Garden Gate Health Care Facility
January 14, 2025 Complaint Survey

Standard Health Citations

FF15 483.25(e)(1)-(3):BOWEL/BLADDER INCONTINENCE, CATHETER, UTI

REGULATION: 483. 25(e) Incontinence. 483. 25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain. 483. 25(e)(2)For a resident with urinary incontinence, based on the resident's comprehensive assessment, the facility must ensure that- (i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary; (ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary; and (iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. 483. 25(e)(3) For a resident with fecal incontinence, based on the resident's comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 14, 2025
Corrected date: N/A

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review completed during a complaint investigation (Complaint #NY 847), the facility did not ensure that each resident received adequate treatment and services for a foley catheter (tube that drains urine) for one (Resident #4) of two residents reviewed for catheter care. Specifically, staff did not keep the urine collection bag below the level of Resident #4's bladder during care and the resident had a history of [REDACTED]. The finding is: Review of the policy titled Catheter Drainage Bag Care dated 1/01/2000 revealed urinary drainage bag care is performed appropriately to prevent complications caused by the presence of an indwelling urethral catheter. The catheter and tubing must remain patent, with the drainage bag kept below the level of the bladder, to maintain unobstructed urine flow and prevent pooling and backflow of urine into the bladder. Care should be taken to make sure the tubing does not touch or drag on the floor. Resident #4 had [DIAGNOSES REDACTED]. The Minimum Data Set (a resident assessment tool), dated 10/11/2024, documented Resident #4 had mild cognitive impairment, was usually understood, usually understands, and had an indwelling catheter. Review of the Comprehensive Care Plan initiated on 11/12/2024 revealed Resident #4 had [MEDICAL CONDITION] (obstruction in the urinary tract) with the use of a Foley catheter and frequent urinary tract infections with directions for catheter care every shift. Review of the Medical Visit Note History and Physical dated 11/11/2024 revealed the resident was recently readmitted to the facility from the hospital where they were diagnosed with [REDACTED]. 19. Review of the Kardex (used by staff to guide care) dated 12/30/2024 directed staff to complete urinary catheter care every shift. During an observation on 12/24/2024 at 11:28 AM, Certified Nursing Aides #1 and #2 were at the resident's bedside providing hands on care. During the provision of care Certified Nurse Aide #2 placed the urine collection bag through a pair of pants and hung it over the footboard toward the top of the board; the resident was lying on their back with the head of the bed slightly elevated. The urine collection bag was level with the resident's bladder and cloudy yellow urine with mucous shreds was visible in the tubing and occasionally back flowed with the resident's movement and position changes during care. The collection bag remained in that position during incontinence care. At 11:51 AM, Licensed Practical Nurse #1 entered the room and applied a treatment to the resident's buttocks. During the treatment, the urine collection bag remained in the same position and the resident was in the same recumbent (lying down on back) position. The resident was transferred to a wheelchair via a mechanical lift with the urine collection bag placed on the resident's lap. The urine collection bag was not placed below the resident's bladder until the resident was seated in their wheelchair. During an interview on 12/24/2024 at 12:05 PM, Certified Nurse Aide #1 stated they did not notice the position of the urine collection bag and did not handle the collection bag, the other Certified Nurse Aide (#2) did. During an interview on 12/24/2024 at 12:17 PM, Certified Nurse Aide #2 was unaware of the position of the urine collection bag during Resident #4's care and stated it should be kept below the resident's bladder and was unaware that they had placed the bag just over the top of the footboard in an incorrect position. During an interview on 12/24/2024 at 12:19 PM, Licensed Practical Nurse #2, Unit Manager stated a Foley catheter bag should remain below the resident's bladder during hands on care to prevent urinary tract infections. During a telephone interview on 1/14/2025 at 2:59 PM with the Assistant Director of Nursing and Director of Nursing, who was also the facility's Infection Preventionist, the Assistant Director of Nursing stated that during hands on care staff were required to keep the Foley below the resident's bladder to prevent urinary tract infections. The Director of Nursing agreed with this statement. 10 NYCRR 415. 12(d)(1)

