**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and records reviewed, the facility failed to ensure one Resident (#23), out of a total sample of 18 residents, received care and treatment to prevent and to promote healing of a pressure injury consistent with professional standards of practice. Specifically, the facility failed to implement treatments as ordered and notify the physician of worsening Moisture-Associated Skin Damage (MASD-inflammation and erosion of the skin caused by prolonged exposure to various sources of moisture, including urine or stool) resulting in a delay in treatment and deterioration of the wound to a stage 2 pressure ulcer (PU- partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer) to the Resident's left ischial tuberosity (bone in the lower part of the pelvis that absorbs weight when you sit). Findings include: Review of the facility's policy titled Pressure Ulcer/Injury Risk Assessment, revised March 2022, indicated but was not limited to the following: -Risk factors that increase a resident's susceptibility to develop or to not heal PU/PIs include but are not limited to impaired/decreased mobility and decreased functional ability -Once the assessment is conducted and risk factors are identified and characterized, a resident-centered care plan can be created to address the modifiable risks for pressure ulcers/injuries -Conduct a comprehensive skin assessment with every risk assessment -The care plan must be modified as the resident's condition changes, or if current interventions are deemed inadequate Documentation: -The type of assessment conducted -Any change in the resident's condition, if identified -The condition of the resident's skin (i.e., the size and location of any red or tender areas), if identified -Initiation of a (pressure or non-pressure) form related to the type of alteration in skin if new skin alteration noted -Documentation in the medical record addressing MD notification if new skin alteration noted with change of plan of care, if indicated -Report other information in accordance with facility policy and professional standards of practice Resident #23 was admitted to the facility in July 2017 and had diagnoses including Alzheimer's disease and MASD on the left buttock. Review of the Minimum Data Set (MDS) assessment, dated 4/25/24, indicated Resident #23 had short and long-term memory problems, severely impaired cognitive skills for daily decision making, was dependent on staff for turning and repositioning and was non-ambulatory. The MDS also indicated that Resident #23 had MASD and utilized a pressure reducing device in bed. Review of a Norton Plus Pressure Ulcer Scale, dated 4/23/24, indicated Resident #23 had a score of 6.0 (score of less than 10 is very high risk) and was at very high risk for developing pressure ulcers. Review of the comprehensive care plans indicated but was not limited to the following: FOCUS: Resident has bowel/bladder incontinence related to dementia, impaired mobility (4/11/21). GOAL: Resident will remain free from skin breakdown due to incontinence. INTERVENTIONS: Clean peri-area with each incontinence episode. FOCUS: Resident has impaired functional mobility related to bilateral upper extremity contractures and one side lower extremity contracture, weakness (7/31/21) GOAL: Safety will be comfortable in environment and have no skin breakdown. INTERVENTIONS: Totally dependent for positioning in bed and chair. FOCUS: Skin: Actual alteration in skin integrity related to left buttock (4/1/24). GOAL: Resident will have signs of healing and/or resolution of non-pressure skin issue. INTERVENTIONS: Consult and treatment by Certified Wound Medical Doctor (MD) or Certified Wound Nurse as needed (prn); observe for signs/symptoms of infection and report to MD and obtain prescription (Rx); weekly documented skin check. Further review of comprehensive care plans failed to indicate a care plan for pressure ulcer risk had been developed. Review of the medical record indicated Resident #23 was seen weekly by the facility's Wound Care consultant. Review of the Wound Care Consultant's note, dated 4/2/24, indicated the MASD to the Resident's left buttock measured 2.5 centimeters (cm) in length x 0.5 cm in width x 0.1 cm depth, had scant serous exudate (clear or slightly yellow wound drainage) and was macerated (softening and breaking down of skin resulting from prolonged exposure to moisture) due to incontinence. The Wound Care consultant indicated the wound is expected to heal and the plan of care was discussed with staff. Treatment recommendations