Health inspection·December 31, 2024

F690 Bowel/Bladder Incontinence, Catheter, UTI 42 C.F.R. § 483.5 Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. 42 C.F.R. §483.25(e)(2) For a resident with urinary incontinence, based on the resident’s comprehensive assessment, the facility must ensure that (ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident’s clinical condition demonstrates that catheterization is necessary; and (iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible.

F684 Quality of Care   42 C.F.R. § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility patients. Based on the comprehensive assessment of a patient, the facility must ensure that patients receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the patients’ choices, including but not limited to the following:    On 11/14/2024 at 8:40 AM, an unannounced visit was conducted by the Department of Public Health at the facility to investigate a complaint regarding the quality of care and Patient 1’s death. As a result of the investigation the Department determined the facility failed to: 1. Ensure that Resident 1 received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan when the nursing staff failed to assess and monitor Resident 1’s urinary output from her indwelling catheter (a thin, flexible tube that drains urine from the bladder into a collection bag outside the body). 2. Comply with regulations for nursing services when it did not record fluid intake and output for Resident 1, who had an indwelling catheter, and did not evaluate these records at least weekly and every shift, and maintain each evaluation included in the licensed nurse’s progress notes, as evidenced by the facility’s inability to produce any record showing that the facility staff ever monitored the I&O (a procedure on inserting a catheter to the into the urethra to the bladder to check for urine output) of Resident 1. 3. Ensure Resident 1’s right to be free from neglect was not violated by failing to provide necessary services to be free of physical harm, when it failed to manage Resident 1’s risk of infection due to an indwelling catheter by assessing her urine output appropriately and otherwise performing the necessary services required by standards of nursing care for management of an indwelling catheter and prevention of urosepsis (a life-threatening medical emergency that occurs when a urinary tract infection spreads into the bloodstream and causes a systemic infection). 4. Implement its policy on indwelling urinary catheter (a thin, flexible tube that drains urine from the bladder into a collection bag outside the body) by failing to maintain an accurate record of Resident 1’s daily urine output to prevent a catheter-associated urinary tract infection (infection of the urinary system that collects and drains urine, such as the ureter, bladder, kidney, and urethra). 5. Immediately report to the physician when Resident 1 was noted without urine output with an in-and-out catheter on 12/14/2023 at 6:59 AM. 6. Monitor for signs and symptoms of UTI such as presence of sediment (a solid particles containing bacteria, blood crystal that exit through the urine), foul odor, blood, color, and pain or burning with urination or back pain while having indwelling urinary catheter.   These deficient practices resulted Resident 1’s hospitalization to a General Acute Care Hospital (GACH), transported via 911 (an emergency service) that required ICU ( Intensive Care Unit- an area in the hospital that care for residents with critically ill or with life threatening illness) care including IV (Intravenous or into the vein) fluids due to dehydration (severe loss of body fluids), IV medications to help increase BP, and high level of oxygenation due to hypoxia (low oxygen level in the blood). Resident 1 expired on 12/16/2023 at 1:50 PM at the GACH with the primary cause of death septic shock (a life-threatening infection in the blood that occurs when the body's immune system has an extreme response to an infection or injury) and urosepsis.   A review of Resident 1’s Admission Record indicated Resident 1 was an 88 years old female admitted to the facility on 11/29/2023 with diagnoses that included dementia (a progressive brain disorder that results in impaired reasoning and loss of memory), severe sepsis without septic shock and pneumonia (a severe infection of the lungs that results in difficulty breathing) and cerebral vascular accident (CVA-blockage or disruption of blood flow to the brain).   A review of Resident 1’s Progress Notes, indicated the facility admitted the Resident 1 from the GACH with an indwelling urinary catheter on 11/29/2023.  