Every finding on record at Andrews County Hospital District

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 a review of the clinical record and interviews. 1 of 4 (25%) records reviewed, there was evidence that the Registered Nurse failed to ensure the patient's nursing needs were adequately met per the plan of care. This resulted in unmet care needs during the end-of-life process during the period after-hours related to symptoms control. Record #56742 was reviewed and identified the patient elected hospice care on 1/4/2022. A 68-year-old female patient with diagnosis that included Mild Protein Caloric Malnutrition, Alcohol Dependence, (resolved), and Cognitive Communication Deficit. Nursing frequency was 1-2 times a week and PRN for symptom management. The Caregiver, the daughter, on 1/11/2022, had requested Respite Care for her mother as she had herself, been diagnosed with COVID-19. During a nursing visit by hospice staff at the bedside visit on 1/11/2022, the daughter indicated the hospice RN [Staff ID: 85154] ordered 0.5 ml TID PRN Lorazepam Intensol (2 mg/ml). Later that day after one dose of Lorazepam, the patient became anxious, tearing pictures off the wall and then later falling. EMS was called by the daughter and the EMS personnel examined the patient, checked her vitals and stated that she was” in the clear." Later that evening, the patient fell two additional times with the third fall leaving her" immobile and stiff." The hospice RN [Staff ID: 85154] arrived the following morning of 1/12/2022, and called EMS, and had this patient transported to a local hospital for further examination. The Emergency Department indicated that the patient had a contusion on her left femur, and she was sent home. A review of the clinical record revealed that the hospice RN [Staff ID: 85154] had during the visit documented a full nursing comprehensive assessment on 1/11/2022, at 10:00 to 10:45 AM. Under the comment section, the nurse documented, “Daughter had requested Respite care, for her mother. Daughter stated, "I need something to help calm her down. My mom is real anxious, and we hardly didn't sleep last night. (Patient) pleasantly confused, though communicates fairly well at times. She can answer some questions appropriately but is a poor historian r/t dementia. Patient requires assist with all ADLs as she is unable to stay on task and very forgetful. New medication ordered, due to new med, SN instructed caregiver, that this medication is used to treat anxiety. SN instructed cg/patient to report the following Lorazepam side effect symptoms, drowsiness, dizziness, loss of coordination. Caregiver voiced understanding to Medication/Lorazepam teaching.” On 1/12/2022, at 08:00 AM to 8:45 AM. [Staff ID: 85154] documented a full nursing comprehensive assessment. Under the comment section, the nurse documented “SN received patient in bedroom. Patient presented anxious and lying on bed. Caregiver stated, "I started her on the Ativan last night and she's had several falls all through the night." Caregiver questioned Ativan side effects. The original Ativan 2 MG/ML 0.5 ml TID PRN order was written 1/11/2022 and discontinued 1/12/2022. Ativan teaching reinforcement completed, SN instructed caregiver Ativan may cause the following side effects in elderly - mental/mood changes, sleeping problems, hallucinations. Loss of coordination, drowsiness, and increased risk for falls. Cg voiced understanding related to Ativan teaching. Patient stated, "My hip hurts." Facial grimacing noted during assessment, inspection and palpation of hip, no bruising/swelling noted to left hip area at this time. Patient could not bear weight and not being able to lift, move or rotate (turn) leg. SN called 911 and patient was transported to Hospital via ambulance. Fall and injury reported to MD (hospice physician). SN will f/u on any changes to the POC.” The Patient Medication Record indicated that Norco Oral Tablet 5-325 mg 1 Tablet every 4 hours for pain had been ordered on 1/12/2022 and discontinued on 1/13/2022. Morphine Sulfate Oral Solution 20 mg/ml (30 ml) dose 0.25 ml, Q1H, SL PRN pain or SOB had been ordered 1/13/2022. On 1/14/2022, hospice RN [Staff ID: 41131], performed a full comprehensive assessment during a visit at 8:30 to 9:15 AM, with a change in medication to DC Order for Morphine Sulfate 0.25 ml and increase to 0.75 ml Q1H PRN pain or SOB. The patient was transferred to the hospital on 1/14/2022, for Respite services, for 5 days, at approximately 3:30 PM. [Staff ID: 41131], further documented that the patient tested positive for COVID, at the hospital, and was placed in isolation. The X-Ray repeated on 1/15/2022 and report stated FX left femoral neck with migration. No surgical intervention planned at this time per family." In summary, the patient remained on Respite services until 1/20/2022 and was discharged per request of the daughter.” The patient was admitted to another hospice and died 1/26/2022. In addition, the agency indicated that the hospital bed had been offered and refused on 1/4/2022. The