**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to supervise, implement, and assess fall interventions to reduce the risk of falls for 1 of 3 residents (R1) reviewed for falls. This resulted in actual harm when R1 fell and sustained a laceration to the middle of her forehead which required an emergency department (ED) visit and sutures. Findings include: R1's Face Sheet dated 4/29/24, indicated R1 had arthritis in both hips, spinal stenosis (abnormal narrowing of the spinal canal), and mild cognitive impairment. R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 had mild impaired cognition, had two or more falls without injury and one fall with minor injury, and needed extensive assistance with transfers, toileting and bed mobility. R1's Fall Risk assessment dated [DATE] indicated R1 had three or more falls in the last 90 days, was confined to her chair, needed assistance with elimination, and not steady on her feet without assistance. R1's score was 20 (a score of 10 or higher put the resident at risk for falls). R1's care plan dated 10/2/24, identified R1 was at risk for falls due to cognitive impairment. An intervention directed staff would not leave R1 in her wheelchair in her room alone. R1 would stay in a common area if she did not want to sit in her recliner after meals or activities. Additional interventions identified encouraging R1 to wear glasses, wear good footwear, and to use a reacher when grabbing items out of reach. R1's Emergency Department (ED) Provider Encounter note dated 11/18/24, indicated R1 had a large laceration in the middle of her forehead that needed 15 sutures to close. On 11/19/24 at 12:51 a.m., a progress note written by registered nurse (RN)-A indicated on 11/18/24 at around 6:14 p.m., R1 was found in her room on the floor in front of her closet, yelling for help. R1's wheelchair was behind her. R1 was bleeding from her forehead, she was assessed and sent to the ED. A facility communication book was located on each unit (Garden Terrace and Town Square) and in the administration office. The front of the book indicated staff were to review the book at the start of the shift, and staff were to sign after reading the new information. The Garden Terrace communication book had eleven updates from 11/4/24 to 12/11/24, with three staff signatures total. The Garden Terrace communication book lacked updates pertaining to R1 and her fall on 11/18/24. The Town Square communication book had eleven updates from 11/4/24 to 12/11/24, with two staff signatures on several pages. The Town Square communication book lacked updates pertaining to R1 and her fall on 11/18/24. The administration office communication book had ten updates from 11/4/24 to 12/11/24 with three staff signatures on one page. An update to the administration office communication book dated 11/19/24 indicated R1 could not be left alone in her room in her wheelchair. There were no other changes to R1's fall risk interventions in the administration office communication book. On 12/11/24 at 12:19 p.m., nursing assistant (NA)-A stated she was an agency staff member on 11/18/24. After dinner, she went into R1's room and asked if she wanted to go to bed and R1 declined. She left R1 in her wheelchair in her room alone. She was not aware R1 was not supposed to be left alone in her room while she was in her wheelchair until after she fell the evening of 11/18/24. She has been directed to look in the communication book for any changes in interventions for residents, but she could not recall the last time she looked in the communication book. She had access to document in R1's electronic medical record (EMR), but was not given access to review R1's care plan and interventions. On 12/12/24 at 10:54 a.m., RN-B stated the facility did not have a good way to communicate with agency staff. The facility had relied on word of mouth, but this was not working. The facility had a communication book for any changes in interventions or other updates on residents. Staff were to read and sign when they come into work. RN-B stated she was not sure who was responsible for ensuring the communication book had been read by staff, and she was not sure why the communication book was not being signed by staff. There was a hole in the process that had not been fixed. On 12/12/24 at 11:01 a.m., RN-A stated on 11/18/24 at around 6:14 p.m., she was getting report from another staff member when she heard someone yelling. She went into R1's room and saw R1 on the floor in front of her closet. R1's wheelchair was behind her, and she was bleeding from her head. R1 had been left alone in her room in her wheelchair, and shouldn't have been. She assessed R1 and sent her into the ED due to R1's forehead laceration. On 12/12/24 at 11:19 a.m., the director of nursing (DON) stated agency staff had access to document in the resident's EMRs, but were not able to review resident care plans or interventions. The EMR had a care stream section that showed activity of daily living (ADL) needs, but it would have been a hit or miss if fall interventions were in the care stream