Every finding on record at Bristol Hospice - Hawaii, LLC

Based on interview and record review, the service provider failed to develop an individualized written plan of care for Patient (P)1 that effectively managed his respiratory symptoms and anxiety. As a result of this deficient practice, P1s quality of life and comfort was hindered. --- Findings include: Based on interview and record review, the service provider failed to develop an individualized written plan of care for Patient (P)1 that effectively managed his respiratory symptoms and anxiety. As a result of this deficient practice, P1s quality of life and comfort was hindered. Findings include: Patient (P)1 was a 75-year-old male admitted for hospice services on 06/26/24. Diagnoses documented at the start of P1s care included, but were not limited to, COPD (chronic obstructive pulmonary disease) with acute exacerbation, acute and chronic respiratory failure with hypoxia (low levels of oxygen in his body tissues that can cause symptoms like confusion, restlessness, difficulty breathing, rapid heart rate, and bluish skin), urinary incontinence (leaking urine by accident), and full incontinence of feces (inability to hold his bowel movement until he can get to a toilet). On 10/04/24 the State Agency (SA) received a phone complaint from a provider volunteer detailing how the provider was not meeting P1s needs. The complainant described how P1, who lived alone, had difficulty getting up to the door or around his apartment, was frequently complaining of shortness of breath, was no longer able to perform his ADLs (activities of daily living such as personal hygiene) independently, including using the bedside commode or preparing food, and lived in an apartment infested with roaches. The complainant explained how he had repeatedly and consistently documented P1s increasing needs for months and reported to the care team and administration his belief that P1 would benefit from placement in a skilled nursing facility where he could receive around-the-clock services. On 12/05/24 the SA entered the service provider facility for an abbreviated complaint survey. Review of P1s electronic health record (EHR) noted that P1 was discharged from hospice due to a hospital admission on 10/06/24 with an admitting diagnosis of Acute Hypoxic (not enough oxygen in the blood) Respiratory Failure. P1 was readmitted to hospice on 10/11/24 after being discharged from the hospital to a skilled nursing facility, where he passed on 10/17/24. Review of the Volunteer Activity Records revealed that beginning on 07/20/24, Volunteer (V)1 began visiting P1. On the initial visit, V1 made the following documentation: ";Patient does not appear to have the support system in place to live comfortably... He does not sleep in a bed, but sleeps upright on the floor. He says he cant sleep horizontal due to his condition. He needs a hospital bed that adjusts. He doesnt have any bed at this time... Theres no way he can take care of himself." On 07/27/24, V1 documented the following visit: ";As you know, hes calling after hours a lot. And he keeps being told ";stop calling so much". Now I understand that this is something about what is hospice and what is medical treatment. So if he wants actual medical treatment beyond what he is provided, he must drop hospice. So heres the problem in my mind: how do you expect someone who is having trouble breathing, and alone, to not call and ask for treatment..." On 07/28/24, V1 documented the following visit: ";Last night was a bad night. In addition to his regular breathing struggles, he also has coughing fits and has phlegm in his throat... Its like hes drowning with his head above water... without being in a care facility, its an act of cruelty..." On 08/22/24, V1 documented the following visit: ";Not so much pain but shortness of breath. When I was in the hallway after leaving I heard him say he couldnt breathe. I went back in until he was better." On 09/02/24, V1 documented the following visit: ";Yes He was really struggling for breath and had called the nurse." On 09/05/24, V1 documented the following visit: ";He struggles for breath more frequently than when I first started visiting him." On 09/23/24, V1 documented the following visit: ";Patient was not doing well... Struggling." On 09/28/24, V1 documented the following visit: ";... he cant feed himself anymore without having a breathing episode, so hes relying on me and others as much as possible." On 09/30/24, V1 documented the following visit: ";Patient is struggling and alone. Cant walk to the door anymore and getting something from the kitchen causes dizziness and shortness of breath excacerbated [sic]." In addition, V1 consistently documented ";Yes" for the following questions on the Volunteer Activity Record, even when he felt the patient