**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical review, interviews and facility policy review, the facility failed to ensure that two residents (#75 and #10) were free from injuries from a preventable accident. The deficient practice could lead to serious injury or death to residents. Findings include: - Regarding resident #10: Resident #10 was admitted to the facility on [DATE] with diagnoses of myocardial infarction type 2, acute respiratory failure with hypoxia, chronic obstructive pulmonary disease with acute exacerbation, psychotic disorder with hallucinations due to known physiological condition, bipolar disorder current episode with hypomanic, burn of third degree of abdominal wall, burn of second degree of abdominal wall, dependence on supplemental oxygen, depression and anxiety disorder. Review of a smoking policy signed by the resident dated [DATE] revealed that the policy indicated that smoking is prohibited in any area where oxygen is being administered or stored. The policy indicated acknowledgement by the resident that the policy was reviewed and that violations may result in forfeiture of smoking privileges. A smoking care plan initiated on [DATE] indicated a goal of smoke safety at designated areas at scheduled times. Interventions included orientation to smoking procedures and areas, and smoking policy provided to resident/resident representative. Review of the smoking evaluations dated [DATE], [DATE], and [DATE] revealed that resident #10 did not have cognitive loss, no visual deficit and no dexterity problems. Frequency was 2-5 cigarettes per day and preferred to smoke mornings, afternoons, evenings and at night. He was considered a safe smoker due to he could light his own cigarette and did not require any adaptive equipment such as: a smoking apron, cigarette holder, supervision or one to one assistance. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed resident #10 had a BIMS (Brief Interview for Mental Status) score of 15, indicating no cognitive impairment. A progress note dated [DATE] documented that at approximately 5:00 PM, resident #10 was outside smoking when he dropped his cigarette causing his oxygen tank, clothes right flank, stomach, and upper thigh to catch fire. According to the note the resident ' s wounds were cleansed, covered with Silvadene, and a border dressing was applied. Additionally, the note indicated that 911 was called and the resident was transported to the hospital for further evaluation. An emergency department (ED) note dated [DATE] revealed that resident #10 presented to the ED with burns to this right hip, thigh flank area after oxygen tubing caught fire while the resident was smoking during supplemental oxygen use. The note indicated that the resident ' s symptoms included pain. The intervention noted was bandage applied. The note cited that resident sustained 3rd degree burn in a small area on right side. The plan of care indicated was to have resident follow-up with outpatient wound clinic. It was noted that the injury did not require skin graft. Further description of the burn indicated that it was approximately a 5 x 8 cm area that may be full-thickness burn with some surrounding erythema (redness) and blistering. The resident ' s disposition was listed as home discharge. Further review of the ED noted revealed a provider which described the encounter as resident presented to ED with burns to right hip, thigh area after oxygen tubing caught on fire as he was smoking during supplemental oxygen use. The note indicated that the resident stated that he dropped his cigarette on his sweatpants and it started to smolder. The note stated that the resident could not assist himself and stated that I do not have any legs. The note documented that the resident ' s friends had to respond by using a blanket to put the fire out. An emergency room (ER) discharge instruction dated [DATE] revealed that resident #10 was diagnosed with second degree burn of flank and third degree burn of flank. The instruction indicated for the resident to follow-up with the wound clinic that week due to the likelihood that the skin will need debrided. A smoking care plan revised on [DATE] revealed resident required supervision. Interventions indicated that to ensure safety while smoking, the resident required staff supervision. - Regarding resident #75 Resident #75 was admitted to the facility on [DATE] with a diagnosis of orthostatic hypotension, chronic obstructive pulmonary disease, and cervicogenic headache. A smoking care plan initiated on [DATE] indicated a goal for the resident to smoke safely. Interventions included for facility staff to supervise resident #75 while smoking at designated times and that facility will store smoking materials between designated times. However, review of the resident's smoking evaluation dated [DATE] indicated that the resident did not require any supervision or one to one assistance. The evaluation stated that the facility did need to store the resident's lighter and cigarettes. A progress note dated [DATE] revealed that resident #75 was outside smoking when he gave another resident a cigarette and that resident caught his oxygen (O2) tubing on fire. The note documented that resident #75 turned off the other resident ' s O2 and patted the fire with his right hand to put it out. The note indicated that resident #75 sustained blisters on the tips of his 3 middle fingers and the palm of his hand. The note stated that resident #75 ' s wounds were cleansed and petroleum dressing was applied. Review of the admission MDS dated [DATE] revealed a BIMS score of 15 indicating that the resident was cognitively intact. Resident #25 admitted to the facility on [DATE] with a readmission date of [DATE] with