Plan of Correction: ApprovedFebruary 2, 2025

The facility will continue to ensure that each resident receives adequate treatment and services for a foley catheter, specifically proper placement of urine collection bag below waist-level to prevent complication. Corrective action took place immediately following care to Resident #4, placing urinary collection bag below level of bladder. Resident was assessed and monitored for 5 consecutive days for adverse effects. None noted. The residents care plan was reviewed and in concert with the current needs and a medical records review was completed with no abnormal findings. The Certified Nursing Assistants (#1 and #2) and Licensed Practical Nurse (#1) was immediately counseled and re-educated regarding proper placement of urinary collection bags during and after care, patency of tubing, and drainage bag below level of bladder to maintain unobstructed urine flow and prevent backflow of urine into the bladder. Staff has been audited by the Clinical Instructor and successfully demonstrated understanding of procedures. No further concerns have been identified. The facility identified other areas that could potentially be affected by the deficient practice by: All residents with foley catheters had the potential to be affected by the deficient practice. The Clinical Instructor conducted resident audits on all those with catheters verifying proper placement. There were no further issues. Measures that will be put in place or systematic changes to ensure that the deficient practice will not recur: The Clinical Instructor provided an educational program to all certified nursing assistants and licensed nursing staff on proper placement of urinary collection bags during and after care, patency of tubing, and drainage bag below level of bladder to maintain unobstructed urine flow and prevent backflow of urine into the bladder The Clinical Instructor/ Designee will conduct weekly audits of 50% of the resident population who have Foley catheters to verify proper placement of drainage bags. Audits will continue until 100% compliance is attained for 8 consecutive weeks. Results of the above will be provided to the Quality Improvement Committee on an ongoing basis to monitor compliance. The Director of Nursing will be responsible for monitoring compliance and follow up as necessary. If 100% compliance is not found, the staff involved will be counseled. The Quality Improvement Committee may make further recommendations including, but not limited to, ongoing education, additional audits, and/or process changes. Corrective action will be completed by (MONTH) 6, 2025. The Director of Nursing is responsible for the implementation of this plan with the Facility Administrator having overall responsibility for the conduct of the plan.

FF15 483.80(a)(1)(2)(4)(e)(f):INFECTION PREVENTION & CONTROL

REGULATION: 483. 80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. 483. 80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: 483. 80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to 483. 71 and following accepted national standards; 483. 80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. 483. 80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. 483. 80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. 483. 80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 14, 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 investigation (Complaint #NY 847), 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 #4) of three residents reviewed for infection control practices. Specifically, Resident #4 was on enhanced barrier precautions (interventions designed to reduce transmission of multi-drug resistant organisms including gown and glove use during high contact resident care activities) and staff did not wear proper personal protective equipment (gowns) during care while emptying a urine drainage bag, applying a skin treatment, and while handling soiled linens. Additionally, there were no receptacles for soiled linen or personal protective equipment in or near the resident's room. The finding is: Review of the facility's policy titled Policy on Disease-Specific Isolation/Precautions dated 1/01/2000 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 #4 had [DIAGNOSES REDACTED]. The Minimum Data Set (a resident assessment tool) dated 10/11/2024, documented Resident #4 has mild cognitive impairment, usually understood, and usually understands. Resident #4 required partial/moderate assistance for personal hygiene, substantial/maximal assistance for toilet hygiene and dressing, and was dependent on staff for bed mobility and transfer. Review of the Comprehensive Care Plan initiated on 11/12/2024 revealed Resident #4 required moderate assistance for personal hygiene, maximal assistance for upper and lower body dressing, had a Foley (tube inserted into the bladder to drain urine) catheter with plans for incontinence care every shift, and required incontinent care every 2-3 hours for frequent loose stools. The resident was identified at risk for infection related to pressure ulcers and urinary tract infections and the resident was placed on enhanced barrier precautions. Review of the Kardex (used by staff to guide care) dated 12/30/2024 revealed the resident required maximal to moderate assistance of one staff for bathing and dressing their upper and lower body, was a mechanical lift with the assistance of two staff for transfers and required enhanced barrier precautions. During an observation on 12/24/2024 at 11:28 AM, a sign for enhanced barrier precautions was posted on Resident #4's door and directed staff to use a mask, gowns, and gloves for hands on care. Two Certified Nurse Aides #1 and #2, were observed at the resident's bedside wearing a mask and gloves, but no gowns. Certified Nurse Aide #1 emptied Resident #4's urine collection bag into a plastic measuring canister. Certified Nurse Aide #1 placed the canister with cloudy urine with mucus threads on a paper towel on the sink counter, measured the urine, emptied the canister into the toilet and returned to the resident's bedside after washing their hands and changing gloves. Certified Nurse Aide #2 placed the urine collection bag through a pair of clean pants, partially dressed the resident in the pants and hung the urine collection bag over the footboard toward the top. At 11:44 AM, Certified Nurse Aide #2 unfastened the resident's incontinence brief, provided Foley care, and washed the resident's buttocks which were reddened with a large area of moisture associated skin damage (skin inflammation and damage caused by prolonged exposure to moisture). The soiled gown, incontinence pad, sheets, and bedcover were gathered by Certified Nurse Aide #1 and placed directly on the floor under the windowsill. While wearing the gloves used to wash the resident, Certified Nurse Aide #2 used their gloved hands to pull up their own pants and adjust their own clothing. Licensed Practical Nurse #1 entered the room without donning a gown and applied a treatment to the resident's buttocks. During the treatment the Licensed Practical Nurse #1's uniform came in direct contact with the bed linens. Certified Nurse Aide #1 gathered the soiled linens off the floor and held them next to their chest directly in contact with their uniform clothing and took them down the hall to the soiled linen room. There was no receptacle for soiled linen or barrier bags used at the resident's bedside or in the resident's hallway outside the room. During an interview on 12/24/2024 at 12:05 PM, Certified Nurse Aide #1 stated yes, they should have had a gown on in Resident #4's room, they forgot. Certified Nurse Aide #1 stated they should have had a gown on when they emptied the urine collection bag and was unsure if they were supposed to wear a gown during other hands-on care activities with the resident. Certified Nurse Aide #1 stated they did not use a hamper for the soiled linen because there wasn't one in the room. During an interview on 12/24/2024 at 12:17 PM, Certified Nurse Aide #2 stated they were unsure why the resident was on enhanced barrier precautions and was not aware that their contaminated gloves came in contact with their uniform clothing. Certified Nurse Aide #2 stated they probably should have worn a gown. During an interview on 12/24/2024 at 12:20 PM, Licensed Practical Nurse #1 stated they were unaware the resident was on enhanced barrier precautions because they were off for an extended period of time and did not notice the sign on the door. During an interview on 12/24/2024 at 12:19 PM, Licensed Practical Nurse #2, Unit Manager stated staff were required to wear mask, gloves, and gown when proving hands on resident care which included, personal hygiene, Foley care and resident treatments for residents on enhanced barrier precautions, which included Resident # 4. Soiled linens should not be on the floor, they should be placed in a soiled linen bin in the room which should be in all residents' rooms who were on enhanced barrier precautions. During a telephone interview on 1/14/2025 at 2:59 PM, with the Assistant Director Nursing and the Director of Nursing, who was also the facility's Infection Preventionist, the Assistant Director of Nursing stated that staff were required to wear a gown, gloves and a mask, when providing hands on care for a resident that was on enhanced barrier precautions to prevent any potential for spread of infection. The Director of Nursing agreed with this statement. 10 NYCRR 415. 19(a)(2)

