Health inspection·January 19, 2024

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews, the facility failed to honor the resident's choice regarding the name that the resident preferred to be called by, as conveyed on the day of admission, and as documented in the resident's records, for 1 of 2 sampled residents (Resident #10), reviewed for choices. The findings included: A review of Resident #10's records revealed that the resident was admitted to the facility on [DATE] with diagnoses of Major depressive disorder, Dementia, unspecified severity with other behavior disorders, and Generalized anxiety disorder. Record review of Resident #10's care plan, dated 01/04/24, related to Engagement and Socialization, documented that the resident had a preferred first name that was different than her legal name. The care plan specified that the resident should be called by her preferred name. The preferred name was entered incorrectly on this care plan. Record review of Resident #10's Initial Physical Therapy Evaluation and Care Plan, dated 12/30/23, documented Resident #10's preferred name in the Precautions Section. An interview was conducted on 01/17/24 at 5:15 PM with Staff B, Certified Nursing Assistant (CNA), in D Hall. When asked what she called Resident #10, Staff B answered, I call her Ms. (legal first name). An observation on 01/18/24 at 9:39 AM revealed Resident #10 being assisted at the sink in her room by Staff G, Physical Therapy Assistant (PTA). While talking to Resident #10, Staff G consistently used the resident's legal first name instead of her preferred name. A phone call interview was conducted with the representative of Resident #10 on 01/19/24 at 10:05 AM. Resident #10's representative stated that, She's never been called (legal first name). Not even as a child. Resident #10's representative reported that on the day of admission she personally informed the facility's physician, the Director of Nursing (DON), the resident's CNA and the Director of Rehabilitation, that they should call Resident #10 (preferred name). She stated, I wanted them to know that it could help them in her care. The representative for Resident #10 also informed the interviewer that she wrote and placed the sign seen in Resident #10's room that says, Call Me (preferred name), on the day of admission. Photographic Evidence Obtained An interview was conducted on 01/19/24 at 10:28 AM, with Staff C, CNA, in Resident #10's room, Page 1 of 5 106013 106013 01/19/2024 Chatsworth at Pga National 347 Hiatt Drive Palm Beach Gardens, FL 33418

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few regarding the sign beside the resident's bed with written instructions. The sign said, Call Me (preferred name). Staff C reported that, We use both names. Her daughter wrote that, because saying (preferred name) calms her. We use (preferred name) to calm her down. An interview was conducted on 01/19/24 at 10:34 AM, in the Rehabilitation Gym with Staff D, Certified Occupational Therapy Assistant (COTA). Staff D reported, She (Resident #10) prefers to be called by (preferred name) Staff D added that the preferred name was, .established in her initial evaluation. An observation on 01/19/24 at 10:45 AM in the dining room, revealed Resident #10 seated with a group led by Staff E, Activity Assistant. Staff E introduced Resident #10 by her surname, rather than her documented preferred name. An interview was conducted on 01/19/24 at 11:12 AM, in D Hall, with Staff F, Registered Nurse (RN). Staff F was asked how she called Resident #10. Staff F replied that she calls Resident #10, Miss (surname), or (nickname), which is the resident's legal first name shortened. An interview was conducted on 01/19/24 at 2:15 PM, in the Rehabilitation Gym with Staff G, PTA. When asked about Resident 10's name, Staff G reported that, Her preference is (preferred name), but I call her (legal first name). I forget. An observation on 01/19/24 at 2:24 PM revealed Staff E, Activity Assistant, entering Resident 10's room. Staff E knocked on Resident #10's door and said, Hi, Ms. (surname). During an interview with the Director of Nursing (DON) in the conference room, on 01/19/24 at 3:03 PM, the DON was asked how she called Resident #10. The DON replied, How do I refer to her? Ms. (surname)? 106013 Page 2 of 5 106013 01/19/2024 Chatsworth at Pga National 347 Hiatt Drive Palm Beach Gardens, FL 33418

