Every finding on record at Amity Care

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current: Prescription and over the counter (OTC) drugs; supplements; herbal remedies; other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: The effectiveness of drug therapy; Drug side effects; actual or potential drug interactions; duplicate drug therapy; drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added, or changes are made to existing medication. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 19 (11%) clinical records reviewed, the agency did not ensure that medication profile contained the patient's current prescription and over the counter drugs. Clinical Record 1: The patient elected the hospice benefit on 04/04/2024, with a terminal diagnosis of Atherosclerosis Sclerosis Heart Disease. The initial nursing assessment dated 04/04/2024 included documentation "patient is on 02 at 2L per minute as needed for shortness of breath. The medication profile dated 04/04/2024 did not include oxygen. Clinical Record 3: The patient elected the hospice benefit 08/29/2024.with a terminal diagnosis of Perforated intestines. The Initial nursing assessment dated 08/29/2024 included documentation "patient is on 02 at 2L per minute as needed for shortness of breath. The medication profile dated 08/29/2024 did not include oxygen. During a joint clinical record review and interview on 10/22/2024, the Director of Nursing confirmed that the medication profile did not include oxygen.

It is required that each patient’s individualized written plan of care includes medical supplies and appliances necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 7 of 19 (37%) clinical records reviewed revealed the agency did not ensure medical supplies necessary to meet the needs of the patient were identified in the plan of care. Clinical Record 3: The patient elected the hospice benefit on 08/29/2024. with a terminal diagnosis of Perforation of Intestines. The RN documented on 08/29/2024 that the patient was incontinent. Chucks, diapers size XL briefs, gloves and wipes were sent to the patient's home for incontinent care. Clinical Record 5: The patient elected the hospice benefit on 08/30/2022, with a terminal diagnosis of CHF. On 08/30/2022, the RN documented that the patient was incontinent of bowel and bladder. Chucks, diapers, briefs, gloves and wipes were sent to the patient's home for incontinent care. Clinical Record 1: The patient elected the hospice benefit on 04/04/2024, with a terminal diagnosis of Atherosclerosis Sclerosis Heart Disease. On 04/05/2024 the RN documented that patient was incontinent of bowel and bladder. Chucks, diapers, briefs, gloves and wipes were ordered and sent to the patient's home for incontinent care. Clinical Record 6: The patient elected the hospice benefit on 01/24//2024, with a terminal diagnosis of Senile Degeneration of Brain. On 01/24/2024 RN documented that patient was incontinent of bowel and bladder. Chucks, diapers, briefs, gloves and wipes were ordered and sent the patient's home for incontinent care. Clinical Record 7: The patient elected the hospice benefit on 09/01/2023, with a terminal diagnosis of Alzheimer's Disease. On 09/01/2024, the RN documented that patient was incontinent of bowel and bladder. Chucks, diapers, briefs, gloves peri wash, and wipes were ordered and sent to the patient's home for incontinent care. Clinical Record 4: The patient elected the hospice benefit on 11/17/2022, with a terminal diagnosis of Alzheimer's Disease. On 11/17/2022, the RN documented that patient was incontinent of bowel and bladder. Chucks, diapers size small, briefs, gloves and wipes were ordered and sent to the patient's home for incontinent care. Clinical Record 2: The patient elected the hospice benefit on 04/11/2024, with a terminal diagnosis of Parkinson's Disease. On 04/12/2024 the RN documented that patient was incontinent of bowel and bladder. Chucks, briefs size small, wipes and gloves were ordered and sent to the patient's home for incontinent care. During a joint clinical record review and interview on 10/22/2024, the Director of Nursing confirmed that the plans of care for the records identified, were not individualized to include the supplies that were related to the palliation and management of the patient's terminal illness and related conditions. No further information was provided.

