Health inspection·August 10, 2023

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Based on interview and record review, the facility failed to ensure that licensed nurses demonstrated competency when one of four sampled resident's (Resident 1), urine sample was not able to be processed due to incomplete documentation of the sample collection. This failure resulted in delay in treatment of Resident 1's urinary tract infection. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility in May 2023 with multiple diagnoses including fracture of right ulna (forearm bone) and right humerus, (upper arm bone), diabetes (too much sugar in the blood), and retention of urine (bladder does not empty all the way during urination). A review of Resident 1's Minimum Data Set (MDS- an assessment tool), Cognitive Patterns, dated 5/13/23, indicated Resident 1 had a Brief Interview for Mental Status (BIMS- tool to assess cognition) score of 15 out of 15 that indicated she was cognitively intact. A review of Resident 1's MDS, Bowel and Bladder, dated 5/13/23, indicated Resident 1 had an indwelling foley catheter (tube placed in the bladder to drain urine) upon admission. A review of Resident 1's Progress Note, dated 5/15/23, indicated .patient rejected removal of foley catheter, provided teaching to the patient why we are removing the catheter. patient still rejected . A review of Resident 1's Progress Note, dated 5/20/23, indicated .Resident c/o [complaining of] dysuria [painful or difficult urination] and burning sensation upon urination .received the following orders per MD [[medical doctor] .STAT [immediate] UA CNS [urinalysis -urine test with culture and sensitivity-test to determine germ causing infection and what antibiotic will treat it] . A review of Resident 1's Progress Note, dated 6/4/23, indicated .urine was collected at 2:04 am and put in for U/A and C/S . A review of Resident 1's Medication Administration Record (MAR), for 5/1/23 to 5/31/23, indicated order .Discontinue the foley catheter one time only until 05/15/2023 .Start Date .05/15/2023 . A review of Resident 1's MAR, for 5/1/23 to 5/31/23, indicated order .Urinalysis with C&S STAT .Start Date .05/20/2023 . Page 1 of 4 555333 555333 08/10/2023 Lincoln Meadows Care Center 1550 Third Street Lincoln, CA 95648

F 0726 Level of Harm - Minimal harm or potential for actual harm A review of Resident 1's MAR, for 5/1/23 to 5/31/23, indicated order .DC foley on 5/22, one time only for 1 day .Start Date .05/22/2023 . A review of Resident 1's MAR, for 5/1/23 to 5/31/23, indicated order .Collect UA CNS due to contaminated culture STAT .Start Date .05/26/2023 . Residents Affected - Few A review of Resident 1's MAR, for 6/1/23 to 6/30/23, indicated orders .Repeat UA/C&S on 6/2/23 one time only for 2 days .Start Date .06/02/2023 .UA with C&S may do straight cath [urinary catheter taken out right after it is used], if needed .Start Date .06/03/2023 . A review of Resident 1's Lab Results Report, collection date 5/21/23, reported date 5/26/23, indicated .CULTURE, URINE Multiple organisms isolated probable contaminant, repeat culture if indicated . A review of Resident 1's Lab Results Report, collection date 5/27/23, reported date 5/30/23, indicated .recollect urine for ua cs . A review of Resident 1's Lab Results Report, collection date 6/4/23, reported date 6/7/23, indicated .CULTURE, URINE .ISOLATE .Klebsiella pneumonia [bacteria that normally lives in the intestines] .ESBL POSITIVE [extended spectrum beta -lactamase, an enzyme found in some bacteria that may be resistant to antibiotics] . During a telephone interview on 8/9/23 at 3:24 p.m. with Resident 1's family member (FM), the FM stated that Resident 1 left the faciity on 6/4/23 and was taken to the emergency room where she was diagnosed with E Coli (Escherichia coli, a bacteria found in intestines) and Klebsiella pneumonia of the bladder and had to be treated with intravenous (tubing directly into a vein) antibiotics. The FM stated that the foley catheter was placed at the hospital and removed at the facility on 5/16/23, and Resident 1 started having problems after that. The FM stated she asked for urinalysis to be done but it was not done until the day before she left the facility. During an interview on 8/10/23 at 10:36 a.m. with the Director of Nursing (DON), the DON stated that the facility receives urinalysis lab results within 24 hours and culture and sensitivity results within 72 hours. During an interview on 8/10/23 at 11:58 a.m. with the Case Manager/ Discharge Planner (CMDP), the CMDP acknowledged that there was no documentation how Resident 1's urine samples were collected, clean catch or straight catheter, for sample collection on 5/21/27 and 5/27/23. During an interview and record review on 8/10/23 at 12:13 p.m. with the DON, the DON acknowledged that the urine samples may have been done by clean catch (method of collecting urine to prevent bacteria from contaminating the urine specimen) but it was not documented how sample was collected. The DON stated that the lab indicated that the sample taken on 5/27/23, and did not have sufficient quantity to analyze. The DON stated that Licensed Nurse (LN) 4 had signed off in the MAR that the urine samples were obtained on 5/21/23 and 5/27/23. The DON acknowledged that there was no documentation in the progress notes about how the samples were collected and who collected them. Reviewed that LN 4's Licensed Nurse Master Competency Worksheet, did not indicate that LN 4 received competency evaluation on how to obtain urine samples. The DON acknowledged that samples that were collected but not able to be analyzed may cause a delay in treatment. The DON confirmed that Resident 1's urine sample identifying Klebsiella pneumonia was reported on 6/7/23 after Resident 1 had left the facility. 555333 Page 2 of 4 555333 08/10/2023 Lincoln Meadows Care Center 1550 Third Street Lincoln, CA 95648

