Health inspection·November 30, 2023

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 clinical record review, facility policy review, and staff interviews, it was determined that the facility failed to ensure residents received appropriate treatment and services to prevent urinary tract infections and complications related to the use of a catheter (thin tube that can be inserted through the urethra and into the bladder, allowing urine to drain) by catheterizing more times than required and improper placement of a foley catheter, for one of three residents reviewed for use of a catheter (Resident 1). Findings Include: Review of facility policy, titled Catheterization, Intermittent, Female Resident, revised October 2010, revealed, Verify that there is a physician's order for this procedure. Review of Resident 1's clinical record revealed diagnoses that included obstructive and reflux uropathy (disorder where urine cannot flow through the urinary tract due to an obstruction) and retention of urine (condition where one is unable to empty urine from the bladder, which can cause urine to back up into the kidneys and damage them). Review of Resident 1's physician orders revealed an order for a foley catheter with 10 cc [cubic centimeter] balloon and drainage bag to gravity, may change as needed for leakage, dislodgement or occlusion (blockage), effective September 22, 2023. Review of Resident 1's nursing progress notes dated October 28, 2023, at 11:03 PM, revealed that no urine output was noted on evening shift so a bladder scan was done, which revealed 900 ml (milliliters) of urine in the bladder. The Foley Catheter was removed. A straight catheterization was done (soft, thin tube used to pass urine from the body that is inserted through the urethra and into the bladder, and removed after urination). 850 ml was drained. The nurse removed the straight catheter and inserted a new foley catheter at that time. Review of Resident 1's nursing progress notes dated October 29, 2023, at 6:03 AM, revealed, in part, No urine output noted for this shift as of this time. Review of Resident 1's nursing progress notes dated October 29, 2023, at 1:49 PM, revealed in part, Resident noted to have no urine output throughout this shift. Bladder scanned at 89 cc at 1315. At approximately 1340, resident's daughter approached writer, stating that resident was experiencing chills and was shaking. Upon assessment, resident noted to be increasingly pale. Vital signs were abnormal, BP [Blood Pressure]: 86/76, Temp: 101.6, Pulse: 132, O2 [Oxygen saturation]: 98% ra [room Page 1 of 2 395016 395016 11/30/2023 Hanover Hall for Nursing and Rehabilitation 267 Frederick Street Hanover, PA 17331

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few air], resp [respirations]: 24. Foley bag remained empty, re-scanned bladder at over 1000cc. TC [telephone call] to Dr. [NAME], he advised resident to transported to [NAME] Hospital ED [Emergency Department] for evaluation and treatment. Resident transported via EMS [Emergency Medical Services] at 1355. Review of Resident 1's hospital emergency department notes dated October 29, 2023, revealed, Patient states that she has not made urine since yesterday evening despite the foley catheter being replaced by NH [Nursing Home] staff .Physical exam revealed Foley catheter balloon inflated within the vaginal canal. Review of grievance form dated October 30, 2023, revealed that Resident 1's spouse filed a grievance on that date regarding improper placement of Resident 1's foley catheter. Further review revealed the incident was investigated and Employee 1 received the following education on November 10, 2023: When foley was removed from resident and bladder scan showed urine in the bladder, another foley should have been inserted rather than a straight catheter. Resident was subjected to 2 catheter insertions instead of one, and when foley was inserted with empty bladder, there was no way to know if it was in bladder. Review of Resident 1's physician orders failed to reveal any orders to perform a straight catheterization. During an interview with the Nursing Home Administrator (NHA) on November 29, 2023, at 1:01 PM, she confirmed that the facility learned from hospital documentation that Resident 1's foley catheter was found to be improperly placed. During a later telephone interview with the NHA on November 30, 2023, at 2:40 PM, she agreed that Resident 1 should not have been straight catheterized without an order, and that she should not have been catheterized twice when not required. 28 Pa. Code 211.12(d)(1)(5) Nursing services 395016 Page 2 of 2