**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review, facility document review, and in the course of a complaint investigation, the facility staff failed to follow professional standards of quality for one of 17 residents in survey sample (Resident # 54). Nursing staff did not follow professional standards of clinical practice during medication administration. Resident #54 was not properly identified and was administered the roommate's medications in error. Resident #54 was sent to the emergency room and was admitted to the intensive care unit. Resident #54 developed hypotension (low blood pressure) & bradycardia (low heart rate) which required intravenous (IV) fluids, medication, and continued telemetry (heart) monitoring. This indicated harm. The findings included: Resident #54 was admitted to the facility with diagnoses that included, but not limited to: unspecified kidney injury, hypokalemia, hypomagnesemia, encephalopathy, Parkinson's, and dementia. The MDS (minimum data set) that was completed for Resident #54 was an OBRA admission Assessment with an ARD (assessment reference date) of 07/02/2021. Resident #54 was assessed with a cognitive summary score of 08, which indicated moderate cognitive impairment. The clinical record was reviewed on 09/20/2022 beginning at approximately 8:30 a.m. The progress note section was reviewed and contained the following: 07/02/2021 10:48 AM During AM medication administration, rsd (resident) was administered wrong medications. Rsd VS (vital signs) obtained. 135/79, 72. 98.2, 18, O2 (oxygen) 96% on RA (room air), family in room at time. MD notified of error. Family requested to send rsd to ED (emergency department) (Name of hospital). 911 activated and report called to ED. On 09/20/2022 at approximately 11:30 a.m., the administrator was asked if the facility had investigated the above incident. The administrator presented the facility investigation of the incident at approximately 1:30 p.m. She was asked if the facility had any follow-up information from the hospital after the resident was sent to the ED. She stated she would look. The facility reported incident contained the following: Incident Date: 07/02/2021 Time: 1000 (10:00 a.m.) Describe Injury: Med. (medication) error Narrative of incident and description of injuries: During AM med. Administration rsd received wrong meds. VS: 135/79, 72, 18, 98,.2, O2 98%, family in room and requesting be sent to ED. Report called to ED. Two witness statements were attached to the Incident report. The first statement contained the following: This Nurse called in report to (Name of hospital) in regards to the wrong medications given to the pt (patient). Medications as followed: Amlodipine 7.5 mg (antihypertensive) * Vitamin C 1,000 mg (supplement/vitamin) * Calcitrol 0.25 mg (supplement) * Carvedilol 6.75 mg (antihypertensive) * Clonidine 0.2 mg (antihypertensive) * Vitamin B-12 1000 mcg (supplement/vitamin) * Eliquis 2.5 mg (anticoagulant) * Famatodine 20 mg (Given to decrease stomach acid) * Senna-S 8.6-50 mg (stool softener) * Sevelamer HCL 800 mg (mineral binding agent) * ED nurse stated that none of these medications were of great concern and there was probably nothing they could do, but they would monitor her BP. *NOTE drug indications in () were not part of the witness statement but added for clarification/information. The second witness statement, written by the nurse who made the medication error contained the following: During AM med. Administration @0920 (9:20 a.m.) rsd was given wrong meds while sitting in the hallway. First day on this hallway with this pt, and I thought she was her roommate .Daughter sitting in doorway & notified that rsd received wrong meds & requested that she be sent to ED for eval (evaluation). Daughter was very understanding & stated to me that it was okay, don't be upset we all make mistakes, and no one is perfect. Rsd with no s/s (signs/symptoms) of distress or c/o (complaints of) discomfort, then obtained VS: 135/79, 72, 98.2, 18, O2 96%. EMS (emergency medical services) arrived @ 0945 (9:45 a.m.) Along with the incident report was a MEDICATION ERROR/OMISSION REPORT which contained the following: Wrong medication .medications administered in error: Furosemide 20 mg, Amolidipine 7.5 mg, Vitamin C 500 mg, Calcitrol 0.25 mg, Carvedilol 6.25 mg, Clonidine HCL 0.2 mg, Vitamin B-12 500 mcg (2 tabs), eliquis 2.5 mg, Famatodine 20 mg, Senna S 8.6-50 mg, Sevelamer HCL 800 mg Physician notified at 0930 (9:30 a.m.) .date 7/2/21. Physician Comments: None, family in room, requested rsd go to hospital . At approximately 1:45 p.m. on 9/20/22, the administrator stated, We actually have