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 8/10/23 at 1:34 p.m. with LN 1, LN 1 stated urine sample can be obtained by clean catch. If that sample was contaminated may do straight catheter to obtain sample. LN 1 stated that she documents in the progress notes when a sample was collected and sent. During an interview on 8/10/23 at 1:51 p.m. with LN 2, LN 2 stated if urine specimen needed can use bed pan or use catheter to collect urine. LN 2 stated, Need a clean sample, best to do straight cath for sample. It is a sterile process. When asked if he had received any education on collecting urine samples, LN 2 stated had received education in school but not at the facility. During an interview on 8/10/23 at 2:43 p.m. with LN 3, LN 3 stated to obtain urine sample, need to use clean catch or sterile catheter. LN 3 stated to obtain sample by clean catch use hat (specimen collector placed on the toilet) to collect urine. The sample collection is documented in the progress notes. During an interview on 8/10/23 at 3:23 p.m. with the DON, the DON acknowledged that all nurses may not be aware of urine collection process and are not clear about documentation. The DON stated, Not charting or not doing correctly causes inaccurate results and can delay treatment. More education is needed. During an interview on 8/10/23 at 3:30 p.m. with the Director of Staff Development (DSD), the DSD acknowledged that the Licensed Nurse Master Competency Worksheet does not indicate any competency evaluation on how to collect urine samples. The DSD stated, It was not included and should have been. The check list needs to be revised. During a telephone interview on 8/11/23 at 3:34 p.m. with LN 4, LN 4 stated she obtained two urine samples from Resident 1. LN 4 stated the first sample she collected was from the foley catheter which was still in place on 5/21/23, when she collected the sample. LN 4 stated a few days later she collected a urine sample by straight cath as the foley catheter had been discontinued. LN 4 stated she did not use clean catch to obtain any urine sample. LN 4 stated she obtained about two milliliters for the second sample from the straight cath. LN 4 stated she had learned in nursing school that two milliliters is all you need for sample. LN 4 stated that using a straight cath is a clean procedure not a sterile procedure. LN 4 stated she did not know how the first sample drawn on 5/21/23 became contaminated. LN stated she did not chart in the progress notes how sample was obtained or the next steps. LN 4 stated she only documented in MAR that it was completed. LN 4 stated that has always been the process to just check off in the MAR and not document in the progress notes. During a telephone interview on 8/16/23 at 10:54 a.m. with the laboratory General Manager (GM), the GM stated that Resident 1''s urine sample collected on 5/21/23 had multiple organisms, likely contaminants. The GM stated that the sample collected on 5/27/23 had insufficient amount as it appeared specimen container had leaked but was unable to see from the notes how much was in the container. When asked what the minimum amount of urine needed for sample, the GM stated that two milliliters was likely not enough. During a telephone interview on 8/16/23 at 11:59 a.m. with the DON, the DON stated that the minimum for urine sample is probably more than two milliliters but would need to check the policy to confirm. The DON stated that aseptic (free from contamination- maintains sterility) technique is used for straight catheter insertion to obtain urine sample. The DON acknowledged that documentation for Resident 1's urine sample collection was not complete and she has identified areas for improvement regarding documentation. The DON stated, Nurses may have learned procedures in school, but we need to 555333 Page 3 of 4 555333 08/10/2023 Lincoln Meadows Care Center 1550 Third Street Lincoln, CA 95648

F 0726 'rehash' the competency checklist. Level of Harm - Minimal harm or potential for actual harm A review of the facility's policy and procedure (P&P) titled Urine Specimen: Straight Catheterization, not dated, indicated .The purpose of this procedure is to obtain a urine specimen using a straight catheter .Open the straight catheter package and use the inside of the package as the sterile field .Don sterile gloves .Minimum 20-30 cc [cubic centimeters-milliters] needed for specimen .Documentation .The date and time the specimen was collected .The character, clarity and color of urine .All assessment data obtained during the procedure .How the resident tolerated the procedure . Residents Affected - Few A review of the facility's P&P titled Catheter Care, Urinary, revised 8/22, indicated .Use aseptic technique when inserting a urinary catheter .Use aseptic technique handling or manipulating the drainage system .The following information should be recorded in the resident's medical record .The date and time that catheter care was given .The name and title of the individual(s) giving the catheter care .How the resident tolerated the procedure . A review of the facility's P&P titled Clean Catch Urine Specimen, revised 10/10, indicated .The purpose of this procedure is to collect a clean catch urine specimen for laboratory analysis .The following should be recorded in the resident's medical record .The date and time that the specimen was collected .The name and title of the individual(s) who performed the procedure .The character, clarity and color of the urine .The date and time the specimen was sent to the lab .How the resident tolerated the procedure . 555333 Page 4 of 4