**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** C. Resident #15 1. Resident status Resident #45, under age [AGE], was admitted on [DATE]. According to the October 2022 computerized physician orders (CPO), diagnoses include chronic obstructive pulmonary disease (COPD), history of falling, generalized anxiety disorder, cerebral infarction (stroke), unsteadiness on feet, muscle weakness, and difficulty walking. The 9/9/22 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental health status score of 11 out of 15. According to the MDS assessment the resident required extensive assistance from two people with bed mobility, transfers, toileting and one person assistance with walking in the room, corridor, on and off the unit, personal hygiene, and dressing. The resident was unsteady while moving from seated to standing position, surface to surface transfers, walking, turning around, and moving on and off the toilet. The resident has a manual wheelchair that requires substantial to maximum assistance, the helper does more than half of the assistance. 2. Resident interview and observation Resident #45 was interviewed on 11/1/22 at 10:41 a.m. The resident said that he had fallen once about four months ago, right after he started using the walker. The resident said he was trying to get up and the floor was slick, then his legs gave out and he slipped and fell off the bed. The resident said that he used the walker when he was walking in the hallways, used a manual wheelchair when he was going to the shower room, and did not use any assistive devices while walking in his room. The resident said the only fall prevention intervention the facility provided was to move him closer to the nurses station in order to monitor his movements. The resident was observed on 11/1/22 at 10:41 a.m. The resident was in bed; the bed was in the lowest position. The resident did not have non-skid slip strips or fall mat on the floor at the bedside, while he was in bed. 3. Record review The comprehensive care plan, implemented on 7/11/22, documented the resident had an actual fall in the facility, poor balance, poor communication, poor comprehension, and unsteady gait. The goal was to resume usual activities without further incident. Interventions included to continue the interventions on the at-risk plan, determine and address the causative factors of the fall, monitor and report changes in mental status, use a urine leg bag while awake, and resident room moved closer to the nurses station for more frequent checks every shift. -The care plan did not explain what the actual interventions were, or provide details of the fall at-risk prevention plan for Resident #45. The comprehensive care plan documented generic interventions, to continue to follow the intervention on the at-risk plan, and determine and address the cause of falls, but failed to document individualized person centered approaches and interventions. On 8/10/22 at 6:45 a.m., Resident #45 had an unwitnessed fall in his room and sustained a skin tear to the right elbow. No treatment of the skin tear was documented. The resident was found sitting on the floor next to the bed facing the television with the walker behind him. -No new interventions were put into place. The post fall investigation reports documented that the IDT and resident physician would discuss the effectiveness of interventions, with possible clinical indications (reasons) for the resident's continued falls, or need for additional interventions to prevent future falls and injury from falls. On 8/12/22 at 5:00 a.m., Resident #45 had an unwitnessed fall in his room.The nurse responded to a loud noise from the resident room and found the resident lying face down on the floor with blood coming from the resident's forehead, the resident's walker was nearby. The resident sustained a laceration on his forehead that required four stitches. Interventions included encouraging the resident to use the call light for help -The facility failed to document the size or appearance of the laceration. The resident went to the hospital emergency room for further assessment (see hospital note below). Upon the resident's return to the facility, there was no documentation or monitoring of the wound for signs of infection or healing The hospital note dated 8/12/22 revealed the resident was admitted to the emergency room for assessment after a fall with injury and head trauma after tripping over oxygen tubing and hitting his head on the floor. Based on hospital evaluation the resident was found to have suffered a right frontal subdural hematoma (occurs when a blood vessel in the space between the skull and the brain the subdural space is damaged following a trauma to the head), resulting from the resident's fall in the facility. The resident received four stitches to the forehead. Computerized tomography notes dated 8/12/22, revealed the resident sustained a right frontal lobe injury 3-4 millimeter hyperdense collection (a small area of pool blood or fluid within the skull, but outside the brain), consistent with a small acute subdural hematoma. On 8/17/22 at 1:50 p.m., Resident #45 had an unwitnessed fall. The resident was found on the floor on his knees and lying partly across the bed. The resident did not sustain an injury. Interventions included removing the wheelchair from the room to discourage the resident from attempting to transfer himself without help. This intervention included removing the resident wheelchair from his room to discourage the resident from self transferring to the wheelchair unassisted. -This intervention was not implemented consistently, as the resident's wheelchair was observed at bedside during an observation on 11/1/22 at 10:41 while the resident was lying in bed resting. On 8/31/22 at 9:30 a.m., Resident #45 had an unwitnessed fall in his room; the resident was not injured. The resident was found sitting on the floor with his back to the dresser. The resident told the nurse that he fell out of his wheelchair. Interventions included moving the resident to a new room closer to the nurses station. The resident's room was moved. -No other new interventions were put into place. The 9/18/22 fall risk assessment documented the resident had a history of three or more falls in the past three months with three or more predisposing diagnoses for falls, indicating the resident was at risk for falls. The resident's gait and balance were unsteady, and the resident required assistive devices for mobility including a wheelchair or walker. The fall care plan revised on 9/21/22, documented the resident had several falls without injury. The care focus revealed Resident #45 had poor balance, poor communication and poor comprehension skills. Interventions included moving the resident to a room closer to the nursing station for more frequent monitoring, and to assess and determine the causative factors of the fall. -No other new interventions were put into place. 