the discharge summary from the hospital, I'm not sure why we have it, but here it is. The (hospital) discharge summary contained the following: Physician Discharge Summary admit date : [DATE] discharge date : [DATE] admission Diagnosis: Hypotension due to medication Discharge Diagnosis: Hypotension due to medication .Overdose of antihypertensive agent, accidental or unintentional, initial encounter. Indications for admission: presents to the emergency department via EMS with a chief complaint of feeing shaky. Evidently she had been given another patient's oral medication this morning including furosemide 20 mg, sevelamer 800 mg, vitamin B-12 1000 mg, apixaban 2.5 mg, amlodipine 7.5 mg, famotadine 20 mg, vitamin c 1000 mg, carvedilol 6.25 mg, clonidine 0.2 mg and calcitrol 0.25 mg. In the ER, she was initially normotensive (137/63) with normal sinus rhythm (71) with normal respirations (180) and oxygenation on room air (98%). She was awake and alert, Labs revealed a mild anemia with H/H (hemoglobin/hematocrit) 10.8/34.3. CMP (Comprehensive Metabolic Profile) was essentially normal. ECG (electrocardiogram) revealed a sinus rhythm (60) with a RBBB (right bundle branch block) which is unchanged from 6/27/21. Poison Control was contacted and advised observation for 6 hours. She was observed on telemetry and developed sinus bradycardia into the 40's and hypotension in the systolic 70's. She remained alert and was fairly asymptomatic. She was given IV fluids for pressure support and IV calcium gluconate 1000 mg. She had improvement in her BP with this therapy although it remained low and her bradycardia persisted. After 8 hours of observation in the ER I was asked to admit for observation. Hospital Course: She was admitted to the ICU (intensive care unit) for close observation on telemetry. She received IV fluids for pressure support. She remained in sinus rhythm throughout her stay with some bradycardia in the 40's that has recovered to the 50-60's this morning. She developed no other complicating symptoms. Her labs this morning are stable. Her blood pressure had normalized off IV fluids. I discussed her discharge plans with her daughter who plans to care for her at home with other family. I have placed a referral to home health . Entering right after the administrator, the ADON (assistant director of nursing) presented the medication administration policy as requested and stated, The nurse who gave the wrong meds was reeducated after that happened and the pharmacy came in and did med pass audits. She was asked if a plan of correction had been developed for the incident. She responded, No. The facility policy for medication administration contained the following: General Dose Preparation and Medication Administration .Prior to administration of medication, facility staff should take all measures required by facility policy and applicable law, including, but not limited to the following: Facility staff should: Verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident .During medication administration, facility staff should take all measures required by facility policy and applicable by law, including, but not limited to the following: Identify the resident per facility policy. On 09/20/2022 at approximately 4:00 p.m., the nurse who made the medication error, RN (registered nurse) #3 was interviewed over the phone. She was asked if she remembered the medication error and if so what had happened. She stated, I was an LPN (licensed practical nurse) then .the resident was sitting in the doorway to her room. She and her roommate were new admissions .I gave her, her roommate's meds. She was asked how that had happened. She stated, The residents there don't wear armbands. We have to identify them by the picture in their record .neither one of them had a picture in there. She was asked how she identified residents in the case of no picture. She stated, You hope they don't have dementia and can tell you their name .they have their names on the door and there are typically pictures in there, but with new admits that doesn't always happen. On 09/21/2022 at approximately 9:00 a.m., the administrator and the ADON were asked about the facility policy regarding identification of residents. The administrator stated, We get a picture of them as soon as they arrive and upload it into the system. She was told what RN #3 had stated about there not being a picture in the record at the time of the medication record. She stated, I don't know, it's in there now. She was asked if the resident's wore arm bands. She stated, No. During a meeting with the DON (director of nursing) the ADON, the nurse consultant, and the administrator, on 09/21/2022 at approximately 9:30 a.m., the above information was discussed. The facility staff were informed that based on the investigation the survey team had identified harm to Resident #54. She was given the wrong medications, was sent to the local emergency room, and subsequently admitted to ICU for telemetry monitoring, administered IV medication, and IV fluids. The administrator was asked if any additional information was available the survey team would review it. No further information was presented prior to the exit conference on 09/21/2022. This is a complaint deficiency.