for staff to see. Staff should look in the communication book for any interventions or changes to resident care. The nurse managers were responsible for making sure staff were looking at the communication books and signing them. She was not sure why staff were not looking at the communication book. On 12/12/24 at 11:57 a.m., physician's assistant (PA)-A stated she was aware R1 had a fall, but was not aware staff were not following the care plan. It was possible if the care plan had been followed, R1 would not have fallen. R1 had been was declining prior to the fall, but after the fall on 11/18/24, R1 had a more rapid decline, and was more confused and agitated. The facility Fall Prevention and Management policy dated 2/15/24, directed there will be interventions implemented to minimize future falls.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure treatment and care in accordance with professional standards of practice for 1 of 3 residents (R1) reviewed who did not receive the necessary care and monitoring related to multiple incorrect insertion attempts of an indwelling catheter which resulted in bleeding, blood clots, pain, discomfort, low urine output, and low blood pressure, leading to a diagnosis of sepsis and admission to the Intensive Care Unit (ICU) via ambulance. This resulted in actual harm for R1. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], identified severely impaired cognition and no behaviors noted. MDS indicated R1 had an indwelling catheter, always incontinent of bowel, and neurogenic bladder (interference of the relationship between the nervous system and bladder function and affects the way bladder functions due to injury or disease). MDS also indicated R1 had impairment on one side of his upper and lower body and was dependent upon staff for all cares, transfers, and repositioning. R1's health conditions form dated 6/2/24, to 7/2/24, were identified as anemia, benign prostatic hyperplasia (enlargement of the prostate) (BPH) with lower urinary tract symptoms, hemiplegia and hemiparesis (weakness and/or paralysis on one side of the body) following cerebral infarction (stroke) affected left non-dominant side, neuromuscular dysfunction of bladder (the nerves and muscles don't work together very well. As a result, the bladder may not fill or empty correctly), and dementia. R1's care plan (CP) dated 7/10/24, identified risk for bleeding due to anticoagulant (blood thinner) use, directed staff to monitor vitals and for bleeding, and contact provider with changes and update as needed. CP identified R1 was at risk for urinary tract infection (UTI) due to indwelling catheter and directed staff to observe and monitor for signs of infection and urine quality changes (change in urine color/sediment). R1 had an indwelling Foley catheter 14 F (French) 10 cc (cubic centimeters), and directed staff to document urine output at the end of every shift. R1's physician order dated 6/21/24, identified change 14 F catheter with 10 cc every 28 days at evening 2 p.m. to 10:30 p.m. once a month and change the bag at the same time. R1's physician order dated 6/21/24, identified empty catheter bag and document output three times day (morning 6:00 a.m. to 2:30 p.m., evening 2:00 p.m. to 10:30 p.m., night 10:00 p.m. to 6:30 a.m.). R1's House Standing Orders signed and dated 2/29/24, identified may irrigate catheter with 30 to 60 ml (milliliters) of sterile normal saline with signs of blockage (clots, no urine flow or bypassing around catheter). Change indwelling catheter PRN (as needed) if becomes obstructed or comes out of bladder. R1's electronic medication administration record (EMAR) from 6/29/24, through 7/2/24, identified: -6/29/34, urine output evening shift 2:00 p.m. to 10:30 p.m. 150 ml; EMAR lacked documentation for morning or night shift output. -6/30/23, urine output evening shift 2:00 p.m. to 10:30 p.m. 600 ml; EMAR lacked documentation for morning or night shift output. -7/1/24, urine output 6:00 a.m. to 2:35 p.m. 450 ml, 2:00 p.m. to 10:30 p.m. 300 ml, and 10:00 p.m. to 6:30 am. 0 ml. -7/1/24, Acetaminophen oral tablet 500 mg (milligrams) 2 tablets by mouth as needed one time per day was documented as administered at 9:30 p.m., not effective. -7/1/24, 2:00 p.m. to 10:30 p.m. blood pressure (BP) 97/57 mmHg (millimeters of mercury) and the only blood pressure documented in R1's EMAR. -7/1/24, evening shift 2:00 p.m. to 10:30 p.m. change 14 F catheter with 10 cc balloon every 28 days (once a month). R1's progress notes from 6/28/24, through 7/5/24, identified: -6/28/24, at 12:07 a.m. to 7/2/24, at 12:15 a.m. no documentation noted in R1's medical record (four days). -7/2/24, at 12:15 a.m. 14 F was inserted at 9:20 p.m. and tolerated well. Later at 11:15 p.m. resident woke up screaming ouch and in pain. Irrigation, repositioning, and massage of bladder done but no urine output and still in a lot of pain. Small amount of thick blood and clots in bag and bloody urine bypassing. On call notified and she said to call on call provider if pain increased. -7/2/24, at 12:15 p.m. From report the evening