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 observation, interview, record review, and policy review, the facility failed to ensure care and services for the prevention of Urinary Tract Infections (UTIs) or other complications for 3 of 3 sampled residents who had an indwelling urinary catheter. Nursing staff failed to maintain proper positioning and securing of the catheter tubing for Residents #24 and #45, and failed to educate Resident #38 of the risks of refusing to follow-up with a urology consult and discontinue use of the indwelling urinary catheter. The findings included: Review of the policy Urinary Catheters dated 06/2021 documented, Procedure: 1. Catheter Care . c. Use of proper infection control practices regarding hand washing, catheter care, tubing and the collection bag will be followed at all times. h. Maintain unobstructed urine flow. i. Catheter tubing, bag or spigot cannot touch the floor. 1) Review of the record revealed Resident #24 was admitted to the facility on [DATE] and was ordered an indwelling urinary catheter on 11/14/23 for urinary retention with obstruction. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 1, on a 0 to 15 scale, indicating the resident was severely cognitively impaired. This MDS also documented the resident was dependent upon staff for all Activities of Daily Living (ADLs). During an observation on 01/17/24 at 11:13 AM, the collection bag for the resident's indwelling urinary catheter was noted in a dignity bag hooked to the low bed, with the tubing lying directly on the floor. Sediment was noted in the tubing leading to the drainage bag (Photographic Evidence Obtained). Observation of the resident's thigh revealed the catheter was stretched tightly from the resident's adult brief. A second observation on 01/17/24 at 4:52 PM revealed the indwelling urinary catheter tubing directly on the floor again (Photographic Evidence Obtained). On 01/17/24 at 5:15 PM, Staff B, Certified Nursing Assistant (CNA), was asked about the tubing on the floor and agreed it should not be there. Upon further observation of the resident, the CNA identified an anchor on the innermost aspect of the resident's right thigh, but the catheter was not in the clamp of the anchor. The CNA confirmed the anchor was for the catheter tubing, but when the CNA placed the catheter into the clamp, she failed to do so at the Y connection (a place on the catheter for obtaining a urine sample and used for proper securing) that would keep the catheter from pulling. The CNA was asked if the catheter was secure, and the CNA demonstrated how it moved freely in the clamp on the anchor. At 5:33 PM, the Clinical Manager was asked to assist the CNA, and the catheter was properly placed into the anchor and urinary drainage bag was replaced. An observation of care for Resident #24 was made on 01/18/24 at 10:35 AM with Staff C, CNA, assisted by Staff A, CNA, for positioning of the resident. Proper indwelling catheter and peri-care (personal care) was observed. Upon completion of the care, the CNA covered the resident and stated she was done. The surveyor asked the CNA to observe the catheter at the anchor. When asked what was wrong, the CNA did not know. The catheter was hooked in the anchor in such a way that the catheter was kinked so that urine would not be able to flow freely into the collection bag. The indwelling catheter 106013 Page 3 of 5 106013 01/19/2024 Chatsworth at Pga National 347 Hiatt Drive Palm Beach Gardens, FL 33418

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some bag was noted on the floor. When asked what happened, the CNA stated it fell. When asked what she needed to do, the CNA stated she needed to clean it off. The Assistant Director of Nursing (ADON) was brought into the room and notified of the findings. The ADON provided education to the CNA, assisted the CNA on proper catheter positioning, and changed out the indwelling catheter collection bag. 2) Review of the record revealed Resident #45 was admitted to the facility on [DATE] and had an indwelling urinary catheter upon admission. The resident had the indwelling urinary catheter placed prior to admission for inability to void. Review of the current MDS assessment dated [DATE] documented the resident had a BIMS score of 15, on a 0 to 15 scale, indicating the resident was cognitively intact. This MDS also documented the use of an indwelling urinary catheter. A progress note dated 01/12/24 documented Resident #45 went to the urologist, who placed him on an antibiotic for three days. During an interview with Resident #45 on 01/16/24 at 3:34 PM, Staff B, CNA entered the resident's room and proceeded to empty the indwelling urinary catheter leg bag. The CNA donned gloves but failed to don a gown as per their Enhanced Barrier Precautions (EBP), utilized by the facility to protect the resident from infection. The catheter was not anchored in any way and was noted to be stretched tightly down the resident's leg. After the CNA left the room, when asked about the anchor, Resident #45 stated when he first got it (the catheter), they were careful about putting the tube in the anchor, but it comes out. A cloth/Velcro type anchor secure device was noted on the resident's thigh, but not being used. When asked if the urinary catheter was pulling, the resident stated, Now that you mention it . yes. When asked if staff routinely clean the catheter each shift or daily, the resident stated, sometimes they clean it, but would not specify. During an observation on 01/17/24 at 11:57 AM, Resident #45 had just returned from therapy. The resident's urinary catheter leg bag was noted, the tubing was not anchored, and the tubing was taunt (Photographic Evidence Obtained). The urinary catheter tubing was visible to all staff as the resident was wearing shorts. A washcloth was noted over the collection bag as per the resident's request, but part of the catheter was visible along with the unused anchor. On 01/18/24 at about 11:30 AM, the ADON was shown the photo of the lack of catheter anchor for Resident #45 and agreed with the concern. On 01/19/24 at 10:58 AM, when asked who was responsible for ensuring the urinary catheters were properly secured, the Clinical Manager stated it was the nursing teams responsibility, which included the CNAs, nurses, and managers. 3) During an interview on 01/16/24 at 10:51 AM, when asked why she had an urinary catheter, Resident #38 stated, I couldn't walk to the bathroom. They wanted to take it out last week, I think, but I told them no. Think I will ask them to take it out this week or next. When asked if she was aware of the risks of long-term catheter use, the resident stated she knew she could get an infection, but was unaware of any other risks such as difficulty returning back to a normal urinary function, damage to the bladder or urinary tract, or any other possible complication. Review of the record revealed Resident #38 was admitted to the facility on [DATE], transferred back to the hospital on [DATE] related to surgical complications, and returned to the facility on [DATE]. 106013 Page 4 of 5 106013 01/19/2024 Chatsworth at Pga National 347 Hiatt Drive Palm Beach Gardens, FL 33418

