Health inspection·July 25, 2024

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, record review and interview the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 4 residents observed for catheter use. Resident #1's catheter urine drainage port was draped over the side rail (above the body) restricting flow of urine to the collection bag. This failure could place residents who use cathethers at risk for potential complications or infections related to obstructed urine flow. The finding were: Review of admission record revealed Resident #1 was an [AGE] year-old female with the following diagnoses: Alzheimer's Disease, Muscle Wasting, Dehydration, need for assistance with personal care, lack of coordination and functional urinary incontinence. Resident #1's Minimum Data Set, dated [DATE] section H revealed resident #1 had an indwelling catheter and a BIMS of 0 indicating resident was unable to complete assesment. Review of Resident #1's care plan revised date 03/06/24, revealed resident had catheter due to obstructive uropothy [structural hinderance to urine flow]. Care plan indicated, Catheter: The resident has 16F indwelling catheter, Position catheter bag and tubing below the level of the bladder and away from the entrance of the door Observations on 07/23/24 at 9:55 a.m. revealed Resident #1 was laying in a supine position, well groomed and appropriately dressed. A tubing could be seen coming out from under a blanket and hanging over the left side handrail. Resident was alert but lacked mobility to move the tubing and was unable to provide information on how or who positioned the tubing in that location. Observation on 07/23/24 at 10:50 am revealed resident position on left lateral side. Resident #1 was sleeping. The tubing could be seen coming out from under the residents blanket and hanging over the left side rail. Observation and interview on 07/23/24 at 11:55 am was conducted with CNA A. CNA A confirmed the tubing hanging over Residents #1's side rail was part of Resident #1's catheter. Page 1 of 2 676125 676125 07/25/2024 Windsor Atrium 1814 Atrium Place Harlingen, TX 78550

F 0690 Fluid could be seen in the tubing. CNA A said the tubing should not be above the body. Level of Harm - Minimal harm or potential for actual harm In an interview on 07/23/24 at 11:57 a.m. with CNA B said the tubing for the catheter should not be above the resident's body because it could cause back flow of urine and create complications. Residents Affected - Few Interview an interview on 07/23/24 with the DON at 12:10 p.m. she said staff were trained upon hire and throughout the year on how to provide care for residents with catheters and other specialized care. The DON said the catheter tubing should be placed below the bladder to prevent any possible back flow which could lead to infections. Resident #1 did not have any signs or symptoms of urinary tract infections. Facility Female Urinary Indwelling Catheter Care Competency revealed: 29. Hang the collection bag below the bladder. 30. secure the catheter to the resident thigh using leg band with velcro closure or tape 676125 Page 2 of 2