a diagnosis of aftercare following joint replacement surgery, anxiety disorder, depression cognitive communication deficit, bipolar disorder and nicotine dependence. Review of the MDS dated [DATE] revealed a BIMS score of 15, indicating no cognitive impairment. Review of the smoking evaluation dated [DATE] revealed the resident had no cognitive loss, no visual deficit and no dexterity problems. Frequency was 5-10 cigarettes per day and preferred to smoke in the morning, afternoon, evenings and at night. Resident #25 was considered a safe smoker due to she could light her own cigarette and did not require any adaptive equipment such as: a smoking apron, cigarette holder, supervision or one to one assistance. The evaluation stated she could store her own lighter and cigarettes. Review of the State Agency ' s (SA) complaint database revealed a Facility Reported Incident (FRI) submitted on [DATE]. The FRI, indicated that resident #10 was in the designated smoking area when he accidentally dropped his cigarette in his lap, setting himself on fire. An interview was conducted on [DATE] at 1:10 PM with the Executive Director, staff #100. He stated he was in his office getting ready to leave for the day when the Director of Nursing (DON), staff #300, came into his office and told him resident #10 had set himself on fire while smoking. Staff #100 and staff #300 went to resident #10's room to speak with him. Upon entrance, the resident's sweatpants had been removed, he was back in bed, and the nurse was treating his burns. Resident #10 explained he was smoking and he dropped the cigarette on his pants. He was trying to find it, but his pants began smoking and then a fire started. He stated that staff #300 came out and poured a pitcher of juice on his pants and put out the fire. Staff #100 stated that resident #10 has gone back and forth with smoking and not smoking. He had quit for quite some time and just recently started again. He states he completed a BIMS test on him at bedside and resident #10 passed. Staff #300 completed wound care on the resident and paramedics arrived and took resident #10 to the hospital. Staff #100 stated the facility has an open smoking policy, which means residents are assessed to be a safe smoker or a supervised smoker. However, any resident residing in the behavioral unit does require supervision. The most recent evaluation completed on resident #10 prior to the incident was on [DATE] and the resident was deemed a safe smoker. Since this incident, the staff have done a reevaluation and deemed the resident unsafe to smoke on his own and requires supervision. An interview was conducted on [DATE] at 2:54 PM with Resident #10. Upon entrance to his room, it was observed that resident #10 was on a nasal cannula and had a portable oxygen tank on the back of his wheelchair. He stated I just decided to smoke because my friend goes out there and it just looks like they all have a good time so I just decided to start smoking again. I just dropped the cigarette because my hands were slippery, they are just that way. My friend, (resident #75) was out there, he was here before and he just came back. He (resident #75) helped me put the fire out. Then someone came out and threw Gatorade on the flames. I went to the hospital but they did not do much for me really. I don't blame anyone but myself for this. When asked if he had his oxygen on when he went out to smoke, he stated I had the tubing in my nose but I don't think the tank was on because I would've blown up if it was. An interview was conducted on [DATE] at 3:24 PM with Assistant Director of Nursing (ADON), staff # 200. She stated "The process for evaluating a resident as a safe smoker consists of: 1. Identify resident as a smoker. 2. Observe resident smoke. Determine if resident can get the cigarette out of the pack, light the cigarette, hold the cigarette, are cognitive to know what they are doing. 3. Determine if resident can extinguish the cigarette and dispose of it in the container. If they can meet all of these things they are considered a safe smoker and can keep their lighter and cigarettes with them and go in and out on their own. If they are deemed an unsafe smoker, staff keep their cigarettes and lighter. An unsafe smoker will have to inform staff when they want to go out to smoke. Staff will then get their cigarettes and lighter and go out with them to supervise. According to staff #200, resident #10 quit smoking for a long time and just started again. I think it's because his friend (resident #75) was out there. Staff #200 was asked what is the process for a resident smoker who is on oxygen. She stated the oxygen should be turned off and the nasal tubing should be removed before they engage in smoking. Staff #200 indicated that it was unclear if the resident #10 ' s oxygen was off when he went out to smoke. She stated we don't really know for sure because staff did not see what happened. His friend (resident #75) told us the oxygen was off but the cannula was on his face. An interview was conducted on [DATE] at 3:45 PM with Resident #75. He stated I feel like this thing is all my fault. I went out to smoke and resident #10 was there, he's my best friend. He asked me if I had a cigarette and I said yes. I gave him one. Everyone keeps telling me it's not my fault, but if I wouldn't have given him the cigarette, this wouldn't have happened! We were sitting there, and resident #25 was out there too with us, and all of a sudden resident #10's pants started smoking and then a flame came up. I told resident #25 to go and get help. I wheeled myself over to him, and went kind of behind him so I could reach my hand along the side of his pants and put the flames out. As I was doing that, there was a