A review of Resident 1’s Care Plan, dated 11/30/2023, indicated Resident 1 had an indwelling catheter in a closed system drainage for neurogenic bladder (a condition that occurs when the nerves and muscles of the bladder do not communicate properly with the brain, resulting in a loss of bladder control) related to stroke (also known as CVA). The care plan interventions indicated to monitor and document the fluid intake and output of Resident 1 per facility policy to prevent the Resident from urinary tract infection.   A review of Resident 1’s Minimum Data Set (MDS – a resident assessment tool), dated 12/05/2023, indicated that the Resident 1’s cognition (mental action or process of acquiring knowledge and understanding through thought, experience, and senses) was severely impaired and that the resident had an indwelling urinary catheter. A review of the Nursing Progress Notes, dated 12/13/2023 at 6:48 PM, indicated Resident 1’s family complained that the resident had trouble breathing with oxygen saturation at 92%, lung sounds clear, and was complaining of pain, and requested the facility staff to remove the indwelling catheter due to pain. The note indicated the family and Resident 1 could not specify the exact location of the pain. A review of Resident 1’s Physician Order and Summary Report indicated, the physician ordered on 12/13/2023 at 10:58 PM to remove Resident 1’s indwelling catheter and start in and out catheter (inserting a catheter to determine the amount of urine in the bladder) every six hours for two days, and if residual ( the amount of urine remaining in the bladder) is greater than 300 cc/ml (milliliters, unit of volume) reinsert the catheter and notify the physician. A review of Resident 1’s Physician Order and Summary Report indicated, the physician ordered on 12/13/23 at 10:59 PM, the physician ordered to start voiding trial (a procedure to determine the Resident can urinate without the indwelling catheter) and start in and out catheter every six hours for two days. A review of the Medication Administration Record (MAR) indicated Resident 1’s indwelling catheter was removed on 12/13/2023 at 11PM. A review of Resident 1’s Physician Order and Summary Report indicated, the physician ordered on 12/13/23 at 11:53 PM, to monitor output every shift and if no urine output do a straight catheter every six hours for two days. During a review of the Change of Condition report, dated 12/13/2023, timed at 11:23 PM, indicated Resident 1 had shortness of breath and labored breathing that started in the afternoon at 5:23 PM with BP 155/91 and heart rate 103 and respiratory rate 18 per minute and oxygen saturation at 97%. The COC indicated Resident 1 had a “decrease in level of consciousness (sleepy, lethargica) with gradual change in level of consciousness, “which was reported to the physician at 6:36 PM. The COC indicated Resident 1’s family was concerning that Resident 1 was exhibiting pain from indwelling catheter and requesting indwelling catheter to be removed, noted with dark amber urine. The MD (medical doctor) aware with new orders noted and carried out.” A review of the Nursing Progress Notes on 12/14/2023 at 6:49 AM, indicated Resident 1 was on monitoring after the removal of the indwelling catheter and Resident 1 had no urine output. The notes indicated 50cc was collected when the straight catheter (a procedure to remove urine in the bladder using a flexible catheter) was performed. The report indicated on 12/14/24 at 6:55 AM, Resident 1’s blood pressure was 152/98, heart rate 86 per minute, oxygen saturation 93-94% receiving oxygen at 2 liters per minute. A review of the Nursing Progress Notes, dated 12/14/2023 at 9:09 AM, indicated, RN 1 was requested by LVN 1 to assess Resident 1 who was not responsive to painful stimuli, sternal rub (rubbing the chest to check for pain) with no response, resident with rales noted in upper lobes of the lungs, resident also noted to have sternal retractions with breathing and variable respiratory rates with apnea (slow shallow breathing) episodes, physician order received to send via 911 to hospital, Resident was placed on Non Rebreather (NRB) mask (a device used to deliver high concentrated oxygen) mask and RN stood at the resident’s bedside until 911 arrived, report given at bedside. A review of the Nursing Progress Notes on 12/14/2023 from 6:49 AM to 9:09 AM, there was no indication the physician was informed about Resident 1’s urine output of 50 cc. A review of Resident 1’s Paramedic Report, dated 12/14/2023 indicated the paramedics (medical