NYS Health Profiles
Find and Compare New York Health Care Providers
NYS Health Profiles
Find and Compare New York Health Care Providers
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 12, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review completed during a Complaint (#NY 959) investigation, the facility did not ensure that each resident received adequate treatment and services for a Foley catheter (tube that drains urine) for one (Resident #2) of two residents reviewed for catheter care. Specifically, staff did not keep the urine collection bag below the level of Resident #2's bladder during care and the resident had a history of [REDACTED]. The finding is: Review of the policy titled Catheter Care, Urinary obtained from the Med-Pass Nursing Services Policy and Procedure Manual for Long-Term Care dated 2001, provided by the Director of Nursing, revealed staff are required to always position the drainage bag lower than the bladder to prevent urine flowing back into the urinary bladder. The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections. Resident #2 had [DIAGNOSES REDACTED]. The Minimum Data Set (a resident assessment tool), dated 11/23/24, documented Resident #2 had moderate cognitive impairment, was usually understood, usually understands, and had an indwelling catheter. Review of the Comprehensive Care Plan initiated on 12/2/24 revealed Resident #2 had [MEDICAL CONDITION] and required the use of a foley catheter with directions for catheter care according to established policy and to keep the catheter bag below the resident's bladder. Review of the current Closet Care Plan (used by staff to guide care) dated 11/14/24 documented Resident #2 under continence had a Foley catheter. Review of the Operative Report dated 2/4/25 revealed the resident had a cystoscopy (medical procedure to examine the bladder and urethra) for a right [MEDICAL CONDITION] (thin tube that carries urine from kidney to the bladder) exchange and removal of kidney stones in the right ureter. Surgical aftercare remained the use of a Foley catheter and treatment with [MEDICATION NAME] (antibiotic medication used to treat infections) 500 mg (milligram) tablets daily. Review of Medication Orders dated 2/4/25 directed the use of [MEDICATION NAME] 500 mg (milligrams) tablet daily for seven days for [MEDICATION NAME] (measure taken to prevent disease or infection) treatment. Review of the Physician's Progress note dated 2/6/25 revealed the resident has a history of [MEDICAL CONDITION] with frequent urinary tract infections and had a cystoscopy, with plans to continue the use of a Foley and for the resident to complete a course of [MEDICATION NAME]. During an observation on 2/10/25 at 11:52 AM, Certified Nurse Aide #1 was at the resident's bedside preparing to provide hands on care. The resident was lying flat in bed with the urine collection bag on the bed mattress. The resident remained lying flat during the bed bath and brief change. The Certified Nurse Aide #1 emptied the urinary collection bag full of clear yellow urine by lifting the bag approximately a foot above the resident's torso; the urine was visibly backflowing towards Resident #2's bladder. Certified Nurse Aide #1 placed the urinary collection bag through the pant leg while dressing the resident in bed and left the urinary collection bag on the mattress with the resident still lying flat in bed at 12:09 PM. During an interview on 2/10/25 at 12:27 PM, Certified Nurse Aide #1 stated the urine collection bag the resident had after recent surgery several days ago did not reach below the resident's bladder and was reported to nursing staff. Certified Nurse Aide #1 said they always emptied the urine collection bag in the same manner and was aware that the bag is supposed to remain below the resident's bladder to prevent infection. During an interview on 2/10/25 at 2:20 PM, the Registered Nurse Nurse Manager #1 stated it was unacceptable to empty a urinary catheter bag by raising it above the resident's bladder to prevent infections. The Registered Nurse #1 Nurse Manager also stated when the resident returned from surgery last week, staff had informed them that the urinary catheter bag placed in surgery had shorter tubing. The Registered Nurse Nurse Manager #1 stated they would call the surgeon today to determine how to proceed with this issue. During a telephone interview on 2/11/25 at 9:39 AM, the Surgeon/Physician stated that staff did not inform them of a problem with Resident #2's urinary catheter bag until 2/10/25 after the surveyor's observation. The Physician/Surgeon stated that it is important to keep the bag below the bladder to decrease risk of infection especially for this resident who was at high risk for urinary tract infections. During an interview on 2/10/25 at 12:26 PM, the Registered Nurse #3 Infection Control Preventionist stated they were aware that Resident #2 went to surgery last week and was sent back to the facility with a different urine collection bag that was shorter and did not have clips for hanging the bag. Registered Nurse #3 Infection Control Preventionist stated they do not change devices placed by surgery until there is surgical follow up and stated they did not report the problem to anyone else. During the interview an observation of the urinary drainage bag was performed at the resident's bedside with Registered Nurse #3 Infection Control Preventionist who viewed that the bag was able to reach slightly below the resident's bladder and the urinary drainage bag had slits at the top to accommodate clips and/or straps to secure the urinary drainage bag below the resident's bladder. 10 NYCRR 415. 