Every finding on record at Bristol Hospice, LLC

Based on employee file review and interview, the provider failed to ensure employees received the providers emergency preparedness training during orientation in four of five employee files reviewed (Employees A, B, D, and E). This deficient practice has the potential to affect all patients served by the provider. --- Findings included: Review of employee files showed: EMPLOYEE A:-Date of hire: 04/03/2023; and -No evidence of emergency preparedness training at orientation. EMPLOYEE B:-Date of hire: 07/01/2023; and-No evidence of emergency preparedness training at orientation. EMPLOYEE D:-Date of hire: 06/01/2022; and-No evidence of emergency preparedness training at orientation. EMPLOYEE E:-Date of hire: 06/28/2023; and-No evidence of emergency preparedness training at orientation. During an interview conducted 09/19/2023 at 2:40 PM, the administrator stated that he/she would expect emergency preparedness training to be completed during orientation and then annually for all employees. All employees were provided emergency preparedness training 09/13/2023.

Based on review of the providers emergency plan and interview, the provider failed to conduct exercises to test the emergency plan annually, to analyze the provider's response to, maintain documentation of drills, tabletop exercises, and emergency events, and revise the provider's emergency plan as needed. This deficient practice has the potential to affect all patients served by the provider. --- Findings included: Review of the providers emergency preparedness plan showed:- The provider failed to document they conducted exercises to test the emergency plan for the years of 2021 or 2022; and- There was a documented sign in sheet for a fire drill with office participation dated on 07/19/2023. During an interview on 09/20/2023 at 2:06 PM, the quality assurance coordinator stated that he/she was unsure if there was documentation of a full scale exercise, actual emergency, table top or community drill. No further information was provided prior to exit.

