Every finding on record at Brighton Hospice

Based on interview and document review, the agency failed to report allegations of misappropriation of property to the State Agency (SA) immediately, but no more than 24 hours, when family member (FM)-A reported drug diversion by the hospice nursing assistant (NA). --- Findings include: A facility document, complaint form, dated 8/1/25, indicated registered nurse (RN)-A spoke with the certified nursing assistant coordinator (CNAC) on 8/1/25 at 3:07 p.m., to report FM-A told him NA-A took four morphine pills.A report made to the SA on 8/20/25 at 11:05 a.m., indicated the hospice agency had received a complaint from FM-A alleging NA-A removed four tablets of morphine from P1’s home. The report to the SA lacked a date of the incident. An agency document, Vulnerable Adult (VA) Reporting Form, dated 8/20/25, indicated the hospice agency became aware of the complaint of four missing morphine pills by FM-A on 8/1/25, following cares provided by NA-A and notified the SA on 8/20/25.P1’s plan of care (POC) for certification period 6/27/25 through 9/24/25 indicated she had a diagnosis of lung cancer with metastases (spread) to the bone. The POC indicated the aide care plan included assistance with personal cares. On 9/3/25 at 12:22 p.m., the director of nursing assistant services (DNAS) stated on 8/1/25, registered nurse (RN)-A informed certified nursing assistant coordinator (CNAC) of a complaint made by FM-A alleging NA-A took four tablets of P1’s morphine. She stated the allegation of drug diversion was not reported to the SA until 8/20/25 because NA-A was off work on a leave of absence and unavailable to interview on the issue.On 9/3/25, at 12:43 p.m., CNAC stated on 8/1/25 registered nurse (RN)-A informed her of a complaint made by FM-A alleging NA-A removed four tablets of morphine from P1’s medication bottle and placed them in her pocket. She stated RN-A made a visit to P1’s home and confirmed with FM-A that four tablets of morphine were unaccounted for. CNAC stated she immediately reported the incident to the DNAS. On 9/3/25 at 2:33 p.m., NA-A stated she provided personal care to P1 on 8/1/25, in her home. She denied removing any of the morphine from the prescription bottle. On 9/3/25 at 2:40 p.m., FM-A stated he frequently counted the quantity of medications and there were four tablets missing, following NA-A’s visit to their home on 8/1/25. He stated he immediately called RN-A to inform him of the incident. On 9/4/25 at 8:02 a.m., RN-A stated FM-A called him on 8/1/25 to report four missing morphine 5 milligrams (mg) tablets following NA-A’s visit to P1’s home. RN-A stated he made a visit to P1’s home and reviewed the medication counts and log along with FM-A, determining four missing tablets. RN-A stated he immediately informed the CNAC.On 9/4/25 at 11:10 a.m., the director of clinical services (DCS) stated she was not immediately involved with the incident but that it should have been reported to the SA immediately.On 9/4/25 at 11:25 a.m., the administrator stated the allegations of drug diversion “should have been reported within 24 hours” to the SA. On 9/4/25 at 11:40 a.m., the regional director of operations (RDO) stated the hospice agency should have reported the alleged drug diversion by NA-A immediately.A facility document, Assessment of Possible Abuse/Neglect, dated 11/2024 directed hospice will report all suspected cases of abuse, neglect, or exploitation in compliance with appropriate state statutes to appropriate protection organizations. The policy directed the clinician will submit a verbal report of the suspected abuse/neglect to the proper authorities in accordance with state law and complete a suspected abuse and/or neglect investigation report within 24 hours of the incident.

