**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and the facility's policy, the facility failed to ensure one resident (#126) was informed of the risks and benefits of a psychotropic medication prior to the administration of the medication. The deficient practice could result in not being informed and not able to exercise the right to choose the preferred option. Findings include: Resident #126 was admitted to the facility on [DATE], with diagnoses of dementia, anxiety, and mood disturbance. A physician's order dated August 3, 2023, revealed an order for Amitriptyline (antidepressant) 100 milligrams by mouth at bedtime for depression. Review of the MAR (Medication Administration Record) for August 2023 revealed the resident was administered Amitriptyline on August 3, 2023. However, review of the clinical record revealed no evidence the resident was informed of the risks and benefits prior to administration of Amitriptyline on August 3, 2023. An interview was conducted on August 10, 2023 at 10:49 a.m. with the director of nursing (DON/staff #48). She stated that the consent for the use of psychotropic medications that included explaining the risks and benefits must be obtained from the resident or the POA (power of attorney) and/or resident representative prior to the administration of the psychotropic medication. In an interview with a registered nurse (RN/staff #28) conducted on August 10, 2023 at 12:16 p.m., the RN stated that the process for psychotropic medication use included educating the resident or family of the risks and benefits before the medication was administered. She stated that if the resident cannot give consent, she would call the POA and get verbal consent with two nurses present. Further, the RN stated that if no consent was obtained, the psychotropic medication cannot be administered. The facility's policy on Use of Psychotropic Medication revealed residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s). The policy guidelines included, residents and/or representatives shall be educated on the risks and benefits of psychotropic drug use, as well as alternative treatments/non-pharmacological interventions.

Deficiency Text Not Available

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and review of policy, the facility failed to ensure a physician order for indwelling catheter use was obtained for two residents (#2 and #1) and for external female catheter use for one resident (#20). The deficient practice could increase the risk of complications including infections related to catheter use. Findings include: -Resident #2 was admitted on [DATE] with benign prostatic hyperplasia with lower urinary tract symptoms. The admission nursing evaluation dated July 14, 2023 revealed resident was admitted with a catheter type/size 16Fr (French) 10 cc (cubic centimeter); and that, the resident had recurrent urinary tract infections (UTI) as a result of the catheter. The 5-day Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored 5 on the Brief Interview for Mental Status (BIMS) indicating resident had severe cognitive impairment. The assessment also included the resident had an indwelling catheter. The care plan dated July 24, 2023 included that resident had urinary retention. Intervention included catheter care. Despite documentation that the resident had indwelling catheter, the clinical record revealed no evidence of physician orders for indwelling catheter since July 24, 2023. An interview with resident #2 was attempted on August 7, 2023. Resident #2 stated he was having a bladder spasm and did not wish to speak to anyone. -Resident #1 was admitted on [DATE] with diagnosis of urinary tract infection. The admission nursing evaluation dated July 28, 2023 revealed the resident had an indwelling catheter; however, the indwelling catheter type and/or size was not identified. A nursing note dated July 28, 2023 at 10:14 p.m. revealed resident was alert and oriented x1 and responded to touch and voice. Per the documentation, the resident's Foley catheter was draining clear dark urine. A physician order dated July 28, 2023 included for an indwelling catheter; however, the order did not specify the size of catheter to be used. The medication administration record (MAR) for July 2023 revealed that the resident's indwelling catheter was changed on July 29, 2023. However, the documentation did not indicate the type and size of the indwelling catheter used. The admission MDS assessment dated [DATE] revealed the resident had a BIMS score of 0 indicating the resident had severe cognitive impairment. The MDS also included that the resident had an indwelling catheter. Despite documentation that the resident had indwelling catheter, there was no evidence that type and size of the resident's indwelling catheter was verified with the physician from July 28 through August 6, 2023. A physician order dated August 7, 2023 included the indwelling catheter type and size needed for resident. The care plan revised on August 10, 2023 included for indwelling catheter management. The goal was that the resident will not experience UTI or Trauma to catheter site daily. Interventions included catheter care every shift with soap and water, encourage/offer fluids frequently, to insert catheter per MD order observing strict aseptic (infection prevention) technique, to keep catheter site clean and dry and pericare as needed. An observation was conducted on August 7, 2023 at 12:58 p.m. Resident #1 was in his room laying on his bed and his Foley catheter was in place and draining clear urine. An interview with a registered nurse (RN/staff #12) was conducted on August 9, 2023 at 9:34 a.m. The RN stated that a resident with an indwelling catheter need to have a physician order for its use and the order should include the size and type of catheter to be used. The RN stated that if there was no physician order and the resident has an indwelling catheter on, she would call the provider to get an updated order. Further, The RN said that she was not aware if the facility has a policy on catheters. In an interview conducted with another RN (staff #26) on August 10, 2023 at 9:42 a.m., the RN (staff #26) stated that a catheter would require a physician order; and, if there was no order for the indwelling catheter, the risk would include resident having negative side effect or an adverse reaction related to catheter use. During the interview, a review of the clinical record was conducted with the RN (staff #26) who stated that there was no physician order that included the indwelling catheter type and size to use for resident #1 prior to August 7, 2023. During an interview with the Director of Nursing (DON/Staff #48) conducted on August 10, 2023 at 10:29 a.m., the DON stated that a physician order with the type and size of the indwelling catheter should be obtained upon admission for any resident who entered the facility with an indwelling catheter such as Foley catheter. The DON stated that the expectation was for the admission nurse to review the incoming resident's indwelling catheter order; and, if order did not have information related to the type and size of catheter the provider should be contacted for clarification. She stated that by not having a physician order that include the type and size of catheter to use, there would be a risk of putting in the wrong size and this would cause trauma to the resident. A review of the clinical record was conducted with the DON who stated that the indwelling catheter order for resident #1 dated July 28, 2023 did not specify the size needed; and that, this did not meet her expectation. -Resident #20 was admitted on [DATE], with diagnoses of Parkinson's disease, muscle weakness, hypothyroidism, hypertension, fibromyalgia, and cellulitis of the left lower limb. The admission MDS assessment dated [DATE] revealed the resident had a Brief Interview of Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The care plan dated August 3, 2023 revealed no mention of the use of a female external catheter. Review of the clinical record revealed no evidence of a physician order for use of a female external catheter. Further review of the clinical record revealed no evidence that care related to use of female external catheter was provided to resident #20. During an observation conducted on August 7, 2023, the resident was lying in bed, semi-covered with a gown and a catheter tubing was coming from in between resident's legs. The tubing extends to a cylinder of a female external catheter which was on the resident's nightstand. An interview was conducted on August 8, 2023, at 9:30 a.m. with a registered nurse (RN/Staff #45) who stated there should be an assessment done by the Director of Nursing (DON) and a physician order for the use of an external female catheter. The RN stated that the assessment and physician order should be in the resident's electronic record. Further, the RN stated that the facility does not provide external catheters to their residents; and that, the resident was responsible for providing themselves as well as its care and cleaning. During an interview with a DON (staff #31) conducted on August 10, 2023, at 11:30 a.m., the DON stated that it was her responsibility to do the initial assessment for the external female catheter per the facility policy. She stated that this assessment was to ensure that the resident was appropriate for the external catheter and that there are no contradicting factors. The DON stated the application/use of the external female catheter should be documented on the Treatment Authorization Request (TAR), and it would also require a physician order. The DON stated that upon review of the clinical record for resident #20, there was no evidence found related to a physician order or documentation on the TAR for the use and care for the female external catheter as expected per their policy. The undated facility policy on Appropriate Use of Indwelling Catheters revealed that a physician's orders was needed for a resident to have a catheter. The order also needed to specify the type and size of the catheter to be used. Review of the facility policy titled, External Catheter for Female Urinary Incontinence Management dated May 2023 revealed that an evaluation should be done by the Interdisciplinary Team to ensure the resident is appropriate for the catheter and that treatment orders are written per physician order.

