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CLEAR VISTA HEALTH & WELLNESS 3364 KOLBE ROAD LORAIN, OH 44053 Dec. 20, 2018
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, staff interviews and review of policy, the facility failed to ensure nurses met the needs of one of ten sampled patients (#1) related to timely interventions for assessment and treatment of a urinary tract infection. The census was 40 patients.

Findings include:

Per medical record review of Patient #1 on 12/20/18, the patient was admitted on [DATE] from another hospital on [DATE] with a history of schizoaffective disorder, bipolar type, urinary retention and urinary tract infections. The patient had a chronic indwelling urinary catheter related to urinary retention and had a history of urinary tract infections prior to admission. The urinalysis in the emergency room was negative prior to admission on 11/06/18. The urinary catheter was last changed on 11/06/18 at the hospital prior to admission to this facility.

Patient #1 was seen by a Certified Nurse Practitioner (CNP). Per the CNP's documentation on 11/20/18, nursing reported the patient had amber output from the urinary indwelling Foley catheter. The CNP documented the patient's urine in the catheter was cloudy, foul smelling and light red in color. The CNP ordered to send repeat urinalysis culture and sensitivity as urine was amber in color at that time and patient had a history of urinary tract infections prior to admission.

The medical record lacked evidence of the results of the urinalysis ordered on [DATE].

On 12/19/18 at 1:35 PM an interview with Staff B (Corporate Director of Quality and Staff D (Director of Quality) was completed. Staff B confirmed the patient's urine sample had not been picked up timely after obtained on 11/21/18. Staff B stated there was a communication breakdown between nursing staff to ensure the urine sample was sent to the laboratory. Staff B stated the facility had issues with the outside lab staff picking up samples on the weekend. Staff B confirmed the patient's urine sample was not sent to the laboratory until the urinalysis and culture was reordered on [DATE].

The urinalysis laboratory results on 11/26/18 revealed Patient #1 had a urinary tract infection at which time an order was obtained for an antibiotic twice a day for seven days.

On 12/20/18 at 12:50 PM Staff B provided the facility policy "Diagnostic Testing and Procedures" #: CS-39, revised 02/22/18. The policy contained the following documentation: "It is the expectation that upon receiving an order for a specific diagnostic test, the registered nurse (RN) will contact the appropriate contracted party as soon as feasible in order to initiate services within 24 hours of the order, or sooner if specified by the prescriber or specific contract."

Staff B confirmed the facility policy was not followed in regard to obtaining the urine specimen for Patient #1.

This deficiency substantiates Substantial Allegation OH 348.