The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

LONGVIEW REGIONAL MEDICAL CENTER 2901 N FOURTH ST LONGVIEW, TX 75605 Oct. 23, 2018
VIOLATION: CONTENT OF RECORD Tag No: A0449
Based on document review and interview, the facility failed to record documentation to support the need for insertion of a Foley catheter in 1 of 12 (#1-#12) patients reviewed.


This deficient practice had the likelihood to effect all patients of the facility.


Findings included.

On the morning of 10/23/2018 an electronic medical record review patient #1 as actually having documented evidence of Foley catheter in use without a supporting diagnosis for the insertion of the Foley catheter.

Review of the medical record (MR) gave no explanation when or why a Foley catheter was inserted into the bladder of pt #1.

Review of a written complaint submitted by pt #1's daughter indicated the family demanded the insertion of the Foley catheter to reduce their mothers need to ambulate to the bathroom.

The above lack of documentation was confirmed by staff #1 and Staff #3 who were assisting in the electronic MR review.

A review of the policy for F/C use identified the following:

"Does the patient have any of the QUALIFYING INDICATION for indwelling urinary catheter?

1. Hematuria, gross (Large amount of blood in the urine).
2. Obstruction, urinary
3. Urologic surgery/Intra-operative bladder surgery.
4. Decubitus ulcer-open sacral or perineal wound of incontinent patient.
5. I&O (intake and output) critical for patient management.
6. Hemodynamic instability.
7. No Code/comfort care/hospice care.
8. Immobility due to physical constraints (e.g. unstable fracture).
9. Cardiac or Respiratory distress or compromise.

Staff #1 agreed pt #1 did not have a diagnosis of any of the above conditions on 8/7/2018.
There appeared to be no documentation to support the need for or use of an indwelling F/C.
VIOLATION: ORDERS DATED AND SIGNED Tag No: A0454
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and interview, the facility failed to obtain a physician's order for the insertion of a Foley catheter in 1 (#1) of (#1 through #12 patients).

This deficient practice had the likelihood to effect all patients of the facility.


Findings included:


On the morning of 10/23/2018 in the office of the Chief Quality Officer, the electronic medical record (EMR) for patient (Pt/pt) #1 was reviewed with the assistance of staff #1 and staff #3. During the review, pt #1 was identified as having been admitted [DATE], without a Foley Catheter (F/C). On 8/7/2018 pt #1 was identified by the EMR documentation as having 400 cc's urine output via F/C. On 8/8/2018 F/C care was documented as provided to pt #1.

A thorough search of the EMR by staff #1 and staff #3 confirmed there was no physician's order for placement of the indwelling F/C in pt #1's bladder.