Based on staff interview, clinical record review, facility document review, and in the course of a complaint investigation, the facility staff failed to ensure one of 17 residents (Resident #54) was free from unnecessary medications. Resident #54 was administered her roommate's medications in error and was transferred to hospital, where she required treatment. This indicated harm. The findings were: Resident #54 was admitted to the facility with diagnoses, including but not limited to: unspecified kidney injury, hypokalemia, hypomagnesemia, encephalopathy, Parkinson's, and dementia. The MDS (minimum data set) that was completed for Resident #54 was an OBRA admission Assessment with an ARD (assessment reference date) of 07/02/2021. Resident #54 was assessed with a cognitive summary score of 08, which indicated moderate cognitive impairment. The clinical record was reviewed on 09/20/2022 beginning at approximately 8:30 a.m. The progress note section was reviewed and contained the following: 07/02/2021 10:48 AM During AM medication administration, rsd (resident) was administered wrong medications. Rsd VS (vital signs) obtained. 135/79, 72. 98.2, 18, O2 (oxygen) 96% on RA (room air), family in room at time. MD notified of error. Family requested to send rsd to ED (emergency department) (Name of hospital). 911 activated and report called to ED. The facility incident report was presented at approximately 1:30 p.m. and contained the following: Incident Date: 07/02/2021 Time: 1000 (10:00 a.m.) Describe Injury: Med. (medication) error Narrative of incident and description of injuries: During AM med. (medication) Administration rsd received wrong meds. VS: 135/79, 72, 18, 98,.2, O2 98%, family in room and requesting be sent to ED. Report called to ED. Two witness statements dated 07/02/21 were attached to the Incident report. The first contained the following: This Nurse called in report to (Name of hospital) in regards to the wrong medications given to the pt (patient). Medications as followed: Amlodipine 7.5 mg (antihypertensive) * Vitamin C 1,000 mg (supplement/vitamin) * Calcitrol 0.25 mg (supplement) * Carvedilol 6.75 mg (antihypertensive) * Clonidine 0.2 mg (antihypertensive) * Vitamin B-12 1000 mcg (supplement/vitamin) * Eliquis 2.5 mg (anticoagulant) * Famatodine 20 mg (Given to decrease stomach acid) * Senna-S 8.6-50 mg (stool softener) * Sevelamer HCL 800 mg (mineral binding agent) * ED nurse stated that none of these medications were of great concern and there was probably nothing they could do, but they would monitor her BP. *NOTE drug indications in () were not part of the witness statement but added for clarification/information. The second witness statement, written by the nurse who made the medication error contained the following: During AM med. Administration @0920 (9:20 a.m.) rsd was given wrong meds while sitting in the hallway. First day on this hallway with this pt, and I thought she was her roommate .Daughter sitting in doorway & notified that rsd received wrong meds & requested that she be sent to ED for eval (evaluation). Daughter was very understanding & stated to me that it was okay, don't be upset we all make mistakes, and no one is perfect. Rsd with no s/s (signs/symptoms) of distress or c/o (complaints of) discomfort, then obtained VS: 135/79, 72, 98.2, 18, O2 96%. EMS (emergency medical services) arrived @ 0945 (9:45 a.m.) Along with the incident report was a MEDICATION ERROR/OMISSION REPORT which contained the following: Wrong medication .medications administered in error: Furosemide 20 mg, Amolidipine 7.5 mg, Vitamin C 500 mg, Calcitrol 0.25 mg, Carvedilol 6.25 mg, Clonidine HCL 0.2 mg, Vitamin B-12 500 mcg (2 tabs), eliquis 2.5 mg, Famatodine 20 mg, Senna S 8.6-50 mg, Sevelamer HCL 800 mg Physician notified at 0930 (9:30 a.m.) .date 7/2/21. Physician Comments: None, family in room, requested rsd go to hospital . The facility policy for medication administration contained the following: General Dose Preparation and Medication Administration .Prior to administration of medication, facility