cms_GA: 164
Data source: Big Local News · About: big-local-datasette
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 164 | HABERSHAM HOME | 115099 | HIGHWAY 441 NORTH, BOX 37 | DEMOREST | GA | 30535 | 2019-06-27 | 550 | D | 1 | 1 | 3SRU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, staff interview, record review, and review of the policies Urinary Catheter Policy, (Insertion, Maintenance, Irrigation) and Resident's Federal and State Rights the facility failed to place a privacy bag over the indwelling Foley catheter of 3 out of 8 residents (R) (R#3, R#8, and R#127) on 1 of 2 units. Findings include: 1. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] for R#3 revealed in section (C) a Basic Interview for Mental Status (BIMS) score of 11/15 indicating intact cognitive responses, (E) Behaviors - None. (G) Functional Status - 2+ person physical assist. (H) Bowel and Bladder - Indwelling Foley Catheter, and always incontinent of bowel. (I) Active Diagnosis (including but not limited to) - [MEDICAL CONDITION] bladder. (N) Medications - Antianxiety, antidepressant, diuretic, and opioid 7/7 days a week. Review of the medical record for R#3 revealed an order dated (MONTH) 2, 2019 for an 18 French Catheter with 20cc Balloon. Change monthly and as needed related to malfunction. During an observation on 6/24/19 at 1:30 p.m. of R#3 in her room revealed her catheter bag to be hanging, uncovered, on the left side of the frame of the bed and visible from the hallway. During an observation on 6/25/19 at 9:12 a.m. of R#3 in her room revealed her catheter bag to be hanging, with the upper portion of the bag covered, revealing the mid and lower portion of the bag. The catheter bag was noted to be on the left side of the frame of the bed and visible from the hallway. During an observation on 6/25/19 at 11:10 a.m. of R#3 during activities revealed her to be sitting in her wheelchair with the catheter bag hanging below the back of the chair and it was noted to be uncovered. During an interview on 6/26/19 at 9:16 a.m. with Licensed Practical Nurse (LPN)/Unit Supervisor BB she stated if a resident has a catheter, and is in the bed, she would expect the catheter bag to be covered completely and preferably hanging on the opposite side of the bed away from view of the hallway. She stated that if the resident is in a wheelchair she would expect the catheter bag to be hanging below the bladder underneath the back side of the wheelchair, off the floor, and covered. During an interview on 6/26/19 at 9:20 a.m. with Activities Coordinator/CNA AA she stated that she knows from working on the floor as a CNA that catheters should be hung below the bladder and should be covered to protect the privacy of the resident. She stated that she has had in-services regarding care of catheters related to Activities of Daily Living but nothing about privacy or where a catheter bag should be placed. During an interview on 6/26/19 at 9:25 a.m. with RN Supervisor CC she stated if a resident has a catheter she would expect nursing staff to ensure the catheter bag was placed below the bladder and that it was covered with a privacy bag. 2. Review of the Quarterly Minimum Data Set (MDS) for R#8, dated 3/23/19, section (C), revealed a Brief Interview for Mental Status (BIMS) score of 6 indicating severely impaired cognition. (E) Behaviors - None. (G) Functional Status - Extensive one-person physical assist. (H) Bowel and Bladder - Indwelling Urinary Catheter and is frequently incontinent of bowel. (I) Active Diagnosis - (Including but not limited to) [MEDICAL CONDITION]. (N) Medications - Antianxiety and Antidepressant 7/7 days a week. Review of the medical record for R#8 revealed an order dated (MONTH) 25, (YEAR) for an 18 French Catheter with 30cc Balloon. Change monthly and as needed related to [MEDICAL CONDITION]. During an observation of R#8 on 6/24/19 at 12:19 p.m., in his room, revealed his catheter bag uncovered and laying in his lap. During an observation of R#8 on 6/24/19 at 12:25 p.m. sitting in the dining room. Catheter bag noted in R#8's lap, uncovered. Catheter tubing noted to be looped up toward his left shirt pocket. During an observation on 6/24/19 at 12:40 p.m. in the dining room R#8 was served lunch. Catheter remained in his lab and the tubing remained looped up toward his left shirt pocket. During an observation on 6/24/19 at 1:00 p.m. in the dining room Activity Director/Certified Nursing Assistant (CNA) AA took R#8's tray, then R#8 propelled himself out of the dining room and down the hall. Catheter bag remained on R#8's lap, uncovered. During this time the catheter tubing was observed to be resting next to his left leg. During an observation on 6/24/19 at 1:10 p.m. in