huge whoosh and the flame got bigger. I looked at the oxygen tank and saw it was on and then, the tubing was on fire. I grabbed the tube and pulled it off his face and threw it on the ground. The fire was going up the tubing toward the tank. I was going as fast as I could to turn the tank off and I did. Then the big guy came out with lemonade or whatever is in the pitchers of stuff to drink, he had two of them and poured them on the fire. He's a hero! I just keep blaming myself for giving him that cigarette. I told resident #10, no more, don't ask me for cigarettes anymore because I'm not giving you any. I told him to get a patch. I think he's got the start of dementia or something because he can't remember. Something else, why don't they have signs back there in that area that say if you are on oxygen turn it off before you smoke? Now, I just try to go out and smoke when I know resident #10 is in his room. I just don't ever want to see that happen again. It was just terrible! I was so upset and still am. Again, I know everyone says it's not my fault, but in my mind, if I wouldn't have given him the cigarette that wouldn't have happened. I think I'm traumatized or something. It should be noted that as resident #75 was talking, it was noted that he had a pack of cigarettes between his legs resting on his wheelchair. It was observed that resident #75's right hand had a white gauze wrap around the fingers and top part of his hand. He stated he was burned from trying to help put the fire out that was on resident #10. A follow-up interview was conducted on [DATE] at 4:01 PM with the ADON (staff #200). The ADON stated that when a resident is evaluated, we have them sign a paper that they are educated that if they have oxygen to turn it off and remove the cannula. Residents #10 and #75 were both evaluated as safe smokers but now resident #10 is a supervised smoker. During the interview, the ADON confirmed that if a resident is a safe smoker they can keep their lighter and cigarettes with them, even in their room. Staff #200 stated that she is unsure why resident #75 ' s smoking evaluation indicated that the facility will store his cigarette and lighter since he is deemed a safe smoker. Review of the document signed by resident #10 dated [DATE] states Smoking is prohibited in any area where oxygen is being administered or stored An interview was conducted on [DATE] at 4:45 PM with resident #25. She asked Are you here because of the fire? Resident #25 stated that the incident was terrible! Additionally, resident #25 said that I'm so traumatized by what happened. I cried that night when I went to bed. I just can't believe it! According to resident #25, resident #10 is her friend and he could have died from that incident! In hindsight, she commented that she could not believe that she had not thought think to grab that fire blanket there when she goes past it so many times She noted that she just froze. Resident # 25 commented that it was a good thing resident #75 was there., Resident #75 reacted so fast and then staff #300 came out with 2 pitchers of stuff and poured it on the fire. She stated they are heroes! According to resident #25, resident #75 went over there and started patting at the flames and then this huge whoosh came up. It was awful! She indicated that she froze resident #75 had to yell at her to go get help. She said that she went as fast as she could to get help. Resident #25 stated that resident #10 shouldn't be smoking. He quits then he starts again but he shouldn't do it anymore . She commented that resident #10 has signs of dementia. You can just tell. Review of the facility's policy on Smoking dated [DATE] states This facility has established and maintains safe resident smoking practices. Oxygen use is prohibited in smoking areas. Residents are not permitted to give smoking items to other residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation, staff interviews, and review of policies and procedures, the facility failed to ensure one of two sampled residents (#10) received consistent treatment and services related to a suprapubic catheter. The deficient practice could result in complications for residents with indwelling urinary catheters. Findings include: Resident #10 was admitted to the facility on [DATE], with diagnoses that included obstructive and reflux uropathy, diverticulum of bladder, cerebral infarction due to embolism, and hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side. Review of the care plan initiated on January 8, 2021 revealed the resident had a suprapubic catheter. The goals included the resident would show no signs/symptoms of urinary infection. The interventions included monitor for signs/symptoms of discomfort on urination and frequency; monitor/document for pain/discomfort due to catheter; Monitor/record/report to medical doctor (MD) for signs/symptoms of UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Review of the physician's orders revealed: -An order dated January 8, 2021 for a suprapubic catheter, size 18 French, 10 milliliter (ml) bulb to drainage bag. -An order dated January 8, 2021 to change suprapubic drainage bag every two weeks and as needed (PRN) related to obstructive and reflux uropathy. -An order dated January 31, 2021 for the suprapubic catheter: cleanse insertion site with normal saline and pat dry, wrap tube with calcium alginate rope as close to insertion site as able, cover with split gauze, notify primary care physician (PCP) if signs/symptoms of infection. A lab report dated as collected on February 15, 2021 and reported on February 20, 2021 revealed the resident urine culture grew Pseudomonas aeruginosa over 100,000 colony-forming unit (CFU)/milliliter (ml). The physician's orders dated