Every finding on record at Central Coast VNA & Hospice, Inc

Based on observation, interview, and record review, the hospice failed to ensure medications were reviewed and updated for two of three sampled patients (Patient 2 and 3) when: 1. Patient 2s Lactulose (use to treat constipation [difficulty passing stool]) medication was not available when needed; 2. Patient 3s plan of care (POC) did not have specific interventions and goals in managing her Eliquis (blood thinner) medication. These failures had the potential to create an adverse effect for the patients. --- 1. Review of Patient 2s plan of care indicated start of care on 11/8/22, and a diagnosis of heart failure (heart problem). His medications list included Lactulose 10 gram per 15 milliliters oral solution prn (as needed) one time daily for constipation and Bisacodyl (used to treat constipation) 10 milligram (mg, unit of measurement) suppository (form of medication that is inserted into the rectum) prn for constipation. His summary of problems indicated ";Patient (Patient 2) was having constipation AEB (as evidenced by) pebble size stools. The intervention indicated administer stool softeners or laxatives as ordered. Another intervention indicated ";RN/LVN (registered nurse/licensed vocational nurse) would visually reconciled new medications order prior to home visit to ensure proper medication had been delivered". During a home visit observation on 2/7/23 at 10:45 a.m., Patient 2s family member (FM, decision maker) stated ";He (Patient 2) did not have a bowel movement for three days now ";. The FM provided Patient 2s current medication list given by the hospice agency and it was listed Lactulose prn for constipation and Bisacodyl suppository for constipation. The FM stated ";I dont have the Lactulose but I have a powder one which I dont use. The nurse would come to give him (Patient 6) a suppository if no bowel movement for three days". During an interview with the director of patient care services (DPCS) on 2/7/23 at 1:15 p.m., she stated during home visits, the nurses should have reconciled the medications and prn medications were available for patients. 2. Review of Patient 3s plan of care indicated start of care on 12/21/21, and a diagnosis of heart failure, unspecified atrial fibrillation (an irregular and often very rapid heart rhythm). Her medications list included Eliquis 2.5 mg oral daily. Her interventions and goals did not include specific measures to manage Eliquis such as Patient 3s risk of bleeding while taking the medication. During an interview with the DCPS on 2/9/23 at 9:30 a.m., she stated Patient 3s POC did not include specific measures for managing Eliquis and update the POC related to Eliquis. Review of the hospice agencys policy, ";Medication Profile", revised in 2015, indicated ";The medication profile will be reviewed every home visits, updated as changes occur and reviewed by the IDG".

Based on interview and record review, the hospice agency failed to ensure an individualized plan of care (POC) established by the interdisciplinary group (IDG, the team responsible for development and review of the hospice beneficiary's plan of care) was followed when the hospice aide (HA) missed the scheduled home visit for one of 13 sampled patients (Patient 2). This failure could lead to insufficient care rendered to patient 2. --- Review of Patient 2s plan of care indicated a start of care on 11/8/22, and a diagnosis of heart failure (heart problem). His hospice aide visits frequencies order indicated ";HSP Aide: 2 x week for 13 weeks starting 11/13/22 "; During a concurrent interview and record review with the director of quality (DOQ) on 2/7/23 at 3:15 p.m., he reviewed Patient 2s calendar visits, and he stated on week 3 (11/20/22 to 11/26/22), the HA had one visit on 11/22/22. The DOQ was not able to provide evidence of missed visit notification to the physician. Review of the hospice agencys policy, ";Coordination of Patient Care", revised in 2013, indicated ";Hospice has developed and maintains a system of communication and integration to ensure that care and services are provided in accordance with the plan of care and are based on all assessments of the patient and the family needs".