hospital bed was delivered on the 13th, as requested on the 13th. In an interview on 3/28/2022, with the Administrator [Staff ID: 71917], and documented in a communication note on 1/12/2022, "[Staff ID: 85154] reported to me that she received multiple calls from Hospice patient’s daughter through the night, at 9 PM, 12AM, 3AM and 5AM reporting that the patient had been trying to get out of bed and had been falling. I asked [Staff ID: 85154] how the patient was doing now and if she had gone to see patient during the night and she stated no she had not gone to see patient. I told [Staff ID: 85154] to go right now to see/ assess patient. When she came back, she stated patient's daughter was mad because she had not gone to see her mom when she called to report multiple falls [and] stated that she told patient's daughter to call and speak to Administrator, and daughter said, it is too late. I attempted to call patient's daughter, but no answer." Further documentation revealed a communication note dated 1/14/2022. Administrator [Staff ID: 71917], documented “I tried to call daughter of patient, [phone number] several times to try to talk to her regarding respite care and to talk to her about the night of 1/11/2022. No answer to phone, message left to return my call.” In addition, Administrator [Staff ID: 71917], documented in a communication note that on 1/20/2022, hospice RN [Staff ID: 41131], and hospice LVN [Staff ID: 39394] discharged the patient. "I called the phone number multiple times with no answer. I spoke with hospice MD [Staff ID: 30647], who tried to call her. He reported he called multiple times and there was no answer as well.” During an interview, the Medical Director (Staff ID: 30647) confirmed that he had been involved with all aspects of the anxiety, pain control and his concern had been on-call not going out to see the patient, as the caregiver/daughter had requested. The nurses had been instructed to always go out on call for issues related to care and services. ` During the exit conference on 3/28/2022, the Administrator, [Staff ID: 71917] verified that the agency had tried to place the patient in the long-term care facility (LTCF) for respite. The LTCF would not accept the patient as her daughter was positive for COVID-19. The LTCF had accepted COVID-19 patient’s but had just closed the COVID-19 wing. The agency was able to place the patient in respite care on 1/14/2022 at the hospital. The administrator also indicated that there were no on-call notes or documentation to verify the phone calls from the daughter on the night of 1/11/2022 and the morning of 1/12/2022. The nurse had “all calls rolled to the (on call) nurse’s phone, with no on-call records.” In addition, RN hospice [Staff ID: 85154] reported being diagnosed with COVID-19, on 1/21/2022 and she was terminated from employment by this agency on 2/7/2022.

It is required that hospice nursing services, physician services, drugs and biologicals are made routinely available on a 24-hour basis, seven (7) days per week. All covered services are available on a 24-hour basis when reasonable and necessary to meet the needs of the patient and family. This standard was not met as evidenced by clinical record review and interviews. 1 of 4 (25%) records reviewed revealed that nursing services are not availabe 24 hours a day, 7 days per week as per agency policy. Record #56742 was reviewed and identified the patient elected hospice care on 1/4/2022. A 68-year-old female patient with diagnosis that included Mild Protein Caloric Malnutrition, Alcohol Dependence, (resolved), and Cognitive Communication Deficit. Nursing frequency was 1-2 times a week and PRN for symptom management. The policy, "On Call for Patient Care" (PC.2) , Revised 08/16/2007, Skilled Nursing will be available at all times, twenty-four hours a day, seven days a week. Agency will either transfer phones directly to the on-call Nurse or transfer to an answering service. The on call RN will keep a log of all calls. The RN will document date and time of call , patients name and RN's response to the problem presented. The log will be submitted to the Agency at the completion of the on-call rotation. Appropriate activity will be documented on communication notes for the medical record. In an interview on 3/28/2022, with the Administrator [Staff ID: 71917], and documented in a communication note on 1/12/2022, "[Staff ID: 85154] reported to me that she received multiple calls from Hospice patient’s daughter through the night, at 9 PM, 12AM, 3AM and 5AM reporting that the patient had been trying to get out of bed and had been falling. I asked [Staff ID: 85154] how the patient was doing now and if she had gone to see patient during the night and she stated no she had not gone to see patient. During an interview, the Medical Director (Staff ID: 30647) voicied his his concern had been on-call not going out to see the patient, as the caregiver/daughter had requested. The nurses had been instructed to always go out on call for issues related to care and services.`