for the MASD indicated the following instructions: -Incontinence care. -Pat dry. -Apply collagen powder (supports new blood vessel formation, granulation tissue formation, the debridement of the wound and the ability of the wound to re-epithelize) with barrier cream twice a day (BID). Review of the Physician's Orders/treatment administration record (TAR) indicated the order was implemented on 4/2/24. Review of the medical record indicated the Wound Care Consultant saw Resident #23 on 4/9/24, 4/16/24 and 4/23/24 with no new treatment recommendations for the MASD. Review of the Wound Care Consultant's note, dated 4/30/24, indicated the MASD to the Resident's left buttock measured 5 cm in length x 3 cm in width x 0.2 cm depth, had moderate serous exudate and was macerated. The Wound Care consultant indicated the wound is expected to heal and the plan of care was discussed with staff. Treatment recommendations for the MASD indicated the following instructions: -Incontinence care. -Pat dry. -Skin prep (a liquid film-forming dressing that, upon application to intact skin, forms a protective film to help reduce friction during removal of tapes and films) to periwound (the area around the wound). -Apply collagen powder, calcium alginate with silver (used for moderate to heavily exuding, partial- to full-thickness wounds including pressure injuries) -Cover with border dressing daily and prn. Review of the Physician's Orders/treatment administration record (TAR) indicated the order was implemented on 5/2/24, two days after the recommendation was made. Review of the Wound Care Consultant's note, dated 5/7/24, indicated the MASD to the Resident's left buttock measured 3 cm in length x 3 cm in width and had no exudate and the tissue was 100% epithelial (thin layer of tissue that covers organs, glands, and other structures within the body). The Wound Care consultant indicated the wound is expected to heal and the plan of care was discussed with staff. Treatment recommendations for the MASD indicated the following instructions: -Incontinence care. -Apply barrier cream twice daily and prn Further review of the medical record failed to indicate Resident #23's attending physician/NP was notified of the Wound Care consultant's recommendation for a change in treatment. Review of the Physician's Orders/treatment administration record (TAR) indicated the previous order was not discontinued and continued to be administered until 5/30/24, 23 days after the Wound Care consultant recommended a new treatment. According to the National Institute of Health (2012), it is recommended that silver dressings should be used for 2 weeks initially and then the wound, the patient, and the management approach should be re-evaluated. Review of the complete medical record failed to indicate the Resident was seen by the Wound Care consultant on 5/14/24. Review of the Nurse Practitioner (NP)'s Progress note, dated 5/14/24, indicated Resident #23 had a wound to his/her left buttock due to moisture-associated dermatitis, the wound is epithelialized, and the Resident is followed by the wound specialist. The NP's assessment indicated Resident #23 was at high risk for further skin breakdown and moisture-associated dermatitis due to his/her immobility and incontinence and to continue barrier cream and prompt incontinence care. Review of the medical record indicated the Wound Care Consultant saw Resident #23 on 5/21/24 with no new treatment recommendations for the MASD. Review of the Wound Care Consultant's note, dated 5/28/24, indicated the MASD to the Resident's left buttock had increased in size and measured 7 cm in length x 4 cm in width x 0.2 cm in width, had scant serous exudate, and the tissue was 100% dermis (composed of connective tissue). The Wound Care Consultant's note indicated that the wound is expected to heal and the plan of care was discussed with staff. New treatment recommendations for the MASD indicated the following instructions: -Incontinence care -Apply skin prep to periwound -Apply wound gel and cover with sacral dressing daily and prn Further review of the medical record indicated the Wound Care Consultant's treatment recommendation was implemented on 5/31/24, three days after the Wound Care Consultant recommended a change in treatment. Review of the Wound Care consultant's note, dated 6/4/24 and signed at 4:08 P.M., indicated Resident #23's MASD to the left buttock deteriorated to a Stage 2 pressure ulcer on the left ischial tuberosity. The wound measured: 4 cm in length x 3 cm width x 0.2 cm depth, had moderate serous exudate and [NAME] (sic) discoloration with biofilm (forms when microorganisms adhere and proliferate on the surface of the skin). The Wound Care Consultant's note also indicated that the wound is expected to heal and the plan of care was discussed with staff. Treatment recommendations for the stage 2 PU indicated the following instructions: -Incontinence care -Apply skin prep to periwound. -Apply Collagen powder and calcium alginate with silver, and cover with sacral dressing daily and prn. Review of a Weekly Wound Rounds document, dated 6/5/24 and signed as complete by the Director of Nursing (DON), indicated Resident #23 had acquired a stage 2 pressure ulcer to the left ischium with moderate serous drainage and measured 4 cm in length x 3 cm in width x 0.2 cm in depth. The note indicated the physician was notified of the stage 2 PU on 6/5/24. The document indicated the current treatment plan was: -Incontinence care. -Apply skin prep to periwound. -Apply collagen powder and calcium alginate with silver and cover with sacral dressing daily and prn. Review of a 6/6/24 Late Entry Note, written by the DON at 7:11 A.M., indicated Resident #23 continues to have MAD (Moisture Associated Dermatitis) to the coccyx area. Dressing changed as ordered. The noted failed to indicate Resident #23 had a stage 2 PU to his/her left ischium tuberosity. During a treatment observation on 6/6/24 at 2:07 P.M., the surveyor observed Nurse #1 perform a dressing change to Resident #23's left ischium wound. The wound bed had a mostly beefy-red wound base with a small amount of tan slough (non-viable yellow, tan, gray, green or brown tissue) present. Nurse #1 checked the orders in the medical record and applied wound gel to the wound base and it was covered with a silicone super absorbent dressing. Review of a Nurse's Note, dated 6/6/24, indicated the dressing was changed to Resident #23's left buttock. The old dressing had scant sanguineous drainage and small slough (dead tissue, usually cream or yellow in color) was noted on the wound. During an interview on 6/7/24 at 11:38 A.M., the DON said the Wound Care Consultant comes into the facility every Tuesday and the Assistant Director of Nursing (ADON) usually rounds with them. He said if there were any changes with a wound and new treatment recommendations, the consultant would inform the ADON during the visit. He said they would wait for the Wound consultant to send their note, then contact the physician with treatment recommendations. The DON reviewed the Weekly Wound Round note, dated 6/5/24, that he completed. He said he spoke to the physician, and she approved the Wound Care Consultant's recommendations. He could not explain why the treatment orders were not entered into the electronic medical record until 6/7/24. He said he should have entered the orders when he received them from the Physician on 6/5/24. During an interview on 6/7/24 at 11:52 A.M., the ADON said on Tuesday, when the Wound Care consultant was in the facility, she was too busy to round with her and didn't see Resident #23's wound and was not told the Resident developed a stage 2 PU. She said she saw the Wound Care NP in the hallway and she told her she was going to recommend a change in treatment. The ADON said the Wound Care consultant's notes are sent to the DON who then puts it in the Resident's medical record. She said she didn't see the report until yesterday (6/6/24), and after she got home, she entered the order into Resident #23's medical record without first contacting the Physician and obtaining an order for the treatment. During a telephone interview on 6/7/24 at 12:17 P.M., Physician #1 said she usually reviews the Wound Care consultant reports but has not had a chance to review Resident #23's report yet. She said she had not spoken to the DON or anyone else to inform her that Resident #23 had developed a stage 2 PU and the Wound Care consultant had new treatment recommendations. Physician #1 said when she is not there, the NP is there and they may have notified her. She said if the NP was told about it, she would have written a note in daily rounding notes. The Physician said she was looking in Resident #23's medical record on her computer and said the NP had not written a note regarding Resident #23. She said she could only see the note from the Wound Care provider. She said her expectation is that facility staff would call either her or the NP with a change in condition and/or change in treatment either the day the recommendation is made, or no later than the following day. She said for a recommendation made on 6/4/24, it