**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the provider failed to ensure a Foley catheter change was completed per a physician's order for one of one sampled resident (93). Findings included: 1. Observation and interview on 11/14/23 at 9:05 a.m. with resident 93 revealed: *He was in his room sitting in a recliner watching television. *There was a catheter drainage bag hanging below his waist attached to the recliner and covered with a blue bag. *The urine in the catheter bag was concentrated and dark yellow. *There was sediment in the urine and the catheter tubing. *He stated he was seen by a urologist. *The staff were good about emptying the urine from the drainage bag and completed catheter care every morning and evening. *He could not recall if the nursing staff had changed his Foley catheter since he arrived at the facility a couple of months ago. Review of resident 93's electronic medical record (EMR) revealed: *He was admitted on [DATE]. *He had a Brief Interview for Mental Status (BIMS) score of 14 indicating he was cognitively intact. *His diagnoses included urine retention. *Physician orders included the following: -Change catheter monthly and PRN [as needed] every night shift starting on the 1st and ending on the 1st of every month. initiated on 10/5/23 to start on 11/1/23. -Foley catheter 16 French with 10 cc balloon. change if becomes dysfunctional or if sterility is compromised. Initiated on 9/9/23. -Change Foley catheter per facility protocol or MD order Initiated on 09/09/2023. -Monitor urine/catheter output every shift Initiated on 09/09/2023. -Follows urology, [name of urologist], change catheter monthly Initiated on 09/21/2023. *A review of his care plan revealed: -He had an alteration in bladder functioning related to urinary retention with a Foley catheter. -On 9/29/23 they attempted to discontinue the catheter, but he was unable to void (urinate), and the catheter was reinserted. *A review of his November 2023 treatment record revealed: -Change catheter monthly and PRN every night shift starting on the 1st and ending on the 1st of every month with a start date of 11/1/2023 had been listed to have been completed on 11/1/23 but it was not initialed or documented that it had or had not been completed. Interview on 11/16/23 at 10:53 a.m. with the director of nursing (DON) B regarding a missed Foley catheter change for resident 93 revealed: *They had removed his Foley catheter on 9/29/23 per the physician's order and had to replace it because he could not void. *Urology ordered catheter changes monthly for resident 93 on 10/5/23. *His Foley catheter change was scheduled on the 1st of November, and had not been documented as completed. *She was not sure why his Foley catheter change was not completed on the 1st of November as scheduled or within 48 hours after, she had been gone. *Perhaps he refused as they were in a COVID outbreak at that time. *Her day nurse from November 1st reported she had not changed the catheter, and the night nurse was home sleeping and could not be reached. *She had the day nurse change his Foley catheter on 11/16/23 and sent an order/notification to urology that it had been changed late. *Nurses were alerted to tasks due through the dashboard in the PointClickCare EMR system. *If the treatment was not completed it continued to show up for 48 hours as not done until the task was completed and then would fall off the dashboard alerts. *If the treatment was not done within 48 hours, they fell off the dashboard alerts. *She or the assistant director of nursing (ADON) checked missed tasks daily. *She expected that if a treatment was due and it was not completed when scheduled it would have been documented as to the reason why it was not completed, the physician was notified with new orders, and for the scheduled task to have been completed at another time. Interview on 11/16/23 at 11:25 a.m. with registered nurse (RN) D regarding the missed Foley catheter change for resident 93 revealed: *Treatments or tasks scheduled during shifts were located on the resident's treatment administration record and were highlighted on the dashboard in the EMR. *If the scheduled treatment or task was not signed off, it did not go away and hung out on the dashboard in the EMR. *If a nurse had not completed a scheduled treatment, it would have been documented as to why in the EMR, they would have notified the physician by a facsimile (fax), notified the DON or ADON, rescheduled or had the ADON reschedule the treatment in the EMR and reported it to the next shift. *If the above process was not completed then it would have stayed on the treatment record until it was completed. *There was a way to set up treatment orders in the system to have the system continue to notify on the dashboard until the treatment was signed off. *Typically, urology ordered Foley catheter changes every 30 days. Interview on 11/16/23 at 12:40 p.m. with the assistant director of nursing (ADON) C regarding a missed Foley catheter change revealed: *Foley Catheters scheduled to be changed were all set up on the resident's treatment administration record in the EMR per the physician's order. *Most physician's ordered routine Foley catheter changes and the urologists wanted the Foley catheters changed monthly. *Foley catheters scheduled to have been changed alerted the nurses by popping up on the treatment record dashboard in the EMR. *If the Foley catheter change was not completed for some reason on the scheduled date the nurses should have passed it on through the shift change report with the next shift. *She would have expected the missed Foley catheter change to have been reported to the physician and rescheduled in the treatment administration record. *They typically had not had any issues with missed treatments. *His Foley catheter change was missed due to the COVID outbreak all the staff were busy. *She had planned to look at the system and find a way for treatments to not fall off the EMR dashboard alert until completed.