Based on interview and record review, the hospice agency failed to develop and implement individualized plans of care (POC, a process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers) for two of 13 sampled patients (Patients 5 and 7) when: 1. For Patient 5s wound on his buttocks, there was no treatment order, and a care plan was not developed to address his wound. For Patient 5s deep tissue injury (DTI, purple or maroon localized area of discolored intact skin or blood‐filled blister due to damage of underlying soft tissue from pressure and/or shear) on his left heel, there was no evidence indicated in nursing clinical notes (visit notes) nurses assessed and evaluated his progress towards goal. 2. For Patient 7s left heel pressure ulcer (PU, an injury to skin and underlying tissue resulting from prolonged pressure on the skin.) the nurses did not clarify the physician order for frequency of dressing changes, nurses did not provide treatment according to his plan of care, and nurses did not consistently document wound assessment to include wound measurement during visits. These failures had the potential to negatively impact the continuity, safety and quality of patient care. --- 1. Review of Patient 5s profile information indicated a start of care on 11/18/22, and he lived in a skilled nursing facility (SNF). Review of Patient 5s plan of care electronically signed on 11/23/22, indicated he had a diagnosis of malignant neoplasm (cancerous tumor) of prostate and pressure- induced deep tissue damage of left heel. His summary of problems indicated DTI left heel and his intervention indicated to cleanse with NS (normal saline) and pat dry, wipe with skin prep around wound and apply betadine QD (daily). The responsible for wound care were the facility nurse and hospice nurse. The goal indicated to achieve date by 12/16/22. Review of Patient 5s comprehensive admission assessment dated 11/21/22, indicated a DTI on his left heel. Review of Patient 5s hospice nursing clinical note dated 12/2/22, indicated ";Charge nurse reported wound to buttocks with daily dressing change and wound care had already been done today, and no signs of infection were reported. Report would have been given to RNCM (registered nurse case manager)". Review of Patient 5s hospice nursing clinical notes dated 12/6/22, 12/12/22,12/20/22,12/30/22,1/3/23, 1/13/23, 1/19/23, and 1/27/23 did not include a follow up assessment and plan of care was develop for his wound on buttocks. Further review of the notes did not include evidence nurses assessed his left heel DTI, and evidence to evaluate goals after 12/16/22. During a concurrent interview and record review with the director of patient care services (DPCS) on 2/9/23 at 10:30 a.m., she confirmed Patient 5 did not have an order for wound on his buttocks and no evidence nurses did a follow up assessment during visits. The DPCS stated the nurses should have update the plan of care, get a physician order, and document wound condition as part of their assessments during their visits. During an interview with the director of compliance and quality (DCQ) on 2/9/23 at 10:45 a.m. he stated after 12/2/22, he could not find documentation of what happened in Patient 5s wound on his buttocks. The DOQ stated Patient 5s recertification plan of care dated 1/30/23, indicated continue left heel DTI treatment. 2. Review of Patient 7s plan of care indicated start of care on 8/25/22, and with diagnosis including rheumatic aortic stenosis (narrowing of the valve in the large blood vessel branching of the heart) and unstageable pressure ulcer of left heel. His summary of problems indicated left heel wound and his interventions indicated cleanse left heel wound with NS (normal saline), pat dry, cover wound with Silver Alginate (indicated for use as a primary wound dressing in the management of moderate to heavily exuding partial to full thickness wound), cover with gauze, secure with kerlix and tape twice a week and prn (as needed). Review of Patient 7s physician order dated 8/26/22, indicated cleanse left heel wound with NS (normal saline), pat dry, cover wound with Silver Alginate, cover with gauze, secure with kerlix and tape three times week and prn. Review of Patient 7s nursing initial comprehensive admission assessment dated 8/26/22, indicated ";Wound #1on left heel, pressure ulcer (PU) with injury, open, stage and unstageable pressure ulcer or injury. The length, width, depth per centimeter (cm, unit of measurement). Patient response to treatment was to measure wound for the next SNV (skilled nurse visit) by the nurse. Review of Patient 7s hospice nursing clinical note (visit note) dated 8/30/22, indicated ";wound care or dressing change to coccyx (tail bone) was performed as per orders..." The note did not indicate nurse measured his left heel PU and no evidence nurse provided treatment to patient 7s left heel PU. Review of Patient 7s hospice nursing clinical notes indicated on 9/1/22, left heel PU, open, unstageable, no wound measurement, and necrotic. On 9/6/22, left heel PU, open, and no wound measurement. On 9/8/22, left heel PU, open, stage 2, and no wound measurement. The nurse cleansed with NS, dressed with Xeroform dressing, and covered with gauze/kerlix. On 9/13/22, no wound assessment, and no evidence treatment was provided to left heel PU. On 9/14/22, left heel PU, open, stage 2, no wound measurement, bloody, and sloughing. On 9/20/22, right heel PU, open, stage 2, no wound measurement, granular, Nurse cleansed with wound cleanser, dressed with Xeroform, covered with gauze, and secured with kerlix. Nurse documented to provide or assess patient right heel pressure wound. Wound care to ";right heel" carried out per POC". On 9/22/22, granular, no measurement. Nurse documented wound appears to have decreased in size. On 9/27/22, no wound assessment, and no evidence treatment was provided to left heel PU. On 9/29/22, left heel, no measurement. The nurse documented ";changed dressing to left heel area and continued to have small amount of exudate with no foul odor ";. During a concurrent interview and record review with the DPCS on 2/9/23 at 1:00 p.m., she stated Patient 7s left heel PU measurement should have been taken on admission and every 14 days. The DPCS stated she could not find evidence regarding clarification of patient 7s frequency of dressing changes. The DPCS stated Patient 7 did not have an order to change to Xeroform dressing on 9/8/22 and 9/20/22. DPCS stated nurses should have describe what they saw on the wound, documented the assessment, and implement treatment order for each visit. During an interview with the clinical supervisor (CS) on 2/9/23 at 1:45 p.m., she stated the nurse who provided the visit on 8/30/22 did not document about patient 7s wound care to coccyx. Review of the hospice agencys policy, ";Professional Standards of Practice ";revised on 2013, indicated ";Hospice staff would provide care, treatment and services to each patient according to the IDG plan of care and physician orders". Review of the hospice agencys policy, ";IDG Care Planning Process", revised in 2014, indicated in order to assure that care provided was appropriately planned to meet each patients specific needs and problems. Hospice would utilize data/information gathered during the comprehensive assessment, updates to the comprehensive assessment and reassessment in the care planning process to provide care that was consistent with the patient family needs, with the patients needs and goals as priority". Review of the hospice agencys policy, ";Physician Orders" revised in 2014, indicated ";Physician Orders should have verified when there are questions or discrepancies with orders".

Based on interview and record review, the hospice agency failed to get a physician order for one of 13 sampled patients (Patient 6) when volunteer services were provided without a physician order. This failure had the potential to result in unnecessary services. --- Review of Patients 6 plan of care (POC) indicated start of care on 11/16/22. Review of Patient 6s physician order dated 11/23/22, indicated ";HSP Volunteer one time month for 3 months starting 11/23/22. Review of Patients 6 calendar visits with the benefit period of 11/16/22 to 2/13/23, indicated a volunteer visit on 12/3/22, 12/6/22, and 12/13/22. During a concurrent interview and record review with the volunteer coordinator (VC) on 2/9/23 at 4:50 p.m. the VC confirmed Patient 6 did not have an order for volunteer visits on 12/6/22 and 12/13/22. Review of the hospice agencys policy, ";Physician Orders" revised in 2014, indicated ";Care and services provided will be provided according to physician orders ";.