Based on policy review, clinical record review, observation, and interview, the provider failed to ensure that the comprehensive assessment identified the physical needs (specifically pain) related to the terminal illness, that must be addressed in order to promote the hospice patient's well-being in, but not limited to, one of five full records reviewed (Record/Patient #2). This deficient practice has the potential to affect the pain management of all the provider's patients. --- Findings included: Review of the providers policy titled, "Comprehensive Assessment," Policy No. 1-014 dated May 2020, showed, in part, that during the comprehensive assessment all baseline data and other relevant information would be documented in the patients clinical record, including: - An assessment of pain, including the origin, location, duration, severity, and relief measures (See ";Pain Assessment"); and - Current treatment and patients response to treatment. Review of the providers policy titled, "Initial Assessment," Policy No. 1-013 dated May 2020, showed, in part: - Admitting registered nurse uses an assessment scale/rating tool to assess for problems and to establish a baseline status of each symptom rated. Items assessed may include, but are not limited to, the following: * Pain assessment; and - If the comprehensive assessment is completed during the admission visit, the initial assessment will be included as a part of the comprehensive assessment. Review of the providers policy titled, ";Pain Assessment" Policy No. 1-018 dated May 2020, showed, in part: - All patients will receive pain assessments. When pain is identified, a more comprehensive pain assessment will be completed when warranted by the patients condition. Pain assessments will be appropriate to the patients age and will be documented to facilitate regular reassessment and follow-up by clinicians; - During the initial assessment and on an ongoing basis, the patient will be asked a general screening question regarding current or recent pain as part of the baseline data. Clinicians will consider the patients personal, cultural, spiritual, and ethnic beliefs when assessing pain or discomfort; - When the patient or the clinician identifies pain, the following in-depth pain assessment information will be obtained whenever possible: A. Pain intensity using a rating scale (on a scale of 0 – 10: 0 = no pain, 10 = unbearable pain). Pain intensity should include current pain, worst pain, and least pain using the scale. The patient will be reassessed every visit for the existence and intensity of pain and the effectiveness of interventions to relieve pain; - Pain location and frequency; - Pain quality, patterns of radiation, and character. Use the patients own words whenever possible; - Pain onset, duration, variations, and patterns; - Alleviating and aggravating factors; - Present pain management regimen and effectiveness; - Pain management history, to include a medication history, presence of common barriers to reporting pain and using analgesics, past interventions and response, and manner of expressing pain; - Effects of pain. These include impact on daily life, function, sleep, appetite, relationships with others, emotions, concentration, etc; - The patients pain goal, including pain intensity and goals related to function, activities, and quality of life; - Physical exam or observation of the site of pain; - Secondary symptoms related to pain such as nausea, vomiting, respiratory distress, or nutritional compromise; - If patient is unable to communicate pain using the rating scale, is cognitively impaired, or is a child, the clinician will assess behavioral factors that signal pain or discomfort and include this information in the assessment; and - Pain assessments will be part of the comprehensive assessment and will be updated if significant changes occur. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice services on 04/13/2023, with a terminal diagnosis of senile degeneration of the brain (a decrease in cognitive abilities or mental decline. This may include the person's inability to concentrate, to recall information, and to properly judge a situation) and a secondary diagnosis of Chronic Pain Syndrome. The patient resided in a skilled nursing facility (SNF). Review of the clinical record showed: - On 04/13/2023 the registered nurse (RN) assessed the patient; - The patient was alert and oriented to person only; - The nurses narrative note stated, in part, the patient had a history of Kyphoplasty (a procedure to treat spinal fracture) with a Medtronic pain pump (an implanted device that delivers pain medication through the catheter to the spinal area where pain receptors are located) for 20 years. According to facility staff, the patient has unrelieved pain and they were unable to get the patient's pain level at that time; - The nurse evaluated the patient's pain using the PAINAD (pain assessment in advanced dementia 1–3=mild pain; 4–6=moderate pain; 7–10=severe pain) scale with a score of 6 moderate pain; and - The nurse failed to document a complete pain assessment including a description of the quality of the patient's pain, onset and duration of the pain, and what factors provide pain relief. Review of the patients medication list as of 09/18/2023 showed the following pain medication orders: - Acetaminophen/oxycodone 325-10 mg (narcotic pain medication) one tablet every six hours for moderate pain; - Lidocaine 4% patch (topical pain patch) applied to lower back once daily; - Oxycodone 15mg (narcotic pain medication) one tablet every 12 hours for severe pain; - Percocet 325-10mg (narcotic pain medication) one tablet twice daily; - Pregamblin 150 mg (narcotic pain medication) one capsule three times a day; - Acetaminophen 325 mg (non-narcotic pain medication) two tablets every four hours as needed for pain; - Acetaminophen 500 mg (non-narcotic pain medication) two tablets every 6 hours as needed for pain; - Morphine sulfate 20mg/ml (narcotic pain medication) 0.25 ml every four hours as needed for pain; and - Failed to include the patients Medtronic pain pump. Review of the clinical record showed: - Patient was alert to self only on each skilled nurse visit (SNV) per documentation; - SNV on 08/09/2023, a subjective pain assessment was completed with mild continuous pain documented; - SNV on 08/11/2023, a FLACC scale (FLACC is a behavioral pain assessment scale used for nonverbal or preverbal patients who are unable to self-report their level of pain. Pain is assessed through observation of 5 categories including face, legs, activity, cry, and consolability.) pain assessment was completed with a score of 0 (no pain) documented; - SNV on 08/16/2022, 08/18/2023, 08/22/2023, and 08/25/2023, subjective pain assessments were completed with no pain reported; - SNV on 08/29/2023, a verbal pain assessment was completed with mild continuous pain documented; - SNV on 09/05/2023, no pain assessment was completed; - SNV on 09/08/2023, a verbal pain assessment was completed with mild pain 6-9 times per day documented; - SNV on 09/11/2023, a verbal pain assessment was completed with mild continuous pain documented; - SNV on 09/14/2023, a verbal pain assessment was completed with mild pain greater than 9 times daily documented; and - SNV on 09/18/2023, a verbal pain assessment was completed with mild pain 6-9 times per day documented. Observation on 09/19/2023 at 10:30 AM, during the patient's home visit with the medical social worker, at the SNF where the patient resided, showed the patient was: - Alert to self and place; and - Restless, moving their lower body rhythmically, and rubbing his/her legs constantly. During an interview with a SNF staff member at the time of the observation, he/she stated the patients pain has been much more managed since going on hospice services. During an interview on 09/20/2023 at 3:19 PM, the clinical supervisor stated that he/she would expect for the pain assessment to be consistent with all staff members.

Based on record review and interview, the hospice provider failed to ensure an individualized plan of care was developed for each patient in, but not limited to, one of five full records reviewed (Record/Patient #5). This deficient practice has the potential to affect all patients served by the provider. --- Findings included: The provider failed to provide a plan of care policy as requested during survey entrance, throughout the survey, and prior to exit. RECORD/PATIENT #5: Review of the clinical record document titled ";SN (skilled nurse) for Documentation Visit Summary," dated 09/06/2023, showed documentation in the narrative note: "Doppler on the two revealed blood clots and Eliquis (blood thinner) 10 mg (milligram) BID (twice a day) x (times) a week, 5 mg bid two months." Review of the ";IDT (interdisciplinary team) Note," dated 09/07/2023, failed to include any communication about the patient having blood clots and being started on Eliquis. During an interview on 09/20/2023 at 3:25 PM, the hospice quality assurance coordinator stated that he/she would expect any medications to be listed on the plan of care.

