| 79 |
THE PILLARS OF BILOXI |
255093 |
2279 ATKINSON ROAD |
BILOXI |
MS |
39531 |
2017-03-10 |
315 |
E |
0 |
1 |
U1S311 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, and facility policy review, the facility failed to provide catheter care in a manner to prevent the potential for infection and injury, for three (3) of six (6) residents reviewed with catheters. (Residents #5, #15, and #16). Findings include: Review of facility's policy titled, Catheter Care, Urinary, dated 8/25/14, revealed the Foley Catheter should remain secured with a leg strap to reduce friction and movement at the insertion site. (Note: Catheter tubing should be strapped to the resident's inner thigh). Use standard precautions when handling or manipulating the drainage system. Maintain a clean technique when handling or manipulating the catheter, tubing or drainage bag. The urinary drainage bag should be held or positioned lower than the bladder at all times. This prevents the urine in the tubing and drainage bag from flowing back into the urinary bladder. For the female, use a washcloth with warm water and soap to cleanse the labia. Use one area of the washcloth for each downward, cleansing stroke. Resident #16 An observation, and interview on 03/08/16 at 11:45 AM , revealed the State Agency (SA) surveyor and Licensed Practical Nurse (LPN) #3 observed Resident #16 lying in his bed with a Foley catheter in place, and without a leg strap to secure the Foley catheter tubing to his leg. An interview at this time with LPN #3 confirmed the finding, and revealed the use of a leg strap with a Foley catheter is needed to prevent damage by preventing pulling and tugging on the tubing. LPN #3 stated nurses and Certified Nursing Assistants (CNAs) were responsible for checking, and applying the leg straps while delivering care. During an interview on 03/10 17 at 09:30 AM, Registered Nurse( RN) #2 revealed nurses or Certified Nursing Assistants (CNAs) should know from their training that securing a Foley catheter to a resident's leg with a leg strap is part of catheter care. Review of Resident #16's Care Plan revealed facility admitted Resident #16 on 12/29/16. Resident #16's [DIAGNOSES REDACTED]. Resident #6 Observation on 03/08/17 at 3:25 PM, revealed CNA #1, assisted by CNAs #2 and #3 provided Resident #6's incontinent care. The State Agency (SA) surveyor entered the resident's room as the incontinent care was in progress. CNA #1 pulled gloves from her uniform pockets, donned the gloves, and began to clean Resident #6's buttocks. Resident #6 was incontinent of a bowel movement. Resident #6's Foley catheter drainage bag was observed lying on the bed near the resident's feet. Observation on 03/08/17 at 3:35 PM, revealed CNA#1 provided Resident #6's Foley catheter care with assistance from CNA #2 and CNA #3. Resident #6 was lying on her back, and did not have a device to secure the Foley catheter tubing. The Foley catheter bag continued to lie on the bed between the resident's legs during the Foley catheter care. CNA #1 cleaned the peri area by wiping from the back to the front, instead of from the front to the back to prevent contamination. Upon completion of the Foley care, CNA #1 placed the Foley bag into a privacy bag hanging near the foot of the bed. The Foley catheter tubing was hanging unsecured over the resident's left thigh. An interview on 03/08/17 at 4:20 PM, with CNA #1 revealed she didn't know who placed the Foley bag on top of the bed. CNA #1 stated, It's not suppose to be there. CNA #1 revealed she knew it shouldn't have been there, but didn't say anything. CNA #1 further stated by placing the Foley bag on the bed, it could cause an infection. CNA #1 confirmed she removed the gloves from her uniform pocket while performing the incontinent care. CNA #1 stated, I've always done that. I didn't know. CNA #1 confirmed she wiped from back to front during Resident #6's Foley catheter care. Interview on 03/08/17 at 4:30 PM, with CNA #2 revealed she saw the Foley bag lying on the bed, but wasn't' sure who placed it there. CNA #2 stated, it could cause urine to go back inside the resident, and cause a UTI (Urinary Tract Infection). CNA #2 revealed gloves are not clean anymore when placed inside your pockets. CNA #2 confirmed she witnessed CNA #1 wiping Resident #6 from the back to the front during the Foley catheter care. A review of Resident #6's Care Plan revealed the Focus problem to address a Foley catheter in place. Interventions included to ensure a leg strap was in place to secure the Foley tubing, and position the catheter bag and tubing below the level of the bladder. Interview on 03/08/17 at 4:15 PM, with Registered Nurse (RN) #1 revealed the Foley catheter bag should be placed at the foot of the bed below the resident. RN #1 further revealed by placing the bag on the bed it could back up, and cause a bladder infection and pain. RN #1 was asked if staff should store gloves in their uniform pockets, and RN #1 stated, Not that I'm aware of. An interview on 03/09/17 at 9:00 AM, with the Director of Nursing (DON) revealed the Foley catheter bag should hang below the resident's waist on the bed. The DON stated urine can back up in the urethra if the Foley catheter bag was not placed correctly. Interview on 03/09/17 at 9:30 AM, with CNA #3 confirmed the Foley catheter bag was on top of the bed when care was being provided to Resident #6. CNA #3 reported CNA #1 placed the Foley catheter bag on top of the bed. CNA #3 stated, it could back up, and could come open, and contaminate the bed, with the Foley bag being on the bed. CNA #3 confirmed she saw CNA #1 pull gloves from her pocket, and that it could cause the spread of infection. Interview on 03/10/17 at 10:15 AM, with Licensed Practical Nurse (LPN) #2, revealed her understanding of catheter care included observing the presence of a catheter strap. LPN #2 stated the catheter strap was used to prevent injury. LPN #2 revealed the CNAs were suppose to let the nurses know if there was not a strap in place. The nurse replace the straps. The CNA should disconnect the catheter tubing from the strap for the purpose of cleaning. Review of the Face Sheet revealed the facility admitted Resident #6 on 02/01/17 with [DIAGNOSES REDACTED]. A review of the admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 02/08/17, revealed Resident #6 did not fully complete the Brief Interview for Mental Status (BIMS). Per staff interview, Resident #6 had moderate impaired cognitive skills. Resident #15 Observation, and interview on 03/17/17 at 12:25 PM, revealed LPN #1 pulled back Resident #6's covers at which time LPN #1 and the State Agency (SA) surveyor observed Resident #6 had a Foley catheter in place. LPN #1 confirmed there was not a catheter strap in place, and a catheter strap should have been in place. LPN #1 further revealed the nurse that changes the catheter, and performs the body audits was responsible for checking the catheter straps. LPN #1 stated the resident could receive a tear to the urethra, and it could accidentally get pulled out if a strap was not attached. A review of the Face Sheet revealed the facility admitted Resident #15 on 09/20/16, with [DIAGNOSES REDACTED]. A review of the most recent quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 12/16/16, revealed Resident #15 scored 14 on the Brief Interview for Mental Status (BIMS), which indicated cognitively intact. |
2020-09-01 |