Based on observation, interview and record review, the agency failed to ensure the Interdisciplinary Group (IDG - a group of health care professionals who work in a coordinated fashion toward a common goal for a patient) revised the plan of care (POC) to address skin treatment for one of 13 sampled patients (Patient 2). This failure had the potential to negatively impact the quality of patient care. --- Review of Patient 2s plan of care electronically signed on 1/25/23, indicated start of care on 11/8/22, and a diagnosis of heart failure. His medications list included Nystatin (used to treat fungal infections) 100,000 unit/gram topical powder three times daily prn (as needed) for redness /rash. His summary of problems indicated ";At risk for skin breakdown due to being primarily bedbound ...". His interventions and goals did not include treatment for his skin rash. During a home visit observation on 2/7/23 at 10:45 a.m., the hospice aide (HA) applied the nystatin powder on patient 2s inner groin. During a follow up interview with the HA and Patient 2s family member (FM) on 2/7/23, HA stated Patient 2's treatment for skin rashes was needed. The FM stated ";I use it every time I change him and it helps with the redness around his private area. I dont know when I started using the nystatin powder (antifungal powder), and this was new ". During a concurrent interview and record review with the director of patient care services (DPCS) on 2/7/23 at 2:55 p.m., she stated the skin rashes treatment was an ongoing problem. She also stated the POC should have included the specific interventions and goals to address the treatment for Patient 2s skin rash. Review of the hospice agencys policy, ";IDG Care Planning Process", revised in 2014, indicated to measure outcomes that are unique, specific to patient care needs and associated with a timeframe as anticipated from implementing and coordinating the plan of care. Drugs and treatments necessary to meet the needs of the patient.

Based on record review and interview the hospice agency failed to ensure a thorough review of medications for one of three patients (Patient 1) when for Patient 1 medications were not reconciled (a process of comparing a patient's medication orders to all of the medications a patient is taking in the home) during a home visit on 2/17/22. This failure resulted in a medication error when Patient 1 received a medication that was not prescribed for her and had the potential to compromise Patient 1's health when she expired on 2/18/22. Findings: Review of Patient 1's Patient Profile indicated a start of care date of 1/20/22, and a terminal diagnosis of Chronic Obstructive Pulmonary Disease (COPD, lung disease that blocks airflow and makes it difficult to breathe), with acute exacerbation (acute transient worsening of preexisting symptoms), and acute and chronic respiratory failure with hypoxia (low levels of oxygen in your body tissues). Review of the Plan of Care for the benefit period, 1/20/22 through 4/19/22, with a start of care date of 1/20/22, indicated disciplines ordered were for hospice nurse, hospice aide, and hospice social worker. Review of a Hospice Clinical Note dated 2/17/22, indicated Patient 1's Family Member (FM) telephoned registered nurse A (RN A) because Patient 1 was having worsening symptoms and asked RN A to check on Patient 1. It further indicated RN A made a home visit at 1:30 p.m., telephoned the doctor, and obtained a physician's order for Prednisone (medication to treat inflammation) for severe shortness of breath (SOB). It further indicated Patient 1 stated she would take Prednisone 30 milligrams (mg, unit of measurement) upon arrival from the pharmacy. Review of a verbal telephone order taken by RN A on 2/17/22, indicated the physician ordered Prednisone 30 mg for 3 days, 20 mg for 3 days, then 20 mg daily. Review of the Medication Profile dated 2/17/22, indicated Prednisone 10 mg 3, 2, 1 tablets every twenty-four hours. Review of a communication note dated 2/18/22, indicated a local pharmacy switched two prescriptions for two patients. Patient 1 was supposed to receive Prednisone and she received Ambien (a medication for difficulty in sleeping). Review of the Communication Note further indicated the lead pharmacist checked his records and confirmed Ambien was sent to Patient 1's home. Review of a pharmacy delivery receipt dated 2/17/22, indicated Ambien was delivered on 2/17/22 at 4:47 p.m. to Patient 1's home. Review of an image of a photograph of a medication bottle label indicated Patient 1's name on label and medication was for Ambien 5 mg one tablet at bedtime as needed. Review of a Hospice Nursing Clinical Note dated 2/17/22, indicated a licensed vocational nurse B (LVN B) made a visit to Patient 1's home on 2/17/22 at 11:00 p.m., at the request of a neighbor who reported Patient 1's