4. Staff Interview The director of nursing (DON) was interviewed on 11/3/22 at 5:34 p.m. The DON said the floor nurse assessed Resident #45's risk for falls and the interdisciplinary team (IDT) discussed the need and implemented interventions for fall prevention. Interventions for Resident #45 included moving him closer to the nurses station in order to better monitor his mobility. The DON said Resident #45 should have been on a toileting schedule with hourly rounds to ensure the resident was offered assistance with care needs. D. Resident #218 1. Resident status Resident #218, age [AGE], was admitted on [DATE]. According to the November 2022 computerized physician orders, diagnoses included Alzheimer's disease, hypertension, fracture of clavicle and insomnia. The 10/25/22 minimum data set (MDS) assessment indicated the resident had a severe cognitive impairment with a brief interview of mental status score of zero out of 15. It indicated the resident required extensive, two person assistance with activities of daily living. It indicated the resident had at least two falls since admission with no injuries. 2. Resident representative interview Resident #218's representative was interviewed on 11/1/22 at 10:03 a.m. She said the resident had multiple falls since admission. She said she was called at least four times but was unsure how many falls the resident actually had. She said she found the resident on the floor when she went to visit him shortly after he was admitted . She said she could hear him calling for help as she approached his room. She said the resident had dried feces on him and it was upsetting to her to find him like that. She said she did not believe his call light was working and the nurse told her they did not use call lights on the secure unit. She said staff told her they would try to move the resident to a different floor since he was not ambulatory and did not need to be on the secure unit. She said when the staff moved him they would make sure he was close to the nurses' station because his current room was far away from the nurses' station. 3. Observation On 10/31/22 at 11:50 a.m. Resident #218 was observed in the dining room in his wheelchair. Resident was eating lunch and a hospice nurse was sitting next to him. Resident #218 began to slide out of his wheelchair and attempted to grab the table for support. Licensed practical nurse (LPN) #2 went over to the resident and with the assistance of the hospice nurse, repositioned the resident upright in his wheelchair. 4. Record review The fall care plan, initiated 11/1/22, indicated Resident #218 had falls with no injuries. Interventions included assistance with toileting prior to going to bed, bed in lowest position, fall mat in place near bed, and flat call light. -The resident did not have a flat call light based on observation and interview with staff. Progress notes from 10/19/22-11/2/22 revealed the following: -On 10/19/22 a post fall evaluation was completed and indicated the resident had a fall in his room on 10/19/22. It indicated the resident said he did not fall but was on the floor because he was crawling to the bathroom and was found by his wife. The evaluation indicated the resident had small scrapes to his knees. -On 10/19/22 a fall progress note was completed that provided additional fall details. It indicated the resident's wife found the resident on the floor of his room. The resident was assisted to bed ten minutes prior but the resident wanted to use the bathroom and was on the floor to crawl to the bathroom. -On 10/21/22 a fall progress note was completed that indicated the resident had a fall on 10/20/22. A CNA reported they found the resident on the floor of his room near the fall mat. An intervention of frequent checks was added post fall. -On 10/27/22 a fall progress note was completed that indicated the resident had a fall on 10/26/22 in his room. It indicated staff heard the resident calling for help and he was found on the floor near his bathroom. It indicated a new intervention of frequent checks and possible room move to be closer to the nurses station. -On 10/29/22 a post fall evaluation was completed that indicated the resident had a fall in his room on 10/29/22. It indicated the resident was found on his fall mat and did not indicate any injuries. -On 11/2/22 a post fall evaluation was completed that indicated the resident had a fall in his room on 11/2/22. It indicated the resident said he did not fall and instead rolled out of bed. The note indicated the resident was found on the floor mat and his call light was on. -There were no post fall evaluations for the falls on 10/21/22 and 10/27/22. 5. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 11/2/22 at 1:36 p.m. She said Resident #218 had a few falls since he was admitted to the facility. She said interventions included having the resident sit in the television room near staff, a fall mat on the floor beside his bed, and a new wheelchair through hospice. She said the resident was able to use his call light. CNA #2 was interviewed on 11/2/22 at 1:45 p.m. She said when a call light was activated the nurse's phone was paged. She said a light outside of the resident's door would not illuminate. She said Resident #218 was able to use his call light and he had a pointed call light, not a flat button. Registered nurse (RN) #1 was interviewed on 11/3/22 at 9:48 a.m. She said Resident #218 had a few falls that occurred in his room at night or early morning. She said interventions included a floor mat that was placed beside his bed, the bed in a low position, and hourly rounding. She said his room was far away from the nurses station and it could be safer if he was closer. She said he was able to use his call light but needed reminders. The director of nursing (DON) was interviewed on 11/3/22 at 5:34 p.m. He said Resident #218 had fallen since admission. He said a post fall evaluation should be completed two to four days after a fall and the care plan would be updated as well. He said the interdisciplinary team would meet to discuss interventions. He said the resident's falls typically happened from his bed because the resident attempted to transfer himself. He said the staff wanted to move Resident #218 to a room that would be closer to the nurses station. He said staff checked on the resident hourly when he was in bed and took him to the bathroom every two to four hours. 