should not take until 6/7/24 to communicate the information and implement the new treatment. During a telephone interview on 6/7/24 at 12:50 P.M., the NP said she was in the facility on 6/4/24 and did not see the Wound Care consultant. She said she was in the facility yesterday (6/6/24) and was not notified that Resident #23 had developed a new stage 2 PU or was made aware of any treatment recommendations by the Wound Care consultant. The NP said she does not receive a copy of Wound Care consultant reports. She said she thinks they get emailed to the DON. On 6/7/24 at 12:38 P.M., a voice message was left for the Wound Care Consultant with no return call. Review of the medical record indicated a Nurse's Note, dated 6/7/24, indicated Corporate staff #1 contacted Physician #1 regarding the Wound Care consultant's treatment recommendation from the last visit on 6/4/24. The Physician agreed to the recommendation. Review of the medical record indicated the following Physician's order was entered into the electronic medical record on 6/7/24, three days after the recommendation was made: -Left buttock: skin prep, apply collagen powder and calcium alginate with silver, cover with sacral dressing daily/prn. Review of the June 2024 Treatment Administration Record (TAR) indicated this order was not initiated until 6/8/24, four days after the Wound Care consultant made the recommendation for a change in treatment for the newly acquired stage 2 PU.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and records reviewed, for one Resident (#36), of 18 sampled residents, the facility failed to provide Foley catheter (a tube inserted through the urinary tract into the bladder, connected to a drainage bag to drain urine from the bladder) care and management consistent with professional standards of practice. Specifically, for Resident #36, the facility failed to: -Ensure his/her Foley catheter was properly positioned to ensure adequate drainage from the bladder, -Document care and maintenance of a Foley catheter, -Implement provider orders for Intake and Output (I&O) monitoring to ensure adequate output, and -Notify his/her provider of an abnormal radiology report resulting in Resident #36 being hospitalized for four days due to a malpositioned (wrong or faulty position) Foley catheter resulting in bilateral hydroureteronephrosis (swelling of both kidneys and ureters, a thin tube that drains urine from the kidney to the bladder, which occurs when urine can't drain and builds up in the kidneys and ureters), impaired kidney function, and a urinary tract infection. Findings include: Review of the facility's policy titled Intake Monitoring, dated as revised 4/2022, indicated but was not limited to: -the purpose of this procedure is to accurately determine the amount of liquid a resident consumes in a 24-hour period -at the end of your shift, total the amounts of all liquids the resident consumed in the clinical record Review of the facility's policy titled Output Monitoring, dated as revised 4/2022, indicated but was not limited to: -the purpose of this procedure is to accurately determine the amount of urine that a resident excretes in a 24-hour period -pour or drain the urine from the bedpan, urinal, or catheter into the graduate (measuring container) -record the amount noted on the output side of the intake and output record -document in the clinical record amount of output Review of the facility's policy titled Catheter Care, dated as revised 4/2022, indicated but was not limited to: -perform twice daily with A.M. and P.M. care, and as needed after incontinence or bowel movements Review of the facility's policy titled Indwelling Catheter Care, dated as revised 4/2022, indicated but was not limited to: -catheter care will be performed at least daily and as needed (PRN) and in accordance with a physician's and/or nursing order. Review of Human Anatomy & Physiology, Ninth Edition, Urinary Bladder, indicated that a moderately full bladder holds approximately 500 milliliters of urine but can hold nearly double that if necessary. The maximum capacity of the bladder is [PHONE NUMBER] milliliters and when it is over distended it may burst. Review of Lippincott Manual of Nursing Practice, Eleventh Edition, Catheterization Procedure, indicated that a urinary catheter should be inserted 6 to 10 inches and advanced another 1 inch once urine flow is observed. Resident #36 was admitted to the facility in February 2024 with the following diagnoses: dementia and neurogenic bladder (a urinary dysfunction in which the bladder does not empty properly