breathing was shallow and labored. Patient 1 required morphine (medication used in hospice to ease the feelings of shortness of breath) and lorazepam (medication used in hospice to help a patient relax) for an episode of SOB. It further indicated LVN B administered both medications. There was no documentation LVN B administered Prednisone or did a medication reconciliation during the home visit. Review of a Communication Note dated 2/18/22, indicated Patient 1's FM telephoned and spoke to RN C and asked her why did Patient 1 get Ambien 5 mg. RN C stated to the FM there was no Ambien ordered and there was an order for Prednisone. The FM went on to state there was a bottle of Ambien 5 mg and one pill is missing. RN C further stated this is a pharmacy error and they sent the wrong medication. During an interview on 9/13/22 at 2:03 p.m., with the Director of Compliance (DOC), he stated he did not know if LVN B executed a full medication reconciliation at the home visit. During an interview on 9/13/22 at 2:33 p.m., with the director of patient care services (DPCS), she stated a medication reconciliation should be done when there are changes in medications. During a telephone interview on 9/26/22 at 11:58 a.m., RN A stated medication reconciliation should be done at every visit. RN A acknowledged the problem could have been identified if a medication reconciliation had been done at the home visit made by LVN B. RN A further stated, in addition we now report any new medications or changes in medications to the team leader/supervisor coming on duty and case managers are to follow up with patients regarding new medication orders or changes in medications. During a telephone interview on 9/27/22 at 2:36 p.m., with the DOC, he stated if LVN B had done a medication reconciliation at the home visit she very well could have identified the problem. During a telephone interview on 9/29/22 at 3:55 p.m., with LVN B, she stated she was aware the prednisone was on the medication administration record. When asked why she did not give the prednisone LVN B stated she did not give the routine medications because she was focused on giving the comfort medications. LVN B also stated she did not do a medication reconciliation during the visit. When LVN B was asked if she could have identified the problem if she had done a medication reconciliation LVN B stated, "I do not know." Review of the agency's policy and procedure, "Medication Reconciliation", revised March 2013, indicated medications ordered while the patient is receiving care will be compared to the medication list/profile. Review of the agency's policy and procedure, "Medication Dispensing", revised 2015 indicated nurses should check medications during patient visits to ascertain correct usage and re-ordering needs.

Based on record review and interview the hospice agency failed to ensure a complete and thorough plan of care (POC) for one of three patients (Patient 1) when no specific medication goals and interventions regarding safe self-administration of medications was included in Patient 1's POC. This failure had the potential to result in unmet patient needs and to negatively impact the continuity, safety, and quality of patient care. Findings: Review of Patient 1's Patient Profile indicated a start of care date of 1/20/22, and a terminal diagnosis of Chronic Obstructive Pulmonary Disease (COPD, lung disease that blocks airflow and makes it difficult to breathe), with acute exacerbation (acute transient worsening of preexisting symptoms), and acute and chronic respiratory failure with hypoxia (low levels of oxygen in your body tissues). Review of Patient 1's POC for the benefit period 1/20/22 through 4/19/22, with a start of care date of 1/20/22, indicated no specific goals and interventions regarding the safe self-administration of medications was documented in the POC. During a telephone interview on 9/27/22 at 2:36 p.m., with the Director of Compliance (DOC), he stated the interdisciplinary group (IDG, team responsible for the development and review of the beneficiary's plan of care) met and determined the patient could self-administer medications, however, it needed to be clearly documented in the POC and it was not. Review of the agency's policy and procedure, "Medication Administration", revised 2014 indicated the IDG, as part of the review of the plan of care, will determine initially and ongoing the ability of the patient/family/caregiver to safely self-administer drugs and biologicals to the patient in his/her home. It further indicated the individualized IDG plan of care must identify if patient/family/caregiver are self-administering drugs and biologicals. It further indicated if the patient/family/caregiver is not capable of safely administering drugs and biologicals in the home, the issue will be addressed in the IDG plan of care.