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Based on staff interviews, review of facility's investigation documents, facility "Display Variance Report," medical record review and review of the facility policies and procedures the facility failed to ensure timely follow up on a quality of care grievance for a patient who developed an ulcer while wearing an external male catheter and failed to receive appropriate discharge instructions, and the facility's failure to ensure multiple size of external male catheters were available for patient care on one (1) of (3) medical records reviewed; Patient #1. This has the potential to affect the quality of care for all patients.

Findings Include:

An interview with Registered Nurse (RN) #2 on 07/17/2025 at 10:35 a.m. confirmed Patient #1 arrived from home wearing a condom catheter and the family requested to keep a condom catheter on patient during his hospital stay. RN #2 confirmed she changed patient's condom catheter on Friday, 05/09/2025, but did not chart it. RN #2 confirmed that the facility's policy is to change the condom catheter at least every 24 hours.

An interview with the Nurse Manager on 07/17/2025 at 10:51 a.m. confirmed Patient #1 came from home wearing a condom catheter and family requested to keep a condom catheter on patient during his hospital stay as the patient had been wearing one for two (2) months to keep urine out of the sacral ulcer. Nurse Manager confirmed that there is a place in the electronic health record to enter "free text notes" or "nursing narrative" for the nurses to be able to chart changing the condom catheter. Nurse manager also reported that the facility's external catheter size was a 35-millimeter latex catheter and per the patient's daughter the home catheters were 29-millimeter non-latex, no reported allergies to latex.

An interview with the Quality and Accreditation (QA) Director on 07/17/2025 at 1:18 p.m. confirmed the facility is now stocking small, medium, and large sizes of external male catheters and has added education on external male catheters and Pure Wick catheters to the annual Skills Fair to be held in August 2025. No documentation provided for training after the incident was identified.

Interview with Registered Nurse (RN) #1 on 07/17/2025 at 1:00 p.m. via phone confirmed Emergency Medical Services (EMS) transport arrived to transport Patient #1 home before the discharge process and instructions could be completed and EMS reported if they did not transport at this time they were not sure when they could return. RN #1 reported she quickly got patient ready for discharge. RN #1 also reported she had not called for EMS transport.

Interview with the Medical Social Worker (MSW) #1 on 07/17/2025 at 11:15 a.m. revealed she sends paperwork to EMS, and the nurse calls for transport when the patient is ready. MSW #1 denies calling EMS for transport.

Review of Patient #1's medical record reveals documentation of external male catheter assessments completed two (2) times during hospital stay before the family member alerted nurse to blood in condom catheter. No documented evidence the eternal male catheter was assessed every shift or changed every 24 hours per policy. "Nursing Narrative," dated 05/10/2025 at 6:22 p.m. by RN #4 documents condom catheter in place to gravity, draining clear yellow urine and on the Genitourinary assessment dated 05/10/2025 at 8:30 p.m. by RN #5 documents dependent drainage bag, no redness, pain or swelling. On 05/12/2025 at 11:30 a.m. RN #2 documented family member "pointed out that the condom catheter on the patient appeared to have blood in it ...will look at it but radiology is here to transport patient ...when patient came back from radiology the condom catheter had come off and patient's penis was weeping blood". Nurse and certified nursing assistant cleaned the patient and the physician was called. No documented evidence the eternal male catheter was assessed every shift or changed every 24 hours per policy was presented.

Review of Patient #1's medical record, "Wound Consult Note," dated 05/12/2025 at 4:29 p.m. reveals decubitus ulcer of penis, stage II, wound care - clean with normal saline, apply Vitamin A and Vitamin D (A&D) ointment, adaptic vaseline gauze, and dry dressing.