staff should take all measures required by facility policy and applicable law, including, but not limited to the following: Facility staff should: Verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident .During medication administration, facility staff should take all measures required by facility policy and applicable by law, including, but not limited to the following: Identify the resident per facility policy. On 09/20/2022 at approximately 4:00 p.m., the nurse who made the medication error (RN #3) was interviewed over the phone. RN #3 was asked if she remembered the medication error and if so what had happened. RN #3 stated, I was an LPN (licensed practical nurse) then .the resident was sitting in the doorway to her room. She and her roommate were new admissions .I gave her, her roommate's meds. On 09/21/2022 at approximately 9:30 a.m., the above information was discussed with the DON (director of nursing), the ADON (assistant director of nursing), the nurse consultant, and the administrator. No further information was presented prior to the exit conference on 09/21/2022. This is a complaint deficiency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #12 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including, but not limited to: Obstructive and reflux uropathy, Benign prostatic hyperplasia, Retention of urine and Diabetes Mellitus Type 2. The most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) 10/01/2018. Resident #12 was assessed as severely impaired in his cognitive status with a total cognitive score of four out of 15. On 02/12/2019 at 9:49 a.m., Resident #12 was observed sitting in his wheelchair (w/c) at the end of a hallway with his eyes closed. His Foley catheter bag was observed hanging from the handles on the back of his wheelchair. The level of his drainage bag was above his waist. Urine observed in the tubing was cloudy, yellow with white sediment. Resident #12 was observed at 3:44 p.m. in activities with his catheter drainage bag hanging from the handles on the back of his wheelchair. The DON (director of nursing) was interviewed at 3:50 p.m. regarding placement of Resident #12's drainage bag. The DON stated, I don't know why they are doing that now. We were making sure the bags were below the chair, but not dragging the floor. Those bags [referring to privacy bags] have straps long enough to hang the drainage bags low. On 02/13/2019 at 8:00 a.m. LPN #1 (licensed practical nurse), wound care nurse, and this surveyor assessed Resident #12's penis and Foley catheter. Resident #12's urinary meatus was split from the opening of his penis to the start of his penile shaft. Catheter tubing was secured to his right thigh and the drainage bag was hanging on the right side of the bed, below the bladder. Resident #12 denied pain from the catheter. Resident #12's clinical record was reviewed on 02/13/2019 at approximately 8:30 a.m. During this review urology visit notes included the following documentation: 03/08/2018 - .he has had foley several months and has penile erosion. Urethral erosion. Foley in several months, with erosion ventrally up 50% of shaft. Consideration for sp [suprapubic] tube is made . 06/21/2018 - .Urinary Retention & Penile Erosion .Significant erosion .I do not feel SP tube is indicated now . 09/27/2018 - .No change in penile erosion . 12/13/2018 - .Penile erosion stable. Cont [continue] monthly tube change. Continue to affix to leg. Watch device & ensure tube/foley is not kinked . 01/17/2019 - .He had gross hematuria and went to ER [emergency room] .Change Foley per routine. We might consider imaging if this recurs. Subsequent review of physician progress notes at the facility dated 06/15/2018, 08/14/2018, 09/18/2018, 10/09/2018, 11/27/2018, and 01/22/2019 did not include any documentation of Resident #12's penile erosion or mention of any of his urology visits. The current POS (physician order sheet) dated February 2019 included the following orders: .Order Date: 11/21/18 Foley Cath Care Every Shift .Change Foley Bag Weekly .Change Foley Catheter 16FR 30ML Balloon as needed .Ensure Foley leg strap/cath secure in place to prevent tension on Foley .Order Date: 02/12/19 Change Foley Catheter 16FR 30ML balloon Q [every] month . Resident #12's CCP (comprehensive care plan) included: ADL (activities of daily living)/Incontinence/Skin .Monitor skin integrity during personal care and notify nurse/MD of any impairements (sic) .Provide foley cath care every shift. Ensure foley leg strap is on with cath secured to prevent tension on foley. Empty cath bag as neede. (sic) Change cath bag weekly. Ensure cath bag is placed below level of bladder. Do not allow