in which the bladder may empty spontaneously or may not empty at all). Review of the Minimum Data Set (MDS) assessment, dated 3/22/24, indicated Resident #36 was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 1 out of 15, and had an indwelling catheter. Review of Resident #36's care plans indicated but was not limited to: -Focus: Resident #36 has a urinary catheter related to obstructive uropathy (condition in which the flow of urine is blocked) and was at risk for developing complications, dated 3/30/24 and revised 6/11/24. -Goal: Resident will have no signs or symptoms of complications from the use of catheter through next review, dated 3/30/23 -Interventions: 1. Follow up with urology as indicated, dated 3/30/24 2. Monitor labs ordered and report results to physician, dated 3/30/24 3. Provide catheter care every shift, dated 3/30/24 Further review of Resident #36's March 2024 Medication Administration Record (MAR) and Treatment Administration Record (TAR) failed to indicate documented evidence that the facility provided Foley catheter care and maintenance of the Foley catheter. During an interview on 6/11/24 at 10:23 A.M., Nurse #4 said a resident with a Foley catheter should have orders for the care and maintenance of the Foley catheter. Nurse #4 said the electronic medical record should have documented evidence of the care and maintenance of the Foley catheter. Review of Resident #36's Encounter Note, written by Physician #1 and dated 3/11/24, indicated but was not limited to: -Urinary retention, suspect neurogenic bladder. The Foley catheter is draining well. He/she should follow-up with urology as an outpatient. Review of Resident #36's Skilled Nursing Note, dated 3/11/24, indicated but was not limited to: -His/her partner is currently with him/her. Intermittent screaming noted, redirected with no effect. Review of Resident #36's Encounter Note, written by Nurse Practitioner (NP) #1 and dated 3/12/24, indicated but was not limited to: -Foley catheter was changed last night due to concern that urine was not draining properly. -Nursing reports catheter has been putting out adequate amount of urine today. -Upon my exam he/she has approximately 400 milliliters (ml) clear yellow urine in drainage bag and does not have any palpable bladder distention or suprapubic tenderness. -He/she denies urinary or suprapubic discomfort. -Nursing reports he/she is moving his/her bowels. -Received a call this afternoon that his/her significant other was still concerned he/she was retaining urine but nursing reports he/she does not appear to have any bladder distention. -Unfortunately, the facility does not have a bladder scanner (a noninvasive tool used to measure urine volume in the bladder). -Asked nursing to place resident on Intake and Output (I&O) for 2 days so we can ensure he/she was drinking enough fluids and putting out enough urine. Review of Resident #36's Nursing/Health Status Note, dated 3/12/24, indicated but was not limited to: -Seen by NP new order for I&O to monitor fluids intake. Review of Resident #36's March 2024 MAR and TAR failed to indicate documented evidence that I&O monitoring occurred between 3/12/24 and 3/15/24. Review of Resident #36's orders failed to indicate evidence that I&O monitoring was ordered between 3/12/24 and 3/15/24. During an interview on 6/12/24 at 8:35 A.M., Nurse #4 said when a resident was on I&O monitoring there would be an order in the electronic medical record the nurses would record and monitor the total amount every shift. During an interview on 6/12/24 at 8:14 A.M., the Assistant Director of Nurses (ADON) said if an order is given for I&O monitoring, the order will be put into the electronic medical record. The nurse will calculate what the patient drinks and tally it daily. The Certified Nursing Assistants (CNA) document in the electronic record but the nurse is responsible for totaling and entering the total in the resident's record. During an interview on 6/11/24 at 11:05 A.M., NP #1 said she had been following Resident #36 for a concern with urinary retention and she believed nursing was monitoring I&O. NP #1 said she saw Resident #36 the day before his/her hospitalization and observed urine in the drainage bag. Review of Resident #36's Skilled Nursing Note, dated 3/12/24, indicated but was not limited to: -His/her partner is currently with him/her. Intermittent screaming noted, redirected with no effect. Review of Resident #36's Encounter Note, written by Physician #1 and dated 3/13/24, indicated but was not limited to: -Yesterday his/her family spoke to nursing