emergency personnel) arrived at the facility on 12/14/2023 at 8:57 AM. The report indicated Resident 1 was found in an altered level of consciousness, which the staff reported the had been altered for three hours, with BP 88/61, HR 128, RR 24, and Oxygen saturation 93%. Resident 1 was transported to the hospital by the paramedics and was given 250 cc NS via IV due hypotension. The report indicated Resident 1 met the criteria for sepsis. A review of the Nursing Home to Hospital Transfer Form indicated on 12/14/2023 at 9:36 AM, Resident 1 was transferred to the hospital due to shortness of breath (bronchitis, pneumonia) with oxygen saturation of 91%. The COC indicated Resident 1 had with increasing respiratory distress and decreased alertness, resident normally alert to self but will interact with staff and attempt to get out of bed on her own, resident noted to have increased respiratory difficulty during evening and night shift. A review of Resident 1’s General Acute Care Hospital (GACH) records indicated that the Resident presented to the emergency unit on 12/14/2023 at 9:28 AM, upon arrival to GACH Resident 1 had altered mental status, somewhat unresponsive, with fever and shaking with low oxygenation and low BP (the measurement of the blood pressure) and received IV fluids given due to low BP, dehydration septic shock. IV antibiotics initiated. A review of the GACH record indicated Resident 1 had the following laboratory test result on 12/14/2023 at 9:38 AM indicated as follows: Lactate level- 5.2 mmol/L (millimole per liter)- a unit of measurement (reference range 0.5-2.2 mmol/L)- a medical emergency due to lactic acidosis in the blood (a condition cause by severe dehydration or sever infection or septic shock) White Blood Count (WBC) – 27.50 (reference range 3.98-10.04 K/uL [cubic milliliter])-can be an indication of presence of infection. Creatinine 3.46 (reference range 0.55- 1.02mg/dL)- indication of kidney failure BUN 65 (reference range 9-23 mg/dL) – indication of kidney failure or dehydration. A review of the History and Physical from the GACH with the date of service 12/14/2023 at 3:47 PM, indicated Resident 1 was admitted to Emergency Department (ED) unresponsive, hypoxic (low oxygen level in the blood) and noted in septic shock and pneumonia in critical condition. The H&P report indicated the VS in the last 24 hours on 12/14/2023 to 12/15/2023 were as follows: Temperature: 97.7 F BP 74/57/ to 132/83 Pulse (heart rate normal range 60-100 per minute) 83 to 126 per minute. Respiratory rate (normal range 16-20 per minute) 20-44 per minute SpO2 (oxygen saturation)-84% to 100%. The H&P report on 2/14/2023 at 3:47 PM, Resident 1’s VS are as follows: BP 99/76 Pulse 124 per minute Respiratory rate 33 per minute SpO2 -90% while receiving 15 liters per minute of nonrebreather mask (a medical device that delivers high concentrated oxygen to Residents who can breathe on their own but need extra oxygen). A review of the Expiration Summary from the GACH records, indicated Resident 1 expired on 12/16/2023 at 1:50 PM with the primary cause of expiration was cardiac arrest (when the heart suddenly stops beating, preventing blood from circulating to the brain and other organs) and contributing causes of death included septic shock and active problems that included acute renal failure. A review of Resident 1’s Death Certificate indicated that the resident expired in the GACH with on 12/16/2023 at 1:50 PM, with the primary cause of death was septic shock and urosepsis. During an interview with the Director of Nursing (DON) on 11/14/2024 at 3:20 PM, she stated that it is the policy of the facility to monitor the I&O (fluid intake and output monitoring) of the residents, if the resident has an indwelling urinary catheter.  During a concurrent review of Resident 1’s medical record with the DON, she stated that she could not find any record that would show that the facility’s staff monitored the I&O of Resident 1 while she had an indwelling urinary catheter during her stay in the facility and when the indwelling catheter was removed. The DON also stated there was no documentation that the physician was informed when the Resident had no urine output and when the residual urine output was 50cc after a straight catheterization was done.   During an interview with the DON on 11/15/2024 at 10:56 AM, she stated I&O catheterization monitors the fluid intake and the urine output of Resident 1 who has an indwelling catheter to determine if the Resident 1 is retaining urine in the bladder. The DON stated monitoring the urine output can also detect if Resident 1 was dehydrat