Review of Patient #1's medical record, "Nursing Progress Report," on 05/13/2020 at 11:27 a.m. documented by RN #1 revealed " ...Patient alert oriented. PEG tube intact ...Discharge instructions given and reviewed with patient and daughter ...verbalized understanding, five (5) French peripheral inserted central catheter (PICC) line in place to left arm". Review of the "Discharge Documentation" on 05/13/2025 at 10:49 a.m. revealed patient to be discharged with home health and Intravenous (IV) Vancomycin and Zosyn for 40 days. List of routine medications and education on preventing pressure injuries included in discharge documents. No documented evidence of instructions on next medication doses per percutaneous endoscopic gastrostomy tube (PEG) are due or when next PEG feedings are due.

Review of the facility's policy, "External Male Catheter Policy", Current as of 04/21/2021, revealed, " ...check drainage device for patency and inspect skin every shift ...change device at least every 24 hours ...".

Review of the Facility's policy titled, "Discharge Plan and Policy," dated April 12, 2022 revealed Home Health referrals should be made on or before the date of discharge ...when the initial visit is made (normally made on the day after discharge, but may be made on the day of discharge is indicated by patient's condition or needs) to provide for continuity of care ..." General Nursing Guidelines f. ... Complete patient/caregiver discharge teaching ...", g. "contact house manager and arrange EMS transport ...".


Review of the formal complaint dated 05/12/2025, from the family of Patient #1 revealed Patient wears an external male catheter and has not developed any skin conditions until four (4) days after being admitted to facility.

Review of the facility's investigation documentation revealed a draft response letter will be sent to the family after approval by Chief Executive Officer (CEO). As of the survey exit date the draft response letter has not been sent to the family. No documentation provided to include the analysis, plan of correction or plan to monitor the quality of care issues. Education on condom catheter management to be provided in August 2025, after a complaint dated 05/12/2025.

Review of the handwritten notes titled, "Answers to Letter," no date, by QA Director revealed " ...2. There is no male purewick-we have condom caths. *We now have S, M, L stocked...4. Discharge process was a mess due to poor communication. MSW set up transport but didn't relay that to the nurses. EMS showed up and was not willing to stay for a few minutes to let discharge nurse do her job thoroughly which led to the oversight of the peripheral IV being left in ...Handwritten Notes/timeline * ...just told me our condom catheter was latex; he had been wearing a non-latex catheter ..."

Cross Reference to A-0398/482.23(b)(6) and A-0805/482.43(a)(1) for additional information

During the Exit Conference on 07/17/2025 at 2:00 p.m. with the Chief Nursing Officer (CNO) and QA Director, survey findings were discussed, and no further documentation was submitted for review.

Based on staff interviews, documentation of the facility's investigation, facility "Display Variance Report," medical record review, and review of the facility's policies and procedures the facility failed to ensure staff followed the facility's policy and procedure for External Male Catheters for one (1) of three (3) medical records reviewed; Patient #1.

Findings Include:

An interview with Registered Nurse (RN) #2 on 07/17/2025 at 10:35 a.m. confirmed Patient #1 came from home wearing a condom catheter and the family requested to keep a condom catheter on patient during his hospital stay. RN #2 confirmed she changed patient's condom catheter on Friday, 05/09/2025, but did not chart it. RN #2 confirmed that the facility's policy is to change the condom catheter at least every 24 hours.

An interview with the Nurse Manager on 07/17/2025 at 10:51 a.m. confirmed Patient #1 came from home wearing a condom catheter and family requested to keep a condom catheter on patient during his hospital stay as the patient had been wearing one for two (2) months to keep urine out of the sacral ulcer. Nurse Manager confirmed that there is a place in the electronic health record to enter "free text notes" or "nursing narrative" for the nurses to be able to chart changing the condom catheter.

An interview with the Quality and Accreditation (QA) Director on 07/17/2025 at 1:18 p.m. confirmed the facility is now stocking small, medium, and large sizes of condom catheters and education on condom catheter and Pure Wick care will be presented at the annual Skills Fair to be held in August 2025.