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. (L628) This standard was not met as evidenced by clinical record review and interview. In 4 of 15 (27%) clinical records reviewed with aide services provided, the agency did not ensure the aide reported changes to the RN. Clinical Record 1: The patient elected the hospice benefit on 04/04/2024, with a terminal diagnosis of Atherosclerosis Sclerosis Heart Disease. The hospice aide plan of care dated 09/12 2024 included an order for oral care every visit three times a week. The aide visit dated 09/13/2024 and 09/23/2024 documented patient refused oral care. There was no documented evidence that the RN was notified. Clinical Record 2: The patient elected the hospice benefit on 04/11/2024, with a terminal diagnosis of Parkinson's Disease. The hospice aide plan of care dated 07/24 2024 included an order for oral care every visit three times a week. The aide visit dated 07/31/2024 documented patient refused oral care. There was no documented evidence that the RN was notified. Clinical Record 15: The patient elected the hospice benefit on 05/24/2024, with a terminal diagnosis of heart disease. The hospice aide plan of care dated 05/24 2024 included an order for partial bed bath 2 days a week and full bed bath 3 days a week. 05/30/2024 documented a full bed bath and a partial bed bath was provided. There was no documented evidence that the RN was notified. Clinical Record 16: The patient elected the hospice benefit on 07/15/2024, with a diagnosis of Malignant Neoplasm of the Kidney. The hospice aide plan of care dated 07/15/2024 included an order to shave and shampoo every visit. The aide visit note dated 07/23/2024 documented patient refused shampoo and shave. There was no documented evidence that the RN was informed of task not completed. During a joint clinical record review and interview on 10/22/2024, the Director of Nursing confirmed the aide did not inform the RN of tasks not performed.

Based on record reviews it was determined facility failed to ensure certified nursing aide (CNA) visits were provided as ordered for two of four clinical records reviewed. 1. A review of records for Patient (P)#1 with a start of care of 10/30/20 and certification period of 6/20/22 – 8/22/22 plan of care stated orders for Certified Nursing Assistant (CNA) visits to be two visits a week for duration of 6/20/22 thru 8/22/22 certification period. Records revealed CNA did not make a visit or document a missed visit during the period of 6/22/22 thru 7/4/22. Primary diagnosis was Sarcopenia. 2. A review of records revealed plan of care for P#3 with a certification period of 6/20/22 thru 8/22/22 had ordered Certified Nursing Assistant (CNA) visits to be three visits a week for duration of 6/20/22 thru 7/3/22 and then two visits a week for duration of 7/4/22 thru 8/22/22. Records revealed a missed visit during the week of 6/26/22 – 7/1/22, 7/17/22 thru 7/22/22, and 8/7/22 thru 8/12/22 without documentation of missed visit.

Based on record reviews and interviews with staff and patients family, it was determined facility failed to maintain a system of communication with patients, families, and staff in accordance with hospices own policies and procedures. 1. A review of policies and procedures related to missed visits and follow up phone calls revealed staff members were to notify patient and physician of missed visit and document reason for missed visit in nurses notes. 2. During interview on 11/8/22 at 4:02 p.m. P#2 family member stated concerns regarding communication from staff in reference to patients plan of care. P#2 family stated pho ne calls were made to facility nurse and CNA without a return call. 3. During an interview on 11/8/22 at 1:30 p.m. administrator and Director of Nursing (DON) admitted a problem with nurses and CNAs answering calls from patients due to using staff personal phones. Administrator stated the need for company phones and education to families to call facility for assistance. 4. A review of records of P #1 and P #3 revealed no documentation of follow up phone calls with families and physician regarding missed visits.