cath bag to touch floor. Change foley catheter monthly and as needed per current MD order . Resident #12's son was interviewed via phone on 02/13/2019 at 11:24 a.m. The son stated, We have had issues since he had the catheter placed. He was retaining urine and unable to empty his bladder. He has had several infections and problems with getting the catheter replaced. He sees a urologist that changes his catheter. I was not aware that he has a split from the catheter. The urologist mentioned a suprapubic catheter once when he first started seeing them, but not recently. The doctor really doesn't like them. The DON and LPN #1 were interviewed on 02/13/2019 at 3:20 p.m. regarding Resident #12's penile erosion. LPN #1 stated, I do skin checks, but I don't always look at penises, so I guess that's on me. I did not know his penis was split until yesterday. No, I have not measured the area. The DON stated, I didn't know either. We identified a problem with assessments and documentation on the first of February and have been inservicing the staff. LPN #1 came to the conference room at approximately 3:45 p.m. and stated the eroded area (split) area on Resident #12's penis measured 3cm x 0.5cm (centimeters). The only mention of Resident #12's penile erosion in nursing notes was in a note dated 02/01/2019 at 9:45 p.m. and a note dated 02/09/2019 at 1:28 a.m., both written by the same LPN. Both notes stated, .Foley cath intact and patent draining clear yellow urine without difficulty .Penile head remains split . These notes had corresponding skin assessments. No other skin assessments were located in the record. On 02/14/2019 at approximately 8:30 a.m. the DON and Corporate Medical Director approached the conference room and asked to speak to the survey team. He stated he had assessed Resident #12 and had written a note. He concluded with stating, His penile erosion is a chronic problem without current acute symptoms. This is very common in elderly males with long term catheter use. He has been seen by the urologist several times and also has been to the hospital for catheter issues. I cannot argue that the documentation sucks and that another urologist should have been consulted, but I do not feel the facility has caused harm. The Corporate Medical Director's clinical note dated 02/13/2019 included: .long term resident of the facility that has had a foley catheter for over 2 years and has had multiple follow ups with the urologist. On assessment the patient has no acute pathology/swelling/evidence of trauma/evidence of foley catheter irritation or allergy to the tubing of the foley catheter. He was last seen by the urologist on 03/08/2018, 12/12/18, and 01/17/2019. The current status of the urethral meatus separation had been present on these last several visits with no urological intervention recommendation except for recommendation that the patients foley not get kinked. The presentation of the patients Penis/urethral meatus on todays visit is the similar appearance that was present during the urological visit and furthermore, the presence of the urethral meatus separation is a common problem in the geriatric population from long standing foley cath use . The Corporate Medical Director stated this was the only time he had ever seen and assessed Resident #12. Several attempts were made on 02/14/2019 at 10:30 a.m. to contact Resident #12's urologist. The phone always rang busy. Facility policy, Catheter Care, Urinary included the following documentation: Maintaining Unobstructed Urine Flow .3. The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder .Changing Catheters .14. Assess the urethral meatus .18. Secure catheter utilizing a leg band. 19. Check drainage tubing and bag to insure (sic) that the catheter is draining properly .Documentation - The following information should be recorded in the resident's medical record: 1. The date and time that catheter care was given. 2. The name and title of the individual(s) giving the catheter care. 3. All assessment data obtained when giving catheter care. 4. Character of urine . The Administrator was informed of the above findings during a meeting with the survey team on 02/14/2019 at 12:10 p.m. No further information was received by the survey team prior to the exit conference on 02/14/2019. Based on observation, resident interview, staff interview, facility document review and clinical record review, the facility staff failed to ensure two of 17 residents were assessed and provided appropriate care and treatment/services for the identification of complications related to the prolonged use of an indwelling catheter. 