DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		 (X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER		 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED
191608 A. BUILDING __________
B. WING ______________ 		01/26/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
HOSPICE OF LEESVILLE 1615 SOUTH 5TH STREET, LEESVILLE, LA, 71446
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See reverse for further instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation
LABORATORY DIRECTOR’S OR PROVIDER/SUPPLIER REPRESENTATIVE’S SIGNATURE

 TITLE

 (X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
(X4) ID
PREFIX
TAG		 SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY SHOULD BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
L0584      
22117 Based on interview, record review and policy and procedures reveiw the provider failed to ensure a licensed staff provided services according to the provider's policy and procedures for inserting a Foley catheter for 1 (#2) of 5 sampled patients out of a total census of 22 patients. Findings: Review of the record revealed Patient #2 was admitted to the provider on 01/30/2020 with the diagnosis of Mild Protein Malnutrition and Downs Syndrome and revoked hospice services on 2/11/2020. Review of the Comprehensive Plan of Care revealed the patient was care planned for having elimination difficulty and the patient required a 12 french catheter, which was ordered to be changed monthly and PRN. Review of the Skilled Nurses note documented by S2 LPN on 2/11/2020 at 1:30 p.m. revealed the patient was in a good mood, alert, able to speak some but not in complete sentences, no signs of distress noted. Caregiver was present during visit, and reported the patient had a poor appetite for food and fluids, had a hard time swallowing and would have coughing fits while drinking. The patient's Foley catheter was present with amber colored urine. The caregiver requested the Foley catheter be changed due to it leaking. The catheter was removed intact by S2 LPN and a new 12 french Foley catheter was inserted, with no distress noted, and no signs of pain at that time. S2 LPN documented there was no urine return initially but instructed the family to watch for return. Documentation revealed S2 LPN called back within the hour and the caregiver stated there was urine output. Review of a PRN SNV dated 02/11/2020 at 5:45 p.m. revealed S2 LPN arrived at the patient's home. The caregiver was present and stated the patient had blood in his catheter. The Foley catheter had 400 ml's of dark amber urine in the Foley bag with a small amount of blood in the tubing. Upon deflating the catheter bulb there was more blood in the tubing and after removing the catheter, blood was also present on the penis. The caregiver was distressed and called the ambulance. After the patient was transported, a revocation was given to the caregiver who refused to sign the form. Review of the hospital Physician's Documentation dated 02/11/2020 at 6:58 p.m. revealed the patient arrived at the emergency room with bleeding from penis after a Foley catheter was inserted and inflated. Further review of the documentation revealed the patient had profuse bleeding from the penis and dysuria. Review of a Consultation report dated 02/11/2020 revealed under the Clinical History section: The patient was in the hospital setting today after the hospice attempted to change the catheter, the catheter balloon was blown up in the prostatic urethra and the patient subsequently had gross hematura. The Impression revealed gross hematura related to urethral injury, urethral trauma from blowing up the prostatic urethra/proximal urethra and possible impending urosepsis. Interview with S2 LPN on 01/26/2021 at 10:00 a.m. revealed she had seen the patient on 02/11/2020 for a regular SNV. She revealed she changed the patient's catheter out due to it was leaking. She also revealed at that time there was no blood in the bag or tubing. She stated she removed the old catheter and inserted the new catheter but there was no urine return. She then stated she did go further with the catheter, to see if she could get a urine return. S2 LPN revealed that after not getting a return she went ahead and inflated the balloon because she thought the resident might have had an empty bladder since the old catheter had been leaking. She stated that upon her departure there was no urine in the collection bag. She stated she called the caregiver back an hour later and was told there was urine in the bag. She stated she had inserted catheters before and not received a urine return, but it was usually due to the patient having an empty bladder or being dehydrated. Review of the provider's Policy and Procedure for Male Foley Catheterization revealed #22: After urine begins to flow, inflate the Foley catheter balloon with indicated amount of sterile water or air. Interview with S1 DON on 01/26/2021 at 10:30 a.m. confirmed S2 LPN had not followed the provider's policy by inflating the Foley catheter balloon once urine flow had began. She revealed she was unaware that the catheter had been inflated in the urethra, because she had tried multiple times to call the caregiver after the patient had been sent to the hospital, but the caregiver would not return any calls.