Every finding on record at Ambercare Hospice Inc

Based on record review and interview, the facility failed to protect the patient's right to be free from pain. --- The findings are: A. The facility failed to ensure the patient had access to pain medication as ordered. Refer to L0512

Based on record review and interview, the facility failed to ensure 1 (P (patient)1) of 6 (P1-P6) patients received pain medication either immediately or within 2 hours of reports of pain. This deficient practice could likely lead to the patient suffering pain that could have been prevented with pain medication and could lead to other patients suffering pain that could be relieved with access to pain medication. --- The findings are: A. Record review of P1s medical record demographic sheet revealed a start of care date of 11/03/2023. 1) Medication order dated 11/03/2023: Morphine Concentrate 100 milligrams/5 milliliters (100mg/5ml) oral solution (a concentrated liquid form of a pain medication commonly used to relieve hospice patients pain, shortness of breath, and discomfort during the dying process. This is considered one of the comfort medications to be administered for pain related to the dying process). Dose 0.5 ml every 2 hours as needed for pain/sob (shortness of breath). B. Record review of P1s medical record nursing note visit number 2, dated 11/07/2023 at 2:34 pm, revealed no medication reconciliation (going over the medication list with the patient/agent to identify which medications are ordered, present, or need to be obtained) was documented in the narrative note by the nurse and, as a result, there was no verification of whether the Morphine Concentrate 100mg/5ml oral solution was available in the patients home for use in case of pain related to the dying process. C. Record review of nursing note visit number 3, dated 11/09/2023 at 1:56 pm, revealed the following: 1) ";Have the patient indicate the phrase that best describes the current level of pain: MODERATE PAIN" 2) "Narrative Note: ...Patient stated she has pain to lower abdomen (belly) and right leg. Pain is increasing. Tramadol (a pain medication) used. Patient's son requested something stronger for pain." D. Record review of nursing note visit number 4, revealed a nurse prn (as needed) visit, dated 11/11/2023 at 12:17 am, revealed: 1) ";What is the reason for the prn visit? CHEST PAIN." 2) ";Narrative Note: Patient c/o (complained of) mild chest pain/discomfort. Pain started a couple of hours prior to visit. Patient is tachycardic (a fast heart rate) at 125BPM (beats per minute). Son reports that patient states it feels like. "Heart attack is coming on." No comfort meds in the home. Advised to take pain medication available...On call nurse will order medications for family to pick up." E. Record review of (name of pharmacy) medication history report for P1 showed Morphine Concentrate 100mg/5ml oral solution was not picked up by anyone until 11/11/2023, despite an order for this medication on 11/03/2023. F. Record review of nursing note visit number 5, dated 11/12/2023 at 10:52 am, revealed patient death from natural causes. G. Record review of the Nursing Resource hand-out form from the Nursing Resource Binder ";Medication & Reconciliation Resource", ";Revised 10/1/2023", (a collection of nursing education, directions and resources that are provided to the nurses) revealed: 1) ";A medication reconciliation is going over all medications with patient/agent for accurateness and comparing: 1. The medication profile in HCHB (HomeCare HomeBase-the computerized patient charting system used by the hospice) to the 2. Medication profile provided by the hospice pharmacy..." 2) ";A medication reconciliation must be completed: at 24/48 HR. (hour) visit by RNCM (registered nurse case manager) or prior to first IDG (Interdisciplinary Group meeting)." ";The medication reconciliation must be documented: In narrative of 24/48 HR visit." H. During an interview on 05/09/2024 at 9:55 am, with Staff (S)1 Area Vice President, S1 confirmed that the Nursing Resource Binder is physically provided to all nurses. S1 confirms this reference is the educational resource for the nurses and the expectation is that the nurses will follow these directions. S1 confirmed that that the nurse should have made sure that the family had the morphine solution on 11/09/2023, ";but it looks like they didnt."