the hall revealed Registered Nurse (RN)/Supervisor CC stand in front of R#8 in the hall, speak to him momentarily, then walk away. During this time Activities Director/CNA AA escorted the resident into her office to complete section F of the MDS. With R#8's permission this surveyor observed the interview. The interview was completed at 1:25 p.m. and CNA AA took R#8 to his room. At no time did RN/Supervisor CC or CNA AA acknowledge the catheter bag in R#8's lap, that it did not have a cover, or place it below the bladder of R#8. During an observation on 6/25/19 of R#8 at 9:00 a.m. revealed him propelling wheelchair down hall with catheter bag noted hanging under chair uncovered. During an observation on 6/25/19 of R#8 at 11:15 a.m. in bed. Catheter bag noted hanging on left side of bed, uncovered, and exposed to hallway. During an observation on 6/25/19 of R#8 at 12:50 p.m. in dining room revealed his catheter bag hanging under his wheelchair uncovered. During an interview on 6/26/19 at 9:16 a.m. with Licensed Practical Nurse (LPN)/Unit Supervisor BB she stated if a resident has a catheter, and is in the bed, she would expect the catheter bag to be covered and preferably hanging on the opposite side of the bed away from view of the hallway. She stated that if the resident is in a wheelchair she would expect the catheter bag to be hanging below the bladder underneath the back side of the wheelchair, off the floor, and covered. LPN/Unit Manager BB stated that a privacy bag should cover the whole catheter bag to insure the resident privacy. She stated that R#8 was just put on antibiotics for a Urinary Tract Infection [MEDICAL CONDITION]. During an interview on 6/26/19 at 9:20 a.m. with Activities Coordinator/CNA AA she stated that she knows from working on the floor as a CNA that catheters should be hung below the bladder and should be covered to protect the privacy of the resident. She stated that she has had in-services regarding care of catheters related to Activities of Daily Living but nothing about privacy or where a catheter bag should be placed. Activity Director/CNA AA stated that she does remember seeing the catheter bag laying in R#8's lap but stated she was focused on what she was doing and just didn't think to place the bag in the correct place and stated she will definitely be more aware in the future. During an interview on 6/26/19 at 9:25 a.m. with RN Supervisor CC she stated if a resident has a catheter she would expect nursing staff to ensure the catheter bag was placed below the bladder and that it was covered with a privacy bag. She stated that if a catheter bag was observed not to be below the bladder she would expect staff to place the catheter bag below the bladder and ensure it was covered with a privacy bag. RN/Supervisor CC stated that R#8 moves his catheter around and sometimes puts it in his lap and staff remind him not to bother his bag. She stated that she remembers seeing the catheter bag in R#8's lap and stated that she had her mind on what she was doing at that time and just didn't think to place the catheter bag in the correct place but would be more mindful in the future. 3. Review of the clinical record for R#127 revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. There was no data available on Minimum Data Set (MDS) due to new admission status with entry tracking MDS dated [DATE]. Observation on 6/25/19 at 11:54 a.m. revealed resident (R) #127 sitting in his wheelchair in the hallway, across from the nurse's station on West Unit. Catheter bag was hanging from the arm of the wheelchair, above the level of the bladder. The tubing was looped over the arm rest of the chair. There was no evidence of a privacy bag covering the drainage bag. Observation on 6/26/19 at 9:06 a.m. revealed R#127 sitting in wheelchair in hallway, across from nurse's station. Catheter bag was hanging from back of wheelchair. There was no evidence of a privacy bag in use to cover drainage bag. Interview on 6/27/19 at 8:19 a.m. with Licensed Practical Nurse (LPN) LL, stated that residents with catheters, should have a privacy bag over the urine drainage collection bag. She stated that she did not notice that R#127 did not have a privacy bag over the drainage bag. Review of the Urinary Catheter Policy, (Insertion, Maintenance, Irrigation) policy revised (MONTH) (YEAR) revealed to maintain unobstructed urine flow by keeping the collection bag below the level of the bladder, and the tubing free of kinks. Urine flow must be downhill. Keep the collection bag off the floor. Review of the policy titled Resident's Federal and State Rights dated (MONTH) (YEAR) revealed the facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. Refer to F656 | 2020-09-01 |