12(d)(1) | Plan of Correction: ApprovedMarch 6, 2025 Schoellkopf Health Center submits that its policies, systems and procedures related to the resident care and comprehensive quality improvement program for monitoring of resident care are appropriate. Additionally, it is important to make clear that the submission of this Plan of Correction is not to be construed as an admission that the cited deficiencies are accurate or that at the time of the survey Schoellkopf Health Center did not have policies, procedures and systems in place to maintain compliance with federal and state requirements. However, in an effort to enhance the care furnished to our residents, we have improved some of our existing policies, procedures and systems. I.) The following corrective action was accomplished for the deficiency stated: A.) The CNA that provided inadequate Foley care to Resident #2 was termed from her agency employment contract on (MONTH) 11, 2025 prior to notification of this deficiency. Due to concerns that the administrator and director of nursing were made aware, the facility had already placed her and her agency contract on a ?ôwatch status?Ø for performance improvement, which was not accomplished. This appears to be an isolated incident with this particular CNA as she is quoted by state surveyor during interview saying she was ?ôaware the bag was supposed to remain below the residents bladder to prevent infection.?Ø B.) Resident #2 had a cystoscopy procedure on 2/4/2025, returned same day to facility with a leg bag attached to her thigh below the bladder. RN unit manager contacted the surgeon on 2/10/2025 and obtained orders to remove leg bag and replace with full urinary collection bag. C.) Resident #2 was on 24-hour report for nursing to monitor for any ill effects s/p cystoscopy or s/s of UTI. D.) The CNA did not care for any other residents with a foley. II.) The following corrective actions have been implemented to ensure all CNA staff are aware of proper Foley care as all residents have the potential to be affected by the same practice. A.) All CNA staff will be in-serviced by IP/In-service Coordinator on proper Foley catheter care to help prevent infections. B.) All residents with an indwelling urinary foley identified and they will be monitor for s/s of UTI. III.) The following systemic changes have been implemented to assure continued compliance with regulations. A.) All nursing staff: RN, LPN, and CNA will be required to complete a Relias training titled ?ôCare of a Urinary Catheter?Ø on a yearly basis. B.) IP/In-service Coordinator or designee will audit 1 resident with a foley per week times 4 weeks, then 1 per month times 2 months to ensure competency in emptying procedure. C.) Administrator and Director of Nursing reviewed policy titled ?ôCatheter Care,?Ø remains appropriate and no changes were made to the policy. IV.) The facilities compliance will be monitored utilizing the following QAPI system: A.) IP/In-service Coordinator will track all staffs compliance with assigned Relias trainings and report results to QAPI committee, which meets quarterly. B.) IP/In-service Coordinator will report audits to the QAPI committee, which meets quarterly. C.) The IP/In-service Coordinator Nurse will be responsible for overall monitoring and evaluation of implemented plans. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 12, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review completed during a Complaint (# NY 959) investigation, the facility did not ensure provision of a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for one (Resident #2) of three residents reviewed for infection control practices. Specifically, Resident #2 was on enhanced barrier precautions (interventions designed to reduce transmission of multi-drug-resistant organisms including mask, gown and glove use during high contact resident care activities) and staff did not wear proper personal protective equipment during care while emptying a urine drainage bag. The finding is: Review of the policy titled Infection Prevention dated 12/2024 revealed procedures for isolation and universal precautions will be placed for residents suspected or confirmed to have a contagious or infectious disease. Masks, gowns and gloves should be used as protective barriers when needed to reduce the risk of exposure of the health care worker's skin or mucous membranes to potentially infectious material. Enhanced Barrier Precautions are used in conjunction with standard precautions and expand the use of personal protective equipment to donning (putting on) of gown and gloves during high-contact resident care activities that provide opportunities for transfer of multi-drug-resistant organisms to staff hands and clothing including dressing, bathing/showering, transferring, changing linens, changing briefs, wound care, and contact with a urinary catheter. Resident #2 had [DIAGNOSES REDACTED]. The Minimum Data Set (a resident assessment tool), dated 11/23/24, documented Resident #2 had moderate cognitive impairment, was usually understood, usually understands. Resident #2 required maximal assistance for personal hygiene, was totally dependent on staff for toilet hygiene and dressing, and moderate assistance for bed mobility. Review of the Comprehensive Care Plan initiated on 12/2/24 revealed Resident #2 required assistance with transfers and activities of daily living due to decreased balance and strength and required Foley catheter care. Review of the current Closet Care Plan (used by staff to guide care) dated 11/14/24 revealed the resident had a Foley catheter for continence and required extensive to maximal assistance for bathing and extensive assistance for bed mobility. Review of Physician order [REDACTED]. Review of the Physician's Progress note dated 2/6/25 revealed the resident has a history of [MEDICAL CONDITION] with frequent urinary tract infections and had a cystoscopy, with plans to continue the use of a Foley and for the resident to complete a course