was ";okay" or ";doing better": ";Did your patient tell you they were experiencing pain during your visit?" ";Did you observe any non-verbal signs of pain during your visit?" Review of P1s nurse visit notes and nurse narrative notes revealed that beginning on 06/26/24, nurses assessed P1 with various degrees of ";dyspnea [feeling short of breath]," respiratory distress and labored breathing, decreased lung sounds and/or oxygen saturations, and a goal of ";Maximize respiratory function and decrease respiratory anxiety" identified at the start of care. Throughout his care, P1s nurses consistently document observations of him sitting on the floor, couch, or chair, and unable to get up from those areas to answer/open the door, in addition to frequent complaints and verbalizations from him that he felt short of breath and ";like he is not getting enough oxygen." P1 also was consistently documented as being unable to find, open, and/or draw up/prepare his medications independently that would assist him with his breathing, comfort, and anxiety. Beginning on 07/03/24, P1 was documented as requesting Nursing Home placement, verbalizing that he was alone, had no caregiver, and needed help meeting his daily needs. Despite daily nurse visits, P1 was frequently documented as calling in after-hours, anxious and short of breath, requesting services. On 07/09/24, Registered Nurse (RN) visit documented that P1 ";Needs assistance with bathing and dressing..." and, ";assisted with administering his routine meds [medications]..." Continued record review noted that nurse documentation reflects awareness that P1 consistently indicated/verbalized that he would get short of breath and dizzy with ambulation, could not prepare his own medication for self-administration, could not sleep laying down flat as he ";could not breath" and therefore could only sleep sitting up, and needed assistance completing his ADLs. P1 was repeatedly described by nurses as ";... cachectic [weakness and wasting of the body due to severe chronic illness], frail pt [patient] with bony prominences [visibly protruding bones], thin extremities..." Nursing notes also validate V1s assertion of a roach problem in his home. Review of material found at https://www.lung.org/blog/copd-particulate-matter shows ";Indoor air quality is critical to everyones health, especially people living with... COPD... Specifically, air pollution in the form of particulate matter can have more significant impacts on the health of people living with this chronic lung disease... It is imperative that individuals with COPD take steps to improve their indoor air quality, especially particulate matter... Clean frequently to avoid re-suspension of particles from carpets and floors such as... cockroach allergens..." On 12/06/024 at 12:26 PM, a phone interview was done with V1. V1 reported that he was so frustrated and disappointed by the hospice providers failing to meet P1s needs that he quit, then continued to visit P1 ";as his friend." V1 described that on 10/05/24, when P1 went to the emergency department which resulted in his hospital admission and subsequent discharge from hospice, he went over for a visit. P1 was having great difficulty breathing, so he encouraged P1 to call the hospice provider for assistance, but P1 was hesitant. V1 stated the hospice provider ";made him feel like shit for calling," and that P1 told him on many occasions that they (the hospice provider) always made him feel bad for calling. At V1s insistence, P1 did call the hospice provider, breathless, and V1 heard ";a female" tell P1 ";do you really need someone to come over?" Review of P1s Hospice Plan of Care for the initial certification period (06/26/24 – 09/23/24) and the recertification period (covering from 09/24/24 until discharge due to hospital admission on 10/06/24) noted no non-pharmacological interventions to address his respiratory anxiety, no interventions to address issues identified with P1s inability to prepare his own medications for pain and anxiety, not having a bed with documented difficulty of getting up from the floor, or the identified roach problem with allergens that had the potential to exacerbate his respiratory status. In addition, the recertification period did not include homemaker services, which due to his declining health, P1 had an increased need for. Also noted were the two plans of care had little revisions besides increasing the home visits made. P1s medication orders for pain and anxiety remained unchanged. Review of the providers policy and procedure, Interdisciplinary Group Coordination of Care, last updated May 2020, revealed the following: ";The exact combination of services and the level of care will be unique to each patient... and will change as the needs of the patient and family/caregiver evolve..."

