Every finding on record at Abundant Hospice Services LLC

Based on record review and interview, the agency failed to report within 24 hours, knowledge of an alleged act of neglect by an agency employee to DFPS and HHSC for one (Patient #1) of one active patient in a pain crises. Failure to immediately report alleged acts of neglect to DFPS and HHSC, has the potential for employees to continue ANE of agency patients. This failure could hinder an investigation by appropriate authorities. Findings include: Incident Report Record review of a three-ring binder of agency complaints, for the year of 2022, revealed one "Incident Report-Pt/Employee" regarding "Patient (Record 1)" with a Date of Contact: 01/22/2022. The type of occurrence was checked as "Delivery Problem" and "Other: Delay in the issuance of comfort medication." Record review of the Incident Report revealed that on 01/22/22, at 1:30 pm, a call was made to the agency's pharmacy by the ADON to determine if the pharmacy had received a triplicate for the agency's "comfort pack." The pharmacy stated that they had received it, but they needed the physician's DEA number before they could release the medications. At 3:38 pm, the Alt Adm called the pharmacy again. The pharmacy again stated they needed the DEA number. At an unknown time, the Alt Adm called the husband [MD 2] of the Med Dir for the triplicate. The incident report stated that the hospice's Med Dir was in a hospital in severe illness. MD 2 did call in the triplicate for the comfort pack, according to the report. The incident report documented, "A lot of calls in between happened and the medication was finally delivered to the patient's place at 2030 (8:30 pm)." Record 1: Record review of Patient 1's record revealed an elderly female on hospice for "Degeneration of the Brain." Patient 1 fell, went to the emergency room, then was readmitted to hospice. The report revealed Patient 1 had pneumonia. The comprehensive assessment dated 01/20/22 revealed mild generalized pain, and moaning when her feel were moved. On 01/22/22, Patient 1 had a pain crises that was not controlled with the Acetamenophen on the medication profile. CC was started at 1813 (6:13 pm). At 2000 (8:00 pm) CC LVN C was with Patient 1. CC LVN documented "Family upset at condition of pt. Labored breathing, calling out for help. Comfort Kit (for symptom control) has been ordered since 1:00 pm today. Still not arrived. Replaced O2 (oxygen) at 4 LPM via NC 67% Sat. ...Many calls to [Agency] with no answer. Then (called) to owner of Company and phone # for his oncall nurse. No one knows why/where medication is. Family screaming mad. Talking with administrator of ALF, etc. No positive answer. Pt with hx of pneumonia, chest congestion. Resp 44 ... 2100 (9:00 pm) medication has arrived." During an interview with the Adm on 03/01/22 at 11:00 am, the surveyor asked if the Agency had reported the complaint to HHSC and DFPS. The Adm stated no, we didn't feel like it was an ANE complaint. The surveyor asked why not? The Adm said we didn't think it was that (ANE). The surveyor stated, your client waited 7 or 8 hours for pain medicine. How could this failure affect your agency's other clients? If it was your loved one who waited in pain, how could not having pain medication available, not affect them? The Adm agreed that they would suffer. Agency Policy The agency policy, "Abuse, Neglect and Exploitation" dated 08/01/19 read in part, "Adult Neglect means the failure to provide for one's self the goods and services, including medical services, which are necessary to avoid physical or emotional harm or pain, or the failure of a caretaker to provide such goods or services. ...Agency management will ...Report if there is cause to believe ANE of the patient has occurred ...by a staff member, representative ... immediately, meaning within twenty-four (24) hours to DFPS ...and HHSC ...."