March 5, 2021 included for suprapubic catheter care with soap and water, or wipes, every shift. Review of the Treatment Administration Record (TAR) for March 2021 revealed: -No documentation that the order to cleanse the suprapubic catheter insertion site was completed: March 5, 9 see nurse notes; March 6 and 12, 7 sleeping. -No documentation that the order to do suprapubic catheter care was completed on the first shift March 7, 5 hold/see nurse notes. -No documentation that the order to change the suprapubic drainage bag was completed on March 6, 9 see nurse notes. A nurse progress note dated March 5, 2021 included: suprapubic catheter/cleanse insertion site; with a note that the resident was up in chair. Review of the nurse progress notes dated March 5, 2021 did not reveal the referred note regarding the suprapubic catheter care each shift. Review of a nurse progress note dated March 6, 2021 included: Change suprapubic drainage bag every two weeks with a note that it was changed at the last urologist appointment. However, review of the clinical documentation revealed the last urology appointment occurred February 11, 2021, which was over 14 days before the scheduled change. Review of the nurses' progress notes dated March 15, 2021 revealed: -The resident was very confused and yelling that he needed to urinate. -The resident was encouraged to drink more water because he was more confused than baseline, some redness remained around suprapubic catheter insertion site. Review of the March 2021 Medication Administration Record (MAR) revealed the resident was administered Tylenol tablet 325 milligram (mg) 2 tablets for a temperature of 103.9 on March 16, 2021 at 4:30 p.m. However, review of the clinical documentation, including a Nurse Practitioner (NP) note dated March 16, 2021, did not reveal that the physician was notified of the elevated temperature, need to urinate, or increased confusion. Review of the nurses' progress notes dated March 17, 2021 at 2:58 a.m. revealed: -The resident was almost non-responsive and soaking wet on his head and shirt when checked at first round of the night shift. Doctor was called and gave order to put in intravenous (IV) and give one liter of normal saline. -By 0630 the liter bag was nearly empty, the resident's arm was swollen up as if infiltrated, but there was no redness at insertion site and no pain reported by the resident. Fluid and IV side were discontinued. Resident continued to have no output to bag, but Certified Nursing Assistant (CNA) reported his brief had been wet yesterday and split gauze around catheter insertion site was damp today. Resident also had a temperature of 100.6 which resolved to 98.3 by 10:00 a.m. without medication. Attempt was made to flush catheter at 10:00 a.m., but no fluid could be pushed into or pulled out of catheter. Urologist was contacted to report issues. He said to send the resident to the emergency department for work up. Resident transported to the hospital at 12:20 p.m. Review of the hospital records for the admission date of March 17, 2021 revealed the resident had a clogged suprapubic catheter for 48 hours and was unable to urinate. Doctor from urology at bedside to replace Foley (urinary catheter), lots of sludge coming out. Labs noted white blood cells 16+(normal range 4.50 to 11.00) and patient started on Rocephin. Urinalysis with red and white blood cells >20, 2+ protein, leukocyte esterase 3+, mucous present, occasional urine bacteria, 2+ blood and cloudy urine. Pubic region very tender. Patient had a catheter associated complicated UTI. Patient with replacement of his suprapubic catheter. Resident received IV ceftriaxone during the hospital visit and was directed to continue cefdinir 300 mg oral two times a day through March 23, 2021. Review of the clinical record revealed the resident was readmitted on [DATE]. The physician's orders dated March 19, 2021 included for cefdinir (antibiotic) capsule 300 mg by mouth two times a day for infection until March 24, 2021. Review of the nurses' progress notes dated March 19, 2021 at 3:10 a.m. revealed: -Suprapubic catheter in place draining dark yellow urine with sediment. Site cleansed with normal saline, covered with split gauze. Large amounts of thick discharge noted at site. -Suprapubic catheter in place draining dark amber urine. Resident on oral antibiotic for UTI. A review of the care plan did not reveal the UTI (March 2021) was addressed on the care plan. Review of the TAR for March 2021 revealed: -No documentation that the order to change the suprapubic drainage bag was completed on March 20, blank/no initials of completion. -No documentation that the order to do suprapubic catheter care each shift was completed on first shift March 21, blank/no initials of completion. -No documentation that the order to cleanse the suprapubic catheter insertion site was completed on March 21, blank/no initials of completion. A nurse progress note dated March 22, 2021 at 7:08 p.m. stated supra pubic catheter present and draining clear yellow urine to bag. Insertion cleaned, possible scant leakage around insertion. Site looks more irritated than previous, but is under treatment. Resident afebrile with mentation more consistent with baseline. Will continue to monitor. A nurse's progress note dated April 3, 2021 stated purulent drainage present on suprapubic catheter dressing. No other signs/symptoms of infection noted. Catheter is patent and flowing with clear yellow urine. Will continue to monitor. Continued review of the nurses' progress notes for April 3, 2021 did not reveal the physician was notified of the purulent drainage. Review of the TAR for April 2021 revealed: -No documentation that the order to change the suprapubic drainage bag was completed