about concern that his/her Foley was not putting out enough urine despite adequate fluid intake. -Nursing did change Foley catheter. Foley catheter was changed on 3/11 due to concern that urine was not draining properly. -Today nursing reports Foley does appear to be putting out an adequate amount of urine. -Patient is a limited historian but denies any suprapubic discomfort or feeling like he/she is retaining urine. Review of Resident #36's Skilled Nursing Note, dated 3/13/24, indicated but was not limited to: -His/her partner is currently with him/her. Intermittent screaming noted, redirected with no effect. Review of Resident #36's Encounter Note, written by NP #1 and dated 3/14/24, indicated but was not limited to: -Chief complaint/nature of presenting problem was abdominal distention. -His/her significant other was concerned last weekend that his/her Foley was not putting out enough urine despite adequate fluid intake. -Nursing changed the Foley catheter on 3/11. -Today nursing reports Foley is putting out an adequate amount of urine. Patient is a limited historian but denies any super pubic discomfort or feeling like he/she retaining urine. -Upon exam his/her abdomen is noted to be distended and firm. He/she does report mild abdominal pain. He/she cannot tell me when his/her last bowel movement was. -Foley draining clear yellow urine, no palpable bladder distention or suprapubic tenderness. -Plan: abdomen is firm and distended on exam today. He/she has a history of significant constipation and is on an aggressive bowel regimen. Ordered a fleet enema (liquid medication used to help someone have a bowel movement, a laxative) times one now and a stat X- ray of his/her abdomen including the kidneys, ureter and bladder (KUB) to assess for ileus (the inability of the intestine to contract normally leading to a build-up of food material)/obstruction. Review of Resident #36's Nurse's Note, dated 3/14/24, indicated but was not limited to: -One time enamel [SIC] given for constipation; he/she had a large bowel movement (BM). New order to obtain KUB, KUB done this afternoon, results pending. Review of Resident #36's KUB radiology report, dated 3/14/24, indicated but was not limited to: Findings: Air is scattered in the colon with minimal dilation of a few bowel loops. No significant small bowel areas seen. There is a soft tissue density arising out of the pelvis to the level of the fourth lumbar vertebra. No other masses or significant calcifications are seen. No fecal retention is seen. Conclusion: There is nonspecific bowel gas pattern. A minimal ileus of the colon may be present. There is a soft tissue density arising out of the pelvis which could be an abnormally distended urinary bladder or possibly a pelvic mass. Pelvic ultrasound is recommended for further evaluation. Further review of Resident #36's KUB radiology report, dated 3/14/24, indicated: -examination date: 3/14/24 at 16:09 -reported date: 3/14/24 at 16:26 During a telephonic interview on 6/13/24 at 11:19 A.M., the Laboratory/Radiology Services Consultant said the KUB results were faxed to the unit that Resident #36 was residing on on 6/13/24 at 16:29. Review of Resident #36's Encounter Note, written by Physician #1 and dated 3/15/24, indicated but was not limited to: -Upon exam his/her abdomen is noted to be distended and firm. -He/she does report mild abdominal pain. -I have personally reviewed all the available labs and tests. -KUB revealed a nonspecific bowel gas pattern. A minimal ileus of the colon may be present. There is a soft tissue density arising out of the pelvis which could be an abnormally distended urinary bladder or possibly a pelvic mass. Pelvis ultrasound is recommended for further evaluation. -Plan: Abdomen is nontender, but firm and distended on exam today. He/she is a poor historian but does report mild abdominal pain. Foley catheter is draining clear yellow urine. No signs of urinary obstruction. Nursing changed the Foley catheter on 3/11. A pelvic ultrasound cannot be obtained at our facility in the next 48 hours due to being a weekend, so I would advise hospital transfer. Review of Resident #36's medical record failed to indicate facility staff notified the provider of the KUB results prior to the physician visit on 3/15/24. During an interview on 6/11/24 at 1:01 P.M., Physician #1 said on 3/15/24 she reviewed Resident #36's KUB report and called the significant other due to concerning results. Physician #1 said the Resident needed to be sent to the hospital because an ultrasound needed to be obtained. Physician #1 said prior to