Based on record reviews and interviews with staff it was determined facility failed to ensure ongoing sharing of information between all disciplines regarding patients care and services. 1. During an interview on 11/8/22 11:00 a.m. Administrator and DON acknowledged a verbal agreement between P#1 family and facility regarding care during the summer. DON stated the daughter was a teacher and would not be working during the summer therefore could support patient during summer schedule, it is unclear when the verbal agreement started or ended. DON first documented the agreement on 7/5/22. There is no evidence of communication between management and staff to justify lack of scheduled CNA visits during the time frame of 6/22/22 – 7/4/22. 2. During an interview on 11/8/22 at 1:03 p.m. CNA AA stated her personal calendar noted no visits before 7/26/22 for P#1. CNA AA stated ";I saw the patient every time I was assigned, I made a visit and did my documentation. I was not assigned to see the patient before 7/26/22". CNA AA acknowledged she was not aware of order for CNA services prior to 7/26/22. 3. During an interview on 11/8/22 with Administrator and DON, admitted there was a lack of communication between staff members regarding an agreement with family, including specific details and dates, to stop CNA visits during the summer per family request.

The agency failed to investigate an allegation of neglect when the on-call nurse did not visit a patient timely to provide pain management, comfort care and a dignified death for 1of 3 sampled patients (P)#1 as she transitioned . The immediate jeopardy was related to the agency's noncompliance with the program requirements Patients' Rights; ( Refer to L509) 42 CFR Part 418.52 (b)(4)(ii) Patient Rights, (Refer to L512) 42 CFR Part 418.52(c), Rights of the patient. The following Condition and Standard level deficiencies were cited:

Based on clinical record review, staff and family interviews it was determined the agency failed to investigate an allegation of neglect when the on-call nurse did not visit a patient in a timely manner or administer morphine for pain management for 1 of 3 patients (P#1). The findings include: Patient #1 resided in an Assisted Living Facility (ALF) and was admitted to hospice services on 10/31/20, with diagnoses of chronic kidney disease (CKD) stage 4, Alzheimer's disease and hyperlipidemia. A review of the Chaplain notes dated 12/22/21, revealed when he called P#1's daughter she complained about RN BB. It was documented that P#1's daughter said she placed a call to RN BB and wanted her to come and visit her mother, but RN BB told P#1's daughter that "this is the natural dying process, and you have to be patient". On the second call, after P#1's daughter stated she was "begging her to come out", the daughter stated RN BB arrived one hour later after the second phone call. It was further noted, according to P#1's daughter RN BB couldn't locate the morphine and apparently the patient never got any and was gasping for breath. P#1's daughter reported to the chaplain that RN BB told her repeatedly that "You need to leave the room." That didn't set well with P#1's daughter because she really wanted to be holding her hand, kissing and supporting her mother; she did finally leave and came back in just before her mother transitioned. It was documented in the notes, it sounds like P#1's daughter and RN BB never connected at all, and P#1's daughter did used the words "cold and unfeeling" to describe RN BB. The daughter said, "I just don't want this to happen to anyone else." (sic) On 1/18/22, at 12:15 p.m., an interview was conducted with Registered Nurse (RN) BB who stated she was on-call on 12/19/21. RN BB stated she left to go to the facility at 3:12 a.m., and arrived at the facility at 4:08 a.m., when she arrived P#1's daughter requested morphine (used to treat pain) to be given. RN BB and the Medication Tech (MT) were not able to find the morphine. RN BB stated she administered Ativan ( used for anxiety) because the morphine was not available. On 1/19/22, at 10:40 a.m., an interview was conducted with the Assisted Living Facility Director of Nursing (DON) who stated on 12/20/21, around 10:00 a.m., she received a phone call from P#1's daughter indicated RN BB response on 12/19/21, "was inappropriate" and she had to beg her to come to the facility to see her dying mother. RN BB was not able to locate the morphine and she watched her mother suffer and die in severe pain. The hospice agency failed to investigate the allegation of neglect when the agency on-call nurse did not visit P#1 in a timely manner upon notification by the family and the ALF staff. The hospice nurse failed to administer morphine for pain management as prescribed by the Medical Doctor.

