Health inspection·May 15, 2024

F 0691 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility staff interview, and policy review, the facility failed to provide comprehensive nephrostomy care to a resident. This affected one (#47) of one resident reviewed for nephrostomy tubes. The facility identified one resident who had a nephrostomy tube used in his care at the facility. The facility census was 67. Findings include: Review of Resident #47's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included hydronephrosis, mild protein calorie malnutrition, and acute kidney failure. Review of the admission Minimum Data Set (MDS)3.0 assessment dated [DATE] revealed Resident #47 had mild cognitive impairment with no behaviors, nephrostomy tubes and was always continent of bowel. Resident #47 required maximal assistance with toileting, lower body dressing, and chair to bed transfers, moderate assistance with showering, and supervision with personal hygiene and bed mobility. Review Resident #47's care plan revealed the resident had nephrostomy tubes dated 03/06/24. Interventions in the care of the nephrostomy tubes included: check tubing for kinks every two hours each shift, dated 03/06/24. Monitor and document intake and output as per facility policy, dated 03/06/24. Check stopcocks on nephrostomy tubes and ensure they are open as ordered, dated 04/30/24. Resident #47's care plan had no documented education provided to the resident to not handle the nephrostomy tubes or documentation regarding the resident being non compliant with the nephrostomy tubes. Review of April 2024 treatment administration record revealed the nephrostomy tubes had the following drainage amounts documented: On 04/25/24, night shift right tube: 50 cc; on 04/25/24, night shift left tube: zero cc; on 04/26/24, day shift right tube: 50 cc; on 04/26/24, day shift left tube: zero cc; on 04/26/24, night shift right tube: documentation was blank; and on 04/26/24, night shift left tube: documentation was blank Review of the progress note 04/26/24 at 2:16 P.M. revealed the nurse attempted to call the nephrologist in regards to nephrostomies. Right one patent and draining. Left one leaking at the site and no drainage was going into the bag. A message was left and waiting on a call back. Telehealth reference note dated 04/26/24 revealed the nurse reported late this evening that resident's left nephrostomy tube was not patent and urine was seeping out around the tube. There had been no urine noted in the drainage tube for a short time. Order given to send out to the emergency room to verify correct Page 1 of 2 365418 365418 05/15/2024 Countryside Manor Nursing and Rehabilitation LLC 1865 Countryside Drive Fremont, OH 43420

F 0691 placement and possible replacement. Level of Harm - Minimal harm or potential for actual harm Review of the emergency room documentation for Resident #47 dated 04/26/24 to 04/27/24 revealed the resident was brought in from the nursing home for evaluation of his left nephrostomy tube that was reported to not be draining. Nursing home staff state left nephrostomy tube had not been draining all day. Resident denied any other symptoms. Residents Affected - Few Emergency department course note dated 04/27/24 at 1:06 A.M. revealed once three way stopcock was opened, the resident had clear drainage from his nephrostomy tube. Plan to discharge the resident with follow up to primary care physician. The progress note on 04/27/24 at 10:00 A.M. revealed the resident returned from the emergency department, and no new orders received. Reminded staff to check stop flow button on drainage tubes. Interview with the Director of Nursing (DON) on 05/15/24 at 1:51 P.M. confirmed Resident #47 was sent to the emergency room on [DATE] due to the left nephrostomy tube leaking and the drainage bag being empty. The DON confirmed the hospital documentation stated the stopcock was in the locked position and once the stopcock was opened, the nephrostomy tube drained clear drainage. The DON stated the resident had history of messing with his nephrostomy tubes and the staff would educate him not to touch them and allow staff to provide care to the tubes. Review of the facility policy titled Care of Nephrostomy Tube, last revised 10/2010, revealed the purpose of this procedure is to provide guidelines for the care of the resident with a percutaneous nephrostomy tube. The general guidelines included to check the placement of the tubing and integrity of the tape during assessments. Drainage should be below the level of the kidneys. Empty drainage bag once per shift and as needed. Measure output as follows: Initially every hour four hours; then every four hours for 24 hours; then every eight hours. This deficiency represents non-compliance investigated under Complaint Number OH00152975. 365418 Page 2 of 2