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Based on record review and interview the facility failed to provide the state agency (that has licensure survey responsibility) phone number and address information for filing a grievance for 2 of 3 patients (#'s 1 and 7) reviewed for grievances, resulting in the potential of denying those patients the the right to file a complaint/grievance in writing with an outside agency. Findings include:

On 9/24/19 at 0915 a review grievances for patient #1 and #7, and review of the facility's "Patient Grievance and Appeals Policy was reviewed with Staff E. Staff E confirmed the state agency contact information was not provided on the follow up notifications letters to neither patient #1 nor #7. Staff E said on admission the patient's are given a folder with the state agency contact information. Staff E said the grievance policy is posted in many areas in the building.
However, when Staff E was asked to explain what would the patient have to do and/or how would the patient (he/she) remember whom to contact outside of the facility for grievances or if the admission folder lost; or would the patient have to return to the building to get the contact information, Staff E said, we can add that to a response letter notification.

A review of the facility's "Patient Grievance and Appeals Policy", date last revised on 05/2017 documented:
Communication of the Grievance Process:
Patients will be informed of the grievance policy and how to initiate it through the patient and visitor folder or booklet. Written material available in the main lobbies where patient services are accessed...

Based on interview and record review the facility failed to ensure that a Registered Nurse followed physicians orders and documented the insertion of an indwelling urinary catheter for one (#1) of 2 patients reviewed for urinary catheter and failed to ensure that nursing staff updated the plan of care for one (#1) of two patients reviewed for urinary status resulting in the increased potential for adverse outcomes for one patient (#1) out of 10 patients reviewed. Findings include:

See specific Tags:
A-0395: Based on interview and record review the facility failed to ensure that a Registered Nurse followed physician's orders and documented the insertion of an indwelling urinary catheter as ordered by the physician for one (#1) of two patient's reviewed for urinary catheter..

A- 0396 : Failure to ensure nursing staff updated the plan of care for urinary status for one (#1) of two patient's reviewed for urinary elimination.

Based on interview and record review the facility failed to ensure that a Registered Nurse followed a physician order and documented urinary catheter placement for one (#1) of two patients reviewed for altered urinary elimination out of a total sample of 10, resulting in the potential for less than optimal outcomes for patient #1. Findings include:
Findings include:

An interview and record review of the medical record for patient #1 was conducted with Nurse Manager Staff B on 9/24/19 at 1000. Staff B said she was aware of the concern regarding the placement of the patient's urinary catheter. Staff B said she had reviewed the patient's medical record. She said she had determined that no one on her nursing staff had documented that they had inserted the patient's indwelling catheter. Staff B said that after reviewing the provider's notes, she concluded her nursing staff inserted the urinary catheter but did not document that they had performed the procedure.

Per record review patient #1 was an 89-year- old male who was admitted to the facility on 4/25/19. A review of the nursing admission assessment dated 4/25/19 at 1641 revealed the patient was oriented to person only and continent of urine.

A physician order for urinary catheter insertion was dated 4/25/19 for hemodynamic monitoring a critically ill patient. The order was acknowledge by nursing staff on 4/25/19 at 1726 but not documented as performed.
A review of nursing documentation (assessment and notes) dated 4/25/19 through 4/27/19 revealed no evidence that nursing staff followed the physician order to insert a urinary catheter.

However, a review of provider notes for patient #1, dated between 4/26/19 and 4/27/19 documented the following:
A provider note authored by (Staff L) dated 4/26/19 at 1455 documented:
"Patient is confused and in urinary retention with several failed attempts to place Foley (urinary) catheter by staff. Urology consulted and 20 french Coude Foley catheter inserted successfully...".
A provider note authored by (Staff M) dated 4/27/19 at 0027 documented:
"Called by nursing, foley catheter is not draining despite bladder scan of 500 milliliters (ml).
Catheter irrigated with 60 ml normal saline instillation with 60 ml blood urine with large clots evacuated, draining yellow cloudy urine with clots following irrigation...".

