Health inspection·April 6, 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 observation, interviews and record reviews, the facility failed to provide appropirate treatment and services to prevent urinary tract infections for one resident (Resident #8) of three residents reviewed for catheter care. Resident #8's catheter drainage collection bag was left on the floor. Resident #8 has history of urinary tract infections. This deficient practice could affect residents with catheters and could result in cross contamination of germs and could result in a urinary tract infection (a painful infection of the urinary system, which includes the kidneys, bladder, urethra, and ureters). The findings included: Review of Resident #8's face sheet dated 04/06/2023, revealed resident was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #8's diagnoses include sepsis due to methicillin resistant staphylococcus aureus (staph infection that is difficult to treat because of resistance to some antibiotics), stroke, acute respiratory failure, neuromuscular dysfunction of bladder (urinary conditions in people who lack bladder control due to brain, spinal cord or never problem), repeated falls, dementia, cerebral aneurysm, type-2 diabetes, and hypertension (high blood pressure). Review of Resident #8's quarterly MDS assessment dated [DATE] revealed Resident #8 had a BIMS score of 0 which indicated he was severely impaired cognitively. Resident #8 with Indwelling catheter, always incontinent of both urinary and bowel continence. Review of Resident #8's care plan dated 4/6/2023 revealed Focus: resident has Foley Catheter and is at risk for Increased Urinary Tract Infections: Date Initiated: 10/05/2022. Interventions: CATHETER: The resident has 16fr catheter; Position catheter bag and tubing below the level of the bladder and away from entrance room door; Check tubing for kinks each shift; Monitor for signs and symptoms of discomfort on urination and frequency; Monitor/document for pain/discomfort due to catheter; Monitor/record/report to medical doctor for signs or symptoms of UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Observation on 04/06/2023 at 9:45 a.m., HHSC Investigator walked by an opened door room [ROOM NUMBER] and observed Resident #8 lying in bed with a drainage collection bag lying flat on the floor next Page 1 of 2 675722 675722 04/06/2023 Focused Care at Fort Stockton 501 N Sycamore Fort Stockton, TX 79735

F 0690 to his bed. Investigator knocked on the door and Resident #8 sound asleep. Level of Harm - Minimal harm or potential for actual harm During an interview on 04/06/2023 at 9:50 a.m., RN C said that staff had just given Resident #8 a bed bath approximately 15 to 20 minutes before. RN C said that the drainage collection bag was supposed to be attached to the bed and not just left lying on the floor. RN C said the risk of the drainage collection bag left lying on the floor is infection control as urine may leak on the floor. RN C said Resident #8 was at risk of urinary tract infections and had history of urinary tract infections last noted during a hospital stay on November 30th, 2022. Residents Affected - Few During an interview on 04/06/2023 at 3:30 p.m., DON said the drainage collection bag should never be left on the floor. DON said the collection bag should be attached to the side below bladder level of the resident. DON said the collection bag being on the floor is an infection control issue due to resident's risk of urinary tract infections. DON said that CNAs and Nurses were responsible to ensure that the collection bag is securely attached to the bed. DON said that monthly in-services are conducted with all facility staff to include infection control. Review of facility Infection Control policy revised 01/15/2022, reads in part this community's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The objectives of the infection control policies and practices are to prevent, detect, investigate, and control infections in the community. Review of facility policy Catheters-Insertion and Care dated 04/2021, reads in part it is the policy of this community that the resident with a urinary catheter will be provided services in a safe and appropriate manner to minimize the risks of urinary tract complications. Procedures include secure urinary drainage bag below the level of the bladder and keep off the floor. 675722 Page 2 of 2