on April 3, blank/no initials of completion. -No documentation that the order to cleanse the suprapubic catheter insertion site was completed: on April 10, code 7 sleeping. -A code of 9 for suprapubic catheter care every shift on April 8 (second shift) and April 16 (first shift). Nursing progress notes dated April 8, 2021 included the resident refused suprapubic catheter care, refused all cares, was angry and combative, yelling leave me alone. A nurse progress note dated April 11, 2021 at 12:17 a.m. revealed the supra pubic catheter was in place draining dark orange urine, site cleaned with normal saline and covered with split gauze, small amount of redness noted. A nurse progress note dated April 13, 2021 at 2:39 p.m. stated the resident was taken to the urologist for a catheter replacement. Review of a nurse progress note dated April 14, 2021 at 5:44 p.m. revealed the suprapubic catheter was draining dark orange urine, there was yellow drainage noted in the resident's brief at the insertion site, some frank blood leaked from the insertion site after dressing change. The nurse progress note dated April 15, 2021 at 11:09 a.m. revealed the suprapubic catheter was in place draining dark, bloody urine. Review of the clinical record, including the NP notes dated April 6 and 15, 2021, did not reveal the provider was notified of the drainage or bleeding at the insertion site or the dark bloody urine. A nurse progress note dated April 16, 2021 at 6:30 a.m. revealed the resident was sent to the hospital for altered mental status. Review of the facility's discharge assessment dated [DATE] included: The resident was transferred to the hospital emergency department because of altered mental status including confusion and aggression. The assessment included the resident's skin was cool and clammy and the suprapubic catheter was intact and draining dark, bloody urine. Review of the emergency room records for April 16, 2021 revealed the resident had a positive urinalysis with a clinical impression of an acute UTI with a prescription for cefdinir (antibiotic) 300 mg two times a day for treatment. Review of a nurses' progress note dated April 16, 2021 at 10:34 a.m. revealed the resident returned from the hospital, Foley (urinary catheter) in place and draining dark red urine. Review of the physician's orders revealed an order dated April 16, 2021 for cefdinir capsule, give one capsule by mouth two times a day for UTI for 10 days. No medication dose was included in the order. Review of the progress notes revealed a late entry/infection surveillance report note with an effective date of April 16, 2021 that included symptoms of hematuria and altered level of consciousness were first observed April 15, 2021. That the resident had a UTI with a culture showing >100,000 Pseudomonas aeruginosa, methicillin-resistant Staph aureus (MRSA), and Enterococcus faecalis. The note included that cefdinir and Macrobid (antibiotic) were ordered and that Macrobid was added for duplicate treatment of UTI once cultures came back positive for MRSA. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the Brief Interview for Mental Status (BIMS) was not assessed. The assessment included, under bowel and bladder, that the resident had an indwelling catheter (including suprapubic catheter and nephrostomy tube) with a diagnosis of obstructive uropathy. The assessment did not code the presence of a UTI. A NP progress note dated April 19 2021 included the resident had a MRSA urinary tract infection and that the antibiotic treatment with Macrobid would be lengthened from 5 days to 15 days given the chronicity of the resident's urinary tract infections. Review of the physician's orders revealed an order dated April 19, 2021 for Macrobid 100 mg capsule by mouth two times a day for MRSA UTI for 14 days and for a urinalysis with culture and sensitivity to be done May 4, 2021. Review of the TAR for April 2021 revealed: -No documentation that the order to cleanse the suprapubic catheter insertion site was completed on April 18, blank/no initials of completion. -No documentation that the order to change the suprapubic drainage bag was completed on April 17, blank/no initials of completion. -No documentation that the order to do suprapubic catheter care each shift was completed on the first shift April 18 or the second shift April 21 and 26, blank/no initials of completion. Review of the care plan revealed a focus dated April 23, 2021 that the resident was on antibiotic therapy related to infection (MRSA UTI) with cefdinir and Macrobid prescribed for treatment. The goal was that the resident would be free of any discomfort or adverse side effects of antibiotic therapy. The interventions included to administer medication as ordered and observed for possible side effects every shift. A urology consult dated May 4, 2021 stated the resident had a partially blocked suprapubic catheter tube and that the tube was changed. A nurse progress note dated May 4, 2021 at 12:49 p.m. revealed the suprapubic catheter was leaking and draining dark yellow urine to the bag. The resident went to a urology appointment on May 4 and the catheter was changed, they reported partial blockage. A NP progress note dated May 4, 2021 at 10:08 p.m. revealed the resident had confusion and malaise and that the nurse would check another urinalysis with a culture and sensitivity as the resident had experienced a change in his overall health. Review of a lab report dated as collected on May 3, 2021 and reported on May 5, 2021 revealed a routine urine culture and was abnormal as it showed gram negative rods greater that 100,000 Cfu (colony forming unit) per ml. The report further included that the test was not performed as the specimen was not received at