Every finding on record at Cima Hospice of Texarkana, LLC

Based on interview and record review, the agency failed to develop, establish, and maintain a comprehensive emergency preparedness program that complied with all applicable federal, state, and local emergency preparedness requirements in that: 1. The agency failed to designate, by title, an employee, and at least one alternate employee to act as the agency's disaster coordinator. 2. The EPP did not include a continuity of operations business plan. 3. The EPP failed to describe the actions and responsibilities of agency staff in each phase of emergency planning, including mitigation, preparedness, response, and recovery. 4. The agency Administrator and Alternate Administrator failed to enroll in an emergency communication system in accordance with instructions from HHSC. These failures could place agency patients at risk of harm or not having their needs met during an emergency and/or disaster. --- Findings included: According to the Texas Administrative Code §558.256(c)(1) (c) ";An agency's written emergency preparedness and response plan must: (1) designate, by title, an employee, and at least one alternate employee to act as the agency's disaster coordinator". According to the Texas Administrative Code §558.256(c)(2) (c) ";An agency's written emergency preparedness and response plan must: (2) include a continuity of operations business plan that addresses emergency financial needs, essential functions for client services, critical personnel, and how to return to normal operations as quickly as possible". According to the Texas Administrative Code §558.256(c)(5) (c) ";An agency's written emergency preparedness and response plan must: (5) describe the actions and responsibilities of agency staff in each phase of emergency planning, including mitigation, preparedness, response, and recovery". According to the Texas Administrative Code §558.256(q)(1) (q) ";Emergency Response System (1) The agency administrator and alternate administrator must enroll in an emergency communication system in accordance with instructions from HHSC". During entrance conference on 03/07/23 at 8:56 a.m., the surveyor informed Hospice Aide/Clinical Coordinator E and the Supervising Nurse that the Emergency Preparedness Plan for 2020, 2021, and 2022 would be reviewed during the survey. Record review of the agencys undated Emergency Preparedness Plan did not indicate who the Disaster Coordinator or Alternate Disaster Coordinator was. Further review did not reveal a continuity of operations business plan. The EPP did not describe the actions and responsibilities of agency staff in each phase of emergency planning, including mitigation, preparedness, response, and recovery. During an interview on 03/08/23 at 2:18 p.m., the Supervising Nurse said the Administrator was probably the Disaster Coordinator and she was probably the Alternate Disaster Coordinator. She said she did not sign a job description for the Alternate Disaster Coordinator position. During an interview on 03/09/23 at 10:02 a.m., the Alternate Supervising Nurse said she guessed the Supervising Nurse was the Disaster Coordinator because she did a lot. She said she did not know who the Alternate Disaster Coordinator was. The Alternate Supervising Nurse said she did not know what the operations would be if something happened to the office during a disaster. During an interview with the Administrator on 03/09/23 at 10:38 a.m., the surveyor asked if the Administrator had enrolled in the Blackboard Connect Emergency Communication System in accordance with "Long-Term Care Regulatory Provider Letter" Number PL 22-32 sent out by Texas Health and Human Services to all provider types on November 28, 2022. The Administrator said she did not know anything about an emergency response system with HHSC. She said she had not signed up for blackboard unless the Alternate Administrator had signed her up. During a phone interview with the Alternate Administrator on 03/09/23 at 10:40 a.m. the surveyor asked if the Alternate Administrator had enrolled in the Blackboard Connect Emergency Communication System and Alternate Administrator said he was not familiar with the term blackboard and did not remember signing up for email notifications for emergencies. During an interview on 03/09/23 at 11:08 a.m., the Supervising Nurse said there were no other binders or documents related to the EPP. The Supervising Nurse verified with the surveyor the missing items from the EPP, which failed to include a continuity of operations business plan and describe each phase of emergency planning. The Supervising Nurse said the agency was not contracted with any other agencies to take on patients in the event of a disaster. During an interview on 03/09/23 at 12:22 p.m., the Supervising Nurse said she could not find anything else regarding the EPP, including the continuity of operations and the phases of emergency planning.. During an interview on 03/09/23 at 2:30 p.m., the Administrator said the Supervising Nurse was the Disaster Coordinator and she was the Alternate Disaster Coordinator. She said no job descriptions were signed for the positions. The Administrator said she was not sure what was missing from the EPP. The Administrator said her job duties were to ensure the agency followed regulations and make sure the agency was in compliance with everything. The agency failed to present documentation that the Administrator and the Alternate Administrator had enrolled in an emergency communication system in accordance with "Long-Term Care Regulatory Provider Letter" Number PL 22-32 sent out by Texas Health and Human Services to all provider types on November 28, 2022. Review of an Emergency Preparedness Plan policy dated 01/10/20 indicated ";1. Policy Overview... will maintain an emergency preparedness plan that is reviewed and updated at least annually... 2. Procedures: 1. Emergency preparedness policies and procedures must include, but are not limited to... E. The development of arrangements with other Home Health Agencies and other providers to receive clients in the event of limitations or cessation of operations to maintain the continuity of services to agency clients... Emergency Preparedness Plan... 1... will develop and maintain an emergency preparedness and response plan (EPP) which includes mitigation, preparedness, response and recovery. 2... personnel that must be involved with the developing, maintaining and implementing the agencys EPP: A. Administrator B. Supervising Nurse (if applicable) C. Disaster Coordinator and Alternate Disaster Coordinator. 3. Only the Administrator or designee can declare a disaster/emergency... 6. The emergency preparedness plan addresses the agency s client population including, but not limited to, the type of services the agency can provide in an emergency, and continuity of operations, including the delegation of authority and succession plans... 10. The response and recovery phases of the plan must: A. The EPP will include a description of actions / responsibilities of agency Staff for each phase of the EPP, including mitigation, preparedness, response and recovery. Agency will include actions and responsibilities when warning of an emergency is not provided..."

Based on interview and record review, the hospice failed to protect and promote each patient's right to receive effective pain management and symptom control for conditions related to a terminal illness for 1 of 15 patient records reviewed. (Patient #11) This failure resulted in Patient #11 experiencing continued pain and discomfort and could result in other patients experiencing pain which is not effectively managed. --- Findings included: Record review of Patient #11s POC dated 06/29/22 – 08/27/22 indicated a SOC date of 06/29/22 and indicated he was a 40-year-old with diagnoses including heart failure (condition that develops when your heart doesn't pump enough blood for your body's needs), chronic (persisting for a long time) kidney disease (your kidneys are damaged and can't filter blood the way they should) stage 4 (severe ), atherosclerotic heart disease (thickening or hardening of the arteries caused by a buildup of plaque), acute pancreatitis (inflammation of the pancreas), calculus of gallbladder (gallstones), and do not resuscitate (a medical order written by a doctor that instructs health care providers not to do cardiopulmonary resuscitation (CPR) if a clients breathing stops or heart stops beating). The POC indicated Patient #11 was ordered skilled nursing visits two times a week for 1 week, then one time a week for 8 weeks, and 3 PRN visits for medical needs. The POC revealed a medication order for Oxycodone (used to relieve moderate to severe pain) Extended Release 10mg tablet, by mouth 4 times daily for pain. This was the only medication listed on the POC. Further review of the plan of care failed to reveal the plan addressed pain and failed to reveal pain parameters were provided to guide the patient/caregiver. The POC also did not include all services necessary for the palliation and management of the terminal illness including other interventions to manage pain and symptoms. There was no order or no documented evidence that the agency was to place the patients pain medication in a lock box or to perform refills every three days. Record review of a Physicians Order by MD N for Patient #11 dated 06/29/22 revealed an order for Oxycodone HCL 30mg tablet by mouth four times daily and Morphine (pain medication) 100mg Extended Release by mouth two times daily. Further review revealed an order for Morphine Extended Release 60mg tablet by mouth twice daily for pain. The POC dated 06/29/22 – 08/27/22 did not reflect these orders. Record review of a certification of terminal illness order for Patient #11 dated 06/29/22 and electronically signed by NP O and MD N and revealed a narrative that indicated the patient said he was taking 30mg of oxycodone (prior to admission). The note indicated the hospice switched client to 10mg due to him not having any narcotics for 2 weeks prior to admission. The note indicated patient was still having significant pain, but the agency was slowly increasing and requiring patient to responsibly manage medications via pill box before willing to prescribe more. Record review of Patient #11s readmit from hospital POC dated 07/13/22 – 09/10/22 indicated he was a 40 year old with diagnoses including chronic congestive heart failure, chronic kidney disease stage 4, atherosclerotic heart disease, ischemic cardiomyopathy (heart's decreased ability to pump blood properly), duodenal ulcer with hemorrhage (upper GI bleeding), liver disease, anxiety, chronic pain, dependance on supplemental oxygen, presence of automatic cardiac defibrillator (send an electric pulse or shock to the heart to restore a normal heartbeat). The POC indicated Patient #11 was ordered skilled nursing visits two times a week for 1 week, then one time a week for 8 weeks, and 3 PRN visits for medical needs. The POC indicated Orders of Discipline and Treatments was Hospice nurse to evaluate patient and develop POC to be signed by physician, hospice nurse to monitor pain level using pain scale of 0-10 with 0 being the