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the physician orders revealed an order dated 11/28/23 for a urology consult related to urinary retention. Further review of the record lacked any evidence of this consult. During an interview on 01/17/24 at 4:04 PM, Staff F, Registered Nurse (RN) and usual day shift direct care nurse for Resident #38, stated she was unaware of a urology consult. The Infection Preventionist (IP), who was at the nurses' station at the time of the interview, stated Resident #38 has canceled two urology appointments. When asked if they had attempted to discontinue the catheter, the IP stated they had, but was unable to locate any documentation in the medical record as to when and the outcome. When asked why Resident #38 still had the indwelling catheter, the IP stated, Because the resident chooses not to have the Foley cath (catheter) discontinued. The IP volunteered that at one point the urinary catheter came out, and when asked what happened, the IP stated the resident wanted it back, so they did, but again was unable to provide any supporting documentation of this or the urology consult. During an interview on 01/17/24 at 4:22 PM, when asked about the urology consult for Resident #38, the Central Supply/Transportation/Scheduling person stated she made an appointment with a urologist when the 11/28/23 order came through. The Scheduler stated the appointment was made, but at that time the resident was not able to walk yet, and refused to go to the appointment or have the urinary catheter taken out. The Scheduler, who was also a Licensed Practical Nurse (LPN), stated she educated the resident, who stated she didn't care. When asked if she documented anything anywhere, the Scheduler stated she doesn't do clinical anymore, so she doesn't document in the record, but that she told the nurse. The Scheduler was unable to locate and provide any information about the first appointment at that time. The Scheduler stated that again this month, when she noted the resident was now up and about, she made a second urology appointment for 01/11/24, and provided an Appointment form that documented the appointment for 01/11/24 at 10 AM. The Scheduler stated when she went to remind the resident the day before the appointment, Resident #38 stated she had called and canceled the appointment herself. When asked what she did at that point, the Scheduler stated she spoke with the nurse again. Review of the working nursing schedule for 01/10/24 and 01/11/24 revealed Staff F, RN, was again the resident's direct care nurse. During an interview on 01/17/24 at 4:38 PM, the RN stated she was not made aware that Resident #38 canceled her second urology appointment. The RN stated if she had known she would have educated the resident, called the family if appropriate, notify the physician, and make a note in the record. On 01/19/24 at 11:05 AM, when asked if they had any further information related to the urology consult for Resident #38, the Director of Nursing (DON), stated she reached out to the physician who stated she knew about the canceled urology visit. A side-by-side review of a physician note dated 01/12/24 documented, Urinary retention - Foley catheter medically necessary. Encouraged resident to follow up with urology - Pt (patient) refused. This note, along with the medical record, lacked any documented evidence of education to Resident #38 of the risks of prolonged use of an indwelling urinary catheter. 106013 Page 5 of 5