Based on clinical record review, staff and family interviews it was determined the agency failed to provide pain and symptom management during transition into death. The serious outcome resulted in a painful death for 1 of 3 patients (P#1). The findings include: Patient #1 resided in an Assisted Living Facility (ALF) and was admitted to hospice services on 10/31/20, with diagnoses of chronic kidney disease (CKD) stage 4, Alzheimer's disease and hyperlipidemia. On 1/18/22, at 12:00 p.m., an interview was conducted with agency Registered Nurse (RN) AA who stated she was the assigned case manager to P#1 and she aware the morphine was locked in the Assisted Living Facility (ALF) Administrator's office, but the on-call nurse did not call me. On 1/18/22, at 12:15 p.m., an interview was conducted with RN BB, who stated she was on-call 12/19/21, and received a phone call at 12:38 a.m., from the ALF's medication technician (MT) who said P#1 had some breathing changes but was comfortable and the daughter was anxious. RN BB said she asked the staff to let her speak to the patient's daughter who told RN BB she had been at the facility for some time and her mother's breathing was changing. RN BB told P#1's daughter that breathing changes was a normal occurrence as patient's decline. RN BB stated at 2:30 a.m., the daughter told the ALF staff to call the on-call nurse a second time, the MT called RN BB who talked to P#1's daughter and she requested morphine (used for pain) be given and asked RN BB to come and visit. RN BB stated she left for the facility at 3:12 a.m., and arrived at the facility at 4:08 a.m., at that time P#1's daughter again requested morphine be given to her mother. RN BB went to the MT, and they could not find the morphine. RN BB stated she administered Ativan (used for anxiety) because the morphine was not available. On 1/19/22, at 10:40 a.m., an interview was conducted with the agency Director of Nursing (DON) who stated on 12/20/21, around 10:00 a.m., she received a phone call from P#1's family who reported that Nurse RN BB response on 12/19/21, was inappropriate and she had to beg the nurse before she came to the facility to see her dying mother, and RN BB was unable to locate morphine while she watched her mother suffered and die in severe pain. The DON confirmed she did not investigate the missing morphine or document the incident in the complaint or grievance log. Review of the Chaplain notes dated 12/22/21, revealed he called to follow up with P#1's daughter. It was documented the daughter complained about RN BB, P#1's daughter said she placed a call to RN BB and wanted her to come and visit her mother, but RN BB told P#1's daughter that "this is the natural dying process, and you have to be patient". On the second call, after P#1's daughter stated she was "begging her to come out", the daughter stated RN BB arrived one hour later after the second phone call. It was further noted, according to P#1's daughter RN BB couldn't locate the morphine and apparently the patient never got any and was gasping for breath. P#1's daughter reported to the chaplain that RN BB told her repeatedly that "You need to leave the room." That didn't sit well with P#1's daughter because she really wanted to be holding her hand, kissing and supporting her mother; she did finally leave and came back in just before her mother transitioned. It was documented in the notes, it sounds like P#1's daughter and RN BB never connected at all, and P#1's daughter did used the words "cold and unfeeling" to describe RN BB. P#1's daughter said, "I just don't want this to happen to anyone else." The hospice agency failed to respond to P#1's family members telephone call when informed that P#1 was crying out in pain. This failure resulted in a painful death for P#1.

The agency failed to communicate with the Assisted Living Facility (ALF) staff where Patient (P) #1 resided. The patient did not receive medication for pain as ordered by the physician and as care planned. This failure resulted in an immediate jeopardy as 1 of 3 patients (P) #1 transitioned to death, lacked dignity, pain management and comfort care. The immediate jeopardy was related to the agency's noncompliance with the program requirements for Refer to L546) 42 CFR Part 418.56 (c)(1), Interventions to manage pain and symptoms. The following Condition and Standard level deficiencies were cited:

Based on clinical record review, staff and family interviews the agency failed to include in the current plan of care the location of pain medications necessary for the management of pain and related symptoms, resulting in failure to relieve pain and suffering (used for pain) during transitioning and death for 1of 3 patients (P#1). The finding include: Patient #1 resided in an Assisted Living Facility (ALF) and was admitted to hospice services on 10/31/20, with diagnoses of chronic kidney disease (CKD) stage 4, Alzheimer's disease and hyperlipidemia. P#1 had a physician's order for morphine sulfate (concentrate) 20mg/ml solution (id:10785129)-0.25-1 ml every 2 hour oral as needed pain/SOB (short of breath) (20)mg/ml solution) dated 10/27/21. The Assisted Living Facility (ALF) staff and the hospice on-call Registered Nurse (RN) reported that P#1's morphine was not accessible as needed on 12/19/21. On 1/18/22, at 12:00 p.m., an interview was conducted with the agency's Registered Nurse (RN) AA, who stated she was the assigned case manager to P#1, and the morphine was locked in the ALF Administrator's office, but the on-call nurse did not call her. On 1/18/22, at 12:15 p.m., an interview was conducted with RN BB who stated she was on-call on 12/19/21. RN BB stated she left to go to the facility at 3:12 a.m., and arrived at the facility at 4:08 a.m., when she arrived P#1's daughter requested morphine (used for pain) to be given. RN BB stated when she went to the Medication Tech (MT) she indicated she was not able to find the morphine. On 1/19/22, at 1:45 p.m., an interview was conducted with P#1's family member who stated that RN BB came to visit her mother four hours after P#1 had been experiencing severe pain and when RN BB arrived she was not able to locate the morphine pain medication. The hospice agency failed to administer morphine to manage P#1's pain and symptoms. This failure caused a serious adverse outcome for P#1 as she transitioned to death. The agency failed to have a system in place that ensured staff had access to the location of morphine to manage P#1's pain and other distressing symptoms in accordance with the current care plan dated 10/26/21.

The agency failed to coordinate interventions that ensured medications were available 24/7. The agency's staff failed to administer pain medication when 1 of 3 patients (P)#1 experienced pain and symptoms of imminent death. This failure resulted in an immediate jeopardy in which the agency failed to provide pain management and comfort care. P#1 was not administered morphine to relieve pain and suffering as she transitioned to death The immediate jeopardy was related to the agency's noncompliance with the program requirements for (Refer to L653) 42 CFR Part 418.100(c)(2), Nursing services and physician services and drugs and biologicals.

Based on review of clinical records, staff and family interviews it was determined the agency failed to administer morphine due to the medication not being accessible to the on-call hospice nurse on a 24/7 basis. This failure resulted in P#1 crying out in pain as she transitioned to death. The failure affected 1 of 3 sampled patients. The findings include: Patient #1 resided in an Assisted Living Facility (ALF) and was admitted to hospice services on 10/31/20, with diagnoses of chronic kidney disease (CKD) stage 4, Alzheimer's disease and hyperlipidemia. P#1 had a physicians order for morphine (used for pain). It was reported by the agency that morphine was not accessible to the hospice on-call nurse on 12/19/21, at the time of P#1's death. The hospice agency failed to administered morphine sulfate (concentrate) 20mg/ml solution (id:10785129)-0.25-1 ml every 2 hour oral as needed pain/SOB (short of breath) (20)mg/ml solution) per the physicians orders dated 10/27/21. A record review dated 12/19/21, at 12:38 a.m., revealed the ALF's medication technician (MT) called the hospice on-call nurse to report P#1 had some breathing changes but was comfortable and the daughter was anxious. RN BB said she asked the staff to let her speak to the patient's daughter who told RN BB she had been at the facility for some time and her mother breathing was changing. RN BB told P#1's daughter that breathing changes was a normal occurrence as patient's declined. RN BB stated at 2:30 a.m., the daughter told the ALF staff to call the on-call nurse a second time, the MT called RN BB who talked to P#1's daughter and she requested morphine (used for pain) be given and asked RN BB to come and visit P#1. RN BB stated she left for the facility at 3:12 a.m. On 1/19/22 at 1:45 p.m., an interview was conducted with P#1's daughter who stated RN BB came to visit her mother four hours after P#1 has been experiencing severe pain and when RN BB, arrived she was unable to locate morphine pain medication and RN BB administered Ativan (used for anxiety) which was too late P#1 stopped breathing few minutes after RN BB arrived.