the Resident's transfer urine was observed in the drainage bag. Physician #1 said it was possible for urine to continue to accumulate in the drainage bag even if the catheter was displaced. Physician #1 said the hospital staff replaced the Foley catheter which resolved the Resident's issues. Review of Resident #36's Interdisciplinary Team (IDT) Discharge & Recapitulation Summary, dated 3/15/24, indicated but was not limited to: -Resident was transferred to hospital related to a distended abdomen Review of Resident #36's Hospital paperwork, specifically the Patient Visit Information, dated 3/17/24, indicated but was not limited to: -He/she was admitted for malfunctioning urinary catheter. -His/her catheter was replaced and it is now functioning properly. -He/she was also noted to have been constipated but has been moving his/her bowels. -He/she was noted to have a urinary tract infection which was treated. Review of Resident #36's Hospital paperwork, specifically the Discharge summary, dated [DATE], indicated but was not limited to: -Resident #36 was transferred to rehab 1.5 weeks prior and 3-4 days ago the healthcare proxy (HCP) noticed Resident #36 was having progressively worsening distention of his/her bladder which then progressed to having worsening oral intake and poor participation in physical therapy. HCP also noted diaphoresis (excessive or abnormal sweating for no apparent reason) and he/she was complaining of difficulty urinating. -In the Emergency Department, Resident #36 was mildly tachycardic (a heartrate greater than 100 beats per minute) to 106, and his/her labs showed a serum creatinine (a blood or urine test that indicates how well your kidneys are filtering waste from your blood) of 2.12 (the typical range for serum creatinine is: for adult men, 0.74 to 1.35 milligrams/deciliter and for adult women, 0.59 to 1.04 milligrams/deciliter) and a blood urea nitrogen (BUN, test reveals how well your kidneys are working) of 67 (a BUN of 6 to 24 milligrams/deciliter is considered normal), his/her urinalysis (a review of the urine) was grossly infected and his/her abdominopelvic computerized tomography scan (CT scan, a type of imaging that uses X-ray techniques to create detailed images of the body) indicated bilateral hydronephrosis and a distended urinary bladder with the Foley catheter positioned within the tip of the penile urethra. -Foley catheter was replaced and 2500 milliliters of urine was removed with improvement in his/her abdominal distention. He/she was administered antibiotics and admitted to the hospital for further management. -Creatinine was down to 0.63 after Foley catheter decompression. -Renal ultrasound was obtained on 3/17/24 to reassess hydronephrosis and indicated no evidence of hydronephrosis on the right (which had been on the CT scan) and bladder was decompressed. Review of Resident #36's CT Scan Report, dated 3/15/24 at 3:37 P.M., indicated but was not limited to: -There was bilateral hydroureteronephrosis which could have been related to the degree of the bladder distention -The ureters were dilated at the level of the ureterovesical junction (UVJ, where the ureter meets the bladder) bilaterally. -The urinary bladder was markedly distended. -The bladder measured over 19 centimeters in craniocaudal (a standard view taken from above) dimension. -There was a malpositioned Foley catheter that appeared to be within the penile urethra. Proximal to this there is a low-density which could be related to distention of the urethra versus the Foley catheter balloon. Review of Resident #36's Encounter Note, written by NP #1 and dated 3/19/24, indicated but was not limited to: -He/she was sent to the hospital on 3/15/24. -He/she was found to have bilateral hydroureteronephrosis, distended urinary bladder, and fecal loading. -Foley catheter was changed and 2500 milliliters (mL) of urine was removed. -He/she returned to the facility on 3/18/24. During an interview on 6/11/24 at 1:41 P.M., the Director of Nurses (DON), the Director of Clinical Services, and the surveyor reviewed Resident #36's medical record. The DON and Director of Clinical Services said they were unable to provide documented evidence of the care and maintenance of the Foley catheter prior to 3/15/24, there was no order or documented evidence of I&O monitoring prior to 3/15/24, and there was no documented evidence from the nurse that a provider was notified of the KUB report. The DON said Resident #36 was transferred to the hospital on 3/15/24 around 11:30 A.M. due to a distended abdomen and abnormal KUB results. Refer to F838