refrigerated temperature. Tests: urinalysis. complete with microscopic examination with reflex to urine culture, routine. Review of the clinical record did not reveal that the test was repeated to include the specific tests ordered. Review of the TAR for May 2021 revealed: -No documentation that the order to cleanse the suprapubic catheter insertion site was completed: on May 2 and 12, blank/no initials of completion. The code of 9 (see nurse notes) was documented on May 1, 7, and 8. -No documentation that the order to do suprapubic catheter care each shift was completed: on May 1 and 12 (first shift) or May 1, 3, or 10 (second shift), blank/no initials of completion. The nurses' progress notes dated May 1, 7, and 8, in regards to cleansing the suprapubic catheter insertions site indicated that the resident refused the care. Review of the nurses' progress notes dated May 10, 2021 revealed: -The suprapubic catheter was in place and intact draining 200 milliliters (ml) of dark yellow urine. Redness noted around the insertion site as well as purulent drainage mixed with blood. Resident stated that he had pain with cleaning. -The resident stated that he was seeing buffalo outside of his window. A NP note dated May 13, 2021 at 11:54 a.m. revealed a psychotropic medication review and included that the resident had been having increased behaviors. The note included the resident was aggressive threating staff at times, smearing feces, trying to pull out catheter, and quite resistant to cares at times. A nurse progress note dated May 13, 2021 at 4:12 p.m. revealed that the suprapubic catheter was draining cloudy yellow urine with sediment. Review of the clinical record, including the NP note from May 13, 2021, did not reveal that the provider was notified of the redness, pain, and purulent drainage at the suprapubic insertion site, nor did the record include that the resident was transported to the hospital or for what reason. The hospital records for the visit starting May 13, 2021 included the resident presented to the emergency room with clogging of the catheter, fever (initial temperature 102.1), and some altered mental status from baseline. The resident met sepsis criteria and was given Rocephin (antibiotic). Catheter was changed out and was flowing. Sepsis criteria: systemic inflammatory response syndrome (SIRS) criteria met evidenced by abnormal heart rate >90; Suspected infection evidenced by UTI; organ dysfunction evidenced by elevated lactate >2. Urinalysis dated May 13, 2021 revealed red blood cells and white blood cells >20, 2+ protein (negative at normal), positive nitrite (negative at normal), 3+ leukocyte esterase (negative at normal), mucous present, moderate bacteria, 3+ blood (negative at normal), cloudy urine, and white blood cell clumps 11-20. The assessment and plan included diagnoses of severe sepsis and catheter associated UTI with Proteus mirabilis, catheter blockage with acute on chronic cystitis, catheter blockage repaired in the emergency room and Intravenous antibiotics. Final blood culture for Proteus mirabilis, critical value. The resident received IV antibiotics: azithromycin, cefepime, ceftriaxone, and vancomycin during the hospital stay and was directed to take cefuroxime 500 mg oral tablet orally 2 times a day through May 24, 2021. Review of the clinical record revealed the resident was readmitted on [DATE] with diagnoses of sepsis, UTI, cystitis unspecified without hematuria, and proteus (mirabilis) (morganii) as the cause of diseases classified elsewhere. Review of the nurse progress note dated May 18, 2021 at 6:41 p.m. revealed the resident arrived back to the facility from the hospital at 4:20 p.m. A physician's order dated May 18, 2021 revealed for cefuroxime axetil 500 mg tablet by mouth two times a day for antibiotic related to sepsis. The nurse infection progress note dated May 19, 2021 revealed the resident was on oral antibiotics for a UTI. Review of the care plan did not reveal that the UTI (May 2021) was addressed on the care plan. Review of the TAR for May 2021 revealed: -The order to cleanse the suprapubic catheter insertion site was not re-instated after the resident's return from the hospital. -No order was obtained, and no documentation was completed, for suprapubic catheter care on the resident's return from the hospital on May 18, 2021. A review of the clinical record revealed no evidence that suprapubic catheter care was provided to the resident from May 18 - 23, 2021. Review of the physician's orders dated May 24, 2021 revealed: -Suprapubic catheter, size 18 French, 10 cubic centimeter (cc) bulb. -Catheter care with soap and water, or wipes, every shift related to obstructive and reflux uropathy. -Change suprapubic drainage bag every 14 days and PRN related to obstructive and reflux uropathy. Review of the TAR for May 2021 revealed no documentation that the order to do suprapubic catheter care each shift was completed on May 30 on the first shift. A nurse progress note noted June 4, 2020 at 1:17 a.m. revealed the resident's catheter was changed yesterday at the urology appointment. The note included the catheter was draining dark brown urine with blood and that fluids were offered frequently. Review of the TAR for June 2021 revealed no documentation that suprapubic catheter care was completed on the first shift on June 20, 27, or 28 and the second shift on June 4, 10, 20, or 24, blank/no initials of completion. A urology appointment consultation report dated July 1, 2021 revealed the suprapubic catheter was changed and that Keflex (antibiotic) 500 mg was given. Review of the TAR for July 2021 revealed no documentation that suprapubic catheter care was completed on the first shift on July 3, 4, or 10, and the second shift