Based on review of National Institutes of Health (NIH) website guidelines related to pain, record review, , interview, and review of agency policy, the agency failed to ensure Registered Nurses (RNs) effectively managed and assessed patients' pain symptoms, provided patient education on pain management, pain medications prescribed, and communicated with the patients' physicians regarding increased patient pain levels for two (Patient's (P) 17 and (P) 19) of 25 patients reviewed for pain. This had the potential to affect patients with pain due to a terminal diagnosis receiving care from the Hospice Agency. --- 1. Review of P17's electronic medical record (EMR) under the "Visit Notes" section revealed the following: On 07/06/23, during an RN's homecare visit, the RN documented that P17 rated his/her pain level an "eight" on a scale of zero to 10 with zero being no pain and 10 being the worst pain possible; was "upset that the pain was uncontrolled;" described the character of the pain as "aching, pressure, stabbing;" and described the duration of the pain as "continuous." The RN called the patient's physician and on 07/07/23, and the patient's physician prescribed Methadone (a medication used in hospice to decrease pain). The patient was not reassessed for the new pain medication's effectiveness until 07/10/23, four days after reporting a pain level of eight out of 10. On 07/10/23, during an RN's homecare visit, the RN documented that P17 rated his/her pain level an "eight" on a scale of zero to 10; reported "new pain to right side of [his/her] chest when taking a deep breath;" described the character of the pain as "aching, sore, stabbing, tender, tingling;" described the duration of the pain as "continuous;" and stated "I stopped taking the Methadone because it was too much for me and I felt like I was going to die." There was no documentation of interventions provided, medication changes, phone calls to the physician, or teaching performed by the RN regarding the patient's pain level. The patient was not reassessed for pain management until 07/18/23, eight days after reporting a pain level of eight out of 10. On 07/18/23, during an RN's homecare visit, the RN documented that P17 rated his/her pain level a seven on a scale of zero to 10; stated that he/she "continues to have pain to right side of chest," described the character of the pain as "aching, numbness, tingling;" and described the duration of the pain as "continuous." There was no documentation of interventions provided, medication changes, phone calls to the physician, or teaching performed by the RN regarding the patient's pain level. On the "Client Medication Report" it was documented that the pain medication the patient was receiving was increased on 07/25/23, seven days after reporting a pain level of seven out of 10. On 08/22/23, during an RN's homecare visit, the RN documented that P17 rated his/her pain level a seven on a scale of zero to 10 to the "right side of neck" and "has difficulty sleeping at night," described the character of the pain as "stabbing, throbbing;" described the duration of the pain as "all the time." There was no documentation of interventions provided, medication changes, phone calls to the physician, or teaching performed by the RN regarding the patient's pain level. There were no other documented RN visits after 08/22/23. 2. Review of P19's EMR under the "Visit Notes" section revealed the following: On 08/23/23, during an RN's homecare visit, the RN documented that P19 rated his/her pain level a 10 on a scale of zero to 10. The patient's pain goal (the highest number acceptable to the patient) was documented as being a four on a scale of zero to 10. The RN documented that P19 was "unable to describe the character of the pain;" the frequency of the pain was "daily;" and the duration of the pain was "intermittent." There was no documentation of interventions provided, medication changes, phone calls to the physician, or teaching performed by the RN regarding the patient's pain level. There were no other documented RN visits after 08/23/23. During an interview on 08/25/23 at 2:00 PM, the Area Vice President confirmed that proper follow-up for pain management had not been performed for P17 and P19. According to the NIH's website at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5806302 revealed, "During the titration (adjusting the medication from a lower dose to a higher dose) phase, close outpatient follow-up, daily telephone progress reports by the patient, family members, home health nurses, or hospice personnel are recommended. Patients should be informed that several titrations might be necessary to reach optimal pain control." There was no documentation indicating that teaching had been provided to the patient regarding how to take the new medication; the side-effects of the new medication; and if the other pain medications prescribed should be stopped. Review of undated policy number 4-046 titled "Provision of Care & Record Management Pain Assessment" indicated " ... All patients will receive pain assessments. When pain is identified, a more comprehensive pain assessment will be completed when warranted by the patient's condition. Pain assessments will be appropriate to the patient's age and will be documented to facilitate regular reassessments and follow-up by clinicians ... Patient and family/caregiver education will focus on the use and side effects of analgesic and/or adjuvant medications, expected responses to therapy, and the importance of administering medications according to prescribed dosage and frequency ..."

