BIG RIVER NURSING & REHAB

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to provide
appropriate care practices related to an indwelling catheter (a tube inserted into the
urinary bladder to drain the bladder) and to obtain a physician’s orders [REDACTED].#6,
#7, and 45) out of three sampled residents for indwelling catheter use. The facility
census was 97.
Record review of the facility’s Indwelling Catheter Insertion and Removal (female and
male) policy, dated 2006, showed:
– Equipment needed: a sterile indwelling catheter in the size ordered by the physician;
– Check size of the balloon;
– At no time should the tubing be placed above the level of the bladder to allow back flow
of urine into the bladder;
– Secure urinary drainage bag below the level of bladder and keep off the floor at all
times, coil extra tubing and secure.
1. Record review of Resident #7’s (MONTH) 2019 physician’s orders [REDACTED].
– [DIAGNOSES REDACTED].
– An order to change indwelling catheter monthly on the 10th and as needed;
– The order did not include the catheter and balloon size.
Record review of the resident’s (MONTH) 2019 through (MONTH) 2019 POS, showed:
– No orders for insertion of an indwelling catheter or monthly catheter changes.
Record review of the resident’s (MONTH) 2019 through (MONTH) 2019 Treatment Administration
Record (TAR), showed:
– Catheter changed on 1/2/19 and 3/22/19;
– The facility failed to changed the catheter on (MONTH) 10th and (MONTH) 10th.
Observation of the resident showed:
– On 4/16/19 at 10:38 A.M., 4/17/19 at 10:46 A.M. and 4/18/19 at 9:36 A.M., the resident
sat in his/her wheelchair with an indwelling catheter.
During an interview on 4/171/9 at 3:37 P.M., The Director of Nursing (DON) said she
expects staff to obtain physician’s orders [REDACTED]. She said it is facility policy to
change catheters once a month.
Observation on 4/18/19 at 2:30 P.M., showed:
– The resident sat in his/her wheelchair with an indwelling catheter;
– Certified Nurse Aide (CNA) D placed the resident’s catheter bag on the resident’s lap,
above the resident’s bladder level which allowed urine to flow back into the bladder;
– CNA D and CNA F transferred the resident to his/her bed with use of a mechanical lift (a
mechanical device to assist transferring of residents);
– CNA D removed the catheter bag from the resident’s lap holding the bag higher than the
resident’s bladder level.
During an interview on 4/181/9 at 2:40 P.M., CNA D said he/she had been taught to keep
catheter bags below the resident’s bladder level.
2. Observation on 4/16/19 at 11:58 A.M., Resident #6 self- propelled wheelchair through
dining room with the indwelling catheter tubing dragging on the ground.
Observation on 4/17/19 at 1:57 P.M., Resident #6 pushed in wheelchair by CNA I from dining
room back to the resident’s room with catheter tubing dragging on the ground.
3. Observation on 4/16/19 at 2:22 P.M., Resident #45 sat in his/her room in a wheelchair
with the indwelling catheter tubing laying on the ground under the wheelchair.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to verify that the
Gastrostomy tube ([DEVICE], a tube surgically inserted into the stomach to provide
nutrition and medication) is functioning before beginning a feeding and before
administering medications and to check for gastric residual for one resident (Resident
#17) out of two sampled residents for [DEVICE]. The facility census was 97.
Record review of the facility’s Enteral Nutritional Therapy (tube feeding) policy, dated
2006, showed:
– Remove plug from end of feeding tube, check position of tube, and attach barrel of
syringe to end of tubing;
– Check position of tube by listening for breath sounds at end of tube or place, check the
length of tube for proper position, and place stethoscope over stomach and instill a small
amount of air into enteral feeding tube and listen for air to enter the stomach;
– Check physician’s orders [REDACTED].
– The amount of residual may determine the amount of current feeding.
1. Record review of Resident #17’s (MONTH) 2019 physician’s orders [REDACTED].
– an order for [REDACTED].>- An order to flush [DEVICE] with 150 cubic centimeters (cc)
every four hours;
– an order for [REDACTED].>- an order for [REDACTED].>- an order for
[REDACTED].>- an order for [REDACTED].>- No order to check [DEVICE] functioning or
gastric residual.
Observation on 4/17/19 at 9:26 A.M., showed:
– The resident sat in his/her wheelchair with a [DEVICE];
– Registered Nurse (RN) E prepared the resident’s medications for administration;
– RN E uncapped the resident’s [DEVICE] and attached the barrel of a syringe into the
[DEVICE];
– RN E did not check placement of the [DEVICE] or residual of the stomach contents prior
to medication administration;
– RN E flushed the resident’s [DEVICE] with 30 cc of water;
– RN E administered each of the resident’s medications and flushed the [DEVICE] with 30 cc
of water after each medication;
– RN E administered one can of [MEDICATION NAME] 1.5 cal and flushed with 100 cc of water.
During an interview on 4/17/19 at 9:45 A.M., RN E said the facility’s policy is not to
check for placement or for residual prior to use of a [DEVICE].
During an interview on 4/18/19 at 11:45 A.M., the Director of Nursing (DON) said she
expects staff to check for placement and residual of a [DEVICE] prior to medication