Based on interview and document review, the hospice agency failed to report an allegation of abuse to the hospice administrator immediately after becoming aware of the situation for 1 of 3 patients (P1) reviewed for abuse. --- Findings include: P1s Hospice Plan of Care (POC), dated 11/1/24, indicated P1 was admitted to hospice on 7/31/24 with a primary diagnosis of Alzheimers Disease. During an interview on 11/18/24 at 11:39 a.m., the assisted living director of nursing (AL DON) of the facility where P1 resided stated she was notified by two nursing assistants (NAs) at the facility on 11/12/24 that they had witnessed nursing assistant (NA)-A ";getting rough" with P1 when NA-A ";forcefully pushed" P1 into her chair when she was not cooperating with sitting down. The AL DON stated the NAs reported to her that NA-A was talking ";aggressively" with P1 telling P1 to ";knock it off." The AL DON further stated P1 had bruising on her inner thigh, knee, and shoulder. During an interview on 11/18/24 at 12:35 p.m., NA-A stated on 11/12/24 she was at the AL giving P1 a tub bath. NA-A stated P1 was a two-person pivot transfer. NA-A stated staff would assist P1 to stand up out of the tub, have her take a few steps backwards until the backs of her legs were touching her wheelchair, and then NA would place an arm under P1s arm and put ";gentle pressure" on her hip to guide her down into her chair. NA-A stated P1 had tried to hit her a few times during the transfer in which NA-A stated ";No" and ";Stop that" to P1. NA-A stated P1 was also trying to stand up out of her wheelchair and NA-A was worried P1 would fall on the wet bathroom floor. During an interview on 11/18/24 at 1:18 p.m., registered nurse (RN)-A stated she was made aware by the AL DON on 11/13/24 of the alleged abuse that occurred between NA-A and P1. RN-A stated her direct supervisor and SW-A were also present during the conversation with the ALF DON. RN-A stated she had a statement from the facility NAs that stated NA-A ";pushed" P1 into her wheelchair and there ";may be bruising" when P1 would not take a few steps back towards her wheelchair. RN-A stated she assessed P1s skin on 11/14/24 and there was some generalized, yellowing bruising on P1s legs but nothing on her hips or inner thighs. RN-A further stated she assessed P1 again on 11/18/24 and all the bruising was gone. During an interview on 11/18/24 at 2:15 p.m., the administrator stated he was made aware of the alleged abuse involving NA-A and P1 on 11/15/24 between 2:00 p.m., and 2:30 p.m. The administrator stated he recognized the gap in being notified since RN-A, her direct supervisor and SW-A were aware of the alleged abuse on 11/13/24. The administrator stated once he was made aware, an internal investigation was started and the event was reported.

Based on observation, interview and document review, the agency failed to complete a comprehensive medication review for 2 of 6 patient's (P13, P15) observed on home visits. --- P12's plan of care (POC) dated 11/723 through 2/4/24, identified a start of care date 11/7/23, with primary diagnosis of heart and kidney disease. The POC identified multiple medications including lorazepam (an antianxiety) 2 milligrams (mg)/milliliter give 0.5 mg by mouth (po) every four hours as needed (prn), morphine 100 mg/5 ml po every two hours prn, haloperidol 2 mg/ ml 0.5 mg po every four hours prn, hyoscyamine (to dry secretions) 0.125 mg sublingual one tab every four hours prn, acetaminophen 500 mg tablet one tablet po at bedtime and prn, albuterol inhaler two puffs every six hours prn, furosemide (diuretic) 40 mg po two times per day, loratadine 10 mg one tablet daily, omeprazole 20 mg one cap daily, terazosin (for prostate) 2 mg capsules give two capsules two times per day, melatonin 3 mg one tablet at bedtime for sleep, Clobetasol 0.05% to apply to affected areas two times per day prn for eczema, Desonide cream to affected area three times per day for rash, latanoprost 0.005% ophthalmic (for eyes) one drop to both eyes at night. Bisacodyl 10 mg suppository one suppository rectally every day as needed for constipation. Nursing notes indicated continuing education on prn medications and support services. Safety measures included medication safety and storage, patient would receive prescribed medications at correct times and patient/caregiver would safely administer medications during care. A home visit was conducted on 11/28/23, at 10:30 a.m. registered nurse (RN)-A assessed P12 general condition and comfort. Family member (FM)-C indicated she set up and administered P12's medications. The medication bottles in the home were compared to the list on P12's POC. Among P12's medication bottles included the medication Zocor 40 mg po every evening. The medication Zocor (treat high cholesterol) was not listed on P12's POC. FM-C stated she gave P12 Zocor every evening and he had been on the medication for quite awhile. During interview on 11/28/23 at 11:00 a.m. RN-A verified P12's POC did not list the medication Zocor and stated if the patient was taking the medication, it should have been listed on the POC when he was admitted. She typically did not have patient or caregivers bring