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
241594 A. BUILDING __________
B. WING ______________ 		01/12/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
BRIGHTON HOSPICE 4500 PARK GLEN ROAD STE 475, SAINT LOUIS PARK, MN, 55416
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)
L0591      
31767 Based on interview and document review the facility failed to ensure timely replacement of a supra pubic catheter for 1 of 3 (P1) patients reviewed with a catheter. Findings include: P1's initial Patient Profile (face sheet) indicated an admission date of 10/19/21, with primary diagnosis of Alzheimer's dementia. P1's Hospice Plan of Care dated 10/19/21, and last reviewed 12/22/21, by the interdisciplinary team (IDT) indicated secondary diagnoses including: hematuria (blood in the urine), benign prostatic hyperplasia without lower urinary tract symptoms (enlargement of the prostate), urinary incontinence, and personal history of urinary tract infections. The plan of care also indicated P1 had a supra pubic catheter (A tube that drains urine from the bladder. It is inserted through a small hole in the lower abdomen and into the bladder.) P1's Care Coordination Note dated 1/1/22, (time not noted), indicated: Writer received a call from facility reporting pt (patient) has pulled out his suprapubic catheter and cut it in half. Pt is comfortable. Will need to have it replaced this morning. Staff reports "no hurry". Writer updated on-call hospice. Review of the print out from the Tiger Text (TT) communication system utilized by hospice on-call staff, indicated on 1/1/22, at 7:10 a.m. triage licensed practical nurse (LPN)-A added a PDF (A file format that provides an electronic image of text or text and graphics that looks like a printed document and can be viewed, printed, and electronically transmitted.) file that indicated registered nurse (RN)-B had been assigned to replace P1's suprapubic catheter and further indicated, "Will need to be replaced this morning." The TT printout from the following morning (1/2/22) indicated a visit was needed to follow up on P1 as he had pulled out his cath yesterday and a visit was assigned and missed yesterday. P1's PRN (as needed) Progress Note dated 1/2/22, at 10:30 a.m. by RN-C indicated: Writer notified by on-call triage, Pt removed catheter and needing replacement of suprapubic cath (catheter). Writer consulted with facility RN who reports cath was removed 01/01/2022. Writer consulted with physician, given length of time without cath. physician advised to cautiously attempt insertion but if resistance found Pt will need to seek medical care. Writer arrived to Pt's apartment to find Pt lying on right side. Pt appeared comfortable with no nonverbal indications of pain or distress evident. Abdomen slightly distended, soft and nontender with palpation. Writer introduced self and explained purpose of visit. Catheter insertion attempted with resistance at approx (approximately) 0.5 cm (centimeters). Writer phoned Clinical Supervisor who advised revocation (the withdrawal or cancellation of something) and to seek medical care. Writer instructed facility aide to call for EMT (emergency medical technician) transport. EMT arrived and Pt was taken to the hospital. On 1/11/22, at 2:26 p.m. RN-A confirmed having worked as the triage nurse on 12/31/21, starting at 8:00 p.m. until 8:00 a.m. on 1/1/22. RN-A stated the call related to P1 removing his catheter came in on 1/1/22, at approximately 6:30 a.m. RN-A further stated she put a message on the TT thread right afterwards (around 7:00 a.m.) as the day shift on-call staff would be starting their day at 8:00 a.m. RN-A confirmed she had indicated the catheter would need to be replaced the same day. RN-A further confirmed that all hospice on-call staff working that day (1/1/22) had access to the TT communication system and were expected to review the communication. On 1/11/22, at 2:36 p.m. RN-B confirmed the visit to replace P1's catheter had been added to her schedule the morning of 1/1/22, though RN-B didn't realize it had been added until after her shift ended at 4:00 p.m. RN-B stated rather than private texting her the addition to her schedule, the addition was in a file sent that had to be opened. RN-B further stated, "I'm not gonna open up all of those messages unless they personally message me and let me know." RN-B stated around 5:00 p.m. on 1/1/22, another nurse resent the same file that had been sent earlier and at that point RN-B opened the file and realized P1's visit had been assigned to her. RN-B confirmed she did not notify the hospice triage nurse or any of the on-call staff that P1's visit had been missed. On 1/12/22, at 9:37 a.m. LPN-A confirmed working triage from 8:00 a.m. on 1/1/22, until 8:00 a.m. on 1/2/22. LPN-A stated RN-A had reported off to her the morning of 1/1/22, that P1 had removed his catheter, was doing ok, but would need to have his catheter replaced that morning. LPN-A confirmed having started her day prior to 8:00 a.m. on 1/1/22, so she could get the assignment sheet sent out before 8:00 a.m. as that was when the on-call nurses started their day. LPN-A further confirmed sending out the assignment sheet on 1/1/22, prior to 8:00 a.m. and thought she had sent the updated file around 7:45 a.m. LPN-A confirmed it was the on-call nurses responsibility to review the thread to look for updates. LPN-A further confirmed if a nurse couldn't get to a patient they were to notify staff via TT that they couldn't make it and see if anyone else could go on the visit. LPN-A stated RN-B had not informed her or any of the other on-call staff that she had missed the visit for P1 on 1/1/22. LPN-A stated she hadn't realized P1 had not been seen or had his catheter replaced until 6:00 a.m. on 1/2/22, after reviewing the visit summaries and not seeing one for P1 from 1/1/22. LPN-A confirmed that RN-C provided a visit to P1 the morning of 1/2/22. On 1/11/22, at 3:16 p.m. family member (FM)-A confirmed P1 had removed and cut his catheter in half, requiring hospice staff to replace the catheter. FM-A stated RN-C had let her know right away on Sunday (1/2/22) that P1 had removed the catheter. FM-A wasn't sure RN-C had told her when P1 had pulled the catheter out; just that he had, and they were having trouble getting it back in and would need to have it replaced in the hospital. FM-A stated being ill at the time so couldn't meet P1 at the emergency room, though approved for P1 to bed discharged from hospice so he could be sent to the hospital to have the catheter replaced. FM-A confirmed P1's supra pubic catheter placement was relatively new. On 1/11/22 at 3:26 a.m. RN-C confirmed seeing the notice on the TT thread on 1/1/22, that P1 had removed his catheter and needed it replaced, though thought it had been taken care of. RN-C stated it wasn't until the morning of 1/2/22, he noticed the assignment had been given to him as the visit had been missed the day before. RN-C stated his initial concern was that the abdominal site might be closing up and called the medical director (MD) prior to attempting replacement of the catheter. RN-C confirmed being advised by the medical director to not push it if meeting resistance and transfer P1 to the emergency department (ED). RN-C stated when trying to replace P1's catheter he was only able to insert approximately 0.5 cm then met resistance. RN-C then made the decision to transfer P1 to the ED for replacement of the catheter. Policies related to Tiger Text and on-call nursing responsibilities was requested but not received. 43077