lowest at each visit and report changes in pain level to physician... Further review of the POC revealed goals listed: a nursing POC will be established that meets the patients needs, client/caregiver will understand the pain scale, how to manage pain and report changes to hospice. The POC revealed a medication order for Oxycodone 10mg tablet, by mouth 4 times daily for pain and Morphine Extended Release 60mg tablet by mouth two times daily. Further review of the plan of care failed to reveal the plan addressed pain and failed to reveal pain parameters were provided to guide the patient/caregiver. The POC also did not include all services necessary for the palliation and management of the terminal illness including other interventions to manage pain and symptoms. There was no order or no documented evidence that the agency was to place the patients pain medication in a lock box or to perform refills every three days. Record review of Patient #11s medication report printed on 03/07/23 revealed an order for Morphine Extended Release 60mg tablet, one tablet by mouth twice daily for pain with a start date of 06/29/22. The medication report revealed the client was ordered Fentanyl 25mcg/hour transdermal patch every 72 hours for pain with a start date of 09/06/22 and discontinued date of 11/21/22. The medication report revealed a new order for a Fentanyl 50mcg/hour transdermal patch every 72 hours for pain with a start date of 11/21/22. Further review of the medication report revealed an order for Oxycodone 10mg tablet, 1 tablet by mouth 4 times daily as needed for pain with a start date of 06/29/22 and a discontinued date of 08/27/22. The medication report did not indicate any other pain medications were ordered for pain control between 08/27/22 – 09/06/22 (10 days), the time frame from when the Oxycodone was discontinued, and when the Fentanyl patch was first ordered. There was no evidence of any other medications ordered for pain control between start of care on 06/29/22 and patients death on 11/30/22. Record review of a Visit Note Report for Patient #11 dated 06/29/22 indicated a SOC visit was completed by RN H. The vital signs section indicated pain was a level 10. The pain section of the assessment indicated pain was severe, continuous, burning, shooting and tender in abdomen, back, chest, lower & upper extremity, and neck. The pain section also indicated the pain was all the time and nothing relieved the pain. Further review of the pain section indicated ";yes" to ";is pain an active problem for the patient?" Review of the narrative section of the visit note indicated patient had been off all his medications for 30 days and pain was a 10 out of 10 all over his body. Record review of a clinical coordination note dated 06/29/22 for Patient #11 by NP O indicated patient was uncomfortable during visit with severe pain and was hypertensive with a blood pressure of 167/123 per RN. Record review of a Visit Note Report for Patient #11 dated 07/06/22 by RN H revealed a pain assessment and indicated pain was a 10 out of 10 on a numeric scale with a goal of 1. The pain section of the assessment revealed ";no" to ";is the patients pain medication regimen effective". Further review of the pain assessment indicated pain was described as continuous, crushing, and shooting in the abdomen, back, chest, lower and upper extremities, head, and hip. The assessment revealed ";nothing" relieved the pain. Review of the narrative section of the visit note revealed patient said his mind was ready to fracture because of the pain and it hadnt been that long with no relief. The note revealed pain was a 10 out of 10 in neck, back, head, chest, down his arm. The note indicated patient didnt know what to do because his neck and back were crushing pain, left arm was a shooting pain, and right knee cracked and popped. The note indicated pain took patients breath away. The note also revealed RN observed patient needing help just to get out of the chair. Further review of the narrative revealed patient was taking 30mg of Oxycodone (prior to admission) and agency switched him to 10mg (upon admission) but the 30mg worked. Patient #11s medication report printed on 03/07/23 revealed an order for Morphine Extended Release 60mg tablet, one tablet by mouth twice daily for pain and Oxycodone 10mg tablet, by mouth 4 times daily for pain with a start date of 06/29/22. The note did not indicate the doctor was notified of patients pain or symptoms. The note also did not indicate that other interventions/treatments were attempted for pain/symptom relief. Record review of a clinical coordination note dated 07/13/22 for Patient #11 by RN H indicated patients pain level was 8 out of 10 in stomach, backside of left arm which was sharp and stabbing pain, right side of body and chest and left back pain were a crushing pain. The note indicated RN H brought over all medications the patient was on in a pill planner along with a pill lock box for the following week. The note indicated RN would continue to monitor medications due to patient running out of pain medications. The note did not indicate the doctor was notified of patients pain or symptoms. The note also did not indicate that other interventions/treatments were attempted for pain/symptom relief. The patients medication profile indicated patient was on Morphine Extended Release 60mg tablet, one tablet by mouth twice daily for pain and Oxycodone 10mg tablet, by mouth 4 times daily for pain. Record review of a clinical coordination note dated 07/15/22 for Patient #11 by RN H indicated patients pain level was 8 out of 10 in stomach, shoulder, neck, left arm, and back. The note did not indicate the doctor was notified of patients pain or symptoms. The note also did not indicate that other interventions/treatments were attempted for pain/symptom relief. The patients medication profile indicated patient was on Morphine Extended Release 60mg tablet, one tablet by mouth twice daily for pain and Oxycodone 10mg tablet, by mouth 4 times daily for pain. Record review of a clinical coordination note dated 07/20/22 for Patient #11 by RN H indicated patients pain level was 10 out of 10 started from left shoulder to chest, left knee, right arm and down to back. The note did not indicate the doctor was notified of patients pain or symptoms. The note also did not indicate that other interventions/treatments were attempted for pain/symptom relief. The patients medication profile indicated patient was on Morphine Extended Release 60mg tablet, one tablet by mouth twice daily for pain and Oxycodone 10mg tablet, by mouth 4 times daily for pain. Record review of a clinical coordination note dated 07/27/22 for Patient #11 by RN H indicated patients pain level was 10 out of 10 in right arm, back, chest and neck described as dull crushing pain. The note indicated patient reported left side shooting pain. The note did not indicate the doctor was notified of patients pain or symptoms. The note also did not indicate that other interventions/treatments were attempted for pain/symptom relief. The patients medication profile indicated patient was on Morphine Extended Release 60mg tablet, one tablet by mouth twice daily for pain and Oxycodone 10mg tablet, by mouth 4 times daily for pain. Record review of a clinical coordination note dated 08/03/22 for Patient #11 by RN H indicated patients pain level was 10 out of 10 due to gallstones, right arm, neck, lower back below coccyx. The note indicated pain was described as stabbing and crushing pain. The note did not indicate the doctor was notified of patients pain or symptoms. The note also did not indicate that other interventions/treatments were attempted for pain/symptom relief. The patients medication profile indicated patient was on Morphine Extended Release 60mg tablet, one tablet by mouth twice daily for pain and Oxycodone 10mg tablet, by mouth 4 times daily for pain. Record review of a clinical coordination note dated 08/05/22 for Patient #11 by RN H indicated patients pain level was 7 out of 10. The note did not indicate the doctor was notified of patients pain or symptoms. The note also did not indicate that other interventions/treatments were attempted for pain/symptom relief. The patients medication profile indicated patient was on Morphine Extended Release 60mg tablet, one tablet by mouth twice daily for pain and Oxycodone 10mg tablet, by mouth 4 times daily for pain. Record review of a clinical coordination note dated 08/10/22 for Patient #11 by RN H indicated patients pain level was 10 out of 10 because he was out of his medication. The note indicated RN H was there to fill patients pill planner. The note did not indicate the doctor was notified of patients pain or symptoms. The note also did not indicate that other interventions/treatments were attempted for pain/symptom relief. Record review of a clinical coordination note dated 08/12/22 for Patient #11 by RN H indicated patient reported pain in the bottom lower right of his back which was a stabbing pain and level was 8 out of 10 intermittently. The note indicated the patient told RN H he took a pain pill (unspecified) and the level went down to 5 out of 10. The note did not indicate the doctor was notified of patients pain. The note also did not indicate that other interventions/treatments were attempted for pain/symptom relief. Record review of a clinical coordination note dated 08/17/22 for Patient #11 by RN H indicated patient reported pain daily 6 out of 10 in his right knee, back, neck, and right shoulder from where he fell in the shower 2 weeks prior. The note indicated RN H filled patients medications for the week from the lock box. The note did not indicate the doctor was notified of patients pain or symptoms. The note also did not indicate that other interventions/treatments were attempted for pain/symptom relief. Record review of a clinical coordination note dated 08/20/22 for Patient #11 by RN H indicated patient had taken all his pain medications from his pill planner and refill was not due until 08/24/22. The note indicated patient was upset that he had no more pain medications, and he said he was desperate and asked the RN if she knew of anyone that sold oxycodone. The note did not indicate the doctor was notified of patients pain or symptoms or that patient was out of his medications. The note also did not indicate that other interventions/treatments were attempted for pain/symptom relief. Record review of a clinical coordination note dated 08/23/22 for Patient #11 by RN H indicated patients pain level was 10 out of 10 and patient reported he had thrown up 5 times since prior Sunday due to the pain. The note indicated pill planner was empty and patient had been out of pain medication and all other medications since prior Friday. The note did not indicate the doctor was notified of patients pain or symptoms. The note also did not indicate that other interventions/treatments were attempted for pain/symptom relief. Record review of a clinical coordination note dated 08/30/22 for Patient #11 by RN H indicated patient continued to have pain 10 out of 10 in knee, back, neck, and left side due to multiple heart attacks and a blocked carotid artery. The note indicated chest