The agency failed to ensure access to medication availability for pain management for one (1) of three (3) Patients (P) #1 who transitioned into death. The immediate jeopardy was related to the agency's noncompliance with the program requirements for (L700) 42 CFR 418.106(e)(3)(ii) Discrepancies in the acquisition, storage, dispensing, administration, disposal of controlled drugs.

Based on clinical record review, staff and family interviews it was determined the agency failed to ensure medications were properly stored, counted and available to be administered. This created a failure to administer morphine as ordered for pain management when one (1) of three (3) patients (P)#1 transitioned into death. The findings include: Patient #1 resided in an Assisted Living Facility (ALF) and was admitted to hospice services on 10/31/20, with diagnoses of chronic kidney disease (CKD) stage 4, Alzheimer's disease and hyperlipidemia On 1/19/21, at 11:00 a.m., an interview was conducted with the agency's Director of Nursing (DON) who stated P#1's daughter called her on 12/20/21, and reported the incident regarding the on-call nurse's failure to administer morphine to a dying family member. T The Assisted Living (ALF) staff reported the morphine was missing from the medication cart. There was no evidence or documentation in the complaint or grievance logs regarding the incident of medications not being available. The agency DON confirmed the incident was not recorded or investigated. The hospice agency and ALF staff was not aware of the missing 30 tablets of Ativan for anxiety, 8 tablets of Tramadol pain, and 60 syringes of liquids morphine for pain until surveyor discovered the missing medications during the complaint investigation.

It is required that the hospice designates an Interdisciplinary Group or groups who, in consultation with the patient's attending physician, prepare a written plan of care (POC) for each patient. The plan of care specifies the hospice care and services necessary to meet the specific needs of the patient and family identified in the comprehensive assessment, relative to the terminal illness and associated conditions. This standard was not met as evidenced by clinical record review and interview. In 1 of 11 (9%) clinical records reviewed revealed that the plan of care did not address the needs identified in assessment. Record #79653 was reviewed and identified the patient elected hospice care on 10/21/2021. The initial Chaplain assessment completed on 10/22/2021 stated that the family refused chaplain services however the plan of care had frequencies for the Chaplain to visit one time every month. Record #79653 was reviewed and identified the patient elected hospice care on 10/21/2021. On the comprehensive assessment completed by the RN on 11/12/21 the nurse noted that the patient had severe fatigue and states that constipation was to be monitored. There was no problem identified in the plan of care for fatigue, bowels, end of life education. The plan of care only had pain and SW interventions identified as active problems on the plan of care. The Administrator and Clinical Director were interviewed on 12/8/21 and stated there was no additional information to provide.

It is required that nursing care and services are provided by or under the supervision of a registered nurse and per the patient plan of care. Nursing services ensure that the nursing needs of the patient are met as identified in the patient’s initial assessment, comprehensive assessment, and any updated assessments. This standard was not met as evidenced by clinical record review and interview. In 1 of 11 (9%) of clinical records reviewed revealed missing comprehensive assessments by the RN. Record #56519 was reviewed and identified the patient elected hospice care on 6/10/2021. The last RN comprehensive assessment was completed on 11/5/21, the most recent was completed on 12/8/21. A RN comprehensive assessment visit was missed on Fri 11/26/2021 (21 days from the 11/5/21 assessment). An LPN completed visits on 11/13/21, 11/18/21, 11/19/21, 11/23/21, 11/26/21, 11/30/21, 12/2/21, 12/8/21. The Administrator and Clinical Director were interviewed on 12/9/2021 and stated there were no additional notes or information to provide.