Based on record review and interview, the hospice failed to ensure the patent's right to have effective symptom control for one (Patient #1) of one patient reviewed in a pain crises. This failure resulted in Patient #1 suffering with pain and discomfort from respiratory distress, and other patients could be at risk of not receiving symptom control in a crises situation. Findings include: Record 1: Record review of Patient 1's clinical record revealed she was on hospice for a terminal diagnosis of "Senile Degeneration of the Brain." Patient 1 had fallen, revoked hospice to go to hospital, and then was readmitted to hospice on 01/20/22. Patient #1 had been diagnosed with pneumonia. Record review of the comprehensive assessment dated 01/20/22, showed a pain level of 1 for generalized pain, and periodic moaning when her feet were moved. Record review of the medication profile showed Acetaminophen 325mg tablet, 2 tablets by mouth every 6 hours as needed for mild to moderate headache, musculoskeletal pain, fever > 100. Not to exceed 3000 mg from all sources in 24 hours. Record review of Patient 1's record revealed a physician order, dated 01/22/22, and an order for a hospice comfort pack. The hospice comfort pack included the medications Morphine Sulfate, Lorazepam, Atropine, Tylenol suppository, Promethazine, and Haldol. The physcian order did not note what time the order was written, but was signed by the Med Dir on 01/22/22. Record review revealed a "Nursing Note for Continuous Care" started at 1813 (6:13 pm) on 01/22/22, which listed a "Reason for Continuous Care" as "Respiratory Distress/Pain Management." At "2000 (8:00 pm) on 01/22/22, CC LVN documented "Family upset at condition of pt. Labored breathing, calling out for help. Comfort Kit (for symptom control) has been ordered since 1:00 pm today. Still not arrived. Replaced O2 (oxygen) at 4 LPM via NC 67% Sat. ...Many calls to [Agency] with no answer. Then (called) to owner of company and phone # for his oncall nurse. No one knows why/where medication is. Family screaming mad. Talking with administrator of ALF, etc. No positive answer. Pt with hx of pneumonia, chest congestion. Resp 44 ... 2100 (9:00 pm) medication has arrived." Incident Report Record review of a three-ring binder of agency complaints, for the year of 2022, revealed one "Incident Report-Pt/Employee" regarding "Patient (Record 1)" with a "Date of Contact: 01/22/2022." The type of occurrence was checked as "Delivery Problem" and "Other: Delay in the issuance of comfort medication." Record review of the incident report revealed "[ADON] called [Pharmacy] at 1330 (1:30 pm) to check on triplicate that should be faxed/called in by hospice [Med Dir]. [Pharmacy] was asking for the Dr's DEA number which [ADON] didn't know. This (Alt) Adm called pharmacy around "1538" (3:38 pm) to check on triplicate and the agency asked for [Med Dir's] DEA number. (Alt) Adm called [MD 2] husband of [Med Dir] for the DEA number so [Pharmacy] could dispense the comfort meds. [Med Dir] was in the hospital at the time of incident up to the present with severe illness, hence, [MD 2] is calling in triplicate on behalf of [Med Dir]. A lot of calls in between happened and the medication was finally delivered to the patient's place at 2030 (8:30 pm)." The medication was delivered by the pharmacy to the patient's ALF room at 9:00 pm, according to the CC nurse who received the medications. Interviews In an interview with the Adm at approximately 10:45 am on 03/01/22, the surveyor stated so you didn't have an assistant medical director at that time. The Adm said at that time no but they have hired two physicians now, one to be a backup. In interview on 03/01/22 at approximately 12:15 pm, the surveyor showed the Adm and Alt Adm the physician's order which was signed by the Med Dir on the day it was needed. The surveyor asked the Adm how the Med Dir signed and dated the order if she was in the hospital with a stroke. Neither the Adm or Alt Adm provided an answer. The surveyor asked how the outcome of this failure of not providing symptom medications to hospice patients in a crises of pain, affect the agency's care, the Adm said that they did change Med Dirs. The Adm agreed they did not want the agency's patients to suffer. In an interview with the hospice pharmacy on 03/08/22 @ 12:35 pm. the surveyor asked the representative [X], who it was that first called in the comfort pack order on Patient 1. X answered that it was [ADON]. X stated, "Then at 3:11 pm, we received a call from [MD 2]. He said he was supposed to call, but for some reason he didn't provide the triplicate. He said he would have hospice [Med Dir] call with the triplicate. At 4:20 pm, we received a call from [Med Dir], and she gave us the triplicate." Agency Policies The agency policy, "Rights of the Elderly" dated 12/01/15 read in part, "An elderly individual has the right to be treated with dignity and respect for the personal integrity of the individual, ...this means that the elderly individual: ...Has the right to be free from abuse, neglect ...." The agency policy, "Rights of the Elderly" dated 12/01/15 further read in part, "Adult Neglect means the failure to provide for one's self the goods and services, including medical services, which are necessary to avoid physical or emotional harm or pain, or the failure of a caretaker to provide such goods or services.