of [MEDICATION NAME] (antibiotic medication to treat infections). During an observation on 2/10/25 at 11:52 AM, a sign for enhanced barrier precautions was posted on Resident #2's door and directed staff to use a mask, gowns, and gloves for hands on care. Certified Nurse Aide #1 was observed at the resident's bedside wearing gloves, but no mask or gowns. Certified Nurse Aide #1 performed a bed bath that included assisting the resident with bed mobility, emptied the urinary collection, changed the resident's clothing, and handled soiled linens while wearing the same pair of gloves; the resident care activities performed were completed at 12:09 PM. During an interview on 2/10/25 at 12:27 PM, Certified Nurse Aide #1 stated yes, they should have had a gown and mask on in Resident #2's room to prevent infection, they forgot. During an interview on 2/10/25 at 12:26 PM, Registered Nurse #3 Infection Control Preventionist stated Resident #2 is on enhanced barrier precautions because of the use of the Foley catheter in accordance with the facility's nursing standard of practice. Staff are required to wear a gown, mask, and gloves for residents on enhanced barrier precautions to prevent the spread of infections. During an interview on 12/10/25 at 1:27 PM, the Director of Nursing stated that the resident is on enhanced barrier precautions for the use of the Foley catheter and staff are required to wear a mask, gown and gloves during hands on care to prevent infections. 10 NYCRR 415. 19(a)(2) | Plan of Correction: ApprovedMarch 6, 2025 Schoellkopf Health Center submits that its policies, systems and procedures related to the resident care and comprehensive quality improvement program for monitoring of resident care are appropriate. Additionally, it is important to make clear that the submission of this Plan of Correction is not to be construed as an admission that the cited deficiencies are accurate or that at the time of the survey Schoellkopf Health Center did not have policies, procedures and systems in place to maintain compliance with federal and state requirements. However, in an effort to enhance the care furnished to our residents, we have improved some of our existing policies, procedures and systems. I.) The following corrective action was accomplished for the deficiency stated: A.) The CNA that provided care to Resident #2 without donning proper PPE was termed from her agency employment contract on (MONTH) 11, 2025 prior to notification of this deficiency. Due to concerns that the administrator and director of nursing were made aware, the facility had already placed her and her agency contract on a ?ôwatch status?Ø for performance improvement, which was not accomplished. This appears to be an isolated incident with this particular CNA as she is quoted by state surveyor during interview saying she ?ôforgot?Ø. This CNA was hired through agency on (MONTH) 10, 2024. During her orientation period she passed bathing and incontinence care, including infection control competency. B.) The facilitys policy and procedure to alert staff of transmission-based precautions, including Enhanced Barrier Precautions were followed as evidence by the proper identification and needed PPE was present outside residents room. II.) The following corrective actions have been implemented to ensure all CNA staff are aware of proper PPE/hand hygiene/infection prevention control technique during resident bathing and incontinence care, as all residents have the potential to be affected by the same practice. A.) All CNA staff in serviced by the IP/In-service Coordinator on the proper PPE/ hand hygiene/infection prevention technique for residents on EBP. Inservice will address the proper PPE to wear for residents on EBP to promote a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infection. B.) All CNA staff will have a competency evaluation performed by the IP/In-service Coordinator on proper PPE/hand hygiene/infection prevention technique while performing resident bathing and incontinence care. C.) IP/In-service Coordinator or designee will provide individualized instruction / training with any CNAs who do not pass competency. D.) All resident on Enhanced Barrier Precautions identified. RN Unit Manger or designee will interview appropriate residents on EBP to confirm staffs compliance with infection control measures as all residents on EBP have potential to be affected by same practice. III.) The following systemic changes have been implemented to assure continued compliance with regulations. A.) In addition to current competency evaluations that the IP/In-service Coordinator or designee performs, all staff will be required to complete a Relias training titled ?ôInfection Control: Enhanced Barrier Precautions,?Ø and ?ôBasics of Personal Protective Equipment?Ø by (MONTH) 1, 2025 and then on a yearly basis. B.) Administrator and Director of Nursing reviewed policy titled ?ôInfection Prevention?Ø remains appropriate and no changes were made to the policy. C.) IP/In-service Coordinator or designee will audit residents care performed by a CNA for a resident on EBP. Will complete I audit per week times 4 weeks, then 1 per month times 2 months to ensure compliance with infection control measures/PPE. D.) IP/In-service Coordinator or designee will provide individualized instruction / training with any CNAs who do not pass competency. IV.) The facilities compliance will be monitored utilizing the following QAPI system. A.) IP/In-service Coordinator will track all staffs compliance with assigned Relias trainings and report results to QAPI committee, which meets quarterly. B.) IP/In-service Coordinator will report audits to the QAPI committee, which meets quarterly. C.) The IP/In-service Coordinator Nurse will be responsible for overall monitoring and evaluation of implemented plans. |