pain was 6 out of 10 and patient could not take deep breaths and had shortness of breath. The note indicated RN observed patient did get short of breath holding a conversation and short of breath at rest. The note indicate patient took Morphine and Oxycodone for pain. The patients medication profile indicated patient was on Morphine Extended Release 60mg tablet. The medication profile indicated Oxycodone was discontinued by RN H on 08/27/22. The note did not indicate the doctor was notified of patients pain or symptoms. The note also did not indicate that other interventions/treatments were attempted for pain/symptom relief. Record review of a clinical coordination note dated 09/02/22 for Patient #11 by RN H indicated patient reported pain 10 out of 10 under his right axillary (armpit) and was painful to touch. The note indicated RN palpated (examination by pressing on the surface of the body) and patient winced in pain, and under axillary was slightly inflamed compared to left side. The note indicated RN would monitor and inform MD N if pain or inflammation became worse. The note did not indicate the doctor was notified of patients pain or symptoms. The note also did not indicate that other interventions/treatments were attempted for pain/symptom relief. Record review of a clinical coordination note dated 09/12/22 for Patient #11 by RN H indicated patient reported pain 10 out of 10 all over and couldnt sleep and had slept possibly 2 hours over the previous 2 days. The note indicated patients pain was in his lower back, left arm, and knee. The note indicated patients caregiver reported patient had restless leg syndrome since RN had changed his pain medication to a patch. The note did not indicate the doctor was notified of patients pain or symptoms. The note also did not indicate that other interventions/treatments were attempted for pain/symptom relief. The patients medication profile indicated patient was on Morphine Extended Release 60mg tablet, one tablet by mouth twice daily for pain and Fentanyl 25mcg/hour transdermal patch every 72 hours for pain with a start date of 09/06/22. There was no evidence that RN H asked the patient about the effectiveness of the Fentanyl patch. Record review of a clinical coordination note dated 09/15/22 for Patient #11 by RN H indicated patient reported he was extremely tired and in pain. The note indicated patients blood pressure was extremely high due to stress and pain level. The note did not indicate the doctor was notified of patients pain or symptoms. The note also did not indicate that other interventions/treatments were attempted for pain/symptom relief. There was no evidence that RN H asked the patient about the effectiveness of the Fentanyl patch. Record review of a clinical coordination note dated 09/19/22 for Patient #11 by RN H indicated patient reported pain and anxiety level 10 out of 10 and was throwing up at least two times daily. The note indicated RN would consult with MD. Patients medical record did not indicate the MD was notified. The note did not indicate that other interventions/treatments were attempted for pain/symptom relief. There was no evidence that RN H asked the patient about the effectiveness of the Fentanyl patch. Record review of a clinical coordination note dated 09/26/22 for Patient #11 by RN H indicated patient reported he continued to have pain 10 out of 10 in his knees, back, and neck and reported the pain medication was not working. The note indicated patients blood pressure was high even after taking blood pressure medication. The note did not indicate the doctor was notified of patients pain or symptoms. The note also did not indicate that other interventions/treatments were attempted for pain/symptom relief. Record review of a clinical coordination note dated 10/03/22 for Patient #11 by RN H indicated patient reported pain was as usual 10 out of 10 in his back, left side and knee. The note did not indicate the doctor was notified of patients pain or symptoms. The note also did not indicate that other interventions/treatments were attempted for pain/symptom relief. Record review of a clinical coordination note dated 10/10/22 for Patient #11 by RN H indicated patient reported pain was in the center of his chest and patient took 3 nitroglycerins (medication used to treat chest pain) due to dizziness of the pain. The note did not indicate the doctor was notified of patients pain or symptoms. The note also did not indicate that other interventions/treatments were attempted for pain/symptom relief. Record review of a clinical coordination note dated 10/17/22 for Patient #11 by RN H indicated patient had decline in ability to care for self and energy and patient continued to have pain 10 out of 10 in knee, back, neck and left side. The note indicated patient continued to be weak and had extreme anxiety related to pain and aggravation. The note indicated patient took morphine and had a fentanyl patch for pain. The note did not indicate the doctor was notified of patients pain or symptoms. The note also did not indicate that other interventions/treatments were attempted for pain/symptom relief. Record review of a clinical coordination note dated 10/24/22 for Patient #11 by NP O indicated patient continued to have pain 10 out of 10 in knee, back, neck, and left side due to multiple heart attacks and a blocked carotid artery. The note indicated patient continued to have increased pain and difficulty taking deep breaths. The note indicated patient had extreme anxiety 9 out of 10 related to pain and aggravation due to health. The note indicated patient continued to decline physically. Record review of a clinical coordination note dated 10/24/22 for Patient #11 by RN H indicated patient reported anxiety and pain 10 out of 10. The note did not indicate the doctor was notified of patients pain or symptoms. The note also did not indicate that other interventions/treatments were attempted for pain/symptom relief. Record review of a clinical coordination note dated 10/28/22 for Patient #11 by RN H indicated patient reported pain 7 out of 10 due to health and moving. The note indicated RN changed out pain patch. The note did not indicate the doctor was notified of patients pain or symptoms. The note also did not indicate that other interventions/treatments were attempted for pain/symptom relief. Record review of a clinical coordination note dated 10/31/22 for Patient #11 by RN H indicated patient reported pain 10 out of 10 in lower back, kidneys, neck, chest, left knee and abdomen. The note did not indicate the doctor was notified of patients pain or symptoms. The note also did not indicate that other interventions/treatments were attempted for pain/symptom relief. Record review of a Visit Note Report for Patient #11 dated 11/04/22 by RN H revealed a pain assessment and indicated pain was a 10 out of 10 on a numeric scale to chest and ribs. The pain section of the assessment revealed pain assessment findings were abnormal assessment findings this visit. The pain assessment indicated pain medications were morphine and fentanyl patch. The narrative section of the note revealed pain level had increased and patient said he had chronic depression from his pain. The note indicated patient was crying due to inability to breathe. The note revealed patients anxiety was at an all-time high from pain and inability to breathe. The note indicated patient had morphine and fentanyl patch for pain. The note did not indicate the doctor was notified of patients pain or symptoms. The note also did not indicate that other interventions/treatments were attempted for pain/symptom relief. The patients medication profile indicated patient was on Morphine Extended Release 60mg tablet, one tablet by mouth twice daily for pain and Fentanyl 25mcg/hour transdermal patch every 72 hours for pain. Record review of a clinical coordination note dated 11/07/22 for Patient #11 by RN H indicated patient reported pain was high at the time and a 9 out of 10 due to not being able to breathe and having continued left side pain in his chest, knee, back, gallbladder, right arm, and abdomen. The note indicated patients right abdomen was painful to light palpation. The note indicated patient reported lack of appetite due to pain. The note did not indicate the doctor was notified of patients pain or symptoms. The note also did not indicate that other interventions/treatments were attempted for pain/symptom relief. Review of a Physicians Order by MD N for Patient #11 dated 11/22/22 revealed an order for Fentanyl Transdermal Patch 50mcg/hour, 1 patch every 72 hours for pain with a start date of 11/21/22. The order revealed a discontinued order for Fentanyl 25mcg/hour transdermal patch. Record review of a Visit Note Report for Patient #11 dated 11/25/22 by RN H revealed pain assessment findings were documented as not applicable for routine visit. The narrative section of the visit note revealed patient was sitting in his hospital chair hunched over and said he had difficulty breathing. The note indicated patient said he lost consciousness before midnight and was up at 6:43 a.m. from pain unwitnessed. The note did not indicate the doctor was notified of patients pain or symptoms. The note also did not indicate that other interventions/treatments were attempted for pain/symptom relief. There was no evidence that RN H asked the patient about the effectiveness of the Fentanyl patch. Record review of a Visit Note Report for Patient #11 dated 11/28/22 by RN H revealed a pain assessment and indicated pain was a 9 out of 10 on a numeric scale with a goal of 3. The pain assessment indicated pain continuous, crushing, aching, and shooting in abdomen, back, chest, upper and lower extremities, and neck. The narrative section of the visit note revealed patient had right sided pain below his right breast and stomach. The note indicated RN noted patient was swollen in the area and upon light palpation it was painful to touch. The note did not indicate the doctor was notified of patients pain or symptoms. The note also did not indicate that other interventions/treatments were attempted for pain/symptom relief. There was no evidence that RN H asked the patient about the effectiveness of the Fentanyl patch. Record review of Hospice IDG (team which is responsible for development, review, and update of the patients plan of care) Comprehensive Assessment and POC Update Reports for Patient #11 dated 07/07/22 and 07/21/22 did not indicate patients pain was addressed. Further review revealed there was no documented evidence at the IDG meetings that the patients medication was to be stored in a lock box, that agency RN was to refill it every three days, and there was no discussion about the patients pain medication and/or pain. Further review revealed there was no documented evidence that the agency optimized comfort for the patient and addressed intervention/treatments as Patient #11 continued to have 8-10 out of 10 pain. Record review of a discharge report indicated Patient #11 expired at home on 11/30/22. During an interview on 03/09/23 at 8:51 a.m., RN H said Patient #11 was non-compliant with taking his pain medication. She said his opioid pain medication was left in a locked