out all their medication bottles each visit to review, as that was done with the start of care visit. RN-A stated medications to treat cholesterol were typically stopped when admitted to hospice. She felt stopping the medication had probably been discussed with FM-A when P12 was admitted and FM-A may have not heard or had misunderstood and had not stopped the medication. P15's POC dated 11/28/23 through 2/17/23, identified a SOC date 11/20/23, and primary diagnosis of Alzheimer's disease. The POC identified multiple medications including prednisone 5 mg daily, duloxetine (antidepressant) 60 mg daily, Lisinopril (for blood pressure) 5 mg daily, Miralax 17 gram daily, senna laxative 8.5 mg daily, quetiapine (antipsychotic medication) 12.5 mg every evening, melatonin 3 mg every night, vitamin D 25 microgram (mcg) every night, oxygen 2 liters as needed, acetaminophen 500 mg two tablets prn, ipratropium-albuterol nebulizer treatment every four hours prn, quetiapine 6.25 mg prn, hydromorphone 1 mg every hour prn, lorazepam 0.5 mg every four hours prn, haloperidol 0.5 mg every four hours prn, hyoscyamine sulfate 0.125 mg every four hours prn, bisacodyl suppository 10 mg daily prn, and morphine 2.5 mg daily. Safety measures included medication safety and storage, with goal patient would receive prescribed medications at correct times with caregiver to administer drugs and biologicals during care. A home visit was conducted on 11/28/23, at 9:00 a.m. RN-B assessed P15's general condition and comfort. RN-B discussed P15's care and treatment with the assisted living staff who were his primary care providers. P15's medication administration record (MAR) was compared to the list on P15's POC. Morphine solutab 2.5 mg was listed on P15's MAR to be given sublingually every two hours prn for shortness of breath. Prn morphine was not listed on P15's POC. During interview on 11/28/23, at 2:15 a.m. RN-B stated she had contacted P15's primary provider and had received an order to clarify the prn morphine should be discontinued. The medication should have been discontinued on his admission to hospice and had been missed, RN-B stated when a patient resided in an assisted living, their medications and MAR would be reviewed weekly, as it was important to know all the medications the patient was receiving. When interviewed on 11/29/23, at 9:45 a.m. the administrator stated overall the nurses go through a patient's medications in the home with the caregiver and provide any needed education to the caregiver. Nurses were expected to review patient's medications at every visit. When a patient resides in an assisted living the agency's general practice was to review a patient's medication list and MAR with a facility staff member. The agency's policy Medication Regimen Review dated 11/1/13, indicated the agency conducted a medication review to identify potential clinically significant medication issues such as drug reactions, ineffective drug therapy, side effects, drug interactions, duplicate therapy, omissions, dosage errors, or noncompliance at the time of admission and with a new medication.

Based on interview and observation, the agency failed to ensure services were provided in accordance with the plan of care for 3 of 18 patients (P1, P4, P11) reviewed. --- P1's Patient Profile form indicated P1 enrolled in hospice on 11/10/23. P1's hospice plan of care (POC) dated 11/10/23, indicated P1 had a diagnosis of Parkinson's disease and required a nursing assistant (NA) twice a week starting 11/12/23. P1's hospice physician order dated 11/10/23, indicated the NA was to visit twice a week starting 11/12/23, for activities of daily living (ADL) management. P1's hospice physician order dated 11/12/23, indicated the NA was to visit three times a week for ADL assistance and was electronically signed on 11/27/23. P1's hospice physician order dated 11/19/23, indicated the NA was to visit three times a week for ADL management effective 11/19/23. P1's hospice physician order dated 11/28/23, indicated the NA was to visit one time a week for one week and then three times a week for five weeks for ADL management effective 11/28/23. P1's interdisciplinary group (IDG) meeting review dated 11/21/23, indicated the NA was to visit twice a week for eight weeks starting 11/12/23. P1's home health aide visit notes in the patient chart indicated P1 had the following NA visits:11/13/23, 11/15/23, 11/17/23, 11/20/23, and 11/22/22. During interview on 11/29/23, at 12:10 p.m., the assistant director of clinical services (ADOCS) stated she wondered if there was a computer glitch and would have to check if the NA had a missed visit. No additional information was provided. P4's hospice POC dated 11/17/23, indicated P4 elected hospice on 11/17/23, and had the following diagnoses: unspecified severe protein calorie malnutrition, unspecified dementia, full incontinence of feces and unspecified urinary incontinence and required a NA twice a week for 12 weeks starting on 11/19/23. P4's hospice physician order dated 11/17/23, indicated the NA was to visit twice a week for 12 weeks starting 11/19/23. P4's IDG meeting review dated 11/29/23, indicated the NA was to visit twice