Based on record review, agency policy review, and staff interview, the Hospice Agency failed to ensure Registered Nurses (RNs) entered accurate ordered medication (Morphine) on one (Patient (P) 15's) "Client Medication Report." This had the potential to affect patients with pain due to a terminal diagnosis receiving care from the Hospice Agency. --- 1. Review of P15's electronic medical record (EMR) revealed the following: Review of the "Client Medication Report" revealed the RN documented P15's Morphine 0.25 milliliters (ml) to 1 ml ordered on 04/18/23 was to be administered every hour, around the clock. Interview with the Area Vice President on 08/24/23 at 2:30 PM confirmed P15's Morphine was entered incorrectly by the RN. The Area Vice President confirmed the order should have been entered as 0.25 ml to 1 ml to be administered every hour as needed (prn) for pain. Review of the "Visit Note" dated 06/26/23 by the RN revealed an order to "Start liquid Morphine every 6 hr. [six hours] schedule." The Morphine medication to be administered every six hours around the clock was not listed on the "Client Medication Report." Review of the "Visit Note" dated 06/29/23 by the RN revealed, "She is getting liquid Morphine every 6 hours which is helping a lot." The Morphine medication to be administered every six hours around the clock was not listed on the "Client Medication Report." Review of the "Visit Note" dated 07/03/23 by the RN revealed, "staff giving liquid Morphine every 6 hours." The Morphine medication to be administered every six hours around the clock was not listed on the "Client Medication Report." During an interview on 08/24/23 at 4:00 PM, the Area Vice President confirmed that the scheduled dose of Morphine to be administered every six hours was not on the "Client Medication Report." Review of agency policy dated 04/19/22 titled "National Patient Safety Goals Series Part 3. Medication & Oxygen Safety" indicated " ... A Registered Nurse creates and maintains a current medication profile and previews all patient medications, both prescription and non-prescription, on an ongoing basis in collaboration with other interdisciplinary group (IDG) members".

Based on record review, agency policy review, and staff interview, the Hospice Agency failed to ensure that the Registered Nurses (RNs) provided oxygen safety teaching to one (Patient (P) 16) and family/caregivers in the home. This had the potential to create a hazard related to the use of oxygen while smoking in the home. --- Review of P16's electronic medical record (EMR) under the "Visit Notes" section revealed the following: Review of P16's "Medication List" dated 08/01/22 revealed supplemental oxygen was listed. On 06/06/23, during an RN's homecare visit, the RN documented that P16 "is not on any supplemental oxygen and he smokes cigars daily." There was no documentation indicating that education had been provided by the RN to the patient or caregivers regarding the dangers of using supplemental oxygen while smoking a cigar. On 06/20/23, during an RN's homecare visit, the RN documented that P16 "does not use 02 and continues to smoke multiple cigars daily." There was no documentation indicating that education had been provided by the RN to the patient or caregivers regarding the dangers of using supplemental oxygen while smoking a cigar. On 06/27/23, during an RN's homecare visit, the RN documented that P16 "is smoking a cigar during the visit" and "patient does not use any supplemental oxygen." There was no documentation indicating that education had been provided by the RN to the patient or caregivers regarding the dangers of using supplemental oxygen while smoking a cigar. On 07/11/23, during an RN's homecare visit, the RN documented that P16 "smokes cigars daily." There was no documentation indicating that education had been provided by the RN to the patient or caregivers regarding the dangers of using supplemental oxygen while smoking a cigar. On 07/20/23, during an RN's homecare visit, the RN documented that P16 "is smoking a cigar during the visit" and "does not use any supplemental oxygen." There was no documentation indicating that education had been provided by the RN to the patient or caregivers regarding the dangers of using supplemental oxygen while smoking a cigar. On 08/01/23, during an RN's homecare visit, the RN documented that P16 "patient is smoking a cigar during the visit." There was no documentation indicating that education had been provided by the RN to the patient or caregivers regarding the dangers of using supplemental oxygen while smoking a cigar. During an interview on 08/24/23 at 3:00 PM, the Area Vice President stated, "I looked and couldn't find any teaching in the notes on smoking with oxygen." The Area Vice President confirmed that P17 had an oxygen concentrator in the home. Review of policy no. 6-030, dated 01/19/23, titled "Risk Management Infection & Safety Control Safe & Appropriate use of Medical Equipment & Supplies" indicated " ... It is the responsibility of the clinician/technician, as appropriate, to instruct patients and their family/caregivers regarding the safe and appropriate use of home medical equipment, home care supplies, and oxygen. These needs will be identified during the initial assessment via the home safety checklist, and ongoing assessment with follow-up, as appropriate, in the plan of care. Evidence of this instruction will be documented in the clinical record ..."