medication box and the agency kept them at the office, and she left his other pills for him at his home. RN H said she would fill his medication planner every 3 days and she would transport the locked medication box that was stored in a locked closet at the Texarkana drop off site to his home and then back to the office. She said she did not remember if it was discussed in an IDG meeting or not about placing medications in a locked box and being kept at the office. During an interview on 03/09/23 at 11:08 a.m., the Supervising Nurse said Patient #11 medications were placed in a lock box and kept at the patients house. She said she did not remember if the lock box was kept in Texarkana. The Supervising Nurse said the agency did not continue to fill patients Oxycodone. During an interview on 03/09/23 at 12:42 p.m., the Supervising Nurse said Patient #11 was a trouble patient and lived in a bad neighborhood with previous break-ins. She said the medications were placed in a lock box. During an interview on 03/09/23 at 1:23 p.m., the Supervising Nurse said if the agency received a referral on a patient in area that was not good, they would put the patients medications in a lock box. During an interview on 03/09/23 at 2:30 p.m., the Administrator said the SN would lock up a patients medications with permission depending on the situation, such as abusing of medication or unsafe environment. During an interview on 03/09/23 at 3:45 p.m., the Supervising Nurse said no consent was signed or doctor order received when patients medications were locked up. She said the SN would just let the doctor know. During an interview on 03/09/23 at 3:47 p.m., RN H said Patient #11s medication lock box was stored in his house and when done, she would store it in Texarkana office in a locked room between patients use. She said she went and filled patients medications 3 days at a time. She said medications were locked in a room or freezer and the medications never left the home. During an interview on 03/10/23 at 8:56 a.m., Patient #11s family member said Patient #11 was on oxycodone (pain reliever) for years and that was the only thing that kept him functioning and helped control his pain. She said his pain medication was stolen so RN H put his medications in a lock box at the house. She said the home was broken into and the medications were stolen again, so RN H had Patient #11 taken off Oxycodone and put him on a Fentanyl patch that did not help with the pain at all. She said RN H also put Patient #11s medications in a lock box and took them to the agencys office and kept them and would fill his medication box every 3 days. Patient #11s family member said Patient #11 got a small dose of Morphine in his box every 3 days, but it did not help his pain. Patient #11s family member said she nor the patient agreed with placing the medications in a lock box at the office but was told patient would be taken off hospice if they did not allow it. She said called the agency several times after hours because patient would be in so much pain and he was told almost every time to take deep breaths and a shower. She said there were no in person visits to assess the pain. Patient #11s family said RN H would not allow patient to be put back on Oxycodone and the family member and patient asked over and over because of his severe pain. The family member said the day before patient died RN H put 2 Fentanyl patches on him. During an interview on 03/15/23 at 12:38 p.m., RN H said Patient #11 was a complicated case and he had major anxiety. She said she felt like he was always in some kind of pain, but it was always controlled. RN H said Patient #11 had severe pain in his chest, back, and he hurt all over and couldnt function or get out of bed. She said he always had pain which was the reason from switching patient from Oxycodone to the Fentanyl patch. During an interview on 03/15/23 at 12:42 p.m., MD N said medications would not be locked up under any circumstance except maybe in a pain control kit. She said the medications went straight from the pharmacy to the patients home and were not kept in the office. MD N said the nurses give the medications to the patient and did not keep them. MD N said the nurses have never told her they locked up a patients medications and she was not sure the protocol on that. She said she was not aware that Patient #11s medications were being locked up and that she knew the nurses were counting his medications and prefilling a planner for a certain number of days due to a history of some issues with the patient. MD N said the agency often had difficulty controlling Patient #11s pain and tried alternate treatments. She said patient had a history of drug abuse and medications missing but the agency wanted to treat pain the best they could without discriminating. She said she could not remember why he was taken off Oxycodone and put on a Fentanyl Patch since it had been some time ago. She said maybe it was because he would run out before his refill was due, so the medication didnt seem to control his pain. MD N said she believed she did order PRN medications but couldnt remember. MD N said Patient #11s pain was discussed during IDG meetings. She said Patient #11 had all over body pain and the agency tried different treatments for physical and emotional pain and wanted to manage the pain the best they could. During an interview on 03/15/23 at 1:06 p.m., RN H said Patient #11 was taken off Oxycodone and put on a Fentanyl patch. She said if one medication was not working the agency would try something different. During an interview on 03/15/23 at 1:09 p.m., NP O said only completed patients face to face visits and did not write orders, she said MD N did that. NP O said medications would be locked up if patient lived in an unsafe home, unstable home, the patient was taking more than they should. She said it was a trust thing, honestly. NP O said some patients neighborhoods are not the best and they have to lock the medications up. She said she was pretty sure needed a doctor order to lock up medications because it was part of patients rights. NP O said she was pretty sure the POC would reflect if a patient had a medication lock box. NP O said she knew Patient #11s medications were locked up, but she was not sure if that was just the agencys decision. NP O said medications would never be taken from a patients home and she had never seen or heard of the nurses doing that. NP O said Patient #11 was a difficult patient. She said nurses would notify MD N for any issues because she did not write orders or prescriptions. NP O said she only saw Patient #11 one to two times and he did not appear to be in distress or pain that medication could not control, she said she would have notified MD N if so. NP O said she did not attend IDG meetings. During an interview on 03/15/23 at 1:37 p.m., RN H said she called the doctor about Patient #11s pain level and he was put on a Fentanyl patch to try to control the pain. She said patients pain was always 10 out of 10 and she notified the doctor each time. RN H said she documentation may have been in IDG, but she did not really know. She said Patient #11s medication lock box consisted of everything but patients normal medications. She said medications locked up were opioids and pain medications, and medications that could be stolen because he did not live in the best neighborhood. RN H said she never dealt with a patients medications being locked up before and this was her first interaction with that. She said she was just doing what she was told to do and did not know what the protocol was. RN H said Patient #11 stated this is what I live with (regarding pain) and he knew he was always going to be in that type of pain due to his condition. RN H said patients pain was always the same and patient was very aware of his condition. During an interview on 03/15/23 at 2:05 p.m., the Supervising Nurse said the doctor was notified anytime a new order was needed or there was a change in the patient. She said Patients #11 POC should have included any updates and changes in patient. She said the POC was patient specific and should include a pain assessment including type, frequency, location, duration, what the agency was doing to keep patient comfortable to manage pain. She said interventions listed on Patient #11's POC should have included pain medications, when to call the doctor, ensuring patient was comfortable, and if the patient was on oxygen. The Supervising Nurse said measurable outcomes on Patient #11's POC should have included how to rate the pain, including a pain scale. She said goals should include goals the agency can meet, and the patient was comfortable with. The Supervising Nurse said a medication lock box should be on the POC, but it was not. Review of a Clients Rights and Responsibilities – Texas policy dated 04/27/20 indicated ";...3. The notice of the clients rights and responsibilities includes, but is not limited to, the clients right... f. to receive effective pain management and symptom control..." Review of a Pain and Symptom Management policy dated 04/27/20 indicated ";1. Policy: The interdisciplinary team ensures the clients right to receive effective pain management and symptom control from the hospice for conditions related to the terminal illness... 6. If the client is not receiving relief from the current pain medication or dosage, the nurse notifies the Hospice Medical Director, and/or attending physician or allowed practitioner, and cries out the recommended action(s) ordered by the physician or allowed practitioner... 8. Guidelines and/or protocols are developed for the assessment and management of common physical symptoms that are addressed by the interdisciplinary team in the clients plan of care, including, but not limited to: a. dyspnea; b. nausea and vomiting; c. anorexia and weight loss; d. anxiety and confusion; e. pressure ulcers; f. constipation; g. fatigue; h. restlessness and agitation; and i. sleep disorders..."

Based on interview and record review the hospice failed to maintained compliance with this Condition of Participation - IDG, Care Planning, Coordination of Services in that: --- Refer to L0546 Based on record review and interview, the hospice failed to develop a written plan of care that included interventions to manage pain and symptoms for 1 of 15 patients whose records were reviewed (Patient #11). This failure resulted in Patient #11 experiencing continued pain and discomfort and could result in other patients experiencing pain which is not effectively managed. Refer to L0548 Based on interview and record review, the agency failed to ensure the plan of care included measurable outcomes anticipated from implementing and coordinating the plan of care for 1 of 15 patients whose records were reviewed (Patient #11). This failure placed patients at risk for not receiving appropriate care and services based on the initial and/or comprehensive assessments. Refer to L0557 Based on record review and interview, the agency failed to ensure ongoing sharing of information was documented for 1 of 15 patients whose records were reviewed. (Patient #11) This failure resulted in Patient #11 experiencing continued pain and discomfort.