a week for 12 weeks starting 11/19/23. P4's home health aide visit notes in the patient chart indicated P4 had the following NA visits: 11/24/23, and 11/28/23. During interview on 11/29/23 at 12:23 p.m., the ADOCS verified P4 did not have a second visit documented for the week starting 11/19/23. P11's certification of terminal illness indicated P11 elected hospice on 11/9/23 with a diagnosis of Alzheimer's disease and was dependent on staff assistance for all ADLs. P11's hospice physician order dated 11/9/23, indicated P11 required NA visits three times a week starting on 11/12/23 for ADL management. P11's home health aide visit notes in the patient chart indicated P11 had the following NA visits: 11/13/23, 11/14/23, 11/20/23, 11/21/23, and 11/22/23. During interview on 11/29/23 at 2:24 p.m., the ADOCS verified P11 did not have NA visits three times a week. During interview on 11/29/23 at 11:58 a.m., the assistant administrator stated staff documentation including missed visits were completed within 24 hours. During interview on 11/29/23 at 12:02 p.m., ADOCS stated missed visits were documented under the nursing clinical notes and showed up as a missed visit and visit orders were entered under hospice physician orders and were also in the IDG meeting review notes and orders were according to the most recent order and were based on need and the reason would be included in the physician order. A policy, Plan of Care dated 12/15/14, indicated hospice services provided to patients and caregivers were in accordance with a written plan of care established by the hospice interdisciplinary team in collaboration with the patient's attending physician. The agency collaborates with the patient, family and or primary care giver or inpatient care when developing and implementing a patient family specific plan of care. The plan of care is implemented and developed to meet the needs of the patient and family primary caregiver based on the findings of the assessments and reassessments that identify the patient and family strengths and weaknesses and needs. The care, services and treatment is provided in accordance with the plan of care that may include ancillary staff that may be provided by the agency employees, volunteers or contracted staff. Physician orders are incorporated in the plan of care. The plan of care is reviewed and updated by the IDG every fifteen days or more frequently as needed.

Based on interview and document review, the agency failed to maintain a copy of advanced directives for 3 of 18 patients (P12, P13, P14) reviewed for advanced directives. --- P14's Patient information form indicated a start of care date of 11/6/23, and do not resuscitate was indicated on the form. P14's medical record was reviewed and lacked an advanced directive signed by P14. During interview on 11/29/23 at 2:10 p.m., the assistant director of clinical services (ADOCS) stated the physician order for life sustaining treatment (POLST) should be scanned in the computer because if it is not uploaded immediately, staff won't know what a patient's code status is. During interview on 11/29/23 at 2:19 p.m., ADOCS verified P14 did not have an advanced directive located in P14's electronic medical record (EMR). A policy, Advance Directives dated 5/7/18, indicated upon admission, or at the time of hospital evaluation, patients will be asked whether or not they have prepared advanced directives. If a patient has prepared such documents, the agency will obtain a copy and retain it in the patient's medical records; if the patient has not signed or has not been advised regarding advanced directives, they would be read and explained to the patient during the hospital evaluation or upon admission. The patient's medical record will reflect whether or not advanced directives have been executed or whether the patient chooses not to execute advanced directives. P12's plan of care (POC) 10/11/23 through 1/8/24, identified a start of care (SOC) date 10/11/23, with a primary diagnosis of malnutrition. Advanced directives were listed on the POC as do not resuscitate (DNR) and do not intubate (DNI) with effective start date 10/11/23. P12's medical record lacked documentation of an advanced directive signed by P12 or designee. P13's POC 11/7/23 through 2/4/24, identified a SOC date 11/7/23, with a primary diagnosis of heart and kidney failure. Advanced directives were listed on the POC as DNR and DNI with effective start date 11/7/23. P13's medical record lacked documentation of an advanced directive signed by P13 or designee. During interview on 11/29/23, at 12:15 p.m. the assistant director of clinical services (ADOS) stated it was the agency's usual practice to upload a patient's advanced directive to their medical record, even if it had not yet been signed by the physician. Their goal was to have the physician sign all advanced directives the same day as the patient was admitted, however, the advanced directive should be scanned into the patient's medical record regardless. ADOS stated it was important to have the scanned document in the patient's medical record to ensure all staff would be able to locate the form and identify the patient's wishes quickly.