Review of Patient #1's medical record revealed three (3) entries regarding patient's condom catheter. The "Nursing Narrative," dated 05/10/2025 at 6:22 p.m. by RN #4 documents condom catheter in place to gravity, draining clear yellow urine and the Genitourinary assessment dated 05/10/2025 at 8:30 p.m. by RN #5 documents dependent drainage bag, no redness, pain or swelling. The third entry on "Nursing Narrative" dated 05/12/2025 at 11:30 a.m., RN #2 noted patient had blood in his condom catheter. No documentation of assessment before Patient was transported to radiology for the placement of a peripheral inserted central catheter (PICC) line. When patient returned from radiology the condom catheter was not in place and the patient's penis was weeping blood.

Review of the facility's, "The Display Variance Report," filed by RN #2 on 05/12/2025 at 3:55 p.m. revealed, " ...patient's penis appeared to have blood on it through the condom catheter ...condom catheter was removed ...penis was swollen and weeping blood from various points on the tip of the penis ...night nurse did not report any redness or swelling with the penis or any additional issues ...".

Review of the statement from Radiologist #1 dated 06/23/2025 revealed, " ...technologists ...did not see a condom catheter on the patient when he was brought to the Radiology department ...groin area was inflamed and there was no catheter present ...".

Review of the statement from Nurse Manager dated 05/12/2025 revealed, " ...the wound (penile) was discovered this morning during RN #2's initial assessment ...nurse removed the condom catheter and contacted the attending hospitalist ...had pending Wound Care Consult ...nurse was directed by Physician #2 to maintain a brief on the patient ...daughter refused and requested Vaseline gauze and abdominal (ABD) pads to the area ...also stated she would be placing antibiotic ointment ...the facility's condom catheter was a 35mm latex catheter ...daughter stated the ones they used were 29mm and non-latex ...patient was seen by wound care Nurse Practitioner (NP) who documented findings and provided orders ...".

Review of Patient #1's medical record, "Wound Consult Note," dated 05/12/2025 at 4:29 p.m. reveals decubitus ulcer of penis, stage II, wound care - clean with normal saline, apply Vitamin A and Vitamin D (A&D) ointment, adaptic vaseline gauze, and dry dressing.

Review of the statement from the Nurse Manager dated 05/15/2025 revealed, " ...patient's daughter ...verbalized concern over bleeding that she noted was present after patient had returned from attempt of PICC line placement ...nurse reported and documented the condom catheter had been removed at some point between 7:17 a.m. and 11:30 a.m. ...condom catheter had not been removed by the facility's staff ...penis examined and provider notified ...wound care consult ordered ...family refused to allow brief to be placed ...as directed by provider ...demanded Vaseline gauze ...asked the daughter if the patient had any known latex allergy ...she was unable to confirm or deny ...discussed with all nursing staff that had cared for patient regarding the condom catheter ...all staff voiced not finding any bleeding from the penis ...".

Review of the statement from RN #3 dated 06/17/2025 revealed patient did not have any wounds on his penis when she was assigned to him on 05/11/2025.

Review of the statement from RN #2, no date, reviewed with surveyor on 07/17/2025 at 10:35 p.m., revealed, " ...appeared there was blood inside the condom catheter ...condom catheter was opaque and not see through ...could not be certain that it was blood or how much there was ...securing device was not in contact with the skin ...when the patient had returned the condom catheter had slipped off ...penis appeared to be weeping blood ...daughter ...was questioning when the condom catheter was last changed ...I told her I did not know when the last time the condom catheter was changed and that there was no way to look up that information ...then called Physician #2 ...explained that the patient's penis was bleeding and swollen ...Physician #2 said to place the patient in disposable briefs and notify wound care ...I ...got the ...unit's digital camera and took a picture of the patient's penis and placed the physical photo on the patient's chart so that wound care could look at it ...".

Review of emails between QA Director and Materials Management on 07/01/2025 revealed, QA Director asked to keep small, medium, and large condom catheters in stock and Materials Management stated, " ...no problem ...we will get them stocked ...".