Based on record review and interview, the hospice failed to develop a written plan of care that included interventions to manage pain and symptoms for 1 of 15 patients whose records were reviewed (Patient #11). This failure resulted in Patient #11 experiencing continued pain and discomfort and could result in other patients experiencing pain which is not effectively managed. --- Findings included: Record review of Patient #11s POC dated 06/29/22 – 08/27/22 indicated a SOC date of 06/29/22 and indicated he was a 40-year-old with diagnoses including heart failure (condition that develops when your heart doesn't pump enough blood for your body's needs), chronic (persisting for a long time) kidney disease (your kidneys are damaged and can't filter blood the way they should) stage 4 (severe ), atherosclerotic heart disease (thickening or hardening of the arteries caused by a buildup of plaque), acute pancreatitis (inflammation of the pancreas), calculus of gallbladder (gallstones), and do not resuscitate (a medical order written by a doctor that instructs health care providers not to do cardiopulmonary resuscitation (CPR) if a clients breathing stops or heart stops beating). The POC indicated Patient #11 was ordered skilled nursing visits two times a week for 1 week, then one time a week for 8 weeks, and 3 PRN visits for medical needs. The POC revealed a medication order for Oxycodone (used to relieve moderate to severe pain) Extended Release 10mg tablet, by mouth 4 times daily for pain. This was the only medication listed on the POC. Further review failed to reveal the plan addressed pain and pain parameters were not provided to guide the patient/caregiver. The POC also did not include all services necessary for the palliation and management of the terminal illness including other interventions to manage pain and symptoms. Record review of a Physicians Order by MD N for Patient #11 dated 06/29/22 revealed an order for Oxycodone HCL 30mg tablet by mouth four times daily and Morphine (pain medication) 100mg Extended Release by mouth two times daily. Further review revealed an order for Morphine Extended Release 60mg tablet by mouth twice daily for pain. The POC dated 06/29/22 – 08/27/22 did not reflect these orders. Record review of Patient #11s readmit from hospital POC dated 07/13/22 – 09/10/22 indicated he was a 40 year old with diagnoses including chronic congestive heart failure, chronic kidney disease stage 4, atherosclerotic heart disease, ischemic cardiomyopathy (heart's decreased ability to pump blood properly), duodenal ulcer with hemorrhage (upper GI bleeding), liver disease, anxiety, chronic pain, dependance on supplemental oxygen, presence of automatic cardiac defibrillator (send an electric pulse or shock to the heart to restore a normal heartbeat). The POC indicated Patient #11 was ordered skilled nursing visits two times a week for 1 week, then one time a week for 8 weeks, and 3 PRN visits for medical needs. The POC indicated Orders of Discipline and Treatments was Hospice nurse to evaluate patient and develop POC to be signed by physician, hospice nurse to monitor pain level using pain scale of 0-10 with 0 being the lowest at each visit and report changes in pain level to physician... Further review of the POC revealed goals listed: a nursing POC will be established that meets the patients needs, client/caregiver will understand the pain scale, how to manage pain and report changes to hospice. The POC revealed a medication order for Oxycodone 10mg tablet, by mouth 4 times daily for pain and Morphine Extended Release 60mg tablet by mouth two times daily. The POC did not include all services necessary for the palliation and management of the terminal illness including other interventions to manage pain and symptoms. Record review of a Visit Note Report for Patient #11 dated 06/29/22 indicated a SOC visit was completed by RN H. The vital signs section indicated pain was a level 10. The pain section of the assessment indicated pain was severe, continuous, burning, shooting and tender in abdomen, back, chest, lower & upper extremity, and neck. The pain section also indicated the pain was all the time and nothing relieved the pain. Further review of the pain section indicated ";yes" to ";is pain an active problem for the patient?" Review of the narrative section of the visit note indicated patient had been off all his medications for 30 days and pain was a 10 out of 10 all over his body. Record review of Hospice IDG (team which is responsible for development, review, and update of the patients plan of care) Comprehensive Assessment and POC Update Reports for Patient #11 dated 07/07/22 and 07/21/22 did not indicate patients pain was addressed or discussed. Further review revealed there was no documented evidence that the agency optimized comfort for the patient and addressed intervention/treatments as Patient #11 continued to have 8-10 out of 10 pain. Record review of SN notes for Patient #11 by RN H dated 07/06/22, 07/20/22, 07/27/22, 08/03/22, 08/10/22, 08/23/22, 08/30/22, 09/02/22, 09/12/22, 09/19/22, 09/26/22, 10/03/22, 10/17/22, 10/24/22, 10/31/22, and 11/04/22 indicated patient reported 10 out of 10 pain each visit. There was no indication that new interventions were attempted or that patient's pain was controlled. During an interview on 03/15/23 at 1:37 p.m., RN H said Patient 11's POC should have included a pain assessment, if patient was on oxygen, bowel and nutrition status, respiratory and skin status. She said the POC should include for the patient to notify if pain was out of control and when to notify the agency. She said the POC should be specific to each patient. During an interview on 03/15/23 at 2:05 p.m., the Supervising Nurse said the doctor was notified anytime a new order was needed or there was a change in the patient. She said Patient #11 POC should have included any updates and changes in patient. She said the POC was patient specific and should include a pain assessment including type, frequency, location, duration, what the agency was doing to keep patient comfortable to manage pain. She said interventions listed on Patient #11 POC should have included pain medications, when to call the doctor, ensuring patient was comfortable, and if the patient was on oxygen. The Supervising Nurse said measurable outcomes on Patient #11's POC should have included how to rate the pain, including a pain scale. She said goals should include goals the agency can meet, and the patient was comfortable with. The Supervising Nurse said the POC was created by the SN that did the admission and then she would approve the POC. She said updates to the POC were made by the SN who saw the patient and was updated with each change. Review of a Plan of Care policy dated 04/27/20 indicated ";1. Policy Overview: The care and services provided to clients and their families are in accordance with an individualized, written plan of care established by the hospice IDG in collaboration with the clients attending physician... 2. Procedures: 1... The clients plan of care specifies the care and services necessary to meet the needs of the client/family as identified in the initial, comprehensive and updated assessments of the client..." Review of a Plan of Care – Content policy dated 04/27/20 indicated ";1. Policy Overview: The plan of care reflects client and family goals and interventions that are based on the problems identified in the initial, comprehensive and updated assessments. 2. Procedures: The clients plan of care includes all services necessary for the palliation and management of the terminal illness and its related conditions. 2. The plan of care includes, but is not limited to: a. interventions to manage pain and symptoms... c. measurable outcomes anticipated from implementing and coordinating the plan of care..." Review of a Pain and Symptom Management policy dated 04/27/20 indicated ";1. Policy: The interdisciplinary team ensures the clients right to receive effective pain management and symptom control from the hospice for conditions related to the terminal illness... 6. If the client is not receiving relief from the current pain medication or dosage, the nurse notifies the Hospice Medical Director, and/or attending physician or allowed practitioner, and cries out the recommended action(s) ordered by the physician or allowed practitioner... 8. Guidelines and/or protocols are developed for the assessment and management of common physical symptoms that are addressed by the interdisciplinary team in the clients plan of care, including, but not limited to: a. dyspnea; b. nausea and vomiting; c. anorexia and weight loss; d. anxiety and confusion; e. pressure ulcers; f. constipation; g. fatigue; h. restlessness and agitation; and i. sleep disorders..."

Based on interview and record review, the agency failed to ensure the plan of care included measurable outcomes anticipated from implementing and coordinating the plan of care for 1 of 15 patients whose records were reviewed (Patient #11). This failure placed patients at risk for not receiving appropriate care services based on the initial and/or comprehensive assessments. --- Findings included: Record review of Patient #11s POC dated 06/29/22 – 08/27/22 indicated a SOC date of 06/29/22 and indicated he was a 40-year-old with diagnoses including heart failure (condition that develops when your heart doesn't pump enough blood for your body's needs), chronic (persisting for a long time) kidney disease (your kidneys are damaged and can't filter blood the way they should) stage 4 (severe ), atherosclerotic heart disease (thickening or hardening of the arteries caused by a buildup of plaque), acute pancreatitis (inflammation of the pancreas), calculus of gallbladder (gallstones), and do not resuscitate (a medical order written by a doctor that instructs health care providers not to do cardiopulmonary resuscitation (CPR) if a clients breathing stops or heart stops beating). The POC indicated Patient #11 was ordered skilled nursing visits two times a week for 1 week, then one time a week for 8 weeks, and 3 PRN visits for medical needs. The POC revealed a medication order for Oxycodone (used to relieve moderate to severe pain) Extended Release 10mg tablet, by mouth 4 times daily for pain. This was the only medication listed on the POC. Further review failed to reveal the plan addressed pain and pain parameters were not provided to guide the patient/caregiver. The POC did not include outcomes that were measurable or patient specific. Record review of Patient #11s readmit from hospital POC dated 07/13/22 – 09/10/22 indicated he was a 40 year old with diagnoses including chronic congestive heart failure, chronic kidney disease stage 4, atherosclerotic heart disease, ischemic cardiomyopathy (heart's decreased ability to pump blood properly), duodenal ulcer with hemorrhage (upper GI bleeding), liver disease, anxiety, chronic pain, dependance on supplemental oxygen, presence of automatic cardiac defibrillator (send an electric pulse or shock to the heart to restore a normal heartbeat). The POC indicated Patient #11 was ordered skilled nursing visits two times a week for 1 week, then one time a week for 8 weeks, and 3 PRN visits for medical needs. The POC indicated Orders of Discipline and Treatments was Hospice nurse to evaluate patient and develop POC to be signed by physician, hospice nurse to monitor pain level using pain scale of 0-10 with 0 being the lowest at each visit and report changes in pain level to physician... Further review of the POC revealed goals listed: a nursing POC will be established that meets the patients needs, client/caregiver will understand the pain scale, how to manage pain and report changes to hospice. The POC revealed a medication order for Oxycodone 10mg tablet, by mouth 4 times daily for pain and Morphine Extended Release 60mg tablet by mouth two times daily. The POC did not include outcomes that were measurable or patient specific. Record review of a Visit Note Report for Patient #11 dated 06/29/22 indicated a SOC visit was completed by RN H. The vital signs section indicated pain was a level 10. The pain section of the assessment indicated pain was severe, continuous, burning, shooting and tender in abdomen, back, chest, lower & upper extremity, and neck. The pain section also indicated the pain was all the time and nothing relieved the pain. Further review of the pain section indicated ";yes" to ";is pain an active problem for the patient?" Review of the narrative section of the visit note indicated patient had been off all his medications for 30 days and pain was a 10 out of 10 all over his body. Record review of Hospice IDG (team which is responsible for development, review, and update of the patients plan of care) Comprehensive Assessment and POC Update Reports for Patient #11 dated 07/07/22 and 07/21/22 did not include outcomes that were measurable or patient specific. There was no documented evidence that Patient #11s pain was discussed. Patient #11's pain continued to be 8-10 out of 10. Record review of SN notes for Patient #11 by RN H dated 07/06/22, 07/20/22, 07/27/22, 08/03/22, 08/10/22, 08/23/22, 08/30/22, 09/02/22, 09/12/22, 09/19/22, 09/26/22, 10/03/22, 10/17/22, 10/24/22, 10/31/22, and 11/04/22 indicated patient reported 10 out of 10 pain each visit. There was no indication that new interventions were attempted or that patient's pain was controlled. During an interview on 03/15/23 at 1:37 p.m., RN H said Patient #11's POC should have included a pain assessment, if patient was on oxygen, bowel and nutrition status, respiratory and skin status. She said the POC should include for the patient to notify if pain was out of control and when to notify the agency. She said the POC should be specific to each patient. During an interview on 03/15/23 at 2:05 p.m., the Supervising Nurse said the doctor was notified anytime a new order was needed or there was a change in the patient. She said Patient #11's POC should have included any updates and changes in patient. She said the POC was patient specific and should include a pain assessment including type, frequency, location, duration, what the agency was doing to keep patient comfortable to manage pain. She said interventions listed on Patient #11's POC should have included pain medications, when to call the doctor, ensuring patient was comfortable, and if the patient was on oxygen. The Supervising Nurse said measurable outcomes on Patient #11's POC should have included how to rate the pain, including a pain scale. She said goals should include goals the agency can meet, and the patient was comfortable with. The Supervising Nurse said the POC was created by the SN that did the admission and then she would approve the POC. She said updates to the POC were made by the SN who saw the patient and was updated with each change. Review of a Plan of Care policy dated 04/27/20 indicated ";1. Policy Overview: The care and services provided to clients and their families are in accordance with an individualized, written plan of care established by the hospice IDG in collaboration with the clients attending physician... 2. Procedures: 1... The clients plan of care specifies the care and services necessary to meet the needs of the client/family as identified in the initial, comprehensive and updated assessments of the client..." Review of a Plan of Care – Content policy dated 04/27/20 indicated ";1. Policy Overview: The plan of care reflects client and family goals and interventions that are based on the problems identified in the initial, comprehensive and updated assessments. 2. Procedures: The clients plan of care includes all services necessary for the palliation and management of the terminal illness and its related conditions. 2. The plan of care includes, but is not limited to: a. interventions to manage pain and symptoms... c. measurable outcomes anticipated from implementing and coordinating the plan of care..."