1. Elopement A. Facility policy and procedure The Wandering and Elopement policy and procedure, revised March 2019, was provided by the nursing home administrator (NHA) on 11/3/22 at 8:30 p.m. It read, in pertinent part, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. An elopement risk assessment is completed by the nursing staff on all residents on the day of admission. B. Resident #61 1. Resident status Resident #61, age [AGE], was admitted on [DATE]. According to the November 2022 computerized physician orders (CPO), diagnoses included dementia, mild cognitive impairment, cognitive communication deficit. The 9/2/22 minimum data set (MDS) assessment indicated the resident had a severe cognitive impairment with a brief interview for mental status (BIMS) score of six out of 15. It indicated the resident required supervision for walking and did not utilize any mobility devices. It indicated the resident had wandering behavior and the wandering placed the resident at significant risk of getting to a potentially dangerous place. 2. Record review The elopement investigation was provided by the nursing home administrator on 11/3/22 at 10:30 a.m. The elopement investigation summary was completed on 8/25/22. It indicated Resident #61 used knowledge of another resident on the secure unit to convince a visiting family member that she was the resident's mother. It also indicated an activity assistant was unfamiliar with the resident, since she was newly admitted , and that the activities assistant used her key fob to allow the resident onto the elevator and off the secure unit. The key fob was required in order to get to the secure unit as well as off the unit via stairwell and elevator. The summary indicated the resident was able to walk to her previous residence where she stayed with family and returned to the facility the next day. Interventions that were put into place included an additional fob needed to require the elevator to leave the secure unit in addition to the fob needed to call the elevator, the heads of department were sent photographs of new admits to share with staff, and elopement risk residents' photographs placed at the reception desk. The elopement evaluation was completed on 8/24/22 and indicated the resident was at risk for elopement. It indicated the resident had verbally expressed a desire to return home and the resident was at risk due to recently being admitted to the facility. On 8/26/22 a progress note was completed that indicated Resident #61 had returned to the facility after eloping on the previous day. The note indicated the resident continued to ask when she could go home and questioned why she was at the facility. The behavior care plan, initiated 9/28/22, indicated Resident #61 left the facility to get in touch with family but made it back safely. It indicated the resident had not made any additional attempts to leave. Interventions included keeping the resident busy, reorient to the situation, and the use of diversion techniques. -There was no care plan specific to wandering or elopement. 3. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 11/2/22 at 9:57 a.m. She said there was one resident, Resident #61, on the secure unit who had a history of elopement. She said Resident #61 would ask to leave to go home. She said staff would let the resident call her family, but the family would not answer. She said she did not know what interventions were in place but staff tried to watch the resident and tried to keep her busy with tasks because the resident liked to be helpful. She said she did not know if the resident had made an attempt to leave since she initially eloped. The nursing home administrator was interviewed on 11/3/22 at 9:19 a.m. He said Resident #61 was admitted to the facility quickly due to an adult protective services case. He said in hindsight he should have had the resident sent to the emergency room prior to admission to have her seen by a physician. He said when Resident #61 was admitted she became close with another resident on the secure unit. He said Resident #61 was near the elevator when a new staff member and a visiting family member approached to leave the unit. He said Resident #61 said she was a resident's mother and had been visiting. The resident was allowed on the elevator with the staff member and family. He said the resident had lived in the neighborhood all her life and was able to navigate to her home. He said a maintenance staff member thought he saw Resident #61 had left and alerted other staff. He said staff began searching the area for the resident and notified police. It was determined the resident returned to her old home though her family would not confirm. He said the following day the resident's case manager through adult protective services was able to get Resident #61 to return to the facility. Registered nurse (RN) #1 was interviewed on 11/3/22 at 9:55 a.m. She said the secure unit did not have an elopement binder for residents that were at risk for elopement. She said Resident #61 had eloped when she first admitted . She said Resident #61 would constantly ask to go home. She said interventions included calling the resident's family. She said an elopement care plan would be beneficial for the resident. Activities assistant (AA) #1 was interviewed on 11/3/22 at 10:27 a.m. She said Resident #61 eloped shortly after she was admitted to the facility. She said the resident would ask about her family but had not made attempts to elope. She said the resident liked to stay busy by helping out like cleaning or sweeping. She said the