1. Facility staff failed to assess, treat, and provide appropriate interventions related to the prolonged use of an indwelling catheter for Resident #29. Resident #29 was identified by the urologist as having urethral erosion from the prolonged use of an indwelling catheter and recommended the resident undergo a procedure for a suprapubic catheter. There was no documentation in the clinical record that the recommendations had been discussed with the responsible party, nor was there any evidence of the facility's ongoing assessment of the area. Resident #29 had severe urethral trauma which was identified as harm. 2. Facility staff failed to assess and provide appropriate services to identify complications related to the use of an indwelling catheter. Findings were: 1. Resident #29 was admitted to the facility on [DATE] with the following diagnoses, but not limited to: Respiratory failure, Parkinson's disease, dysphagia, Type II diabetes mellitus, urinary retention, benign prostatic hyperplasia, and hypertension. The quarterly MDS (minimum data set) with an ARD (assessment reference date) of 01/07/2019, assessed Resident #29 as severely impaired in his cognitive status with a summary score of 06. On 02/12/2019 at approximately 12:15 p.m., Resident #29 was observed sitting in his wheelchair at a table in the dining room. His catheter bag was attached to the top of his wheelchair back, at shoulder level. The catheter tubing was observed coming out of his left pants leg, under the wheelchair, and up the back of the chair to the drainage bag. There was no urine in the tubing. At approximately 3:45 p.m., Resident #29 was observed sitting in his wheelchair in the hallway. His catheter bag was in the same position. The tubing under the chair was filled with bright red fluid. A CNA (certified nursing assistant) came down the hallway and invited Resident #29 to an activity in the dining room. She wheeled him down the hall, she did not reposition the bag. The DON (director of nursing) was in her office with the ADON (assistant director of nursing) and the MDS nurse, LPN (licensed practical nurse) #2. A copy of the facility policy regarding catheters was requested from DON. She was asked about the placement of catheter bags. She stated, Below the level of the bladder. The observation in the hallway was discussed. The ADON and LPN #2 left the office At approximately 4:00 p.m., this surveyor went to the dining room; Resident #29 was no longer in the activity. Resident #29 had been taken to his room by the ADON and LPN #2. The DON came down the hall and entered the room with this surveyor. Resident #29 was lying on his bed, his brief was partially off. The catheter tubing had been emptied. The catheter bag was hanging on the top side rail, at mid chest level. Resident #29 was not circumcised, the foreskin of his penis was retracted by LPN #2. She stated, He has a split here on the underside of his penis. Resident #29's penis was split from the head down shaft; the catheter was not inserted in his penis at all but directly into the scrotal area. There was fresh blood around head of penis. The catheter tubing was not anchored. The ADON was asked why the catheter was not anchored. She stated, The doctor doesn't want his catheter anchored .we have an order not to the family didn't want a suprapubic catheter but they have now agreed. The clinical record was reviewed, and there were no orders to not anchor the Foley catheter. The skin assessments were reviewed. There was no mention on the skin assessments of Resident #29's penis. The DON was asked if there was any documentation regarding the family's refusal of the suprapubic catheter or where anyone had spoken to them. She stated, I'll see what I can find. At 4:30 p.m., the wound nurse went to Resident #29's room to measure the open area on his penis. She was asked if she had measured the area in the past. She stated, No, this is the first time I have looked at him. The area measured, 5.5 cm long and 1 cm wide. The wound nurse stated, I've never seen anything like this .I'm not sure what to do. The catheter tubing was still not anchored. The tubing went out of his brief, down his pants leg, and up to the catheter bag, still hanging at mid chest level. The wound nurse was asked if there was tension on the tubing. She stated, Yes, and moved the catheter bag down on the bed frame. Resident #29 stated, That's enough, that's enough, it's sore. The facility policy Catheter Care, Urinary was reviewed and contained the following information: The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder .Ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site if resident will allow and is able to tolerate .The following information should be recorded in the resident's medical record: 1. The date and time that catheter care was given. 