Based on record review and interview, the agency failed to ensure ongoing sharing of information for 1 of 15 patients whose records were reviewed. (Patient #11) This failure resulted in Patient #11 experiencing continued pain and discomfort. --- Record review of Patient #11s POC dated 06/29/22 – 08/27/22 indicated a SOC date of 06/29/22 and indicated he was a 40-year-old with diagnoses including heart failure (condition that develops when your heart doesn't pump enough blood for your body's needs), chronic (persisting for a long time) kidney disease (your kidneys are damaged and can't filter blood the way they should) stage 4 (severe ), atherosclerotic heart disease (thickening or hardening of the arteries caused by a buildup of plaque), acute pancreatitis (inflammation of the pancreas), calculus of gallbladder (gallstones), and do not resuscitate (a medical order written by a doctor that instructs health care providers not to do cardiopulmonary resuscitation (CPR) if a clients breathing stops or heart stops beating). The POC indicated Patient #11 was ordered skilled nursing visits two times a week for 1 week, then one time a week for 8 weeks, and 3 PRN visits for medical needs. Record review of Patient #11s readmit from hospital POC dated 07/13/22 – 09/10/22 indicated he was a 40 year old with diagnoses including chronic congestive heart failure, chronic kidney disease stage 4, atherosclerotic heart disease, ischemic cardiomyopathy (heart's decreased ability to pump blood properly), duodenal ulcer with hemorrhage (upper GI bleeding), liver disease, anxiety, chronic pain, dependance on supplemental oxygen, presence of automatic cardiac defibrillator (send an electric pulse or shock to the heart to restore a normal heartbeat). The POC indicated Patient #11 was ordered skilled nursing visits two times a week for 1 week, then one time a week for 8 weeks, and 3 PRN visits for medical needs. The POC indicated Orders of Discipline and Treatments was Hospice nurse to evaluate patient and develop POC to be signed by physician, hospice nurse to monitor pain level using pain scale of 0-10 with 0 being the lowest at each visit and report changes in pain level to physician... Further review of the POC revealed goals listed: a nursing POC will be established that meets the patients needs, client/caregiver will understand the pain scale, how to manage pain and report changes to hospice. Record review of a Visit Note Report for Patient #11 dated 07/06/22 by RN H revealed a pain assessment and indicated pain was a 10 out of 10 on a numeric scale with a goal of 1. The pain section of the assessment revealed ";no" to ";is the patients pain medication regimen effective". Further review of the pain assessment indicated pain was described as continuous, crushing, and shooting in the abdomen, back, chest, lower and upper extremities, head, and hip. The assessment revealed ";nothing" relieved the pain. Review of the narrative section of the visit note revealed patient said his mind was ready to fracture because of the pain and it hadnt been that long with no relief. The note revealed pain was a 10 out of 10 in neck, back, head, chest, down his arm. The note indicated patient didnt know what to do because his neck and back were crushing pain, left arm was a shooting pain, and right knee cracked and popped. The note indicated pain took patients breath away. The note also revealed RN observed patient needing help just to get out of the chair. Further review of the narrative revealed patient was taking 30mg of oxycodone (pain medication) and agency switched him to 10mg but the 30mg was working. The note did not indicate the doctor or the Supervising Nurse was notified of patients pain or symptoms. Record review of a clinical coordination note dated 07/13/22 for Patient #11 by RN H indicated patients pain level was 8 out of 10 in stomach, backside of left arm which was sharp and stabbing pain, right side of body and chest and left back pain were a crushing pain. The note did not indicate the doctor or the Supervising Nurse was notified of patients pain or symptoms. Record review of a clinical coordination note dated 07/15/22 for Patient #11 by RN H indicated patients pain level was 8 out of 10 in stomach, shoulder, neck, left arm, and back. The note indicated pain was constant, crushing and stabbing. The note did not indicate the doctor or the Supervising Nurse was notified of patients pain or symptoms. Record review of a clinical coordination note dated 07/20/22 for Patient #11 by RN H indicated patients pain level was 10 out of 10 started from left shoulder to chest, left knee, right arm and down to back. The note did not indicate the doctor or the Supervising Nurse was notified of patients pain or symptoms. Record review of a clinical coordination note dated 07/27/22 for Patient #11 by RN H indicated patients pain level was 10 out of 10 in right arm, back, chest and neck described as dull crushing pain. The note indicated patient reported left side shooting pain. The note did not indicate the doctor or the Supervising Nurse was notified of patients pain or symptoms. Record review of a clinical coordination note dated 08/03/22 for Patient #11 by RN H indicated patients pain level was 10 out of 10 due to gallstones, right arm, neck, lower back below coccyx. The note indicated pain was described as stabbing and crushing pain. The note did not indicate the doctor or the Supervising Nurse was notified of patients pain or symptoms. Record review of a clinical coordination note dated 08/05/22 for Patient #11 by RN H indicated patients pain level was 7 out of 10. The note did not indicate the doctor or the Supervising Nurse was notified of patients pain or symptoms. Record review of a clinical coordination note dated 08/10/22 for Patient #11 by RN H indicated patients pain level was 10 out of 10 because he was out of his medication. The note did not indicate the doctor or the Supervising Nurse was notified of patients pain or symptoms. Record review of a clinical coordination note dated 08/12/22 for Patient #11 by RN H indicated patient reported pain in the bottom lower right of his back which was a stabbing pain and level was 8 out of 10 intermittently. The note indicated patient took a pain pill and the level went down to 5 out of 10. The note did not indicate the doctor or the Supervising Nurse was notified of patients pain or symptoms. Record review of a clinical coordination note dated 08/17/22 for Patient #11 by RN H indicated patient reported pain daily 6 out of 10 in his right knee, back, neck, and right shoulder from where he fell in the shower 2 weeks prior. The note did not indicate the doctor or the Supervising Nurse was notified of patients pain or symptoms. Record review of a clinical coordination note dated 08/20/22 for Patient #11 by RN H indicated patient had taken all his pain medications from his pill planner and refill was not due until 08/04/22. The note indicated patient was upset that he had no more pain medications, and he said he was desperate and asked the RN if she knew of anyone that sold oxycodone. The note did not indicate the doctor or the Supervising Nurse was notified of patients pain or symptoms. Record review of a clinical coordination note dated 08/23/22 for Patient #11 by RN H indicated patients pain level was 10 out of 10 and patient reported he had thrown up 5 times since prior Sunday due to the pain. The note indicated pill planner was empty and patient had been out of pain medication and all other medications since prior Friday. The note did not indicate the doctor or the Supervising Nurse was notified of patients pain or symptoms. Record review of a clinical coordination note dated 08/30/22 for Patient #11 by RN H indicated patient continued to have pain 10 out of 10 in knee, back, neck, and left side due to multiple heart attacks and a blocked carotid artery. The note indicated chest pain was 6 out of 10 and patient could not take deep breaths and had shortness of breath. The note indicated RN observed patient did get short of breath holding a conversation and short of breath at rest. The note did not indicate the doctor or the Supervising Nurse was notified of patients pain or symptoms. Record review of a clinical coordination note dated 09/02/22 for Patient #11 by RN H indicated patient reported pain 10 out of 10 under his right axillary (armpit) and was painful to touch. The note indicated RN palpated (examination by pressing on the surface of the body) and patient winced in pain, and under axillary was slightly inflamed compared to left side. The note indicated RN would monitor and inform MD N if pain or inflammation became worse. The note did not indicate the doctor or the Supervising Nurse was notified of patients pain or symptoms. Record review of a clinical coordination note dated 09/12/22 for Patient #11 by RN H indicated patient reported pain 10 out of 10 all over and couldnt sleep and had slept possibly 2 hours over the previous 2 days. The note indicated patients pain was in his lower back, left arm, and knee. The note indicated patients caregiver reported patient had restless leg syndrome since RN had changed his pain medication to a patch. The note did not indicate the doctor or the Supervising Nurse was notified of patients pain or symptoms. Record review of a clinical coordination note dated 09/15/22 for Patient #11 by RN H indicated patient reported he was extremely tired and in pain. The note indicated patients blood pressure was extremely high due to stress and pain level. The note did not indicate the doctor or the Supervising Nurse was notified of patients pain or symptoms. Record review of a clinical coordination note dated 09/19/22 for Patient #11 by RN H indicated patient reported pain and anxiety level 10 out of 10 and was throwing up at least two times daily. The note indicated RN would consult with MD. Patients medical record did not indicate the MD or Supervising Nurse was notified. Record review of a clinical coordination note dated 09/26/22 for Patient #11 by RN H indicated patient reported he continued to have pain 10 out of 10 in his knees, back, and neck and reported the pain medication was not working. The note indicated patients blood pressure was high even after taking blood pressure medication. The note did not indicate the doctor or the Supervising Nurse was notified of patients pain or symptoms. Record review of a clinical coordination note dated 10/03/22 for Patient #11 by RN H indicated patient reported pain was as usual 10 out of 10 in his back, left side and knee. The note did not indicate the doctor or the Supervising Nurse was notified of patients pain or symptoms. Record review of a clinical coordination note dated 10/10/22 for Patient #11 by RN H indicated patient reported pain was in the center of his chest and patient took 3 nitroglycerins (medication used to treat chest pain) due to dizziness of the pain. The note did not indicate the doctor or the Supervising Nurse was notified of patients pain or symptoms. Record review of a clinical coordination note dated 10/17/22 for Patient #11 by RN H indicated patient had decline in ability to care for self and energy and patient continued to have pain 10 out of 10 in knee, back, neck and left side. The note indicated patient continued to be weak and had extreme anxiety related to pain and aggravation. The