Based on record review and interview, the facility failed to develop an individualized written plan of care that included the medical appliances necessary to meet the needs of Patient (P)1. As a result of this deficient practice, P1 did not receive a hospital bed, potentially hindering him from improving his comfort and achieving his highest practicable well-being. --- Findings include: Cross-reference to L546 Symptom Management. Despite identifying that Patient (P)1 did not have a bed to sleep on, could not rest comfortably laying flat, and was frequently found on the floor at his daily visits, the facility failed to make arrangements for an adjustable hospital bed, document continued refusals to offers of a hospital bed, or document that risks versus benefits of a hospital bed were discussed with P1 at any time. Patient (P)1 was a 75-year-old male admitted for hospice services on 06/26/24. Diagnoses documented at the start of P1s care included, but were not limited to, COPD (chronic obstructive pulmonary disease) with acute exacerbation, acute and chronic respiratory failure with hypoxia (low levels of oxygen in his body tissues that can cause symptoms like confusion, restlessness, difficulty breathing, rapid heart rate, and bluish skin), urinary incontinence (leaking urine by accident), and full incontinence of feces (inability to hold his bowel movement until he can get to a toilet). On 10/04/24 the State Agency (SA) received a phone complaint from a provider volunteer detailing how the provider was not meeting P1s needs. The complainant described how P1, who lived alone, had difficulty getting up to the door or around his apartment, was frequently complaining of shortness of breath, was no longer able to perform his ADLs (activities of daily living such as personal hygiene) independently, including using the bedside commode or preparing food, and lived in an apartment infested with roaches. On 12/05/24 the SA entered the service provider facility for an abbreviated complaint survey. Review of P1s electronic health record (EHR) noted that P1 was discharged from hospice due to a hospital admission on 10/06/24 with an admitting diagnosis of Acute Hypoxic (not enough oxygen in the blood) Respiratory Failure. P1 was readmitted to hospice on 10/11/24 after being discharged from the hospital to a skilled nursing facility, where he passed on 10/17/24. Further review of P1s EHR revealed documentation that P1 was offered and refused a hospital bed in his home at admission on 06/26/24. No documentation found that it was offered again following the initial visit despite identifying that his health and independence was declining. On 12/06/24 at 02:00 PM, an interview was done with the Regional Director of Clinical Operations (DCO) in the conference room. DCO agreed that an adjustable hospital bed would have made P1 more comfortable. As DCO, she also agreed a hospital bed should have been offered more than just at admission for any patient with COPD and respiratory anxiety. In addition, DCO agreed that if a hospital bed had been offered and declined again, it should be documented. DCO confirmed there was no documentation that a hospital bed had been offered more than once.

Based on record review and interview, the facility failed to develop an individualized written plan of care that was based on all assessments of Patient (P)1s needs. Specifically, the facility failed to include the volunteer services assessments, observations, and feedback into modifying P1s plan of care. --- Findings include: Cross-reference to L546 Symptom Management. Volunteer (V)1 consistently and extensively documented and communicated to P1s care team that he had needs that were not being met, despite daily nursing visits.