resident would go on walks outside with staff and did not make attempts to elope while outside. The NHA was interviewed again on 11/3/22 at 10:06 a.m. He said when Resident #61 eloped, it was discovered that there was no elopement book at the reception desk. He said photos of residents who were elopement risks were placed on the side of the desk. The director of nursing (DON) was interviewed on 11/3/22 at 5:34 p.m. He said Resident #61 eloped shortly after she was admitted to the facility. He said an additional elopement risk assessment should have been completed once the resident returned to the facility and an elopement care plan should have been in place. He said the resident continued to ask to go home and staff would redirect. He said all the residents on the secure unit would be elopement risks and he was unsure what residents were in the elopement risk binders that were on the floors. Based on record review and interviews, the facility failed to keep residents safe from accident hazards related to falls and elopement for four (#61, #60, #45, and #218) of six residents reviewed for falls and one (#61) of one resident reviewed for elopement/missing person out of 31 sample residents. Specifically, the facility failed to prevent residents at risk for falls from having repeated falls, falls with injury, and major injury. Resident #60 was admitted to the facility on [DATE]. At the time of admission, the resident was able to walk throughout the facility with staff supervision and weight bearing and balance support. Once the resident was assisted to a standing position with balancing support the resident was able to walk up to 50 feet with a walker assistive device and staff supervision, touch assistance and verbal cuing. The resident did not use a wheelchair for mobility. Resident #60 was assessed to be at low risk for falls upon admission, however the resident started to experience a decline and began to experience repeated falls after admission to the facility. The resident's first fall was on 8/6/22, due to losing balance during a self-transfer out of a chair. The resident had four additional falls while a resident of the facility. Following the first fall, the facility failed to reassess the resident risk for falls, implement an appropriate person centered care plan focus for balance and standing deficits, and implement fall prevention measures with effective interventions against repeated falls. The resident had a second fall on 9/1/22 and fractured the right thighbone, then had three additional falls. The facility's failure to address the resident's balance and gait concerns, consider other medical reasons for the resident's balance deficits, and implement person centered interventions to address a method for staff to ensure the resident received care assistance when needed, for care tasks where the facility assessed the resident needed assistance. These failures led to repeated falls and a fall with a major injury. Resident #45 experienced multiple falls while a resident of the facility. Resident #45 was assessed to have had poor balance, unsteady gait and poor safety awareness. The fall prevention care plan was vague and lacked any specific person centered interventions. After the resident's fall on 8/10/22, the nurse on duty conducted a post fall investigation. It revealed that the interdisciplinary team (IDT) would discuss effectiveness of interventions and possible clinical indications (reasons) for the resident's continued fall and need for additional interventions to prevent future falls and injury from falls. However, the resident's medical record did not document any further assessment or discussion of implementing fall prevention interventions at that time. The facility did not revise the resident's care plan to add a fall prevention focus until 9/21/22; by that time the resident had three additional falls, one with a major injury. The facility's failures led to the resident having continued falls and one fall resulting in a subdural hematoma (bleeding between the brain and skull). Additionally, the facility failed to: -Ensure safe transfers with a mechanical lift and provide the correct size equipment (lift sling) to perform a safe transfer for Resident #60; -Implement person centered detailed fall prevention care plans with individualized interventions for Residents #61, #45 and #218; -Complete a comprehensive post fall assessments following resident falls, for Resident #218; -Ensure that all staff working were made aware that a new resident had been admitted to the secured unit, and ensure that staff working on the secured unit were informed of the newly admitted resident's care needs for Resident #61, -Prevent Resident #61, a newly admitted resident, from eloping out of the secure unit; and -Develop and implement a person centered elopement prevention care plan with individualized interventions for Resident #6. Findings include: I. Resident Falls A. Facility policy and procedure The Fall Clinical Protocol, revised March 2018, was provided by the nursing home administrator (NHA) on 11/3/22 at 8:30 p.m. The protocol read in pertinent part, The physician will help identify individuals with a history of falls and risk factors for falling. While many falls are isolated individual incidents, a few individuals fall repeatedly. Those individuals often have an identifiable underlying cause. The staff and practitioner will review each resident's risk factors and document them in the medical record. -After the first fall, the staff (and physician, if possible) should watch the individual rise from a chair without using the assistance of his or her arms, walk several paces, and return to sitting. If the individual has difficulty or is unsteady in performing this test additional evaluation should occur. -The physician will identify medical conditions affecting fall risk and risk for significant complications of falls and the risks for significant complications for falls. The staff, with the physician's guidance, will follow up on any falls with associated injury until the resident is stable and delayed complications such as a late fracture or subdural hematoma have been ruled out or resolved. -The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. -If the individual continues to fall, staff and physicians will re-evaluate