Based on policy review, observation, and interview, the hospice provider failed to ensure that accepted standards of practice to prevent the transmission of infections was followed in one of one patient observed for wound care (Record/Patient #1). This deficient practice has the potential to affect all patients served by the provider. --- Findings included: Review of the providers policy titled, "Standard Precautions," Policy No. 7-007, dated May 2020 showed hospice personnel were to adhere to the following precaution and change gloves after removing an old dressing. Review of the providers policy titled, "Hand Hygiene," Policy No. 7-009, dated May 2020 showed hospice personnel were to perform hand decontamination using an alcohol-based hand rub after contact with non-intact skin and wound dressings. Review of the providers policy titled, "Bag Technique," Policy No. 7-016, dated May 2020 showed hospice personnel were to clean reusable equipment with alcohol, soap and water, or other appropriate solution prior to returning equipment to the bag. RECORD/PATIENT #1: Observation on 09/19/2023 beginning at 11:27 AM, during the patient's home visit, showed RN A failed to change his/her gloves between dirty and clean wound treatments and failed to clean equipment: - RN A placed dressing supplies on a clean barrier and donned gloves; - RN A removed dirty dressing from the patients left foot, reached in his/her pocket to obtain work phone and took a picture of the foot to send to the physician; - RN A sprayed wound cleanser (promote wound healing and reduce the infection rate) on clean gauze and cleaned the wound; - RN A used a tape measure to measure the wound; - RN A picked up his/her tablet and took a picture of the wound and used his/her gloved fingers to type on the tablet; - RN A applied skin prep (a liquid that when applied to the skin forms a protective film or barrier), medi-honey (hastens the healing of wounds through its anti-inflammatory effects) and foam (foam that protects and cushions wounds) dressing to foot wound, and removed gloves; - RN A sanitized hands and donned new gloves; - RN A removed the dirty dressing from the patients right upper coccyx area; - RN A picked up his/her tablet and took a picture of the wound; - RN A measured the wound with the tape measure; - RN A applied wound cleanser to gauze and wiped the wound, dried the wound with gauze, applied medi-honey and applied foam dressing then removed gloves; - RN A placed tablet and supplies into his/her bag; and - RN A failed to use disinfectant wipes after the home visit to clean his/her equipment. During an interview immediately following the home visit on 09/19/2023 at 12:06 PM, RN A stated that he/she failed to change gloves going from dirty to clean, should have changed gloves prior to touching the tablet and cleaned the equipment after use and between patients. During an interview on 09/21/2023 at 10:57 AM, the administrator stated that he/she would expect the staff to change gloves between dirty and clean and clean the equipment after use.

Based on policy review, and interview, the provider failed to provide documented evidence of a coordinated provider wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the hospice's quality assessment and performance improvement (QAPI) program and includes a method of investigating infectious and communicable diseases, and a plan for implementing the appropriate actions that are expected to result in improvement of disease prevention. This deficient practice has the potential to affect all patients, families, visitors, and the provider's personnel. --- Findings included: Review of the agency's policy titled, "Infection Control Plan," Policy No. 7-001 dated November 2021, showed, in part, the following: - Establish the mechanism by which the hospice will address surveillance, prevention, identification, control and reporting of infections and communicable diseases utilizing current scientific methods and epidemiologic principles; - Provide surveillance systems to track the occurrences and transmission of infectious and communicable diseases; - An agency-wide program for prevention and control mechanisms will be implemented for planning, surveillance, identification, prevention/controls, and reporting procedures; - To determine the effectiveness of the infection control plan, the hospice will measure, assess, improve, and redesign (as appropriate) the surveillance, identification, prevention, and control function annually through its performance improvement program; - Surveillance that is conducted to measure the occurrence of specific infections in multiple patients at the same time; - The hospice will utilize its safety and performance improvement process to identify risks for the acquisition and transmission of infectious agents on an ongoing basis; * All identified infections will be reported via electronic format using the National Incident, Concern and Event (NICE) form; * The Quality Assurance Coordinator will track and trend patient and employee infections on an ongoing basis and report findings to the Administrator and Director of Patient Care Services/Clinical Supervisor for action as deemed appropriate; and * Action plans are expected to result in improvement and disease prevention. During an interview on 09/20/2023 at 2:26 PM, the quality assurance coordinator registered nurse stated that they are tracking infections for QAPI, but no program is in place for monitoring the infection rates, when a patient is diagnosed with an infection staff will submit a NICE form and that information is then entered electronically and pulls to a report. The staff report the infections during the interdisciplinary meetings but no one has been monitoring for possible trends or multiple occurrences.