nurse changed resident catheter with a 14 F (per interview with LPN-A this was a 16 F see below) and then a 16 F with blood output. At 8:30 p.m. writer was called to R1's room, screaming in pain, and guarded his groin area whenever staff tried to reach for that area. R1 refused to have brief closed due to increased pain, bladder scanned for 216 cc. On call nurse was notified and suggested flush/irrigate catheter, push fluids and change catheter to 14 F. When catheter was flushed there was increased pain and no output. Removed 16 F and noted continuous gross hematuria (bleeding) with some blood clots from penis. On call was notified and she said to let him drain for 15 minutes then insert a 14 F. After 15 minutes the gross hematuria was minimum and R1 felt better with less pain. -7/2/24, at 5:09 a.m. R1 was screaming, reported a lot of pain (10 out of 10) when his brief was changed around 3:30 a.m. R1's vitals blood pressure (BP) 90/53, respirations 18, and oxygen saturation 92%. Bladder scan completed and resulted in 249 cc with no urine in output in bag. On call provider notified and gave order to send to emergency room (ER) at 4:30 a.m. -7/2/24, at 10:01 a.m. received call from local hospital, R1 had been admitted with diagnosis of sepsis. R1's family updated and placed on LOA (leave of absence). -7/4/24, at 5:53 p.m. called hospital for update. R1 was moved out of ICU (intensive care unit) and downgraded to medical unit, off drip and BP was ok, and placed on two antibiotics. Possibly be there for two more days. -7/5/24, at 2:13 p.m. was re-admitted back to facility from hospital at 1:30 p.m. R1 had indwelling catheter in place that was free flowing, patent, urine was light yellow in color, without sediment, no blood no unusual odor. R1's catheter was to be changed every 28 days, if anticipated difficulty with catheter contact urology. Continued to be treated with antibiotics for UTI every 12 hours for 11 more days. R1's hospital admission notes dated 7/2/24, indicated indwelling catheter change completed at nursing home facility last evening resulted in significant bleeding and no urine output. An attempted catheter placement in ER resulted in ongoing bleeding and no urine output. CT (computerized tomography) scan was completed and showed catheter balloon inflated in the urethra. Urology was contacted and replaced the catheter over a guidewire with cystoscopy (a hollow tube equipped with a lens inserted into urethra and slowly advanced into the bladder). Principle problems identified: urinary tract infection associated to indwelling catheter, sepsis (life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs), with acute renal failure and septic shock, and anemia with acute blood loss from urethra resulting from Foley catheter placement. R1's lab results dated 7/2/24, urine collected at 9:14 a.m. revealed: urine was amber colored, turbid (cloudy), trace of ketones, large amount of blood, severely increased protein levels (indicates problems with the kidneys), positive nitrate (most likely indicates a bacterial infection in the bladder), and a small number of leukocytes (white blood cells). R1's Complete Blood Count (CBC) dated 7/2/24, identified hemoglobin low 10.7 g/dl (grams/Deciliter) (normal range 13.5 to 17.5. g/dl). R1's CT scan of abdomen pelvis dated 7/2/24, at 6:32 a.m. identified indication: gross hematuria and decreased urine output, sepsis. Impression: malposition Foley catheter with balloon inflated with in the penile urethra. Only mild urinary bladder distension. During an interview on 7/8/24, at 4:00 p.m. licensed practical nurse (LPN)-A stated R1 was due for a catheter change on July 1, 2024. LPN-A stated she had gathered supplies: catheter size 16 F, catheter bag, catheter change kit, and an extra syringe. LPN-A indicated pulled out R1's catheter 14 F after deflating balloon and noted urine was dark amber, cloudy, and sediment in the tubing without odor. LPN-A stated emptied 450 cc of urine from collection bag. LPN-A stated when she inserted the 16 F catheter bright red blood was seen, panicked, and pulled out the catheter. LPN-A stated talked with floor manager LPN-B and informed was normal for R1 to bleed a bit and instructed to insert another catheter. LPN-A stated went back and inserted 16 F catheter and bloody return was noted with a small amount of urine. LPN-A stated she had went to the EMAR and noted the order indicated 14 F, it was then she realized she had inserted the wrong size catheter twice. LPN-A stated she reported to LPN-B and DON and was told it was fine and instructed to let things settle down/stop bleeding before the catheter was changed again. LPN-A stated checked on R1 prior to end of shift and no pain, no urine was flowing out of the tube and offered to flush but RN-A said no it was ok and left for the day. LPN-A stated a provider should have been notified about the wrong size catheter (2 times) and blood returned with little to no urine but did not due to LPN-B and DON indicated it was normal for R1 to bleed some. LPN-A stated they did not document this and should