the situation and reconsider possible reasons for the resident's falling and also reconsider the current interventions. B. Resident #60 1. Resident status Resident #60, age [AGE], was admitted on [DATE] and discharged on 10/19/22. According to the October 2022 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (COPD), diabetes, and heart failure. The 8/9/22 admission minimum data set (MDS) assessment revealed the resident had intact cognition and scored 15 out of 15 on the brief interview for mental status (BIMS). The resident showed no signs of delusions or psychosis and had no aggressive behaviors. The resident did not reject care or assistance. According to the MDS assessment the resident, upon admission, was able to complete some activities of daily living with only set up assistance from staff. The resident needed extensive assistance from staff for bed mobility, transferring, toileting, dressing, and with personal hygiene. Once assisted to a standing position the resident was able to walk unassisted with a walker device. The resident was occasionally incontinent of bladder and bowel. The resident did not have a catheter and was not placed on a toileting program. 2. Record review Review of the resident medical record revealed Resident #60 had five falls while a resident of the facility from 8/1/22 through 10/19/22 when the resident was discharged from the facility due to a decline in health condition. The resident's repeated falls started on 8/6/22, five days after admission (see below for details). On 8/6/22 at 11:55 p.m., Resident #60 had an unwitnessed fall in the dining room; the resident lost balance and fell while getting up from a chair. The resident did not appear to be injured other than some discoloration to the skin to the abdomen below the belly button. There were no recommended interventions. Facility progress notes dated 8/6/22 at 11:54 p.m., revealed the resident told the nurse who assessed the resident post fall a chair where I sat is broken while I was getting up and that's why I fell. There was no documentation to verify if the chair the resident sat in was or was not broken. Facility progress notes dated 8/7/22 at 3:41 a.m., read in part: Resident required Hoyer (mechanical lift) to get up off floor, he is on neurological checks from a fall yesterday morning. He refuses to call staff for assistance, will not wear shoes, after he is Hoyered (lifted) into bed he gets up again immediately. Resident does seem to have good strength as he can lift his lower body up off the bed when supine and can get in a sitting position as well when supine, but he offers no effort during these falling episodes. On 9/1/22 at 7:50 p.m., Resident #60 had an unwitnessed fall in the resident's room while transferring to bed. The resident was assessed to be in severe pain at a level of 10 out of 10 (excruciating pain) and was not able to move the right leg. Deformity of the right knee was noted. Contributing factors included water on the floor and having bare feet. The resident was sent to the hospital emergency room for assessment. Facility progress notes dated 9/1/22 at 7:50 p.m., read in part: Post fall evaluation: Resident stated to nurse that he felt his right knee pop when he landed on floor. Resident stated pain was a 10 and was not able to move right leg. Floor mat was on the floor: No footwear at time of fall: Bare feet. Resident was not using a walker as instructed. Resident was wearing oxygen as prescribed at the time of fall. Bathroom call light on when resident was found: No. Physical Findings: Change in diagnosis status: No. Actioned clinical suggestions: (none listed). Resident #60's comprehensive care plan documented initiation of a fall prevention focus on 9/2/22, after two falls in the facility where one of the falls resulted in a major injury sustaining a fracture to the right thighbone. After the resident had experienced two falls while a resident of the facility (see below). The care focus revealed the resident had actual falls related to repeated unsafe decision making for self-transfers. Interventions included: -Resident choose not to ask for assistance with ambulation, transfers. The resident is able to make needs known, staff will do frequent checks on the resident for assistance offering. -Resident was non-compliant with asking for assistance with ambulation, transfers. Resident was able to make needs known, staff will do frequent checks on the resident for assistance offering. Additionally, the nursing assessment of the resident's physical function and other physiological factors revealed the resident had a decline in function and ability to complete activities of daily living (ADLs) independently. The resident was assessed to need assistance with self-care including transfers and mobility. The resident assessment revealed the resident did not reject or refuse care. Care planned interventions revealed the resident needed two staff to assist the resident with transfers and standing to walk, toileting and bed mobility. The care plan had no person-centered interventions to address the resident's reluctance to call for staff assistance. Hospital treatment notes dated 9/7/22 revealed Resident #60 was admitted on [DATE] and remained in-patient for five days. X-ray assessment of the resident's injuries confirmed a right femur (thighbone) fracture with adjacent soft tissue injury. X-ray right knee results showed pronounced right knee degenerative changes without displaced fracture, although the hospital could not exclude mild impacted fracture of the medial tibial plateau (the flat area of the larger of the two bones of the leg just below the knee). While in care of the hospital, the resident received surgical intervention to treat a right femur shaft (thighbone between the hip and knee) fracture after a fall. The after visit note revealed the resident could walk on the fractured leg post-surgery as tolerated. The facility Safe Resident Handling and Mobility Objective Transfer assessment dated [DATE] revealed Resident #60 could not bear any weight and was not able to follow instructions due to confusion. -The assessment did not address any related risk factors or recommendations to address the assessment findings. On [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** III. Resident #62 A. Resident