Based on policy review, employee file review and interview, the hospice provider failed to ensure that the skills and competence were assessed of all staff furnishing care/services to hospice patients in one of five employee files reviewed (Employee A). This deficient practice has the potential to affect all patients on service with the provider. --- Findings included: Review of the providers policy titled, "Categories/Qualifications of Personnel," Policy No. 1-004 dated August 2023, showed, in part: - Individuals must demonstrate their competency, within their orientation and probationary period, according to the orientation checklists developed for each position. In addition, ongoing competency assessments will be performed through joint visits, based on the degree and complexity of care being performed and by monitoring information regarding performance; and - Failure to meet the hospice's competency expectations may result in termination. Review if the providers policy titled, ";Wound Care," Policy No. 2-056 dated March 2022, showed in part: - Newly hired RNs and LPNs/LVNs will receive education on skin and wound care;- All nursing staff will complete competency assessments for basic and complex wound care; - Competency field visits will be conducted with those staff that require additional instruction; and- Additional education will be provided on an as needed basis either agency-wide or office/team specific. Employee A: Review of the employee file showed:- The date of hire was 04/03/2023 as a registered nurse (RN);- The initial orientation checklist included ";skill/competency assessment", to have been completed during the first week of orientation, was signed by employee A on 04/03/2023 but failed to be signed by the designated trainer; - The initial orientation checklist included ";completion of skills competency checklist", to have been completed during the fourth through sixth week of orientation, was signed by employee A on 04/04/2023 but failed to be signed by the designated trainer; and - The ";skills competency checklist" was not provided. During an interview on 09/20/2023 at 3:03 PM, the clinical supervisor stated that the nurse is expected to perform skills as needed to patients and if there is a skill that requires a check off then the nurse notifies the clinical supervisor who will go, in person, to do a check off. He/she stated that wound care is not a skill that required a competency as it falls under scope of practice. He/she reviewed the wound care policy and stated that a competency check off is required.

Based on state-recognized standards, record review, observation, and interview, the hospice provider failed to ensure an order was obtained for all medications and treatments provided to patients in two of five full records reviewed (Records/Patients #1, and #5). This deficient practice has the potential to affect all patients served by the provider. --- Findings included: Review of the state-recognized standard titled, ";Healthy Living," found on the website https://health.mo.gov/living/lpha/phnursing/physicianorders.php, undated, ";Physician Orders," showed according to the Nursing Practice Act (Chapter 335 Revised Statutes of Missouri) the scope of practice of the professional nurse includes administration of medications and treatments as prescribed by a person licensed by a state regulatory board to prescribe medications and treatments (physician). Therefore, the Missouri Department of Health and Senior Services (DHSS) recommends physician orders should be obtained for administration of all medications and treatments. Review of ";Nursecepts," found on the website https://nursecepts.com/medication-orders/, undated, ";Medication Orders," showed a medication order is written by a practitioner for a medication that will be administered. Medication orders are required before a nurse may administer medications. RECORD/PATIENT #1: Observation on 09/19/2023 beginning at 11:27 AM, during the patient's home visit, showed RN (registered nurse) A applied medi-honey (hastens the healing of wounds through its anti-inflammatory effects) to the left foot wound. Review of the clinical record failed to include a physician order for medi-honey. RECORD/PATIENT #5: Review of the clinical record document titled ";SN (skilled nurse) for Documentation Visit Summary," dated 09/06/2023, showed documentation in the narrative note: Doppler on the two revealed blood clots and Eliquis (blood thinner) 10 mg (milligram) BID (twice a day) x (times) one week, 5 mg bid (for) two months. Review of the clinical record failed to include a physician order for Eliquis 10 mg BID x one week. During an interview on 09/20/2023 at 3:25 PM, the hospice Quality Assurance coordinator RN stated that he/she would expect there to be an order for any medications the patients were on. He/She failed to produce the order.