Based on observation, interview, and policy review the provider failed to ensure necessary infection control practices in one of two shower rooms that included: *Maintenance of a plastic three drawer towel and washcloth storage bin. *An appropriate and sanitary process for the removal of and transport of bowel movement(s) occurring during showering. *Appropriate care and maintenance of a multi-resident use foot soak basin. *Appropriately individualized resident identified personal hygiene products. Findings include: 1. Observation and interview on 11/15/23 at 2:35 p.m. with certified nursing assistant (CNA) E regarding cleaning the shower room revealed: *The shower room was in the south hallway and was used by all residents except for those residents who resided in the memory care unit. *The shower room was a 6 x 6 feet room with no toilet, sink, or hand sanitizer dispenser. *From the doorway at the back right wall was a shower head, with a commode-style shower chair and a floor drain under it. *Approximately 1.5 feet to the left of the shower chair was a three-drawer plastic storage bin with towels and washcloths stored in it. -The storage bin was observed as black at one time but now was covered in a white hard water build-up from the shower water. -The storage bin had approximately one-fourth to one-half inch of white hard water build-up inside the handles and along the left bottom edge from the shower water. *On the floor in front of the storage bin was an empty white ice cream bucket. *On the left wall above the storage bin was a wood cabinet and when opened it contained a box of gloves and more than a dozen assorted bottles and tubes of personal hygiene products consisting of baby powders, barrier cream, lotions, body washes, deodorants, shampoos, and conditioners. -None of the above containers were labeled with the resident's names. *Stored on top of the wood cabinet approximately one-half inch below the ceiling was a pink plastic basin and sitting inside of that basin was a gray bucket. *Hanging off the top edge of the cabinet were three disinfectant spray bottles. *On the wall between the shower and the plastic storage bin was a laminated instruction sheet for cleaning the shower that included a three-minute disinfectant contact time. -The instruction sheet had no instructions for cleaning the storage bin, pink basin or buckets. *She was able to refer to the shower cleaning instructions on the wall and demonstrate appropriate shower cleaning. *When asked about cleaning the storage bin next to the shower she reported she had not cleaned it when she cleaned the shower and confirmed the shower cleaning instructions on the wall did not include cleaning it. *She stated the ice cream bucket on the floor was used by CNAs to put under the commode chair if a resident had a bowel movement during their shower and she used it to put her wet washcloths in to take to the soiled laundry. *She stated the bucket used for residents having a bowel movement during their showers was taken to either the bathroom outside the shower room or the soiled utility room around the corner and down the hall to discard the feces. *When asked how the bucket was transported, she denied having bags or a lid for the bucket. *She stated she cleaned the bucket with the same disinfectant spray they used for the shower. *She denied receiving any training on how to remove the feces in the bucket from the shower room or how to clean that bucket. *When asked about the pink basin on top of the cabinet she stated they used it to soak residents' feet before trimming their toenails. *She reported that the pink basin was cleaned with the same spray bottle of disinfectant used to clean the shower and denied receiving any training on how the basin was to have been cleaned between each resident. *When asked about the personal hygiene products inside the cabinet she reported they belonged to multiple residents and were used during their showers and despite that there was no resident's names on those products she stated she sort of knew what belonged to the residents. Observation and interview on 11/15/23 at 3:00 p.m. with the director of nursing (DON) B in the shower room revealed: *All CNAs were responsible for giving their assigned residents showers during their scheduled shifts. *The instructions for shower cleaning were on the wall and they were to also clean the outside of the storage bin when they cleaned the shower between residents. *The white build-up on the storage bin was from the hard water and they replaced the storage bin several times. -She agreed the build-up in the drawer handles was a concern for the shower water leaking into