Based on observation, clinical record review, staff interviews, and the Centers for Medicare and Medicaid Services (CMS) regulation, the facility failed to ensure that four residents (#12, #16, #125, #227) were offered and received education on the risks and benefits associated with the COVID-19 vaccine. Findings include: A review of the immunization records and the clinical records for residents #12, #16, #125 and #227, revealed no evidence that residents #12, #16, #125 and #227 were offered and educated on the risks and benefits associated with the COVID-19 vaccine. The clinical record of residents #12, #16, #125 and #227 revealed no documentation that these residents refused the COVID-19 vaccine. In an interview with a resident (#12) conducted on August 7, 2023, at 9:30 a.m. resident #12 stated that they were not offered nor were they provided any education in regards to the COVID-19 vaccine when they were admitted to the facility. An interview was conducted on August 7, 2023, at 11:30 a.m. with a registered nurse (RN/Staff #45) who stated that new residents are offered and educated regarding the COVID-19 vaccine starts on admission by the admitting nurse. The RN stated that the admitting nurse would ask the resident if they had been vaccinated; and if the resident said they have been vaccinated, the admitting nurse would ask the resident for documented proof and would document this in the electronic medical record. The RN said that if the resident says that they have not been vaccinated, the admitting nurse would offer the vaccine; and if the resident agrees, the resident would be scheduled for an appointment through a third party such as the pharmacy to administer the vaccine to the resident. During an interview with a Director of Nursing (RN/staff #31) conducted on August 10, 2023, at 11:30 a.m., the DON stated that when a new resident is admitted to the facility, they are screened for COVID- 19 vaccines as to whether they have received it or would like to receive it. She stated that this was solely done through verbal consent; and that, there was no documentation for offering or educating the resident for COVID-19. The DON stated that she was aware that the facility was not in regulatory compliance related to offering and educating residents on COVID-19 vaccine. The CMS regulation on COVID-19 immunizations included that the LTC (long term care) facility must develop and implement policies and procedures to ensure all the following: (i) When COVID-19 vaccine is available to the facility, each resident and staff member is offered the COVID-19 vaccine unless the immunization is medically contraindicated or the resident or staff member has already been immunized; (ii) Before offering COVID-19 vaccine, all staff members are provided with education regarding the benefits and risks and potential side effects associated with the vaccine;(iii) Before offering COVID-19 vaccine, each resident or the resident representative receives education regarding the benefits and risks and potential side effects associated with the COVID-19 vaccine.