Health inspection·September 13, 2018

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #352 was admitted to the facility on [DATE] with diagnosis including cerebral vascular disease, depression, anemia, cognitive communication deficit, chronic kidney disease, anxiety, coronary artery disease, dementia. Review of the most current MDS assessment dated [DATE] identified the resident with moderately impaired cognition, dependent on staff for the completion of ADL and rejection of care. Review of a nursing plan of care dated 11/13/17 revealed the residents need for assistance with ADL's. Interventions included to allow the resident time to complete task as able, monitor the need for clothing or personal care items and assist with purchasing, two staff assist with all care. Additionally on 11/21/17 a plan of care was developed due to the resident's behavior of resistance to care. Interventions included explain procedures prior to beginning, use two care givers with care, when episodes of refusing care are noted approach with calm manner, explain all care, attempt to address any concerns related to care, notify social worker or Registered Nurse for follow up. Surveyor observations on 09/10/18 at 11:10 A.M., 1:00 P.M., 2:20 P.M. and on 09/11/18 at 11:08 A.M., 1:09 P.M. and 2:55 P.M. noted the resident was in bed wearing a hospital house gown. The resident had a wardrobe closet with approximately five shirts and one pair of pants. On 09/11/18 at 2:58 P.M., interview with State Tested Nurse Aide (STNA) #101 revealed no attempts were made to get the resident dressed due to behavioral concerns and resistance to care. STNA #101 also noted the resident lacked adequate clothing. On 09/11/18 at 3:01 P.M., interview with Licensed Practical Nurse (LPN) #200 confirmed the resident was resistive to care and was not dressed or out of bed on 09/10/18 or 09/11/18. Review of the medical record for 09/10/18 and 09/11/18 revealed no documentation indicating the resident was resistive to care on those dates. Based on medial record review, observation, and review of facility policy the facility failed to ensure residents with indwelling catheters had their catheters managed in a dignified manner. This affected one Resident (#147) of four reviewed for activity of daily living (ADL) care. The facility identified 41 residents as having indwelling catheters. In addition, the facility failed to ensure dependent residents were dressed on a daily basis. This affected one Resident (#352) of four reviewed for ADL care. The facility identified 24 residents as being dependent for dressing. The facility census was 392. Findings Include: Page 1 of 5 366325 366325 09/13/2018 Ohio Veterans Home 3416 Columbus Ave Sandusky, OH 44870

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 1. Review of Resident #147's medical record revealed an admission date of 12/04/16. Diagnoses included hyperlipidemia, chronic atrial fibrillation, hypertension, major depressive disorder, hemiplegia, dysphagia, and anxiety disorder. Review of Resident #147's Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively intact. Resident #147 required extensive assistance with transfer, dressing, and personal hygiene. Resident #147 was totally dependent on staff for toilet use. Resident #147 had an indwelling catheter. Review of Resident #147's care plan updated 07/10/18 revealed supports and interventions for ADL assistance, risk for falls, pain, indwelling catheter, risk for aspiration, risk for dehydration, risk for malnutrition, limited range of motion, and refusal of care. Observation on 09/10/18 at 11:48 A.M. found Resident #147 in bed with a full, uncovered, catheter bag hanging on the side of the bed. Resident #147 emitted a strong smell of body odor and urine. At the time of the observation Resident #147 was interviewed but the resident refused to comment on his hygiene or catheter bag. Interview on 09/10/18 at 11:49 A.M. with Licensed Practical Nurse (LPN) #410 verified Resident #147's catheter bag was full, uncovered, and visible from the hallway. LPN #410 lifted the full catheter bag and placed it in the catheter bag cover. Review of facility policy titled, Urinary Catheterization Work Instructions, dated 05/16/11 revealed the collection bag was to be emptied on each shift and as needed. Drainage bags should be placed in cloth/vinyl bag for aseptic purposes. 366325 Page 2 of 5 366325 09/13/2018 Ohio Veterans Home 3416 Columbus Ave Sandusky, OH 44870