Review of the facility's policy, "External Male Catheter Policy", Current as of 04/21/2021, revealed, " ...check drainage device for patency and inspect skin every shift ...change device at least every 24 hours ...".

Cross Reference to A-0286/482.21(a)(1)(2)(c)(2)(e)(3) for additional information

During the Exit Conference on 07/17/2025 at 2:00 p.m. with Chief Nursing Officer (CNO) and QA Director, survey findings were discussed, and no further documentation was submitted for review.

Based on staff interview, review of the facility's complaint investigation documentation, facility "Display Variance Report," medical record review, and review of policy and procedures the facility failed to initiate a timely discharge planning evaluation by the Register Nurse (RN) before ambulance transport arrived which gave the family an extremely short notice. This further created rushed discharge instructions regarding feedings and medications and also failure to remove peripheral Intravenous (IV) catheter for one (1) of three (3) patient reviewed; Patient #1. This has the potential to affect post-discharge care and outcomes for patients discharged from this facility.

Findings Include:

Interview with Registered Nurse (RN) #1 on 07/17/2025 at 1:00 p.m. via phone confirmed Emergency Medical Services (EMS) transport arrived for transport of Patient #1 to home before the discharge process and instructions were concluded and EMS reported if they did not transport at this time they were not sure when they could return. RN #1 reported she quickly got patient ready for discharge. RN #1 also reported she had not called for EMS transport.

Interview with the Medical Social Worker (MSW) #1 on 07/17/2025 at 11:15 a.m. revealed she sends paperwork to EMS, and the nurse calls for transport when the patient is ready. MSW #1 denies calling EMS for transport.

Review of the Facility's policy titled, "Discharge Plan and Policy," dated April 12, 2022 revealed Home Health referrals should be made on or before the date of discharge ...when the initial visit is made (normally made on the day after discharge, but may be made on the day of discharge is indicated by patient's condition or needs) to provide for continuity of care ..." General Nursing Guidelines f. ... Complete patient/caregiver discharge teaching ...", g. "contact house manager and arrange EMS transport ...".

Review of the medical record "Nursing Progress Report," on 05/13/2020 at 11:27 a.m. documented by RN #1 reveal, "Patient alert oriented. PEG tube intact ...Discharge instructions given and reviewed with patient and daughter ...verbalized understanding, 5fr PICC line in place to left arm". Review of the Discharge Documentation on 05/13/2025 at 10:49 a.m. reveal patient to be discharged with home health and IV Vancomycin and Zosyn for 40 days. List of routine medications and education on preventing pressure injuries included in discharge documents. No documentation presented for review for when patient received last medication or when next percutaneous endoscopic gastrostomy tube (PEG) feedings are due, no documentation of removal of peripheral intravenous (IV) site, no documentation of the status of the peripherally inserted central catheter (PICC) line site.

Review of the handwritten notes titled, "Answers to Letter," by the Quality and Accreditation (QA) Director revealed " ...4. Discharge process was a mess due to poor communication. MSW set up transport but didn't relay that to the nurses. EMS showed up and was not willing to stay for a few minutes to let discharge nurse do her job thoroughly which led to the oversight of the peripheral IV being left in.

Review of facility's draft response to the complainant, dated 07/09/2025, (not sent to family as of 07/17/2025) revealed " ...4. ...we do agree that due to a lack of communication between the MSW and nursing department the discharge nurse was not ready when EMS transport showed up ...we are working with both departments to ensure better communication ...". No documentation of an action plan or monitoring plan presented to obtain or sustain compliance.

Cross Reference to A-0286/482.21(a)(1)(2)(c)(2)(e)(3) for additional information

During the Exit Conference on 07/17/2025 at 2:00 p.m. with the Chief Nursing Officer (CNO) and QA Director, survey findings were discussed, and no further documentation was submitted for review.