Based on interview and document review, the agency failed to ensure a comprehensive discharge summary of the patients stay was completed for 2 of 2 patients (P19, P20) reviewed for discharge. --- P19's plan of care (POC) dated 9/27/23 through 12/25/23, identified a start of care (SOC) date 6/29/23, with diagnosis a unspecified severe protein-calorie malnutrition. Skilled nurse documentation dated 11/7/23 indicated P19 had a steady increase in her weight and improved condition with a plan to discharge for no longer terminally ill within the next two weeks with an anticipated discharge date of 11/10/23. A Hospice Discharge Summary form (HIS) dated 11/10/23, identified an admission date 6/29/23, as well as P19 was in her second hospice benefit period with principal diagnosis of malnutrition. The HIS identified P19's primary physician was consulted and agreed with the discharge. Education and instruction was provided to P19's primary caregiver. Care summary in the above identified the hospice interdisciplinary group had discussed P19's care and condition and all agreed P19 was no longer considered terminally ill. Hospice medications were destroyed per agency protocol and a notice of Medicare non-coverage was signed by P19's care giver. P19's medical record lacked documentation of all the required components for discharge summary to P19's provider, including a summary of P19's episodes of care, services received, treatments, symptoms, pain management, current drug profile, physician order and other pertinent information needed to provide care for P19. P20's POC 8/10/23 through 11/7/23, identified a SOC date 8/10/23 with diagnosis of Huntington's disease. Skilled nurse note dated 11/7/23 indicated P20 remained appropriate for hospice services, was dependent with activities of daily living, had muscle spasms, needed assistance to manage oral secretions and was fed through a feeding tube. Social worker visit note dated 11/20/23, identified a face-to-face visit was made as P20's primary caregiver, family member-B had elected to revoke P20 from hospice services. A reason for the revocation was not identified. A Hospice Benefit Revocation form dated 11/20/23, identified P20's FM-B had elected to revoke hospice, effective 11/20/23. A Hospice Discharge Summary Non-Visit form dated 11/20/23, identified admission date 8/10/23, and reason for record as discharged 11/20/23, however the remainder of the form had not been completed. P20's medical record failed to identify if P20's attending physician had been consulted and agreed with the discharge and had received a discharge summary which included; discharge instructions, disciplines and services received, a summary of P19's episodes of care, services received, treatments, symptoms, pain management, current drug profile, physician order and other pertinent information needed to provide care for P19. During interview on 11/29/23, at 9:45 a.m. the assistant administrator stated it was the agency's usual practice to complete a discharge summary when a patient left hospice. The agency's discharge summary form contained all the required components needed in the summary and the expectation was for the entire discharge summary to be completed within 24 hours after the patient's discharge. A discharge policy was requested, however was not received.

Based on interview and document review the facility failed to ensure timely replacement of a supra pubic catheter for 1 of 3 (P1) patients reviewed with a catheter. Findings include: P1's initial Patient Profile (face sheet) indicated an admission date of 10/19/21, with primary diagnosis of Alzheimer's dementia. P1's Hospice Plan of Care dated 10/19/21, and last reviewed 12/22/21, by the interdisciplinary team (IDT) indicated secondary diagnoses including: hematuria (blood in the urine), benign prostatic hyperplasia without lower urinary tract symptoms (enlargement of the prostate), urinary incontinence, and personal history of urinary tract infections. The plan of care also indicated P1 had a supra pubic catheter (A tube that drains urine from the bladder. It is inserted through a small hole in the lower abdomen and into the bladder.) P1's Care Coordination Note dated 1/1/22, (time not noted), indicated: Writer received a call from facility reporting pt (patient) has pulled out his suprapubic catheter and cut it in half. Pt is comfortable. Will need to have it replaced this morning. Staff reports "no hurry". Writer updated on-call hospice. Review of the print out from the Tiger Text (TT) communication system utilized by hospice on-call staff, indicated on 1/1/22, at 7:10 a.m. triage licensed practical nurse (LPN)-A added a PDF (A file format that provides an electronic image of text or text and graphics that looks like a printed document and can be viewed, printed, and electronically transmitted.) file that indicated registered nurse (RN)-B had been assigned to replace P1's suprapubic catheter and further indicated, "Will need to be replaced this morning." The TT printout from the following morning (1/2/22) indicated a visit was needed to follow up on P1 as he had pulled out his cath yesterday and a visit was assigned and missed yesterday. P1's PRN (as needed) Progress Note dated 1/2/22, at 10:30 a.m. by RN-C indicated: Writer notified