On 9/24/19 at 1120 the medical record for patient #1 was reviewed with Registered Nurse Staff H. Staff H confirmed that she had made an attempt to insert a urinary catheter on patient #1 after troubleshooting for problems with a catheter that was already present. She said the catheter was removed without difficulty. She explained that she was unable to replace the catheter. She said it was difficult. She said got the okay for urology to see the patient to replace the urinary catheter. Staff H said she was training a different nurse who was providing care for patient #1 on that date. Staff H said did not review nor had reviewed the orientees nursing documentation.

However, Staff H was unable to explain why she did not document that her attempts to reinsert the patient's (#1's) urinary catheter had been unsuccessful. Staff H was unable to explain why she did not obtain a physician order to remove or replace the urinary catheter.

On 9/24/19 at 1150 the medical record for patient #1 was reviewed with Registered Nurse Staff I. Staff I confirmed that she had performed the patient's admission and assessment on 4/25/19.
Staff I said she acknowledged all physician orders on 4/25/19. However, Staff I was unable to explain why she did not insert the urinary catheter or if she did why did she not document that she did.

On 9/24/19 at 1215 during an interview with the Chief Nursing Officer (Staff A), she confirmed nursing staff should have documented the insertion of the indwelling catheter when performed. Staff A said we follow "Lippincott Procedures" (reference for nursing standards of care).

A review of the facility's "Nurse Driven Urinary Catheter Assessment", dated 02/2018 documented:
I. Insertion of indwelling urinary catheter:
A. Indwelling urinary catheter will be ordered per a physician as: Foley Catheter..
C. The insertion order will generate a task for the nurse. After inserting the catheter, the nurse documents the insertion details...
II. Discontinuation of indwelling catheter:
A. Every shift hours, the nurse will be tasked to re-evaluate the need for indwelling urinary catheter. The nurse cannot reschedule the task. If task not addressed, it will move to "overdue" status in 4 hours.
B. If the catheter DOES meet any indications, the nurse documents the details which completes the task.
i. The task to re-evaluate the need for the indwelling urinary catheter will be generated every shift hours.
C. If the catheter DOES NOT meet any indications;
i. The nurse enters an order to discontinue the indwelling urinary catheter which will be co-signed by the provider
ii. The discontinue order generates a nursing task to remove the catheter
iii. Nursing documents the discontinue details via PowerForm which completes the task.

A review of the facility's reference to "Lippincott Procedures-Documentation", revision date June 14, 2019 documented:
Documentation:
Document the patient's vital signs, your assessment findings, the patient's care plan, your interventions, patient and family teaching, and the patient's response to your interventions, according to your facility's documentation system.

Based on interview and record review, the facility failed to ensure nursing staff updated the plan of care for urinary status for 1 (#1) of 2 patient's reviewed with altered urinary elimination out of a total of 10 sampled patients resulting in the potential for less than optimal outcomes for patient #1.

An interview and record review of the medical record for patient #1 was conducted with Nurse Manager Staff B on 9/24/19 at 1000. Staff B said she was aware of the concern regarding the placement of the patient's urinary catheter. Staff B said she had reviewed the patient's medical record. She said she had determined that no one on her nursing staff had documented that they had inserted the patient's indwelling catheter. Staff B said that after reviewing the provider's notes, she concluded her nursing staff inserted the urinary catheter but did not document that they had performed the procedure.

Per record review patient #1 was an 89-year- old male who was admitted to the facility on 4/25/19. A review of the nursing admission assessment dated 4/25/19 at 1641 revealed the patient was oriented to person only and continent of urine.

Further review of the medical record revealed a nursing care plan dated 4/25/19 at 1739 that addressed the patients (#1's) urinary "incontinence". However, there were no further updates on the urinary plan of care nor within the medical record that addressed the patient's urinary catheter.

Additionally, provider notes dated 4/26/19 at 1455 and on 4/27/19 at 0027 documented that the patient required the provider to assess and reinsert/ irrigate the patient's urinary catheter due to nursing staff unsuccessful attempts to maintain the patient's catheter.

On 9/24/19 at 1215 during an interview with the Chief Nursing Officer (Staff A), she confirmed the patient should have had a nursing plan of care for the urinary catheter.

A review of the facility's "Nurse Driven Urinary Catheter Assessment", dated 02/2018 documented:
Daily hand off communication will address information pertaining to the plan of care of the indwelling urinary catheter.