note indicated patient took morphine and had a fentanyl patch for pain. The note did not indicate the doctor or the Supervising Nurse was notified of patients pain or symptoms. Record review of a clinical coordination note dated 10/24/22 for Patient #11 by RN H indicated patient reported anxiety and pain 10 out of 10. The note did not indicate the doctor or the Supervising Nurse was notified of patients pain or symptoms. Record review of a clinical coordination note dated 10/28/22 for Patient #11 by RN H indicated patient reported pain 7 out of 10 due to health and moving. The note indicated RN changed out pain patch. The note did not indicate the doctor or the Supervising Nurse was notified of patients pain or symptoms. . Record review of a clinical coordination note dated 10/31/22 for Patient #11 by RN H indicated patient reported pain 10 out of 10 in lower back, kidneys, neck, chest, left knee and abdomen. The note did not indicate the doctor or the Supervising Nurse was notified of patients pain or symptoms. Record review of a Visit Note Report for Patient #11 dated 11/04/22 by RN H revealed a pain assessment and indicated pain was a 10 out of 10 on a numeric scale to chest and ribs. The pain section of the assessment revealed pain assessment findings were abnormal assessment findings this visit. The pain assessment indicated pain medications were morphine and fentanyl patch. The narrative section of the note revealed pain level had increased and patient said he had chronic depression from his pain. The note indicated patient was crying due to inability to breathe. The note revealed patients anxiety was at an all-time high from pain and inability to breathe. The note indicated patient had morphine and fentanyl patch for pain. The note did not indicate the doctor or the Supervising Nurse was notified of patients pain or symptoms. Record review of a clinical coordination note dated 11/07/22 for Patient #11 by RN H indicated patient reported pain was high at the time and a 9 out of 10 due to not being able to breathe and having continued left side pain in his chest, knee, back, gallbladder, right arm, and abdomen. The note indicated patients right abdomen was painful to light palpation. The note indicated patient reported lack of appetite due to pain. The note did not indicate the doctor or the Supervising Nurse was notified of patients pain or symptoms. Record review of a Visit Note Report for Patient #11 dated 11/25/22 by RN H revealed pain assessment findings were documented as not applicable for routine visit. The narrative section of the visit note revealed patient was sitting in his hospital chair hunched over and said he had difficulty breathing. The note indicated patient said he lost consciousness before midnight and was up at 6:43 a.m. from pain unwitnessed. The note did not indicate the doctor or the Supervising Nurse was notified of patients pain or symptoms. Record review of a Visit Note Report for Patient #11 dated 11/28/22 by RN H revealed a pain assessment and indicated pain was a 9 out of 10 on a numeric scale with a goal of 3. The pain assessment indicated pain continuous, crushing, aching, and shooting in abdomen, back, chest, upper and lower extremities, and neck. The narrative section of the visit note revealed patient had right sided pain below his right breast and stomach. The note indicated RN noted patient was swollen in the area and upon light palpation it was painful to touch. The note did not indicate the doctor or the Supervising Nurse was notified of patients pain or symptoms. Record review of Hospice IDG (team which is responsible for development, review, and update of the patients plan of care) Comprehensive Assessment and POC Update Reports for Patient #11 dated 07/07/22 and 07/21/22 did not indicate patients pain was addressed or discussed. Further review revealed there was no documented evidence that the agency optimized comfort for the patient and addressed intervention/treatments as Patient #11 continued to have 8-10 out of 10 pain. During an interview on 03/15/23 at 12:42 p.m., MD N said Patient #11s pain was discussed during IDG meetings. She said Patient #11 had all over body pain and the agency tried different treatments for physical and emotional pain and wanted to manage the pain the best they could. During an interview on 03/15/23 at 1:37 p.m., RN H said she called the doctor about Patient #11s pain level and he was put on a Fentanyl patch to try to control the pain. She said patients pain was always 10 out of 10 and she notified the doctor each time. RN H said she documentation may have been in IDG, but she did not really know. During an interview on 03/15/23 at 2:05 p.m., the Supervising Nurse said the doctor was notified anytime a new order was needed or there was a change in the patient. Review of a Coordination of Services policy dated 04/27/20 indicated ";The IDG ensures that there is a coordinated and effective ongoing sharing of information amongst and between all disciplines, with all contracted services provided and in all settings... 2. An assigned hospice RN coordinates the clients plan of care and facilitates the ongoing sharing of information with the attending physician or allowed practitioner..."

Based on interview and record review the hospice failed to maintained compliance with this Condition of Participation - Organization and administration of services, in that: --- Refer to L0650 Based on interview and record review, the hospice failed to provide care that optimized comfort and dignity and was consistent with patient and family needs and goals for 1 of 15 patients records reviewed (Patient #11) in that: The agency did not provide pain management for the comfort of Patient #11. This failure resulted in Patient #11 experiencing continued pain and discomfort. Refer to L0651 Based on interview and record review, the governing body failed to ensure the administrator managed the daily operations of the hospice in that: 1. The hospice failed to protect and promote each patient's right to receive effective pain management and symptom control for conditions related to a terminal illness for Patient #11. 2. The hospice failed to provide care that optimized comfort and dignity and was consistent with patient and family needs and goals for Patient #11. 3. The hospice failed to develop a written plan of care that included all services necessary for the palliation and management of the terminal illness and related conditions for Patient #11. 4. The hospice failed to ensure ongoing sharing of information for Patient #11. These failures resulted in Patient #11 experiencing continued pain and discomfort.

Based on interview and record review, the hospice failed to provide care that optimized comfort and dignity and was consistent with patient and family needs and goals for 1 of 15 patients records reviewed (Patient #11) in that: The agency did not provide pain management for the comfort of Patient #11. This failure resulted in Patient #11 experiencing continued pain and discomfort. --- Record review of a Visit Note Report for Patient #11 dated 06/29/22 indicated a SOC visit was completed by RN H. The vital signs section indicated pain was a level 10. The pain section of the assessment indicated pain was severe, continuous, burning, shooting and tender in abdomen, back, chest, lower & upper extremity, and neck. The pain section also indicated the pain was all the time and nothing relieved the pain. Further review of the pain section indicated ";yes" to ";is pain an active problem for the patient?" Review of the narrative section of the visit note indicated patient had been off all his medications for 30 days and pain was a 10 out of 10 all over his body. Record review of a clinical coordination note dated 06/29/22 for Patient #11 by NP O indicated patient was uncomfortable during visit with severe pain and was hypertensive with a blood pressure of 167/123 per RN. Record review of a Visit Note Report for Patient #11 dated 07/06/22 by RN H revealed a pain assessment and indicated pain was a 10 out of 10 on a numeric scale with a goal of 1. The pain section of the assessment revealed ";no" to ";is the patients pain medication regimen effective". Further review of the pain assessment indicated pain was described as continuous, crushing, and shooting in the abdomen, back, chest, lower and upper extremities, head, and hip. The assessment revealed ";nothing" relieved the pain. Review of the narrative section of the visit note revealed patient said his mind was ready to fracture because of the pain and it hadnt been that long with no relief. The note revealed pain was a 10 out of 10 in neck, back, head, chest, down his arm. The note indicated patient didnt know what to do because his neck and back were crushing pain, left arm was a shooting pain, and right knee cracked and popped. The note indicated pain took patients breath away. The note also revealed RN observed patient needing help just to get out of the chair. Further review of the narrative revealed patient was taking 30mg of Oxycodone (prior to admission) and agency switched him to 10mg (upon admission) but the 30mg worked. Patient #11s medication report printed on 03/07/23 revealed an order for Morphine Extended Release 60mg tablet, one tablet by mouth twice daily for pain and Oxycodone 10mg tablet, by mouth 4 times daily for pain with a start date of 06/29/22. The note did not indicate the doctor was notified of patients pain or symptoms. The note also did not indicate that other interventions/treatments were attempted for pain/symptom relief. Record review of a clinical coordination note dated 07/13/22 for Patient #11 by RN H indicated patients pain level was 8 out of 10 in stomach, backside of left arm which was sharp and stabbing pain, right side of body and chest and left back pain were a crushing pain. The note indicated RN H brought over all medications the patient was on in a pill planner along with a pill lock box for the following week. The note indicated RN would continue to monitor medications due to patient running out of pain medications. The note did not indicate the doctor was notified of patients pain or symptoms. The note also did not indicate that other interventions/treatments were attempted for pain/symptom relief. The patients medication profile indicated patient was on Morphine Extended Release 60mg tablet, one tablet by mouth twice daily for pain and Oxycodone 10mg tablet, by mouth 4 times daily for pain. Record review of a clinical coordination note dated 07/15/22 for Patient #11 by RN H indicated patients pain level was 8 out of 10 in stomach, shoulder, neck, left arm, and back. The note did not indicate the doctor was notified of patients pain or symptoms. The note also did not indicate that other interventions/treatments were attempted for pain/symptom relief. The patients medication profile indicated patient was on Morphine Extended Release 60mg tablet, one tablet by mouth twice daily for pain and Oxycodone 10mg tablet, by mouth 4 times daily for pain. Record review of a clinical coordination note dated 07/20/22 for Patient #11 by RN H indicated patients pain level was 10 out of 10 started from left shoulder to chest, left knee, right arm and down to back. The note did not indicate the doctor was notified of patients pain or symptoms. The note also did not indicate that other