status Resident #62 , under the age of 65, was admitted on [DATE]. According to the computerized physician's orders, diagnosis included schizoaffective disorder, bipolar type, pressure ulcer stage 4, dementia, insulin dependent diabetes mellitus. According to the 9/9/22 minimum data set assessment (MDS) the resident had severely impaired cognition as evidenced by a score of five out of 15 on the brief interview for mental status (BIMS). The resident required extensive assistance from one staff member for transfers, bed mobility, toilet use, hygiene, and was totally dependent on staff for bathing. The Resident was always incontinent of bowel, and had an indwelling catheter in place. B. Resident observations and interview On 10/31/22 at 10:18 a.m., Resident #62 was observed. Resident #62 was observed sitting on the side of her bed. The resident's Foley catheter drainage tube was exiting upwards over the top of the resident's waistband of her pants then extended downward towards the floor. The tubing was then looped upward from the drainage bag which was then attached to her walker assistive device at a height above her bladder. -This placement of the catheter bag and tubing promotes urine to drain properly. When the drainage tube is placed below the level of the resident's bladder it will flow out of the bladder with gravity and prevent the urine from flowing backwards into the bladder. When urine flows back into the bladder once it has left the body the individual risks infections and other bladder complications. On 10/31/22 at 12:20 p.m., Resident #62 was observed exiting the lunchroom with the Foley catheter drainage tubing running up the resident leg above the bladder and exiting the top of the resident's pants over the waistband, causing the urine flow to flow out of the resident's bladder against gravity risking that the expelled urine may flow back into the resident's bladder. The catheter drainage tubing was long and was dragging on the floor. The urine in the tube was clearly visible and was observed to be cloudy, milky in color with stringy mucus present. A CNA approached and said this is not right and asked the resident if she would walk to the bathroom so the catheter tubing could be readjusted correctly. On 11/1/22 at 10:30 a.m. Resident #62 Foley catheter leg bag was observed. The leg bag was over full and bulging out with cloudy yellow urine. Resident #62 was interviewed on 11/2/22 at 11:30 a.m. Resident #62 was unable to describe how the nurses took care of her catheter or understand the reason the nurses changed the overnight bag to the leg bag in the daytime while awake. C. Record Review The resident's October 2022 CPO was reviewed. Orders pertinent to the catheter revealed: -Indwelling Foley catheter, change each month on the 24 of the month, with 16 French, 30 cubic centimeters (CC) bulb inflation. The CPO did not document the reason for the catheter placement,orders for routine catheter care, maintenance to ensure proper function, placement of tubing or use of a leg bag during waking hours. D. Staff interviews Registered nurse #3 was interviewed on11/3/22 at 1:15 p.m. RN #3 reviewed the resident's CPO and confirmed the resident did not have orders for Foley catheter care, monitoring and assessment. RN #2 and RN #4 were interviewed on 11/3/22 at 2:10 p.m. RN #4 said when a patient was admitted with a Foley catheter the admitting nurse conducts an assessment to determine why the catheter was in place, including whether or not the catheter is new or had been in place for a significant amount of time. The nurse should also consider why the catheter is in place, is a trial removal to be performed. If a catheter is in place at admission, the admitting nurse will use a collaborative practice order to initiate nursing care for the catheter. The DON was interviewed on.11/3/22 at 5:34 p.m. The DON stated that the facility had a check off process regarding who can perform catheter care and when. The DON said that nurses should be checking for drainage tube leaks, and monitor positioning of the drainage tube daily. The DON said Resident #62 drainage tubing. should have been draining to gravity and not draining upward over the resident's pants waistband. The DON said that catheter orders are considered treatment orders and the order set should be activated by a nurse when a resident was admitted or ordered to have a Foley catheter placed. IV. Facility follow-up On 11/3/22 at 8:00 p.m, the facility obtained orders for catheter care, assessment, and use of leg bag and entered the order into the resident's treatment administration records. Based on observations, staff interviews, and record review, the facility failed to consistently provide catheter care, treatment and services to minimize the risk of urinary tract infections for two (#60 and #62) of two residents reviewed for catheter care, out of 31 sample residents. Resident #60 admitted to the facility on [DATE] without having a catheter in place. The resident did not have a medical diagnosis to provide clinical indication (reason) for the need for a catheter. While in the care of the facility, the resident fell and fractured a hip and required surgical intervention. The resident returned to the facility on 9/1/22 with the indwelling catheter. The facility failed to ensure Resident #60 had orders for the use of an indwelling catheter to assist the resident with bladder function. The facility failed to conduct a comprehensive assessment to determine if the indwelling catheter was clinically indicated. The facility failed to have order for routine catheter care to maintain a healthy bladder and prevent catheter associated urinary tract infections to the extent possible. Once the catheter was in place, the facility failed to continually assess the resident's catheter for possible removal to aid the resident in maintaining and/or restoring bladder continence to the resident's best optimal ability. Additionally, the facility failed to ensure proper maintenance and care of the resident's indwelling catheter and the resident's bladder health declined, the resident became increasingly confused and was in a weakened condition, leading the facility to send the resident to the hospital where the resident was assessed and diagnosed with a significant urinary tract infection with sepsis