Health inspection·November 27, 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, interview and record review the facility failed to ensure that 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 (Resident #4) reviewed for indwelling catheter. The facility failed to ensure Resident #4's indwelling catheter bag was kept from touching the floor. This deficient practice could place residents with indwelling catheters at risk of disease and infection. Findings include: Record review of Resident # 4's face sheet, dated 11/27/24, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #4 had diagnoses which included urinary tract infection (a bacterial infection that affects the urinary tract, which includes the bladder, ureters, and kidneys) and retention of urine (a condition that occurs when a person is unable to empty their bladder completely). Record review of Resident # 4's quarterly MDS, dated [DATE], revealed an intact cognition BIMS score of 14 to be able to recall and make daily decisions. Resident #4 was diagnosed with Neurogenic Bladder (condition that occurs when the nerves and muscles in the bladder don't communicate properly with the brain, resulting in loss of bladder control) and retention of urine. Record review of Resident #4's care plan, dated 06/03/24, revealed indwelling catheter related to infection. Check tubing for kinks each shift. Monitor and document intake and output as per family policy. Resident #4 was coded for indwelling catheter. Record review of Resident #4's order recap, dated 06/02/24, revealed Foley catheter: Change drainage bag as needed for leaking/obstruction. Privacy Bag for urinary drainage bag at all times while in bed, while walking or in wheelchair every shift. Record review of Resident # 4's care plan, dated 06/02/24, revealed bladder incontinence with the presence of catheter: Indwelling. Assess resident for bowel and bladder training. Change catheter/drainage bag/tubing per MD orders. Ensure staff aware of correct placement of catheter gravity drainage bag and tubing. Keep tubing/bag below the bladder, do not kink tubing. Page 1 of 2 745038 745038 11/27/2024 Avir at Tierra Este 14300 Pebble Hills Blvd El Paso, TX 79938

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation and interview on 11/19/24 at 10:13 AM, with Resident #4 revealed Resident #4 was on his bed lying down and watching television. A nurse's tray table was positioned towards Resident #4's left side. It was observed Resident #4's catheter bag was hanging off the left side touching the floor and the leg of the nurse's tray table. Resident #4 stated he did not notice his catheter bag was on the floor. Resident #4 stated it could have been when the nurse or CNA was in the room where they did not hang it on the side of the bed. Resident #4 stated he could not remember when the last time they had gone into the room. During an interview on 11/26/24 at 10:32 AM, LVN B stated catheter bags were to be hooked on the resident's bed with a privacy bag on it. LVN B stated the bags were hung so as not to pull on the resident's private parts which could hurt them or cause injury. LVN B stated the catheter bag was to be off the floor and not touching the floor. LVN B stated it was the nursing staff's responsibility to ensure the catheter bags like Resident #4's was off the floor and hung. LVN B stated the risk would be contamination and hygiene purposes. During an interview on 11/26/24 at 11:11 AM, , the DON stated residents who had catheter bags were to have them hooked on the side of the residents' bed. The DON stated the catheter bags were not to be on the floor due to the risk of infection. The DON stated Resident #4's catheter bag should have been hung and not on the floor. The DON stated everyone was responsible for ensuring the catheter bag(s) were hung on the bed or the wheelchair depending on where the resident was at. During an interview on 11/26/24 at 10:16 AM, CNA A stated residents were to have the catheter bags next to the resident. CNA A stated when the resident was in the wheelchair then it would be hung underneath. CNA A stated if the resident was on the bed, then it would be hung on the side of the bed. CNA A stated the catheter bag could not be on the floor due to contamination. Record review of the facility's Indwelling Catheter Use and Removal, dated 07/20, revealed Policy: It was the policy of the facility to ensure that indwelling urinary catheters that are inserted or remain in place area justified or removed according to regulations and current standards of practice . The use of indwelling catheters increase the risk of urinary tract infections. If an indwelling catheter was in use, the facility will provide appropriate care for the catheter in accordance with current professional standards of practice and resident care policies and procedures. Record review of the facility's Infection Prevention and Control Program policy, dated 03/2022, revealed The facility has established and maintains an infection prevention control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. 745038 Page 2 of 2