2. The name and title of the individual(s) giving the catheter care. 3. All assessment data obtained when giving catheter care. 4. Character of urine such as color .clarity .and odor. 5. Any problems noted at the catheter-urethral junction during perineal care such as drainage, redness, bleeding, irritation, crusting, or pain. 6. Any problems or complaints made by the resident related to the procedure. 7. How the resident tolerated the procedure. 8. If the resident refused the procedure, the reason(s) why and the intervention taken. 9. The signature and title of the person recording the data. On 02/13/2019 the clinical record was reviewed for further information. The POS (physician order sheet) for January 2019 contained the following: Foley care q [every] shift; Flush Foley twice weekly; Change 16 [french] Foley catheter with 30 cc balloon monthly per urology. The nurse's notes were reviewed from 08/01/2018 - 02/13/2019. There was no documentation as outlined in the facility policy regarding assessments, problems with the catheter site, interventions, etc., during any of the catheter changes or when catheter care was provided each shift. The urology notes were reviewed and contained the following: 01/04/2018 Recurrent UTI's, Chronic urinary retention, Acquired hypospadial urethral erosion .recommendations: I will discuss with [physician name] re: SPT [suprapubic catheter] vs continued Foley . 08/13/2018 Chronic urinary retention .urethral erosion. Recommendations: Change Foley catheter every 4 weeks, *Flush Foley at least twice a week, strongly consider suprapubic catheter if patient can be medically cleared. There was no documentation in the clinical record from either the nursing staff of the primary physician that the need for a suprapubic catheter was discussed with the family. On 02/13/2019 at approximately 2:00 p.m., the DON and the wound nurse came to the conference room to discuss Resident #29. The DON stated, I can't find very much in the record .here's a note from April 2017, one form November 2017 and one from April 2018 that's it. The notes contained the following: 04/26/2017 While looking at RSD (resident) penis for cath care, I observed some tearing and a small mount of blood on the underside of the penis at the urethral opening. I contacted MD .he ordered a consult to urology . 11/3/2017 Resident went to ER .due to pulling at Foley. Resident transferred himself to the bathroom without assistance .Resident states . he accidentally sat on his cath. The head of resident's penis is torn and resident is having some bloody drainage . The DON was asked if there was any follow-up documentation or measurements of the areas described in the notes. She stated, No, this has been a slow ongoing thing with him .when he came back from the urologist in August [2018] the nurse wrote an order to change the catheter every 4 weeks, because we were changing it weekly per the family's request, she wrote to consider suprapubic catheter placement after he was medically cleared .I asked her if she discussed that with the family and she doesn't remember .there aren't any notes in the record from [name of Resident #29's physician] about it. The DON was asked since it was a slow ongoing thing wouldn't that be all the more reason to be documenting the measurements/appearance of the area in the clinical record. She nodded her head, indicating Yes. The wound nurse stated, I called his sister last night .he [Resident #29] was trying to get out of the bed, kicking off his covers, pulling at his catheter .she said that she knew he had pulled it out twice in the past .she said he just doesn't realize he is hurting himself . The wound nurse stated, He does pull at his catheter sometimes. The DON was asked if there was any place in the record other than on the TAR (treatment administration record) where nurse's documented catheter care or changing of the catheter. She stated, No. She was asked where the documentation outlined in the facility policy regarding care of the Foley catheter would be documented. She stated, It isn't. The care plan was reviewed, the focus area: ADL/Incontinence/Skin .Foley cath in place d/t [due to] urinary retention/obstructive uropathy, had the following interventions: Provide Foley cath care. Keep cath bag below level of bladder and empty bag as needed throughout the shift. Do not allow cath bag to touch the floor 1/29: Urethral tear has worsened . An additional focus area: Catheter/UTI [Urinary Tract Infection] risk .has urethral tear from Foley cath [no date this was added]; 