requiring antibiotic treatment and intravenous fluids. The resident required intravenous (IV) antibiotic therapy and hospital care to treat a catheter associated urinary tract infection (CAUTI). In addition, the facility failed to: -Ensure Resident #62 was provided appropriate catheter care assistance using acceptable standards of nursing care, to ensure the resident's catheter was draining to gravity and not backing up into the resident's bladder; -Ensure orders for catheter care and maintenance; and, -Ensure Resident #62's leg bag was emptied timely and not bulging full of urine. Findings include: I. Professional reference According to [NAME], P.A., [NAME], A.G. , et.al. Fundamentals of Nursing, ninth ed., 2017, pp. 1121: Routine catheter care: Patients with indwelling catheters require regular perineal hygiene, especially after a bowel movement, to reduce the risk for catheter-associated urinary tract infections (UTI) and catheter associated UTI (CAUTI). -In many institutions, patients receive catheter care every 8 hours as the minimal standard of care. -Empty the drainage bags when half full. An overfull drainage bag can create tension and pulling on the catheter, resulting in trauma to the urethra (the duct by which urine is moved out of the body from the bladder) and/or urinary meatus (the opening in the body from which the urine leaves the body), and increase risk for CAUTI. -Expect continuous drainage of urine into the drainage bag. In the presence of no urine drainage, first check to make sure that there are no kinks or obvious occlusion of the drainage tubing or catheter. Preventing catheter-associated infection (CAUTI): A critical part of routine catheter care is reducing the risk for CAUTI. -A key intervention to prevent infection is maintaining a closed urinary drainage system. Another key intervention is prevention of urine backflow from the tubing and bag into the bladder. The nurse should monitor the system to prevent pooling of urine within the tubing and to keep the drainage bag below the level of the bladder. II. Facility policy and procedure The Urinary Tract Infections (Catheter-Associated), Guidelines for Preventing policy and procedure, revised September 2017, was provided by the nursing home administrator (NHA) on 11/3/22 at 8:30 p.m. It read in pertinent part: It is the responsibility of the interdisciplinary team to maintain vigilant practices to prevent CAUTI and to recognize and report early indications that a UTI may be developing. Facility-wide surveillance of infections is collected as part of the infection control program. The following CAUTI prevention strategies have been adopted and are to be followed: -Insert catheters only for indications deemed appropriate for urinary catheter insertion, and as ordered. -Leave catheters in place only as long as needed. Conduct ongoing assessment and monitoring of residents with indwelling catheters to establish continued need. Document every 24 hours or per facility protocol. -Do not insert or maintain a urinary catheter unless you have been properly trained and demonstrated competency in this area. -Always practice vigilant hand hygiene and standard precautions when handling catheter systems. -After aseptic insertion, maintain a sterile closed drainage system. -Maintain unobstructed urine flow. -Perform daily meatal hygiene with soap and water for residents with an indwelling catheter. Document: The continued need for the resident's indwelling catheter; and any signs or symptoms of urinary tract infection. III. Resident #60 A. Resident status Resident #60, age [AGE], was admitted on [DATE] and discharged on 10/19/22. According to the October 2022 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (COPD), diabetes, and heart failure. The 8/9/22 admission minimum data set (MDS) assessment revealed the resident had intact cognition and scored a 15 out of 15 on the brief interview for mental status (BIMS). The resident showed no signs of delusions or psychosis and had no aggressive behaviors. The resident did not reject care or assistance. The resident upon admission was able to complete some activities of daily living with only set up assistance from staff. The resident needed extensive assistance from staff for bed mobility, transferring, toileting, dressing, and with personal hygiene. Once assisted to a standing position the resident was able to walk unassisted with a walker device. The resident was occasionally incontinent of bladder and bowel. The resident did not have a catheter and was not placed on a toileting program. C. Record review Review of the resident's medical record revealed the resident was admitted on [DATE] without an indwelling catheter. At the time of admission the resident needed minimal assistance setting up the task from staff to walk and perform activities of daily living including using the bathroom. While the resident had occasional episodes of bladder incontinence there was no documentation that the resident was having difficulty emptying the bladder. There was no documentation that the resident was having problems emptying the bladder. The resident had a fall on 9/1/22 and fractured a hip. Following the fall the facility provided the resident an indwelling catheter. The record failed to document a clinical indication or an assessment of need for the catheter. Review of the resident's October 2022 physician's orders, medication and treatment administration record (MAR/TAR) and comprehensive care plan revealed: -No orders for placement of the indwelling catheter and no clinical indication (reason) of why the catheter was placed; -No orders for routine catheter care, maintenance or monitoring of the resident catheter; and -No care interventions to promote a healthy bladder, to maintain bladder continence or restore bladder continence and/or function as possible. Facility progress notes failed to show the date and time the resident was provided with the indwelling catheter, as per the admission MDS the resident admitted on [DATE] without an indwelling catheter (see above). The first progress notes to document the resident's catheter were on 9/12/22 and 9/14/22. -A progress note: Spiritual care note, dated 9/12/22 at 9:59 a.m., read in part: Resident #60 complained that his Foley is painful sometimes. (Resident) says he prefers