on July 1, 3, or 5, blank/no initials of completion. A nurse progress note dated July 10, 2021 stated that the resident was admitted to the hospital. Review of the clinical record did not reveal the reason that the resident was transferred to the hospital. Review of the hospital records for the visit starting July 10, 2021 revealed that the patient was sent to the hospital for a clogged catheter but it was draining foul looking urine and the patient's temperature was 101.7, white count 16,200 and lactate 3.36. Severe Sepsis criteria was met related to SIRS criteria evidenced by abnormal temperature >100.9, abnormal white blood cells; suspected infection evidenced by UTI, Pneumonia/respiratory; and organ dysfunction evidenced by elevated lactate >2. Assessment and Plan included diagnoses of severe sepsis likely due to recurrent UTI from suprapubic catheter. Urine culture for hospital stay showed >100.000 Cfu/ml proteus mirabilis. Discharge diagnosis, severe sepsis. Received IV ceftriaxone and azithromycin (antibiotics) during hospital stay with orders to continue amoxicillin-clavulanate (antibiotic) 875 mg-125 mg oral tablet two times a day until July 18, 2021. The physician order dated July 12, 2021 included for amoxicillin-potassium clavulanate 875-125 mg tablet by mouth two times a day for antibiotic related to UTI. A nurse admission progress note dated July 13, 2021 at 12:08 a.m. stated the resident was admitted to the facility at approximately 7:00 p.m. in stable condition. Resident's catheter was patent and flowing with clear yellow urine, redness present at suprapubic catheter site and purulent drainage present on catheter dressing. NP and wound nurse notified. The NP progress note dated July 13, 2021 at 11:29 a.m. included that the resident was being seen for hospital follow up. The NP stated that the resident was taken to the hospital for malaise and found to have a urinary tract infection. The NP stated that the resident did not return on antibiotics and that as the resident was asymptomatic the NP would watch for now. Review of the care plan did not reveal that the UTI (July 2021) was addressed on the care plan. Review of the clinical record up to July 15, 2021 at 9:36 a.m. revealed no orders were obtained for the use of the suprapubic catheter (including size and amount of bulb inflation), or suprapubic catheter care at the resident's return from the hospital on July 12, 2021. During an observation conducted of suprapubic catheter care on July 15, 2021 at 2:09 p.m. with an RN (staff #71) and a Certified Nursing Assistant (CNA/staff #79), the catheter was observed draining clear amber urine with a small amount of sediment present in the dependent loop of the tubing. The insertion site was not observed to be red or with drainage. An interview was conducted with a Registered Nurse (RN/staff #37) on July 15, 2021 at 9:36 a.m. She stated that she would expect to see a check mark and the nurse's initials on the MAR/TAR to show that care was given. The RN stated that blanks on the administration record meant that the care had not been signed as completed and that there would be no evidence to show the care had been given. She stated that suprapubic catheter care was usually done one time a day and that there should be orders for the care. The RN stated that she would have to check the resident's order to see when the site care should be done. She did a review of the resident's orders and stated that there were no orders for the resident to receive suprapubic catheter care. The RN stated that the last suprapubic catheter care was documented for day shift on July 12th, however, per the clinical documentation the resident was at the hospital at that time. An interview was conducted with a Licensed Practical Nurse (LPN/staff #41) on July 15, 2021 at 12:22 p.m. She stated that when a resident has a suprapubic catheter, staff are to monitor the area for redness or inflammation every shift and document the monitoring on the administration record, and monitor the characteristics of the urine. The LPN stated that it would be concerning if the urine was dark, cloudy, had sediment, or an odor when emptied. She stated that if changes occur, the physician should be notified and the nurse should document the communication and observations/assessment in the clinical record. The LPN stated that if an infection was suspected the nurse should look for signs/symptoms including changes in behavior and fever. She stated that if a suprapubic catheter became clogged and the physician decided the resident was to be sent to the hospital, the nurse should document the change of condition and do a discharge assessment in the electronic clinical record. The LPN stated that the change of condition documentation should include vital signs and a progress note. The LPN stated the risk of not providing suprapubic catheter care could be infection of the site, redness or drainage around the site. She stated that if the suprapubic catheter was clogged, the nurse would not see urine output in the drainage bag and the resident may have a distended bladder. The LPN stated that any change in the resident's condition should be documented in the progress notes, the physician and family should be notified, and staff should follow orders as directed by the physician. She stated that if the emergency room found the resident to have an elevated temperature and purulent urine on arrival, the facility staff should have identified the problems before transfer. The LPN stated that things do not develop overnight and that the facility staff should catch signs/symptoms of infection. An interview was conducted on July 15, 2021 at 1:07 p.m. with the Clinical Compliance nurse/interim Director of Nursing (DON/staff #82). She stated that it was her expectations that documentation of care be completed as close to real time as possible. She stated that if care was not completed, the nurse should document the reason in the progress notes. She stated that she expected documentation on the MAR/TAR to include the nurse's initials to show the care was completed. The DON stated that if there were blanks on the MAR/TAR, it meant that staff did not document that the care was completed, or did not give the care. Staff #82 stated that you have to assume that the care was not given. She stated that any resident clinical record found with blanks on the MAR/TAR would not meet expectations, and would pose a risk for a decline in status, acute problems, or not being to manage the resident's acute illnesses. She stated that care plans were to be updated with the resident's changes and that the resident should have his current infection on the care plan. The DON stated that if the care plan was not followed the resident may not get medication/treatments as ordered. She stated that if interventions on the care plan were not followed then the care plan was not being implemented as required and it could lead to complications/declines for the resident. She stated that when a resident is transferred to the hospital there should be a discharge assessment on the resident including vital signs. She stated that the clinical record should show what was happening with the resident and why they were sent to the hospital. On review of the clinical record for this resident, the DON stated that she was unable to find complete vital signs for the March 17, 2021 hospitalization; she was unable to find the required assessment before the hospital transfer on May 13, 2021; and she was unable to find an assessment, vital signs, or transfer information relating to the resident hospitalization on July 10, 2021. She stated that there was no further transfer information other than what was provided for this resident. On review of the emergency room record she stated that the facility staff should have identified that the suprapubic catheter was draining foul looking urine, that the resident had an elevated temperature, and a history of sepsis and UTIs. The DON stated that she did not believe that the signs/symptoms developed between the resident leaving the facility and arriving at the emergency room. She stated that the risk of not identifying an illness timely was the risk of unidentified infection, hospitalization, or death. The DON stated that if the staff had identified the signs/symptoms of infection for the resident, the hospitalization may have been prevented. She stated that if a resident had a change in condition, staff are to assess the resident, obtain vital signs, notify the physician, take appropriate actions, notify the family, and document. The DON stated the resident should have current orders for the suprapubic catheter including the size, an order to monitor the suprapubic site, an order to change the catheter bag, an order to provide catheter care, and an order for replacing the catheter. She stated that the orders should be scheduled and PRN (as needed). The DON stated that the nurse should assess and document the condition of the insertion site each shift. She stated the CNA would assist with the catheter care and the nurse would make sure the care was done and would document the care on the TAR. On review of the clinical record she stated that the site had not been documented as assessed on the TAR from July 13, 2021 at 12:58 a.m. through her review on 7/15/21. She stated that there was no way to show that the resident received the catheter care required each shift since returning from the hospital. The DON stated that if a suprapubic catheter did not receive care or was not properly monitoring for infection, the risk would be that the resident's current infection could have worsened and staff would be unable to tell if the infection was improving or resolving. Review of a facility policy on suprapubic catheter care revised October 2010 included: The purpose of this procedure is to prevent skin irritation around the stoma site and to prevent infection of the resident's urinary tract. The guidelines included: Observe the resident's urine level for noticeable increases or decreases; should the resident indicate that his/her bladder is full or that he/she needs to void, report it immediately to your supervisor; check urine for unusual appearance (i.e., color, blood, etc.); and observe the resident for signs and symptoms of urinary tract infection and urinary retention, report findings to your supervisor. The steps in the procedure included to inspect the stoma site and skin around the stoma for any redness or skin breakdown, and check the urine for color and clarity. The documentation that should be recorded in the resident's medical record included: all assessment data obtained during the procedure, the results of the skin assessment around the stoma site, and the character of the urine such as color, clarity, and odor. Review of a facility policy on change in a resident's condition or status revised December 2016 included: Our facility shall promptly notify the resident, his or her attending physician, and representative of changes in the resident's medical/mental condition and/or status. The nurse will notify the resident's attending physician or physician on call including when there is a need to alter the resident's treatment significantly. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider. Except in medical emergencies, notifications will be made within 24 hours of a change occurring in the resident's medical/mental condition or status. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.