Health inspection·June 23, 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. Based on observation, interview, record review, and review of the facility policy, the facility failed to ensure an indwelling urinary catheter was stabilized and maintained in a manner to prevent urinary tract infection (UTI). This affected one resident (#17) out of three residents reviewed for an indwelling urinary catheter. The facility census was 45. Findings include: Review of the medical record for Resident #17 revealed an admission date of 04/25/22 with diagnoses including type II diabetes mellitus, chronic kidney disease, and calculus of kidney. Review of Resident #17's admission Minimum Data Set (MDS) 3.0 assessment, dated 05/01/22, revealed Resident #17 was cognitively intact. Resident #17 required the extensive assistance of two staff members for bed mobility and transfers. Resident #17 had an indwelling catheter for urine and was always continent of bowel. Review of the plan of care, dated 04/26/22, revealed the resident had an indwelling urinary catheter due to urinary retention. Interventions included positioning catheter bag below level of bladder, manipulating tubing as little as possible during care, reporting UTIs, and changing the catheter per physician order. Review of physician orders, dated 04/26/22, revealed an order for catheter care every shift for indwelling 16 French with 10 cubic centimeter (CC) balloon due to urinary retention. Observation on 06/21/22 at 11:16 A.M. revealed Resident #17 sitting in her wheelchair with her urinary catheter drainage bag sitting next to her on the wheelchair seat. The urinary catheter drainage bag was not secured to the chair and the drainage tube was looping upward and stationary in a position above the resident's bladder. Interview and observation on 06/21/22 at 11:21 A.M. with Licensed practical Nurse (LPN) #905 verified the aforementioned findings. LPN #905 further verified the drainage tube was kinked which prevented urine from flowing through the drainage tube, and the Foley catheter stabilization device/lock normally located on Resident #17's inner thigh had become unattached and unsecured. LPN #905 retrieved and replaced the stabilization device. Review of the facility policy titled Infection Control Program, reviewed January 2022, revealed an important facet of infection prevention includes educating staff and ensuring they adhere to proper techniques and procedures. Page 1 of 3 366342 366342 06/23/2022 St Mary of the Woods 35755 Detroit Road Avon, OH 44011

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview,record review, and review of facilities policy, the facility failed to notify and obtain physician orders for the use of oxygen for one resident (Resident #14) of three residents reviewed. The facility census was 45. Residents Affected - Few Findings include: Record review for Resident #14 revealed an admission date of 04/21/22. Diagnoses include unspecified fracture of shaft of right fibula, subsequent encounter for closed fracture with routine healing, mild cognitive impairment and unspecified dementia without behavioral disturbance. Record review of the Minimum Data Set (MDS) for Resident #14 dated 06/02/22 revealed resident had moderately impaired cognition and required extensive assistance for bed mobility transfers and mobility. Record review of the progress note dated 06/19/22 at 10:29 A.M. completed by Licensed Practical Nurse (LPN) #906 revealed State Tested Nursing Assistant (STNA) was toileting (Resident #14) and while washing (Resident #14) hands with the STNA, (Resident #14) knees felt weak and was lowered to ground. STNA called for the nurse, and nurse assessed (Resident #14). Patient stated her legs gave out. Vital signs were 128/75, 97%, two liters of oxygen, respirations were 16. No complaints of pain or shortness of breath. Record review of the physician orders for June 2022 revealed Resident #14 had no orders for use of oxygen. Observation on 06/21/22 at 10:53 A.M. revealed Resident #14 was sitting up in a recliner chair. A nasal cannula connected to a concentrator running at two liters per minute was lying on the bed next to Resident #14. Resident #14 revealed she was unsure how to put the cannula back on. Interview on 06/21/22 at 10:54 A.M. with LPN #906 revealed Resident #14 was to be wearing oxygen continuously at two liters per minute per nasal cannula. Observation with LPN # 906 verified the oxygen tubing was lying on the bed and revealed the therapy department must have forgot to put the oxygen back on after the therapy session. Observation revealed LPN #906 placed the nasal cannula back on Resident #14 to provide oxygen at two liters per minute. Observation on 06/22/22 at 09:05 A.M. revealed Resident #14 was sitting in the recliner chair. Resident #14 was wearing oxygen at two liters per minute per nasal cannula. Observation on 06/22/22 at 2:03 P.M. revealed Resident #14 was sitting in the recliner chair. Resident #14 was wearing oxygen at two liters per minute per nasal cannula. Interview on 06/22/22 at 2:42 P.M. with Certified Occupational Therapy Assistant (COTA) #908 confirmed she worked with Resident #14 on 06/21/22. COTA #908 confirmed she worked with Resident #908 without the use of oxygen. COTA #908 confirmed Resident # 14 did not have orders for oxygen. COTA #908 confirmed Resident #14's oxygen saturation was 95 with activity and did not require oxygen. Interview on 06/22/22 at 2:56 P.M. with LPN #906, verified Resident #14 did not have physician orders for the use of oxygen. LPN #906 revealed on 06/19/22 Resident #14 had a syncope episode. LPN #906 366342 Page 2 of 3 366342 06/23/2022 St Mary of the Woods 35755 Detroit Road Avon, OH 44011

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few revealed at that time she put oxygen at two liters per minute on Resident #14 as a nursing judgement. LPN #906 confirmed Resident #14 had been wearing the oxygen since 06/19/22. LPN #906 confirmed she did not update the physician or the Certified Nurse Practitioner (CNP) that she applied the oxygen or continued use of the oxygen. Interview on 06/22/22 03:07 P.M. with CNP #907 confirmed she or Resident #14's physician was not aware Resident #14 had been wearing oxygen that was initiated 06/19/22 and continued. CNP #907 confirmed the nursing staff could initiate the use of oxygen in an emergency but should have notified the physician or CNP within 24 hours, not four days, to obtain an order. Record review of the facility policy titled, Care Standards Oxygen Therapy dated January 2022, revealed oxygen will be administered per physician order by qualified personnel. In an emergency situation, the licensed nurse may administer no more than four liters of oxygen until the physician can be notified for further orders. 366342 Page 3 of 3