Health inspection·May 23, 2024

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 observation, interview and record review, the facility failed to attempt to remove an indwelling urinary catheter that was placed after recent surgery, failed to ensure the drainage bag did not touch the floor and failed to have a baseline care plan for indwelling catheter care. This applies to 1 of 3 residents (R47) reviewed for urinary catheter care in the sample of 17. Findings include: R47's EMR (Electronic Medical Record) showed R47 was admitted to the facility on [DATE], with multiple diagnoses including, presence of left hip artificial joint aftercare, chronic diastolic congestive heart failure, type 2 diabetes mellitus with other diabetic kidney complications, essential hypertension, chronic obstructive pulmonary disease, and leukocytosis. R47's MDS (Minimum Data Set) dated April 26, 2024, showed R47 was moderately cognitively impaired and required assistance with ADLs (Activities of Daily Living) including partial staff assistance with eating, oral and personal hygiene, dependent on staff for assistance with toileting, and substantial assistance required with bathing, dressing, bed mobility, and transfer. On May 22, 2024, at 1:00 PM, V2 (IP Nurse) stated when a resident is admitted to the facility with an indwelling urinary catheter, the facility should be sure there is a follow up appointment with urology and a voiding trial should be attempted to remove the catheter if possible. V2 stated the facility did not do a voiding trial for R47. V2 also stated he spoke with R47's NP (Nurse Practitioner) today who ordered a voiding trial for R47. R47's EMR showed R47's Incontinence/Indwelling Foley Catheter Observation dated April 24, 2024, showed .7. Has a trial of a toileting program (e.g., . scheduled toileting, prompted voiding, or bladder training) been attempted on admission/entry or reentry or since urinary incontinence was noted in this facility? .answer No . 8.What was the resident's response to the trial program? .answer, not assessed .9. Current toileting program or trial? answer .not assessed/no information. There was no additional catheter assessment completed. On May 22, 2024, at 10:50 AM, V4 (MDS/Care Plan Nurse) showed a baseline care plan dated April 24, 2024, that did not have a plan for indwelling urinary catheter. V4 stated the care plan had no goal and no interventions listed for catheter care and maintenance. V4 stated the care plan for indwelling catheter care should include to maintain the drainage bag in a privacy bag, be sure there were no kinks in the tubing and be sure the drainage bag was not on the floor. The care plan for indwelling Page 1 of 4 146181 146181 05/23/2024 Avondale Estates of Elgin 1754-1760 Capital Street Elgin, IL 60124

F 0690 urinary catheter was initiated on May 22, 2024. Level of Harm - Minimal harm or potential for actual harm On May 20, 2024, at 10:49 AM, R47 was in bed, receiving care from V8 (Wound Care Nurse) Residents Affected - Few at the end of the bed, the urinary drainage bag was lying on the floor, next to the privacy bag on the left side visible from the doorway. On May 22, 2024, at 10:45 AM, V6 (LPN) stated R47's indwelling urinary catheter was inserted in the hospital on April 21, 2024. R47's hospital assessment and plan dated April 19, 2024, showed R47 had acute urinary retention most likely due to recent anesthesia effect, does have recurrent urinary retention s/p (status post) indwelling urinary catheter placement. The facility's policy titled Catheter Care, Urinary, dated November 2017, showed Infection Control .c. Be sure the catheter tubing and drainage bag are below the resident's bladder and kept off the floor .e. Cover the urinary bag to provide privacy. 146181 Page 2 of 4 146181 05/23/2024 Avondale Estates of Elgin 1754-1760 Capital Street Elgin, IL 60124

F 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure three resident's central venous catheter dressings were changed within 48 hours as per the facility policy. Residents Affected - Few This applies to 3 of 3 residents (R44, R23, and R357) reviewed for central venous catheters in the sample of 17. The findings include: 1. R44 is a [AGE] year old male admitted to the facility on [DATE] with diagnoses that include Aftercare Following Joint Replacement Surgery, and Infection and Inflammatory Reaction Due to Other Internal Joint Prosthesis. On May 20, 2024 at 11:38 AM, R44 had a right upper arm central venous catheter with gauze covering the insertion site, and a transparent dressing was on top. The dressing was dated May 19, 2024. R44 stated they changed his central line venous dressing yesterday. On May 22, 2024 at 9:05 AM with V7 (RN), R44's right upper arm central venous catheter dressing was still dated May 19, 2024, and the insertion site was still covered with the same gauze and transparent dressing. 2. R23 is a [AGE] year old female admitted to the facility on [DATE] with diagnoses that include Bacteremia and Effusion of Left Knee. On May 20, 2024 at 3:06 PM, R23 had a left upper arm central venous catheter with gauze covering the insertion site, and the transparent dressing on top was dated May 19, 2024. On May 22, 2024 at 9:07 AM with V7, R23's left upper arm central venous catheter dressing was still dated May 19, 2024, and the insertion site was still covered with the same gauze and transparent dressing. 3. R357 is a [AGE] year old male admitted to the facility on [DATE] with diagnoses that include Osteomyelitis, Inflammatory Conditions of Jaws, and Cutaneous Abscess of Face. On May 20, 2024 at 3:08 PM R357's had a right upper arm central venous catheter with gauze covering the insertion site, and the transparent dressing on top was dated May 19, 2024. On May 22, 2024 at 9:11 AM with V7, R357's right upper arm central venous catheter dressing was still dated May 19, 2024, and the insertion site was still covered with the same gauze and transparent dressing. V7 stated that she is not aware what the policy is in regards to changing the central venous catheter dressings. V7 stated V2 (Infection Preventionist) would know. On May 22, 2024 at 1:58 PM, V2 (Infection Preventionist) stated that peripherally inserted central catheter (PICC) lines or midline catheter insertion site dressing changes should be completed every 5-7 days. However, if gauze is used on the dressing the dressing should be changed every 48 hours. On May 23, 2024 at 10:28 AM, V2 stated that the reason for changing central venous line dressing 146181 Page 3 of 4 146181 05/23/2024 Avondale Estates of Elgin 1754-1760 Capital Street Elgin, IL 60124

F 0694 with gauze is to prevent infection and to monitor the insertion site and integrity of the dressing. Level of Harm - Minimal harm or potential for actual harm R44, R23, and R357's Treatment Administration Records showed that their central venous line dressings were all last changed on May 19, 2024. Residents Affected - Few The facility's Midline Dressing Policy dated September 2, 2016 showed the following: Policy: Midline catheter dressings will be changed at specified intervals, or when needed, to prevent catheter-related infections associated with contaminated, loosened or soiled catheter-site dressings. General Guidelines: 4. Use a sterile, transparent, semi-permeable membrane (TSM) or gauze dressing. If gauze dressing is used, cover the gauze with a TSM dressing and change the dressing every 48 hours. 146181 Page 4 of 4