Plan of Correction: ApprovedFebruary 2, 2025

The facility will continue to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by: Resident # 4 immediately received perineal care and clothing change. The resident was monitored for 5 consecutive days for any adverse effects. None noted. The residents care plan was reviewed and is in concert with the residents current needs and a medical record review completed with no abnormal findings. Environmental surfaces within the room were immediately disinfected and receptacles for soiled linen was placed inside the room and stocked cart of PPE supplies placed outside of the room. The Certified Nursing Assistants (#1 and #2) and Licensed Practical Nurse (#1) who provided care and handled linen was immediately counseled and re-educated regarding infection control practices including Enhanced Barrier Precautions (EBP) protocols, donning and doffing PPE, incontinent care, foley care, skin barrier application, linen handling, and handwashing procedures. Staff also received education on facility protocols for precaution signage to identify resident needs. Staff has been audited by the Clinical Instructor and successfully demonstrated understanding of procedures. No further concerns have been identified. The facility identified other areas that could potentially be affected by the deficient practice by: All residents had the potential to be affected by the deficient practice. The Clinical Instructor conducted 5 resident audits per unit verifying proper infection prevention and control practices. Audits also verified appropriate EBP setup was in place and accessible to staff. Any further issues were immediately rectified and staff counseled. Measures that will be put in place or systematic changes to ensure that the deficient practice will not recur: The Clinical Instructor provided an educational program to all certified nursing assistants and licensed nurses regarding infection prevention and control and specifically related to EBP. Such education also included donning and doffing PPE, incontinent care, foley care, skin barrier application, linen handling, and handwashing procedures. The Clinical Instructor/ Designee will conduct weekly audits of (2) residents per unit to verify appropriate infection prevention and control standards. Audits will continue until 100% compliance is attained for 8 consecutive weeks. The Environmental Services Manager will ensure rooms identified requiring EBP have the proper receptables for donning and doffing PPE. Auditing of each EBP room setup will be conducted weekly. Audits will continue until 100% compliance is attained for 4 consecutive weeks. Results of the above will be provided to the Quality Improvement Committee on an ongoing basis to monitor compliance. The Director of Nursing will be responsible for monitoring compliance and follow up as necessary. If 100% compliance is not found, the staff involved will be counseled. The Quality Improvement Committee may make further recommendations including, but not limited to, ongoing education, additional audits, and/or process changes. Corrective action will be completed by (MONTH) 6, 2025. The Director of Nursing is responsible for the implementation of this plan with the Facility Administrator having overall responsibility for the conduct of the plan.