Health inspection·May 12, 2022

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 facility policy, record review, observation, and interview, the facility failed to maintain in-dwelling urinary catheters according to facility policy for 2 of 2 sampled residents (#44 and #54). The findings included: Facility policy titled: Foley Catheter Care and Maintenance effective date 01/01/2020 reads, 1. Keep the drainage bag below the level of your bladder and off the floor at all times. 2. Keep the catheter secured to your thigh to prevent it from moving. 1). Record review revealed Resident #44 was admitted to the facility on [DATE], with diagnosis that include Cerebral Vascular Accident (stroke) and Dementia. The quarterly assessment on 04/09/2022 documented the resident as being severely cognitively impaired and having a functional status of total dependence on staff performance for all activities of daily living and care. A Physicians order dated 03/22/2022 documented,, Foley catheter care every shift per facility protocol Care Plan dated 01/26/2022 documented, Catheter care per facility protocol. Keep drainage bag off the floor. During observations for Resident #44 on 05/09/2022 at 7:55 AM, the in-dwelling urinary catheter drainage bag was noted to be lying on the floor on the right side of the bed. At 10:25 AM the catheter drainage bag was again noted on the floor (photographic evidence obtained). During an observation of wound care performed by the Director of Nurses (DON) at 2:09 PM, it was noted the in-dwelling urinary catheter was not secured to the resident's thigh and pulled tight during turning. On 05/10/2022 at 10:30 AM, during an observation of catheter care for Resident #44, performed by Staff A assisted by Staff B and Staff C, it was again noted that the in-dwelling urinary catheter was not secured to the thigh. Post urinary catheter care, the bed was lowered, and the catheter drainage bag was noted on the floor. 2) Record review revealed Resident #54 was admitted to the facility on [DATE] with diagnosis that include Cerebral Vascular Accident (stroke) and Dementia. The admission assessment on 04/22/2022 documented the resident as being severely cognitively impaired and having a functional status of total dependence on staff performance for all activities of daily living and care. A Physicians order dated 04/12/2022 documented, Foley catheter care every shift per facility protocol Care Plan dated 04/15/2022 states, Catheter care per facility protocol. Keep drainage bag off the floor. During observations for Resident #54 on 05/09/2022 at 8:55 AM, the in-dwelling urinary catheter drainage bag was noted to be lying on the floor on the right side of the bed. At 9:37 AM, the catheter Page 1 of 2 106018 106018 05/12/2022 Glades Health Care Center 230 South Barfield Highway Pahokee, FL 33476

F 0690 drainage bag was again noted on the floor (photographic evidence obtained). Level of Harm - Minimal harm or potential for actual harm On 05/10/2022 at 7:35 AM, Resident # 54's urinary catheter drainage bag was noted to be on the floor (photographic evidence obtained). At 9:35 AM, during an observation of catheter care performed by Staff B and Staff C, it was noted the catheter was not secured to the resident's thigh. Post urinary catheter care, the bed was lowered, and the catheter drainage bag was noted on the floor. Residents Affected - Few On 05/10/2022 at 10:30 AM, Staff A stated they currently do not have any catheter leg straps. She stated the resident came from the hospital with one, but it had become soiled and was causing leg irritation, so it was removed. On 05/10/2022 at 11:30 AM, the Director of Nurses stated that urinary catheter drainage bags must be kept off the floor. She stated she had removed the leg strap from Resident #44 due to irritation and stated they needed to order more replacements. 106018 Page 2 of 2