have. During a telephone interview on 7/9/24, at 2:00 a.m. registered nurse (RN)-A stated she started her night shift at 6:00 p.m. RN-A indicted she had received report from the LPN-A regarding R1's Foley catheter change. RN-A stated LPN-A indicated she she inserted a 14 F and got blood so removed it, placed another catheter this time a 16 F and was still bleeding when she realized she had used the wrong size catheter. RN-A indicted LPN-A reported to DON and floor manager LPN-B and they both came to conclusion the urethra was already irritated, so it was ok to leave it in until morning, monitor for bleeding, and replace it the next day with a 14 F catheter. RN-A stated she had never seen blood in R1's catheter prior to this day. RN-A stated she peaked in on R1 at 6:30 p.m. prior to a medication pass that evening and there was approximately 100 cc of bloody drainage in the collection bag and in the catheter tubing and R1 reported no pain at that time. RN-A stated she had been told in the past when the catheter was not placed properly due to the BPH and neurogenic bladder a small amount of blood was normal for R1. RN-A stated when she had placed R1's catheter in the past, she had never seen any bleeding. RN-A stated later, a staff nursing assistant came and got her and indicated R1 was in pain. RN-A went to R1's room and he complained of pain and said, ouch ouch. RN-A stated she tried to close his brief, but he would not allow and yelled out. RN-A checked urinary output which had remained the same as earlier (6:30 p.m.) then called the on-call nurse (DON) and was directed to massage the bladder area, push fluids, and then flush the catheter tubing. RN-A stated a provider should have been notified when R1 started to have no urine output with bleeding but she relied on DON for direction instead. RN-A stated DON instructed her the provider did not have to be called because there was nothing he could do and would round the next day. RN-A indicated she was unable to flush the catheter tubing, R1 complained of more pain, then she contacted DON again. RN-A stated DON indicated R1's 16 F catheter should be removed and replaced with a 14 F. RN-A stated she removed the 16 F catheter and R1 had gross hematuria from the penis and replaced it with a 14 F with approximately 80 cc of bloody drainage in bag and allowed more time to see when urine would drain and what color. RN-A stated she had bladder scanned R1 prior to the insertion of the catheter and noted 216 cc. RN-A verified at 11:00 p.m. R1 complained of pain again, but was unable to give more Tylenol. RN-A texted DON and instructed to reposition R1, massage the bladder area and if in one hour still in pain call the on call provider and ask for order to use emergency kit to give a different analgesic. RN-A stated R1 indicated he was ok and then checked on him again at 3:00 a.m. bloody output had remained the same in bag at 50 ml and no urine noted and R1 had started to complain about pain again. RN-A called on call provider and informed them R1 had no urinary output and bladder pain then received order, and sent R1 into the hospital. During an interview on 7/9/24, at 11:00 a.m. hospital physician assistant (PA)-A (provided urological care to patients) verified she was notified about R1's admission to ER and asked to provide assistance with insertion of a catheter. PA-A stated R1 had a large prostate and obstructive urinary symptoms and required the use of a guide wire and cystoscopy (a hollow tube equipped with a lens to view the urethra and bladder) as she inserted the indwelling catheter. PA-A indicated was unable to see if there was a false tract (a false passage in the urethra is formation of an epithelialized tract created when the catheter was inserted aggressively against the urethral wall and/or a weak part of the urethra rather than guided through the urethra lumen, into the bladder, and may occur more often in men due to an enlarge prostate) due to excessive bleeding in the urethra. PA-A stated reinsertion of a catheter had the potential to cause more damage and/or bleeding. PA verified when staff nurse inserted the catheter, got blood return a provider should have been notified right away and not waited. PA-A stated additionally, no urine output for up to 12 hours can cause increased risk for infection due to stagnate urine and possibly go into the kidneys which can be serious. During an interview on 7/9/24, at 11:37 a.m. primary provider/physician assistant (PA)-B stated R1 had no urine output from 9 p.m. until sent to ER (7 hours). PA-B indicated when a nurse lacked skill for catheter insertion they may butt up to the inside of the urethra and felt like it was in the bladder, but no urine appeared. PA-B stated lack of urine would be the most thing to worry about but when catheter was placed incorrectly and in the wrong spot and/or a clot blocked off urine flow that would have been concerning. PA-B stated when R1 was catheterization improperly more than once that increased his risk for urethral damage and increased bleeding. PA-B stated R1's gross hematuria