1/29: Urethral tear from Foley has worsened. Urology consult for suprapubic cath scheduled .Interventions included: Change Foley per current MD order; Monitor for s/sx [signs and symptoms] of UTI ., change catheter drainage bag weekly; cue/remind resident as needed of importance of keeping drainage bag below bladder to decrease the risk of infection; Monitor Foley insertion site for s/sx of trauma/infection, i.e. redness, purulent drainage, pain, etc and report to nurse/MD; Provide Foley cath care. Keep cath bag below level of bladder and empty as needed throughout the shift. Do not allow cath bag to touch floor; Assist resident with proper placement of catheter drainage bag below level of bladder; Flush Foley per current MD order. The DON and the wound nurse were informed that there were no interventions on the care plan, nor had there been any documentation observed in the clinical record regarding Resident #29 pulling at his Foley catheter. On 02/14/2019 at approximately 8:50 a.m., the Corporate Medical Director came to the conference room to speak with the survey team. He stated that he had examined Resident #29 for the first time the previous evening. He stated that penile/urethral erosion was very common in elderly due to long term catheter usage. He stated that in his opinion, the facility's lack of documentation and assessment was not the issue, but the failure was that the urologist had not provided appropriate interventions and that the facility needed to get a second opinion from another urologist. He stated that he did not think the facility had caused the resident harm and what he saw was not an acute problem. The Corporate Medical Director was referred to a nurse's note written on 02/10/2019 which contained information that Resident #29 had >100,000 mixed bacterial flora in his urinalysis and the culture and sensitivity was pending. He was asked if he felt the placement of the catheter bag, well above the level of the bladder would contribute to a urinary tract infection, He stated, No, the contributing factor to his UTI's is the placement of the catheter, not the position of the bag. The Corporate Medical Director's was reviewed at approximately 9:45 a.m. The note contained the following: This is an [AGE] year old patient that is a long term resident of the facility that has had a Foley catheter for about 2 years and has had multiple follow-ups with the urologist. On assessment, the patient has no acute pathology/swelling/evidence of trauma/evidence of Foley catheter irritation or allergy to the tubing of the Foley catheter the presentation of the patient's penis/urethral meatus on todays [sic] visit is similar in appearance that was present during the urological visit and furthermore, the presence of the urethral meatus separation is a common problem in the geriatric population from long standing Foley cath use . At 10:10 a.m., the urologist that had examined Resident #29 was contacted via telephone. A message was left with his office staff asking him to call this surveyor regarding Resident #29. The urologist did not return the call. During and end of the day meeting on 02/14/2019 at approximately 12:15 p.m., with the DON and the administrator the above information was discussed. The DON was asked if the primary care physician had submitted any information regarding the progression of Resident #29's urethral erosion. She stated, Not yet. The DON and the administrator were informed that the facility's failure to assess and document changes in the erosion of Resident #29's penis were identified as harm by the survey team. At approximately 12:45 p.m., the DON presented a note that had been faxed to the facility from the primary care physician regarding Resident #29. Information included: Asked by staff to comment on [name of Resident #29] chronic Foley catheter. He was last seen by urology around August 2018 and option for suprapubic catheter was raised. Apparently, his sister was not in favor of that because of her fear of the risks of surgery and he had been through a lot of issues with his pacemaker right before that. Last fall I was encouraging his sister to move his care to a palliative only direction (Hospice, for example) but she was not in favor of that at the time. He has frequent UTIs and intermittent pain in that area (usually with UTIs). As all patients with Foley catheters in that long, he has erosion and enlargement of his urethra now The DON was asked if the primary care physician had discussed the suprapubic catheter with the family in August. She stated, I don't know, it's not in the note. No further information was obtained prior to the exit conference on 02/14/019.