It is required that hospice aides are assigned to a specific patient by a Registered Nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by interviews and review of clinical records. 2 of 18 (11%) applicable clinical records of patients who received Hospice Aide services, there was no documented evidence that the RN prepared clear written patient care instructions for the Hospice Aide. Record #35019 - The terminal diagnosis was senile degeneration of the brain, and the patient lived at home with her husband. During the dates of service reviewed, the Hospice Aide visit frequency was two times a week. The Hospice Aide care plan (under "clinical orders" and Hospice Aide "interventions") stated, in part, complete "bed bath" and "transfer to or from tub or shower" every visit, which was also populated onto the Hospice Aide visit notes. The Hospice Aide care plan did not provide clear instructions on the type of bath to be performed. Record #77250 - The terminal diagnosis was a hypertensive heart with heart failure, and the patient lived at a facility. During dates of service reviewed, the Hospice Aide visit frequency was two times a week for personal care plus an additional two times a week for the "sweet dreams" program. The Hospice Aide care plan for personal care under "interventions" stated, in part, "complete seated shower" and "OK for bed bath, for now, patient in isolation," which was assigned in the "special instructions" section of the Hospice Aide care plan. The Hospice Aide care plan did not provide clear instructions on the type of bath to be performed and if the patient was in isolation. During the dates of service reviewed, the Quality Assurance Coordinator and Director of Patient Care Services confirmed that the patient was not in isolation. During a phone interview, the RN stated, "This patient had shingles and was on isolation before I received this patient," "This patient was transferred to me around July or August," and "In October the patient was not on isolation and should only be receiving a shower." During a phone interview, the Hospice Aide stated, "I remember in October that the patient was no longer on isolation and that the patient was only getting a shower." This standard was not met as evidenced by interviews and review of clinical records with the Quality Assurance Coordinator and Director Patient Care Services.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by interviews and review of clinical records. 2 of 18 (11%) applicable clinical records of patients who received Hospice Aide services, there was no documented evidence that the Hospice Aide provided services included in the plan of care. Record #35019 - The terminal diagnosis was senile degeneration of the brain, and the patient lived at home with her husband. During the dates of service reviewed, the Hospice Aide visit frequency was two times a week. The Hospice Aide care plan (under "clinical orders" and Hospice Aide "interventions") stated, in part, complete "bed bath" and "transfer to or from tub or shower" every visit, which was also populated onto the Hospice Aide visit notes. The Hospice Aide visit note dated 7/20/2021 documented, in part, "performed transfer to or from tub or shower" and "not applicable: bed bath." There was no documented communication with the RN as to why the bed bath was not applicable. Additionally, a Hospice Aide visit note dated 7/23/2021 included, in part, "performed bed bath" and "performed transfer to shower or tub." There was no documented communication with the RN as to why the bed bath and transfer to the shower or tub were performed. Record #77250 - The terminal diagnosis was a hypertensive heart with heart failure, and the patient lived at a facility. During dates of service reviewed, the Hospice Aide visit frequency was two times a week for personal care plus an additional two times a week for the "sweet dreams" program. The Hospice Aide care plan for personal care under "interventions" stated, in part, "complete seated shower" and "OK for bed bath, for now, patient in isolation," which was assigned in the "special instructions" section of the Hospice Aide care plan. The Hospice Aide visit note dated 10/25/2021 documented, in part, the assigned task of "seated shower - OK for bed bath, for now, patient in isolation" was "completed and tolerated well." There was no clear documentation if the Hospice Aide performed the shower as well as the bed bath. Additionally, the Hospice Aide visit note dated 10/27/2021 documented, in part, "shower completed and tolerated well" after the assigned task of "seated shower - OK for bed bath, for now, patient in isolation." There was no documented communication with the RN as to why the shower was completed and why the "bed bath for now patient in isolation" was not completed. During the dates of service reviewed, the Quality Assurance Coordinator and Director of Patient Care Services confirmed that the patient was not in isolation. The RN stated during a phone interview, "This patient had shingles and was in isolation before I received this patient. This patient was transferred to me around July or August, and in October, the patient was not in isolation and should only be receiving a shower." During a phone interview, the Hospice Aide stated, "I remember in October that the patient was no longer on isolation and that the patient was only getting a shower."

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient's attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient's record includes, at a minimum, physician orders. This standard was not met as evidenced by an interview and review of clinical records, 1 of 20 (0.5%) records, and there was no documented evidence that the clinical record included physician's orders for a medication the patient was receiving. Record #28086 - The "IDT Meeting Note" dated 8/5/2021 included, in part, "Daughter administers PRN Benadryl for itching." There was no documented physician's order for Benadryl in the clinical record. During an interview, the Quality Assurance Coordinator stated that a physician's order for the Benadryl was not located in the clinical record.