Every finding on record at At Twilight Hospice & Palliative Care of Tx LLC

Based on record review and interview, the agency failed to include physician orders in the clinical record in 1 (#4) of 1 patient record reviewed where the patient received continuous care service due to respiratory distress and had a change in Oxygen administration. The failure placed the agency's patients at risk of the omission of care or inappropriate care which could result in a negative outcome. --- Patient #4: Record review of Patient #4's clinical record revealed a Plan of Care dated 7/11/2023 to 10/8/2023. The Plan of Care indicated that Patient #4 started on the agency's services on 7/11/2023. The Plan of Care listed Stage 4 Lung Cancer as the terminal diagnosis. The Plan of Care listed Oxygen (prescribed when normal blood oxygen levels cannot be maintained on atmospheric or room air) at 2 liters per minute as a medication. Registered Nurse C conducted a skilled nurse visit on 7/14/2023. Registered Nurse C documented that Patient #4 returned from the emergency room and would start continuous care service. Registered Nurse C documented that Patient #4 was on Oxygen at 10 liters. Patient #4's record contained a document titled "Change in Level of Care Orders/IDT (Interdisciplinary Team) Plan of Care Update," dated 7/14/2023, that indicated Patient #4's level of care changed from routine home care to "continuous care." The Change in Level of Care/IDT Plan of Care Update indicated that the change was made due to respiratory distress. Licensed Vocational Nurse X provided continuous care services on 7/14/2023. Licensed Vocational Nurse X documented administering Oxygen at 10 liters per minute. Licensed Vocational Nurse Y provided continuous care services on 7/15/2023. Licensed Vocational Nurse Y documented administering Oxygen at 10 liters per minute. Patient #4 was not administered Oxygen at 2 liters per minute as ordered in the Plan of Care. The clinical record revealed no new ordered to increase Oxygen from 2 to 10 liters per minute. The "Change in Level of Care/IDT Plan of Care Update dated 7/14/2023 did not show that the Oxygen had been increased to 10 liters per minute. During an interview on 2/21/2024 at 3:11 p.m. with the Administrator and the Director of Nursing, the surveyor discussed that Patient #4 received Oxygen at 10 liters per minute. Patient #4's clinical record did not contain a physician order for Oxygen at 10 liters per minute. The Director of Nursing reviewed Patient #4's clinical record for the physician order. The Director of Nursing stated, "Should be on the level of care change order. Don't see it there." The Director of Nursing was unable to find a physician order for Oxygen at 10 liters in the clinical record. The surveyor discussed that Patient #4 went to the emergency room, returned home on Oxygen at 10 liters. The Supervising Nurse informed the surveyor that the nurse that conducted the 'tuck' (visit to assess patients that returned home from emergency room visits) visit would be the one responsible to include the physician order in the clinical record. During an interview on 2/22/2024 at 10:27 a.m. with Registered Nurse C, the surveyor discussed Patient #4 received Oxygen at 10 liters and that a physician order was not included in the clinical record. The surveyor and Registered Nurse C discussed the process regarding how the continuous care staff received orders. Registered Nurse C informed the surveyor that Registered Nurse C would write the orders for the continuous care nurse and leave at the facility for the continuous care nurse. Registered Nurse C stated, "I would tell the nurses where they could find the orders." Registered Nurse C informed the surveyor when continuous care was completed, the orders and continuous care documentation, "book," would then be taken to the office. The surveyor discussed that a physician order for Oxygen at 10 liters was not in Patient #4's clinical record. Registered Nurse C stated, "An order was written. They (continuous care staff) have to have orders. All orders were written." Registered Nurse C informed the surveyor that the book may have been mishandled at the office. The agency had a policy titled "Orders for Care," labeled PC.5, with a revision or reviewed date of 10/01/2025. The policy read in part; "Purpose To ensure patient care is provided in accordance with physician's orders and federal and state laws and regulations. Policy Agency will obtain orders and provide care in accordance with physician's which are established prior to initiating patient care and reviewed/revised by the physician as needed or at least at the end of each benefit period. Procedure...V. The original order is sent/faxed to the physician for signature, and a copy is retained in the patient's medical record and/or file...VIII. When received by the Agency, the signed order replaces the copy in the patient's medical record..." The agency had a policy titled "Review and Revision of Patient Care," labeled PC.9, with a revision or reviewed date 8/1/2004. The policy read in part; "Purpose To ensure patient care is reviewed and that appropriate changes are made as necessary. Policy Agency will review and revise patient care in accordance with changes in the patients condition...Procedure...2. Upon identifying that patient care needs have changed...adjustments to the care planning documents will be made as follows:...MD (Medical Doctor) Interim Orders...4. All written changes to the plan of care will be incorporated into the patient's medical record as changes occur."