was caused by trauma from cauterization that was for sure and the only thing that made sense. PA-B verified it would have been a good idea to have updated provider after the second time the wrong size catheter was inserted and bleeding continued. PA-B also stated when nurse had contacted the DON 4 to 6 times in a matter of 6 hours she was in over her head, clearly struggled, and required direction from the provider especially when R1 yelled out in pain, increased bleeding, and low urine output. PA-B stated she would have not recommended to change 16 F catheter a 14 F catheter, provider should have been contacted much sooner and R1 most likely sent into hospital earlier. During an interview on 7/9/24, at 12:44 p.m. floor manager (LPN)-B stated R1 has had a history of difficult indwelling catheter attempts with scant amount of blood but would have expected that to stop within an hour. LPN-B stated on 7/1/24, LPN-A informed him she attempted to insert the wrong size catheter 16 French (F) (should have been a 14 F), larger than it should have been, and blood came through the tubing. LPN-B stated the bleeding was caused by insertion of a catheter too large and scraped his urethra (a muscular tube that conveys urine from the urinary bladder to the exterior at the end of the penis). LPN-B stated along with the director of nursing (DON) we had chosen to wait to re-insert another catheter due to urethra being raw, could have caused more damage and discomfort, and allowed that area to recover. LPN-B stated there had been some harm done here, there had been damage to the urethra and R1 bled, required medical intervention, sent to hospital, and admitted . During an interview on 7/9/24, at 2:05 p.m. floor manager registered nurse (RN)-C stated staff had difficulty with catheter placement with R1 in the past with flank blood upon insertion then subsided. RN-C indicated she would have been concerned from the word go when there was more blood than urine that would not be a typical finding after placement of a urinary catheter. RN-C also stated if there was flank blood after insertion of the catheter would have expected it to dissipate and see clean urine within in four hours with at least 50 cc an hour while fluids were pushed also. RN-C stated R1 had an extremely enlarge prostate and therefore made it a more difficult insertion and caused irritation of the urethra which caused bleeding. RN-C verified repeated insertion of a catheter risked irritation to the lining of the urethra, creased an entry of bacteria which increased risk for infection. RN-C stated it was basic nursing education/practice to not inflate balloon until you get urine back. R1's change in condition occurred when he had less than 50 cc of urine out for more than two to three hours and a provider should have been contacted especially when the bleeding should have subsided much sooner. RN-C stated LPN-A placed a larger sized catheter (16 F) rather than 14 F that was ordered and bleeding occurred. RN-C stated LPN-C would be expected to document in the progress notes what transpired from the insertion of the catheters and what was going on during shift change. RN-C stated no follow up had been completed since the incident, no root cause analysis, and had been done or education with the nurses involved. During a telephone interview on 7/10/24, at 8:45 a.m. medical director (MD) stated staff nurses attempted to insert three catheters and the trauma to the urethra most likely was started with the first insertion, when the wrong sized catheter 16 F was used. MD stated a catheter balloon should never be inflated until you get a flow of urine. MD stated would have been important with blood return and no urine a provider should have been notified right away, sent to ER so an evaluation could have been completed at another facility. MD verified when a resident had ongoing bleeding, on an anticoagulant, and bled for more than two hours, would be alarming and something else was going on. MD stated he would have expected more documentation from the nursing especially with low urine output and bleeding, in the medical record, to establish a time-line, and what interventions were tried. During a telephone interview on 7/10/24, at 12:48 p.m. ER supervisor RN-D verified R1 arrived in ER with a 16 F catheter with no urine output and blood in bag. RN-D stated the 16 F was removed and a 5:45 a.m. another catheter was placed by the ER staff with no resistance and into a suspected false tract. RN-D stated if the false tract would have not been there previously before R1 came to ER would have most likely met up with resistance due to R1's BPH but would have then inserted directly into the bladder. RN-D stated urology PA-C was contacted and a catheter was placed with a scope and guide wire into the bladder. During an interview on 7/10/24, at 1:10 p.m. DON stated she had many conversations with both staff nurses starting from 7/1/24, at approximately 4:00 p.m. through 7/5/24, at 11:32 p.m. regarding R1. DON stated last time she had heard from RN-A was at 11:32 p.m. DON stated she arrived