by on-call triage, Pt removed catheter and needing replacement of suprapubic cath (catheter). Writer consulted with facility RN who reports cath was removed 01/01/2022. Writer consulted with physician, given length of time without cath. physician advised to cautiously attempt insertion but if resistance found Pt will need to seek medical care. Writer arrived to Pt's apartment to find Pt lying on right side. Pt appeared comfortable with no nonverbal indications of pain or distress evident. Abdomen slightly distended, soft and nontender with palpation. Writer introduced self and explained purpose of visit. Catheter insertion attempted with resistance at approx (approximately) 0.5 cm (centimeters). Writer phoned Clinical Supervisor who advised revocation (the withdrawal or cancellation of something) and to seek medical care. Writer instructed facility aide to call for EMT (emergency medical technician) transport. EMT arrived and Pt was taken to the hospital. On 1/11/22, at 2:26 p.m. RN-A confirmed having worked as the triage nurse on 12/31/21, starting at 8:00 p.m. until 8:00 a.m. on 1/1/22. RN-A stated the call related to P1 removing his catheter came in on 1/1/22, at approximately 6:30 a.m. RN-A further stated she put a message on the TT thread right afterwards (around 7:00 a.m.) as the day shift on-call staff would be starting their day at 8:00 a.m. RN-A confirmed she had indicated the catheter would need to be replaced the same day. RN-A further confirmed that all hospice on-call staff working that day (1/1/22) had access to the TT communication system and were expected to review the communication. On 1/11/22, at 2:36 p.m. RN-B confirmed the visit to replace P1's catheter had been added to her schedule the morning of 1/1/22, though RN-B didn't realize it had been added until after her shift ended at 4:00 p.m. RN-B stated rather than private texting her the addition to her schedule, the addition was in a file sent that had to be opened. RN-B further stated, "I'm not gonna open up all of those messages unless they personally message me and let me know." RN-B stated around 5:00 p.m. on 1/1/22, another nurse resent the same file that had been sent earlier and at that point RN-B opened the file and realized P1's visit had been assigned to her. RN-B confirmed she did not notify the hospice triage nurse or any of the on-call staff that P1's visit had been missed. On 1/12/22, at 9:37 a.m. LPN-A confirmed working triage from 8:00 a.m. on 1/1/22, until 8:00 a.m. on 1/2/22. LPN-A stated RN-A had reported off to her the morning of 1/1/22, that P1 had removed his catheter, was doing ok, but would need to have his catheter replaced that morning. LPN-A confirmed having started her day prior to 8:00 a.m. on 1/1/22, so she could get the assignment sheet sent out before 8:00 a.m. as that was when the on-call nurses started their day. LPN-A further confirmed sending out the assignment sheet on 1/1/22, prior to 8:00 a.m. and thought she had sent the updated file around 7:45 a.m. LPN-A confirmed it was the on-call nurses responsibility to review the thread to look for updates. LPN-A further confirmed if a nurse couldn't get to a patient they were to notify staff via TT that they couldn't make it and see if anyone else could go on the visit. LPN-A stated RN-B had not informed her or any of the other on-call staff that she had missed the visit for P1 on 1/1/22. LPN-A stated she hadn't realized P1 had not been seen or had his catheter replaced until 6:00 a.m. on 1/2/22, after reviewing the visit summaries and not seeing one for P1 from 1/1/22. LPN-A confirmed that RN-C provided a visit to P1 the morning of 1/2/22. On 1/11/22, at 3:16 p.m. family member (FM)-A confirmed P1 had removed and cut his catheter in half, requiring hospice staff to replace the catheter. FM-A stated RN-C had let her know right away on Sunday (1/2/22) that P1 had removed the catheter. FM-A wasn't sure RN-C had told her when P1 had pulled the catheter out; just that he had, and they were having trouble getting it back in and would need to have it replaced in the hospital. FM-A stated being ill at the time so couldn't meet P1 at the emergency room, though approved for P1 to bed discharged from hospice so he could be sent to the hospital to have the catheter replaced. FM-A confirmed P1's supra pubic catheter placement was relatively new. On 1/11/22 at 3:26 a.m. RN-C confirmed seeing the notice on the TT thread on 1/1/22, that P1 had removed his catheter and needed it replaced, though thought it had been taken care of. RN-C stated it wasn't until the morning of 1/2/22, he noticed the assignment had been given to him as the visit had been missed the day before. RN-C stated his initial concern was that the abdominal site might be closing up and called the medical director (MD) prior to attempting replacement of the catheter. RN-C confirmed being advised by the medical director to not push it if meeting resistance and transfer P1 to the emergency department (ED). RN-C stated when trying to replace P1's catheter he was only able to insert approximately 0.5 cm then met resistance. RN-C then made the decision to transfer P1 to the ED for replacement of the catheter. Policies related to Tiger Text and on-call nursing responsibilities was requested but not received.