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to provide documentation of
ongoing assessments, monitoring, and communication between the facility and the [MEDICAL
TREATMENT] center for two residents (Resident #3 and #28) out of two sampled residents
receiving [MEDICAL TREATMENT] (process for removal of waste and excess water from the
blood due kidney failure). The facility census was 97.
Record review of the facility’s [MEDICAL TREATMENT] policy, dated 8/1/10, showed:
– Coordination with the [MEDICAL TREATMENT] center for emergency management of the
resident to incorporate into the care plan should be done;
– An individual care plan should be developed and followed in coordination with the
comprehensive assessment;
– Coordination with [MEDICAL TREATMENT] center would be done at least weekly so the
facility will stay current on resident’s weights and lab values.
1. Record review of the Resident #3’s (MONTH) 2019 physician’s orders [REDACTED].
– admitted to the facility on [DATE];
– [DIAGNOSES REDACTED].
– No orders to assess and monitor the [MEDICAL TREATMENT];
– No orders to assess and monitor the resident before and after a [MEDICAL TREATMENT]
treatment.
Record review of the resident’s care plan, revised on 1/10/19, showed:
– Resident needs [MEDICAL TREATMENT] three times a week on Monday, Wednesday, and Friday;
– Monitor/document/report as needed any signs of infection to access site;
– Monitor/document/report as needed for signs of [MEDICAL CONDITION];
– Work with resident to relieve discomfort for side effects of the disease and treatment.
Record review of the resident’s medical record 1/1/19 through 4/16/19, showed:
– No documentation to assess and monitor the resident’s condition before and after
[MEDICAL TREATMENT] treatments;
– No documentation of on-going communication between the facility and [MEDICAL TREATMENT]
staff.
2. Record review of Resident #28’s (MONTH) 2019 POS, showed:
– admitted to the facility 6/26/18;
– [DIAGNOSES REDACTED].>- No orders to assess and monitor the [MEDICAL TREATMENT];
– No orders to assess and monitor the resident before and after a [MEDICAL TREATMENT]
treatment.
Record review of the resident’s care plan, revised on 9/13/18, showed:
– The resident needs [MEDICAL TREATMENT] related to [MEDICAL CONDITION];
– Check and change dressing daily at access site and document;
– Do not draw blood or take blood pressure in arm with graft;
– Monitor for dry skin and apply lotion as needed;
– Monitor intake and output;
– Monitor labs and report to doctor as needed.
Record review of the resident’s medical record 1/1/19 through 4/17/19, showed:
– No documentation to assess and monitor the resident’s condition before and after

Based on interview and record review, the facility failed to ensure four of five randomly
selected Certified Nurse Aides (CNA) received the required annual 12 hour resident care
training based on performance reviews. This deficient practice had the potential to affect
all residents. The facility census was 97.
1. Review of the CNA individual in-service records, showed the following:
– CNA A, hired 6/20/13, with 9 hours of in-service training from 6/20/17-6/19/18, no
documentation of a training needs assessment based on performance reviews;
– CNA B, hired 9/15/08, with 3.5 hours of in-service training from 9/15/17-9/14/18, no
documentation of a training needs assessment based on performance reviews;
– CNA C, hired on 4/9/13, with 5.5 hours of in-service training from 4/9/18-4/8/19, no
documentation of a training needs assessment based on performance reviews;
– CNA D, hired 10/28/15, with 8.75 hours of in-service training from 10/28/17-10/27/18, no
documentation of a training needs assessment based on performance reviews.
Record review of the facility’s In-Service Training Program Nurse Aide policy, dated
10/17, showed:
– All personnel are required to attend regularly scheduled in-service training classes;
– The facility will complete a performance review of nurse aides at least every 12 months;
– In-services training will be based on the outcome of the annual performance reviews,
addressing weaknesses identified in the reviews;
– Annual in-services must be no less than 12 hours per year.

Based on interview and record review, the facility failed to implement a water management
plan against waterborne pathogens and failed to review, update, and sign the infection
prevention and control plan (IPCP) annually. This deficient practice had the potential to
affect all residents in the facility. The facility census was 97.
1. Review of the facility’s Legionella Water Management Program policy, dated (MONTH)
(YEAR) and unsigned, showed:
– As part of the IPCP, the facility has a water management program which is overseen by
the water management team;
– The purpose is to identify areas in the water system where Legionella bacteria (can
cause lung infection) can grow and spread, and to reduce the risk of Legionnaire’s disease
(pneumonia caused by Legionella bacteria);
– A detailed description and diagram of the water system in the facility;
– Identification of areas in the water system that could encourage the growth and spread
of Legionella and other waterborne bacteria;
– Identification of situations that can lead to Legionella growth;
– Specific measures used to control the introduction and/or spread of Legionella;
– The control limits or parameters that are acceptable and that are monitored;
– A diagram of where control measures are applied;
– A system to monitor control limits and the effectiveness of control measures;
– A plan for when control limits are not met and/or control measures are not effective;
– Documentation of the program;
– The plan will be reviewed at least once a year or sooner.
Record review of the facility’s water management program documentation showed the facility
had not implemented the plan as follows:
– No water management team;
– No detailed description and diagram of the facility’s water system;
– No identification of areas or situations that could encourage the growth and spread of
waterborne bacteria;
– No measures taken to control the introduction or spread of waterborne bacteria;
– No control limits or parameters;
– Plan not reviewed yearly.
Record review of the facility’s IPCP, dated (MONTH) (YEAR) and unsigned, showed no annual
reviews or updates.
During an interview on 4/18/19 at 1:09 P.M., the Administrator said the facility had not
implemented the water management plan and had no documentation other than the policy. She
said the facility has not assessed or monitored for waterborne bacteria.
During an interview on 4/18/19 at 3:57 P.M., the Director of Nursing said the facility’s
IPCP plan had not been signed or updated on a yearly basis.