at the facility early the next morning on 7/2/24, asked RN-A how R1 was doing and was informed she had sent him to emergency room via ambulance. DON stated she would have expected to be notified R1 was sent to hospital but was not. A vulnerable adult (VA) report was not filed with the State Agency, because the nurses did follow the facility policy, processes, and procedures, except for inserting the wrong catheter size. DON stated because of the long holiday weekend she was not aware until Monday morning (7/6/24), when R1 came back from hospital, and the cat scan (CT) (computer tomography scan) showed R1 had a catheter balloon inflated in the urethra rather than the bladder. DON stated repeated catheter insertion could have raised the risk of complications such as infection and urethral damage/bleeding. DON stated an incident report should have been filed under medication error. DON verified no incident report was filed. DON also verified no investigation was started prior to 7/8/24, when surveyor arrived at their facility and at that time she started reviewing the documents such as medical record and hospital visit notes. DON indicated she had talked to LPN-A on 7/8/24, in the morning after surveyor had already interviewed her and education was completed briefly about lack of documentation, checking doctor's orders more thoroughly prior to changing out of the catheter to ensure the correct size was used. DON stated she had not visited and /or provided RN-A with education since incident. DON also verified there was no internal investigation or root/cause analysis completed within the facility. During a telephone interview on 7/11/24, at 12:00 p.m. emergency care provider, osteopathic doctor (DO) (look at patients as a whole person consisting of a mind, body, and spirit, and tend to focus on preventative medicine) stated the facility inserted a Foley catheter more than once, no urine output and bleeding occurred, clearly it was placed in the wrong spot and not in the bladder. DO stated at that time most likely that was when they started the false tract. DO indicated no urine output was not due to a blood clot because they tried to flush the catheter at the facility, no urine output and only blood. DO stated we removed the Foley catheter once he arrived at ED and inserted a 3 -way catheter without resistance and only a small return of urine. DO stated this indicted there was a false tract prior to his arrival at ED. DO verified the CT scan confirmed the Foley balloon was in the penile urethra therefore suspected R1 had a false tract. DO indicted numerous insertions of a Foley catheter within 10 hours would have caused damage and a false tract when not inserted properly. DO stated the facility continued to re-insert catheters, with no urine out put and bleeding, caused urethra trauma, provider was not contacted right away and should have been, which delayed care and R1 became septic with bacteria in catheter. DO indicated she believed this cause R1 harm. Review of facility policy titled Foley Catheter Insertion, Male Resident dated 2001 identified the purpose of the Foley catheter was to provide for and maintain constant urinary drainage. Verification that there was a physician order was required to identify what size Foley catheter was specified. After preparation insert the catheter gently into the meatus (end of penis) approximately five to seven inches until urine began to flow from the bladder then advance the catheter another two inches and inflate balloon with 5 cc (cubic centimeters) and removed syringe. If resistance met do not force the entry, stop the procedure, and notify supervisor. The physician would be expected to be notified of any abnormalities (i.e. bleeding, obstruction). The following information should be recorded in the resident's medical record: -date and time of procedure -name, title of individual who preformed procedure -all assessment data (e.g. character, color, clarity) obtained during the procedure -the size of the Foley catheter inserted and amount of fluid used to inflate the balloon -how resident tolerated procedure -signature and title of person recording data Facility policy titled Notification of Significant Changes dated 5/2/22, identified policy provided guidance to staff when and who to notify of a significant change in a resident's status. Definition of a significant change meant a change in resident's status, a need to alter treatment, and accident results in injury, or a decision to transfer or discharge the individual receiving services from care center. The charge nurse will immediately (as indicated by the change of condition) informed the resident, consult with the physician, and notify the resident representative for the following significant change: an accident that involved the resident which results in injury and has the potential for required physician intervention, a deterioration in health, in either lift-threatening conditions or clinical complications, and decision to transfer to another provider from the care center without primary physician involvement.