the drawers and contaminating the clean towels and wash clothes. *She stated the plastic bin on top of the cabinet was for soaking resident's feet before clipping their toenails and the gray bucket sitting inside of it was to have been placed under the commode chair if a resident was having a bowel movement while taking a shower so the feces would not go down the water drain and clog it. *She stated the pink basin was cleaned with the same disinfectant spray they used to clean the shower and denied that there were instructions posted in the room or a policy instructing on how to clean the basin used for multiple residents. *She stated a biohazard bag could have been placed in the gray bucket before a resident had a bowel movement and then tied to transport it to the soiled utility room for disposal. *She agreed there were no biohazard bags or lids for the bucket stored in the shower room. *She agreed hand hygiene would have been difficult to maintain in the shower room as there was no handwashing sink and no hand sanitizer in that room. *She agreed the personal products located in the cabinet should have residents' names on them and posed a concern for cross-contamination. *She was not aware of how staff were using the white ice cream bucket located on the floor next to the storage bin with clean towels and washcloths. Interview on 11/16/23 at 12:40 p.m. with assistant director of nursing (ADON) C regarding infection control and the shower room revealed: *She was the infection preventionist. *She had a Centers for Disease Control (CDC) infection preventionist training certificate with a completion date of 1/31/2022. *CNAs received training on showering residents during their CNA course. *She had not trained or monitored staff for infection prevention in the shower room. *She had not made rounds or performed any spot checks in the shower room. *Housekeepers have a routine cleaning schedule for deep cleaning, and it included the shower room. *If the housekeepers had seen something that was not cleaned in the shower room, they would have let the appropriate person know. *The storage bin next to the shower was to have been cleaned when the shower was cleaned. *She agreed the shower cleaning instructions posted in the shower did not include spraying disinfectant and wiping down the storage bin. *She agreed the drawers of the storage bin were not leakproof and agreed that shower water leaking into the drawers and onto the clean towels and washcloths was an infection control concern. *She stated the buckets in the shower room were used if residents had a bowel movement while they were in the shower. *There was no process in place for transporting that bucket from the shower room to the utility room. *She stated staff could use a bag and then take it to the soiled utility room down the hall with the hopper and throw the bag away. *She had not placed bags in the shower room or developed a process for staff to follow. *She agreed leaving the shower room with a bucket of feces that was not covered with a bag or lid did not follow the infection control process. *The pink basin on top of the cupboard was for soaking residents' feet before clipping toenails. *Basins could be a one-time use or could have been used for more than one resident if the staff would disinfect it with the same spray, they used to clean the shower. *She does not train staff on cleaning basins after use or between multiple residents use. *She expected that the dozen or more personal hygiene products stored in the cabinet were to have been labeled with the resident's name. *She agreed that since they were not labeled, there was the potential that the personal hygiene products had been used on multiple residents and that was an infection control concern. A review of the provider's 1/24/23 Infection Prevention Program policy revealed: *The goals of the infection prevention and control program are to: -A. Decrease the risk of infection to residents and personnel. -B. Prevent, to the extent possible, the onset and spread of infection. -C. Monitor for occurrence of infection and control outbreaks and cross-contamination. -D. Monitor for the occurrence of infection and implement appropriate control measures. -E. Identify and correct problems related to infection prevention practices. -F. Maintain compliance with state and federal regulations and standards of practice relating to infection prevention and control. *The facility-wide comprehensive infection prevention and control program addresses detection, prevention, and control of infections among residents and personnel. It is designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases for all.