to use his wheelchair to move around and be able to use the bathroom. -Progress note dated 9/14/22 at 2:54 a.m. read in part: Towards the night time on 9/13/22, this nurse observed that urine in resident Foley catheter bags appears to be dark with spotted patterns of blood clots in the bag and drainage tube. Foley catheter bag emptied and subsequent urine return continues to come out with dark blood stained urine with strings of blood clots .This nurse notified the on-call (physician provider office). The on-call provider gave orders to send the resident to the hospital for further evaluation. -Progress note dated 9/14/22 at 3:27 p.m. read in part: Resident returned to facility at 9:05 a.m. from the hospital emergency room, hospital discharge papers indicate all labs performed at the hospital were within normal (limits). Foley catheter was also changed with 16 fr (French)/ 10 cc (cubic centimeter) balloon. Denies any spasms, Foley is draining dark amber urine. -A progress note dated 9/26/22 at 11:41 a.m. read in part: Resident complained of burning and pain and having the urge to urinate. The Foley catheter was intact and draining well. Complaining of lower abdominal pain with palpation. Foley catheter changed, with 16fr and 10cc; immediate output was 200cc, of cloudy, thick and concentrated urine. -A skilled evaluation note dated 9/27/22 at 1:40 a.m. read in part: Genitourinary: Cloudy in appearance. Complaint of urinary urgency. Complaint of urinary burning. Urine sample collected due to milky urine, (physician office) notified awaiting physician instructions. -A progress note dated 10/5/22 at 5:58 p.m. read in part: Resident is lying on the floor in his room. Resident Foley catheter was out with the balloon intact. Foley catheter 18 fr changed today. Catheter in place due to urinary retention. Prior to the 10/5/22 note, the resident was provided a 16 fr Foley catheter (see notes above). Additionally, there was no documentation about the results of the resident's urinalysis done on 9/27/22 or resolution of the resident's documented symptoms (see notes above). -A progress note dated 10/19/22 at 9:48 a.m. read: Early this morning, right after, the resident was noted to be sleepy, tired and poorly aroused. Resident appeared to be lethargic, and gasping for air. Upon further assessment the resident revealed low blood pressure. Physician notified and urged to send the resident out to the hospital for further evaluation. (See hospital notes above.) Hospital emergency room treatment records dated 10/19/22 revealed the resident was admitted from the facility for a change in mental condition, increased shortness of breath, increased fatigue and hypotension (low blood pressure). The resident's Foley catheter appeared cloudy. The hospital performed a urinalysis and found the resident's urine showed pyuria (the presence of pus in the urine, typically from bacterial infection) and hematuria (presence of blood). Diagnosis, assessment /plan: -Acute complicated cystitis - urine with pyuria and hematuria. Likely secondary to chronic indwelling Foley catheter. -Benign prostatic hyperplasia (BPH) (enlarged prostate gland) with chronic Foley catheter - Uncertain if chronic Foley is due to chronic urinary retention. Consider a void trial while here. The resident was admitted to the hospital on [DATE] for further treatment. Hospital admission notes dated 10/20/22 documented, Intensive care unit (ICU) consulted after (patient) had to be intubated in the emergency room. (Diagnoses included): -Severe sepsis with septic shock. SIRS (a serious condition in which there is inflammation throughout the whole body) criteria: Hypoxemia (lack of oxygen in the blood), leukocytosis (high white blood cell count; indicating the body is fighting and infection), tachycardia (elevated heart rate), tachypnea (rapid breathing) Source: Urinary tract infection. Treatment of infection as below; -Urinary tract infection: On cefepime and Vancomycin; adjust these antibiotics based on (urine) cultures -Acute on chronic renal failure: IV (intravenous) fluids given for sepsis. Renally dose (adjust medications based on renal function) all meds, hold nephrotoxins (substances damaging to the kidneys), and monitor ins and outs (urine intake and output); and, -BPH with chronic Foley catheter: monitor urine cultures. D. Staff interview The director of nursing (DON) was interviewed on 11/3/22 at 5:34 p.m. The DON said the facility ensures nurses and certified nurse aides are competent with catheter care before they provide service for a resident with a catheter. In order to ensure the resident's catheter is maintained properly, nursing staff tracks the date the catheter was changed and monitors catheter function daily. A resident's catheter should be changed once a month and as needed. Between changes, nursing staff were expected to monitor the catheter for leaks. If there are no orders for the resident to continue with the catheter the nurse on duty will contact the resident's physician for an order to maintain and change the resident's catheter once a month. Upon receipt of a physician's order for a resident to use an indwelling catheter the nurse receiving the order will enter the orders for the catheter. A full set of treatment orders for catheter care will auto-populate once the nurse entered the catheter order. The DON should confirm the resident's catheter orders are entered into the resident's TAR. The DON said Resident #60 received physician services from an outside physician provider and with that particular provider, it can be challenging to get physician treatment notes and orders timely. The physician did provide verbal direction that it was better for the resident to keep the catheter in place so the resident would not have to be changed a lot while the resident was in the healing process after recent hip surgery. The DON said Resident #60 had ongoing issues with the indwelling catheter. The physician ordered lab tests on the resident's urine and results were delayed because they were sent to the wrong facility. Because of catheter complications, the resident was sent to the hospital twice for medical assessment and treatment. The resident's condition was progressively declining, being less likely to participate in activities of daily living and other social activities.