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and review of facility policy the facility failed to ensure residents who required staff assistance with activities of daily living (ADL), received adequate care. This affected one Resident (#147) of four residents reviewed for ADLs. The facility census was 392. Residents Affected - Few Findings Include: Review of Resident #147's medical record revealed an admission date of 12/04/16. Diagnoses included hyperlipidemia, chronic atrial fibrillation, hypertension, major depressive disorder, hemiplegia, dysphagia, and anxiety disorder. Review of Resident #147's Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively intact. Resident #147 required extensive assistance with transfer, dressing, and personal hygiene. Resident #147 was totally dependent on staff for toilet use and required supervision, set up only, for eating. Resident #147 displayed the behavior of rejecting care one to three days out of the review period. Review of Resident #147's care plan updated 07/18/18 revealed supports and interventions for risk for falls, pain, indwelling catheter, risk for aspiration, risk for dehydration, risk for malnutrition, limited range of motion, refusal of care, and activities of daily living assistance. Resident #147 disliked changing clothes, bathing, shaving (trimming beard) and haircuts. A specific care plan goal revealed Resident #147 would receive appropriate level of support to adequately and safely complete ADLs while maintaining maximum level of independence. Resident #147 would be clean, dressed, and well groomed each day through the review. Interventions for episodes of refusal of care were to redirect as needed, speak softly, listen to complaint, and reproach at a later time in a calm manner Inappropriate behaviors were to be monitored and document. Review of Resident #147's ADL Exception Comments form revealed Resident #147 refused a brief change on 08/14/18 and refused breakfast on 09/12/18. No other refusals were documented. Review of Resident #147's behavior log revealed tracking was completed for the behavior of refusing of showers. Resident #147 refused showers on 08/04/18, 09/05/18, 09/08/18 and 09/12/18. Showers were listed as being provided on 08/01/18, 08/08/18, 08/11/18, 08/15/18, 08/22/18, 08/26/18, 08/29/18 and 09/01/18. Resident #147's behavior log was silent to refusal of dressing, or other ADL care. Observation on 09/10/18 at 11:48 A.M. revealed Resident #147 was in bed with a full, uncovered, catheter bag hanging on the side of the bed. Resident #147 emitted a strong smell of body odor and urine. At the time of the observation, Resident #147 was interviewed and refused to comment on his hygiene or catheter bag. Interview on on 09/10/18 at 11:49 A.M. with Licensed Practical Nurse (LPN) #410 verified Resident #147 had a strong smell of urine and body odor. LPN #410 reported an oxidizer had been placed in Resident #147's room to help with the smell. LPN #410 reported Resident #147's odor had been an ongoing issue. LPN #410 also verified Resident #147's catheter bag was full and uncovered. LPN #410 lifted the full catheter bag and placed it in the catheter bag cover. Observation on 09/11/18 at 10:31 A.M. of Resident #147 revealed a strong smell of body odor and 366325 Page 3 of 5 366325 09/13/2018 Ohio Veterans Home 3416 Columbus Ave Sandusky, OH 44870

