Health inspection·August 23, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a care plan for bladder scanning for one of three residents (Resident 1) when: 1. Resident 1's bladder scanning, and straight catheterization were not done as ordered by the physician. 2. The Licensed Nurses (LN) did not follow their straight catheterization procedure. 3. The facility did not educate their nurses on bladder scanning and straight catheterization. As a result, Resident 1 had a change of condition and was transported to the hospital where he was treated with intravenous (IV) antibiotics for a urinary tract infection, sepsis (blood infection), and urinary retention. Findings: A review of Resident 1's undated facility face sheet was conducted. Resident 1 sustained a fall at home, which resulted in a collar bone fracture. After stay in the hospital the resident was admitted to the facility on [DATE], with diagnoses which also included a history of type 2 diabetes mellitus (condition of having elevated blood sugar), and stage 3 kidney failure (a moderate amount of kidney damage due to chronic kidney disease). 1. On 4/7/22, a review of Resident 1's facility record was conducted. The record titled Order Summary Report indicated on 2/26/21, Resident 1's physician ordered, Bladder scan every 8 hours. May straight cath (catheterization) if over 400 cc (cubic centimeter) . Per Resident 1's Treatment Record for February and March 2021, the order stated, Bladder scan every 8 hours. May straight cath if over 400 cc and report to MD as needed for Bladder discomfort. Hours: PRN (as needed). Per the treatment record Resident 1's bladder was scanned only twice in 6 days, on 2/27/21 and 3/4/21. Further review of Resident 1's Progress Notes indicated that Resident 1 was straight cathed for 1000 cc of clear urine on 2/27/21, and 1400 cc of cloudy colored urine on 3/4/21, resident noted to be having chills, temperature was recorded at 98 degrees Fahrenheit and blood pressure at 100/53, the physician was notified, and an order was obtained for an antibiotic and a urine culture. Page 1 of 3 555806 555806 08/23/2023 Glenbrook 1950 Calle Barcelona Carlsbad, CA 92009

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Per the record titled Progress Notes dated 3/5/21 at 5:38 A.M., Resident 1 was difficult to arouse, blood pressure was 72/35 and he was non-verbal. Physician 2 (PH 2) ordered for Resident 1 to be transferred to the emergency room for further evaluation. On 4/18/22 at 4 P.M., an interview and concurrent record review was conducted with License Nurse (LN) 1 [in person] and the Director of Nurses (DON) [via phone]. LN 1 stated the physician's order, written for Resident 1 on 2/26/21 to bladder scan was a PRN (as needed) order and not a regular routine every 8-hour order. LN 1 was insistent and repeated that the order was PRN, and the bladder scanning did not need to be done every 8 hours. The DON stated the order clearly indicated the physician wanted Resident 1 to be scanned every 8 hrs. The DON stated the nurses did not follow the physician's order. The DON stated if Resident 1 was retaining urine and he needed the bladder scanning as ordered to prevent bladder and/or kidney infection and possible kidney failure. The DON stated the licensed nurses should have bladder scanned Resident 1 every 8 hrs. as ordered. The DON stated the nurses should have also contacted the physician when the resident was having that much urine retention at one time. On 5/2/22, a review of Resident 1's acute care hospital record was conducted. The record titled Hospital Medicine Discharge summary dated [DATE], indicated that Resident 1 was admitted to the acute care hospital on 3/5/21, from the facility with UTI, sepsis, acute renal failure (kidneys not functioning), and urinary retention. He was treated with IV antibiotics and was discharged to home on 3/10/21, with an indwelling catheter and a recommendation for outpatient urology follow up. On 5/17/22 at 12:09 P.M., a phone interview and concurrent record review was conducted with Physician (PH) 1. PH 1 stated it was his expectation that facility was going to bladder scan Resident 1 every 8 hours and then straight cath the resident if the bladder scan read more than 400 cc in the bladder per his 2/26/22 order. PH 1 stated his order was not a PRN (as needed) order. PH 1 stated Yes, that is a problem if the resident was retaining 1400 cc of urine and not straight cathed. PH 1 stated if continuous bladder retention was occurring and not addressed it could lead to bladder discomfort and could result in renal failure, UTI (urinary tract infection), or post obstructive nephropathy (kidney dysfunction). PH 1 stated he would have expected a phone call from the facility if resident was having continued amount of urine retention. A facility document review was conducted. The document titled Required Services revised 8/02/2021 indicated, .(f) The facility shall ensure that all orders, written by a person lawfully authorized to prescribe, shall be carried out unless contraindicated . 2. A review of a facility document was conducted. The document titled Catheterization, Intermittent, Male Resident with a revision date of 2010 indicated, .Do not remove more than 800 mL (milliliters) of urine at one time . On 4/18/22 at 4 P.M., a phone interview and concurrent record review was conducted with License Nurse (LN) 1 and the facility's Director of Nursing (DON). LN 1 stated she did not follow the policy when straight catheterizing Resident 1 when she removed over 1400 cc of urine from his bladder. LN 1 stated she should have stopped at 800 cc. LN 1 was unable to give a rationale as to why she should not remove more than 800 cc. The DON stated catheterizing someone for more than 800 mL could cause infection, pain, possible renal failure and was just too big of a shift in fluid at one time in the body. On 6/2/22 at 8:50 A.M., a phone interview was conducted with the facility's Director of Staff 555806 Page 2 of 3 555806 08/23/2023 Glenbrook 1950 Calle Barcelona Carlsbad, CA 92009

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Development (DSD). The DSD stated the licensed nurses should not be removing more than 800 cc of urine when straight catheterizing a resident because it is too much of a fluid shift for the resident and could cause medical complications. The DSD stated it is important to remove no more than 800 cc of urine from the bladder at one time when catheterizing a resident to prevent fluid shift complications. 3. On 5/9/22 at 7:07 A.M., a phone interview was conducted with License Nurse (LN) 3. LN 3 stated the facility had a new bladder scanner when Resident 1 was at the facility. LN 3 stated he did not receive formal training from the facility on the new bladder scanner. LN 3 stated he did not remember receiving any education from the facility on straight catheterization of a resident. LN 3 stated if the bladder scanner said a resident had 1500 cc in a resident's bladder, he would straight catheterize them and remove 1300 cc to 1500 cc from their bladder if there was an order to straight catheterize the resident. On 5/17/22 at 10:51 A.M., the facility's Director of Nursing (DON) confirmed via email that LN 1, LN 2, LN 3, and LN 4 who cared for Resident 1 while at the facility did not receive any education or competency evaluation on bladder scanning or straight catheterization of a resident prior to June 2021. On 6/2/22 at 8:50 A.M., a phone interview was conducted with the facility's Director of Staff Development (DSD). The DSD stated it was very important for the Licensed Nurses (LNs) to have education on bladder scanning and bladder catheterization. The DSD stated if the LNs do not catheterize a patient correctly it could lead to bladder infections and kidney problems. The DSD stated if the LNs do not know how to use the bladder scanner properly the LNs may not be able to identify if the resident is retaining urine. The DSD stated if the LNs do not identify if the resident is retaining urine it could lead to the resident getting a bladder infection and/or kidney problems. The DSD stated if the resident is retaining urine the nurse should call the doctor to let them know. The DSD stated the LNs should not be removing more than 800 cc of urine when straight catheterizing a resident because it is too much of a fluid shift for the resident and could cause medical complications. The DSD stated it is important to remove no more than 800 cc of urine from the bladder at one time when catheterizing a resident to prevent fluid shift complications. 555806 Page 3 of 3