Health inspection·February 2, 2024

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure Treatment Nurse (TN) 3 had the specific competencies and skill sets necessary to safely perform a nephrostomy tube (small tube that helped drain urine from kidney) dressing change for one of one sampled resident (Resident 1). This failure resulted in Resident 1 ' s nephrostomy tube being cut, requiring transfer to a general acute care hospital (GACH) and increased the risk for infection and medical complications for the resident. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including hydronephrosis with renal and ureteral calculous (kidney swelling due to back up of urine), obstructive and reflux uropathy (inability for urine to drain through the urinary tract), and benign prostatic hyperplasia (enlarged prostate). During a review of Resident 1 ' s History and Physical (H&P) dated 12/27/2023, the H&P indicated Resident 1 had the mental capacity to understand and make medical decisions. During a review of Resident 1 ' s Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 12/27/2023, the MDS indicated Resident 1 required partial, moderate assistance with activities of daily living (ADL) such as dressing, toilet use, personal hygiene, transfer (moving between surfaces to and from bed, chair, and wheelchair) and bed mobility (how resident moves from lying to turning side to side). During a review of Resident 1 ' s physician orders dated 12/24/2023, the physician orders indicated to cleanse Resident 1 ' s pigtail (catheter in the renal pelvis) nephrostomy tube on the right and left flank (side of the body) with normal saline ([NS] sterile solution of sodium chloride in water), pat dry and cover with non-woven drain sponge (precut dressing with a slit used for drain tubes which helped absorb unwanted fluid ), every shift. During a review of Resident 1 ' s change of condition (COC) dated 12/27/2023 at 2:00 p.m.,the COC indicated, while providing treatment, the tegaderm film (transparent dressing that adhered to the skin) was tangled alongside the catheter and was difficult to remove therefore (TN 3) continued to cut the film around the tube to remove it and Resident 1 ' s nephrostomy tube to the left side was accidentally snipped. The COC indicated Resident 1 was transferred to a GACH for further for further Page 1 of 2 555348 555348 02/02/2024 Granada Post Acute 3565 E Imperial Hwy Lynwood, CA 90262

F 0726 evaluation and treatment. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 1 ' s GACH record dated 12/27/2023, the GACH record indicated Resident 1 presented to the emergency room with a lacerated (cut) tube caused by nursing at the skilled nursing facility. The GACH record indicated the resident needed placement of a new nephrostomy tube. Residents Affected - Few During interviews on 2/2/2024 at 12:20 p.m. and 1:00 p.m. with TN 3, TN 3 stated, she was cleaning Resident 1 ' s wound and the tegaderm was stuck around the nephrostomy tube and difficult to remove so she grabbed scissors and tried to cut the tegaderm in pieces. TN 3 stated, as she was cutting the tape in the middle, she noted that she had cut the tube. TN 3 stated, she used scissors because the tegaderm was tangled. During an interview on 2/2/2024 at 1:23 p.m. with Registered Nurse (RN). RN stated, scissors should not be used to remove resident ' s bandages because there was a potential to cut the tube or cut the resident. RN stated, an adhesive removal could be used if the dressing became sticky or got stuck. scissors. RN also stated, it could be very risky to cut the tubing because it was very thin. During an interview on 2/2/2024 at 1:40 p.m. with the Director of Nursing (DON), the DON stated, Resident 1 ' s nephrostomy tube was still inserted in the resident ' s skin, but the lower half of the tube was cut, and needed to be replaced. The DON stated, when changing the nephrostomy tube dressing, the nurses must assess the site for redness, infection or swelling. DON stated scissors should be used away from the resident because there would be risk of cutting the resident and the resident ' s tube. The DON stated, nurses should be cautious with the tools being used and the incident with Resident 1 could have been avoided. During a review of the facility ' s undated Treatment Nurse Job Description, the Job Description indicated it was the general duty and responsibility of the Treatment Nurse to follow safety policies when administering treatments and to monitor inventory of supplies, equipment and/or treatment materials to meet resident needs. The Job Description indicated specific requirements included, demonstrating knowledge and skills necessary to provide care appropriate to the age-related needs of the residents served. During a review of the facility ' s policies and procedures (P&P) titled, Nephrostomy Tube Care, dated, 9/2015 the P&P indicated to verify that there was a physician ' s order for the procedure and a plan of care to address the nephrostomy tube and any special needs the resident may have. The P&P indicated, equipment and supplies for dressing changes included sterile 4x4 drain dressing, cleansing solution and swabs as ordered by the physician, adhesive tape, disposable underpad, sterile drape and waste bag. 555348 Page 2 of 2