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few urine noted. An oxidizer was running in Resident #147's room. Resident #147's catheter bag was covered and appeared half full of urine. Resident #147 refused to answer questions. Resident #147 was found to be wearing the same clothes as the day before. Interview on 09/11/18 at 10:47 A.M. with LPN #420 revealed Resident #147 refused to drink anything but Dr. Pepper. Resident #147's urine was darker in color and had a stronger odor due to this. LPN #420 reported Resident #147 refused to shower and there was an odor from that as well. Interview on 09/11/18 at 11:00 A.M. with LPN #430 revealed Resident #147 refused to have his sheets changed and would refuse to get out of bed. LPN #430 reported the only time Resident #147 would get out of bed was to shower. LPN #430 reported Resident #147 would throw food if anything was brought to him after he declined to eat and he would hit at staff if they attempted to provide care after he refused. LPN #430 reported some of Resident #147's medications were adjusted for depression and they observed improvements with his cooperation. LPN #430 verified Resident #147 was wearing the same clothes as the day before. Interview on 09/11/18 at 4:19 P.M. with State Tested Nursing Assistant (STNA) #500 revealed Resident #147 would throw food at staff and swing at staff if they provided him food he didn't want or if they tried to provide care he didn't want. STNA #500 stated Resident #147 often refused to get dressed or cleaned up. Interview on 09/11/18 at 4:20 P.M. with LPN #440 found no refusals of care noted for Resident #147. LPN #440 verified Resident #147 was wearing the same clothes as yesterday. Interview on 09/11/18 at 4:25 P.M. with Resident #147 revealed he refused to eat breakfast and dinner. Resident #147 reported he ate all of his lunch and had been eating the snacks he had in his room. Resident #147 smelled unclean and was wearing the same clothes as yesterday (09/10/18). Resident #147 denied refusing to be changed or cleaned up. Interview on 09/12/18 at 10:30 A.M. with STNA #510 revealed Resident #147 was not cooperative with care and required total care for personal hygiene. STNA #510 reported she documented Resident #147's refusals as they were trained. STNA #510 reported Resident #147 had not refused care when STNA #510 worked with Resident #147. STNA #510 reported she would give Resident #147 time and Resident #147 would cooperate if re-approached with a calm tone and demeanor. Observation on 09/12/18 at 10:37 A.M. revealed Resident #147 watching television in his room. Resident #147's catheter bag was covered but was full and bulging. Resident #147 was dressed in a different shirt. Resident #147 still had a strong smell of body odor and urine. Resident #147 refused to be interviewed. Review of facility policy titled, Urinary Catheterization Work Instructions, dated 05/16/11 revealed the collection bag was to be emptied on each shift and as needed. Drainage bags should be placed in cloth/vinyl bag for aseptic purposes. Review of the facility policy titled, Dressing Resident Work Instructions, dated 05/13/17 revealed the policy was silent to the frequency residents should be dressed or have their clothing changed. 366325 Page 4 of 5 366325 09/13/2018 Ohio Veterans Home 3416 Columbus Ave Sandusky, OH 44870

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 medical record review, observation, staff interview and facility work instructions, the facility failed to ensure indwelling urinary catheter care was provided accordingly. This affected one Resident (#17) of three reviewed for indwelling urinary catheter use. The facility identified 42 current residents with indwelling urinary catheters in a facility census of 392. Findings include: Resident #17 was admitted to the facility on [DATE] with diagnosis including, dementia, hypertension, benign prostatic hyperplasia, urethral stricture, urinary retention, coronary artery disease, neuromuscular dysfunction of the urinary bladder, and congestive heart failure. According to the most current minimum data set (MDS) assessment dated [DATE] the resident was identified with severe cognitive impairment, dependent on staff for the completion of activities of daily living (ADL's) and utilized an indwelling urinary catheter. According to the medical record on 10/06/16 a physician order for the placement of an indwelling (foley) urinary catheter was initiated due to the diagnosis of neurogenic urinary bladder. Catheter care was to be performed by cleansing the urinary meatus with soap and water and monitor output every shift. On 10/27/17 a nursing plan of care was initiated to address the use of the urinary indwelling catheter. Interventions included to monitor for signs and symptoms of urinary tract infection, catheter care as ordered, irrigate catheter as ordered, empty catheter drainage bag every shift, change catheter as ordered, cleanse urinary meatus with soap and water and monitor output each shift. On 09/07/18 the resident was noted to have a positive urine culture result indicating two organisms present in the urine. The organisms were identified as citrobacter fraundii and proteus mirabilis. The physician subsequently started the resident on antibiotic therapy for the treatment of a urinary tract infection. Review of the medical record lacked documentation indicating catheter care was being completed each shift. Surveyor observation on 09/12/18 at 9:20 A.M. revealed state tested nurse aide (STNA) #100 was observed at Resident #17's bedside. STNA#100 washed hands and donned non-sterile gloves. STNA#100 proceeded to expose Resident #17's perineum and obtained a disposable incontinence wipe. STNA#100 then cleansed the insertion site of the catheter, wiped the tubing and cleansed the residents scrotal area and with the same portion of incontinence wipe cleansed the insertion site and tubing. Resulting in cross contamination. Interview with STNA #100 on 09/12/18 at 9:27 A.M. verified the cross contamination during the indwelling urinary catheter care. On 09/12/18 at 11:47 A.M. interview with Assistant Director of Nursing(ADON) #1 verified the medical record did not contain documentation regarding the provision of indwelling catheter care each shift. Review of the facility catheter care work instructions updated on 06/01/17 noted the procedure to clean the catheter from the meatus down the catheter. Clean downward, away from the meatus with one stroke. 366325 Page 5 of 5