of indwelling urinary catheter care for Resident #201 was made of Staff A, a Certified Nursing Assistant (CNA) who has been employed by the facility for 1 year. The CNA put on her gown. Staff A assisted Resident #201 from his wheelchair to his bed. There was waterproof padding laid out on the bed. As Staff A was moving the resident to his bed it was noted that Staff A had forgotten to remove the bedside catheter drain bag from the dignity bag attached to the wheelchair. This put an extra strain on the catheter tubing and subsequently Resident #201's genitals. Staff A realized the problem and corrected the issue. Staff A removed Resident #201's pants and opened the resident's disposable under garments. There was a red stain on the front of the undergarment that appeared to be blood. The catheter tubing was not secured to the resident's leg. Staff A covered the resident with a towel. Staff A washed her hands, put on gloves, and filled a wash basin with water. Staff A was about to place the wash basin on the bed then asked Resident #201's Private Page 1 of 2 105598 105598 04/13/2023 Harbours Edge 401 E Linton Blvd Delray Beach, FL 33483

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Duty Aide (PDA) to roll the overbed table over to Staff A. Staff A placed the basin on the overbed table. Staff A took the washcloth she placed in the basin and rung it out over the resident's perineal area. Staff A washed the resident using a wash cloth without paying attention to the urinary meatus or using appropriate technique. Staff A removed alcohol wipes from her pocket and used an alcohol wipe to clean the tubing from the meatus outward. The resident expressed discomfort from the alcohol wipe stating he had sensitivity in the area. Staff A repositioned the resident on his right side. Staff A used a clean, disposable wash cloth to clean the resident's posterior perineal region wiping from front to back. Staff A changed the gravity bag used at night to a leg bag secured to the resident's left leg with two straps, which were supplied with the leg bag. Staff A placed the bedside drainage bag in the bathroom trash without emptying the bag or measuring the urine. Staff A replaced the resident's disposable under garments and the resident's private duty aid finished dressing the resident. Staff A removed her gown and gloves, disposed of them in the trash and washed her hands. After the procedure Staff A was asked if she had anything to report to the nurse and Staff A stated she would report the output in the catheter bag and the blood noted on the undergarment. 105598 Page 2 of 2