interventions/treatments were attempted for pain/symptom relief. The patients medication profile indicated patient was on Morphine Extended Release 60mg tablet, one tablet by mouth twice daily for pain and Oxycodone 10mg tablet, by mouth 4 times daily for pain. Record review of a clinical coordination note dated 07/27/22 for Patient #11 by RN H indicated patients pain level was 10 out of 10 in right arm, back, chest and neck described as dull crushing pain. The note indicated patient reported left side shooting pain. The note did not indicate the doctor was notified of patients pain or symptoms. The note also did not indicate that other interventions/treatments were attempted for pain/symptom relief. The patients medication profile indicated patient was on Morphine Extended Release 60mg tablet, one tablet by mouth twice daily for pain and Oxycodone 10mg tablet, by mouth 4 times daily for pain. Record review of a clinical coordination note dated 08/03/22 for Patient #11 by RN H indicated patients pain level was 10 out of 10 due to gallstones, right arm, neck, lower back below coccyx. The note indicated pain was described as stabbing and crushing pain. The note did not indicate the doctor was notified of patients pain or symptoms. The note also did not indicate that other interventions/treatments were attempted for pain/symptom relief. The patients medication profile indicated patient was on Morphine Extended Release 60mg tablet, one tablet by mouth twice daily for pain and Oxycodone 10mg tablet, by mouth 4 times daily for pain. Record review of a clinical coordination note dated 08/05/22 for Patient #11 by RN H indicated patients pain level was 7 out of 10. The note did not indicate the doctor was notified of patients pain or symptoms. The note also did not indicate that other interventions/treatments were attempted for pain/symptom relief. The patients medication profile indicated patient was on Morphine Extended Release 60mg tablet, one tablet by mouth twice daily for pain and Oxycodone 10mg tablet, by mouth 4 times daily for pain. Record review of a clinical coordination note dated 08/10/22 for Patient #11 by RN H indicated patients pain level was 10 out of 10 because he was out of his medication. The note indicated RN H was there to fill patients pill planner. The note did not indicate the doctor was notified of patients pain or symptoms. The note also did not indicate that other interventions/treatments were attempted for pain/symptom relief. Record review of a clinical coordination note dated 08/12/22 for Patient #11 by RN H indicated patient reported pain in the bottom lower right of his back which was a stabbing pain and level was 8 out of 10 intermittently. The note indicated the patient told RN H he took a pain pill (unspecified) and the level went down to 5 out of 10. The note did not indicate the doctor was notified of patients pain. The note also did not indicate that other interventions/treatments were attempted for pain/symptom relief. Record review of a clinical coordination note dated 08/17/22 for Patient #11 by RN H indicated patient reported pain daily 6 out of 10 in his right knee, back, neck, and right shoulder from where he fell in the shower 2 weeks prior. The note indicated RN H filled patients medications for the week from the lock box. The note did not indicate the doctor was notified of patients pain or symptoms. The note also did not indicate that other interventions/treatments were attempted for pain/symptom relief. Record review of a clinical coordination note dated 08/20/22 for Patient #11 by RN H indicated patient had taken all his pain medications from his pill planner and refill was not due until 08/24/22. The note indicated patient was upset that he had no more pain medications, and he said he was desperate and asked the RN if she knew of anyone that sold oxycodone. The note did not indicate the doctor was notified of patients pain or symptoms or that patient was out of his medications. The note also did not indicate that other interventions/treatments were attempted for pain/symptom relief. Record review of a clinical coordination note dated 08/23/22 for Patient #11 by RN H indicated patients pain level was 10 out of 10 and patient reported he had thrown up 5 times since prior Sunday due to the pain. The note indicated pill planner was empty and patient had been out of pain medication and all other medications since prior Friday. The note did not indicate the doctor was notified of patients pain or symptoms. The note also did not indicate that other interventions/treatments were attempted for pain/symptom relief. Record review of a clinical coordination note dated 08/30/22 for Patient #11 by RN H indicated patient continued to have pain 10 out of 10 in knee, back, neck, and left side due to multiple heart attacks and a blocked carotid artery. The note indicated chest pain was 6 out of 10 and patient could not take deep breaths and had shortness of breath. The note indicated RN observed patient did get short of breath holding a conversation and short of breath at rest. The note indicate patient took Morphine and Oxycodone for pain. The patients medication profile indicated patient was on Morphine Extended Release 60mg tablet. The medication profile indicated Oxycodone was discontinued by RN H on 08/27/22. The note did not indicate the doctor was notified of patients pain or symptoms. The note also did not indicate that other interventions/treatments were attempted for pain/symptom relief. Record review of a clinical coordination note dated 09/02/22 for Patient #11 by RN H indicated patient reported pain 10 out of 10 under his right axillary (armpit) and was painful to touch. The note indicated RN palpated (examination by pressing on the surface of the body) and patient winced in pain, and under axillary was slightly inflamed compared to left side. The note indicated RN would monitor and inform MD N if pain or inflammation became worse. The note did not indicate the doctor was notified of patients pain or symptoms. The note also did not indicate that other interventions/treatments were attempted for pain/symptom relief. Record review of a clinical coordination note dated 09/12/22 for Patient #11 by RN H indicated patient reported pain 10 out of 10 all over and couldnt sleep and had slept possibly 2 hours over the previous 2 days. The note indicated patients pain was in his lower back, left arm, and knee. The note indicated patients caregiver reported patient had restless leg syndrome since RN had changed his pain medication to a patch. The note did not indicate the doctor was notified of patients pain or symptoms. The note also did not indicate that other interventions/treatments were attempted for pain/symptom relief. The patients medication profile indicated patient was on Morphine Extended Release 60mg tablet, one tablet by mouth twice daily for pain and Fentanyl 25mcg/hour transdermal patch every 72 hours for pain with a start date of 09/06/22. There was no evidence that RN H asked the patient about the effectiveness of the Fentanyl patch. Record review of a clinical coordination note dated 09/15/22 for Patient #11 by RN H indicated patient reported he was extremely tired and in pain. The note indicated patients blood pressure was extremely high due to stress and pain level. The note did not indicate the doctor was notified of patients pain or symptoms. The note also did not indicate that other interventions/treatments were attempted for pain/symptom relief. There was no evidence that RN H asked the patient about the effectiveness of the Fentanyl patch. Record review of a clinical coordination note dated 09/19/22 for Patient #11 by RN H indicated patient reported pain and anxiety level 10 out of 10 and was throwing up at least two times daily. The note indicated RN would consult with MD. Patients medical record did not indicate the MD was notified. The note did not indicate that other interventions/treatments were attempted for pain/symptom relief. There was no evidence that RN H asked the patient about the effectiveness of the Fentanyl patch. Record review of a clinical coordination note dated 09/26/22 for Patient #11 by RN H indicated patient reported he continued to have pain 10 out of 10 in his knees, back, and neck and reported the pain medication was not working. The note indicated patients blood pressure was high even after taking blood pressure medication. The note did not indicate the doctor was notified of patients pain or symptoms. The note also did not indicate that other interventions/treatments were attempted for pain/symptom relief. Record review of a clinical coordination note dated 10/03/22 for Patient #11 by RN H indicated patient reported pain was as usual 10 out of 10 in his back, left side and knee. The note did not indicate the doctor was notified of patients pain or symptoms. The note also did not indicate that other interventions/treatments were attempted for pain/symptom relief. Record review of a clinical coordination note dated 10/10/22 for Patient #11 by RN H indicated patient reported pain was in the center of his chest and patient took 3 nitroglycerins (medication used to treat chest pain) due to dizziness of the pain. The note did not indicate the doctor was notified of patients pain or symptoms. The note also did not indicate that other interventions/treatments were attempted for pain/symptom relief. Record review of a clinical coordination note dated 10/17/22 for Patient #11 by RN H indicated patient had decline in ability to care for self and energy and patient continued to have pain 10 out of 10 in knee, back, neck and left side. The note indicated patient continued to be weak and had extreme anxiety related to pain and aggravation. The note indicated patient took morphine and had a fentanyl patch for pain. The note did not indicate the doctor was notified of patients pain or symptoms. The note also did not indicate that other interventions/treatments were attempted for pain/symptom relief. Record review of a clinical coordination note dated 10/24/22 for Patient #11 by NP O indicated patient continued to have pain 10 out of 10 in knee, back, neck, and left side due to multiple heart attacks and a blocked carotid artery. The note indicated patient continued to have increased pain and difficulty taking deep breaths. The note indicated patient had extreme anxiety 9 out of 10 related to pain and aggravation due to health. The note indicated patient continued to decline physically. Record review of a clinical coordination note dated 10/24/22 for Patient #11 by RN H indicated patient reported anxiety and pain 10 out of 10. The note did not indicate the doctor was notified of patients pain or symptoms. The note also did not indicate that other interventions/treatments were attempted for pain/symptom relief. Record review of a clinical coordination note dated 10/28/22 for Patient #11 by RN H indicated patient reported pain 7 out of 10 due to health and moving. The note indicated RN changed out pain patch. The note did not indicate the doctor was notified of patients pain or symptoms. The note also did not indicate that other interventions/treatments were attempted for pain/symptom relief. Record review of a clinical coordination note dated 10/31/22 for Patient #11 by RN H indicated patient reported pain 10 out of 10 in lower back, kidneys, neck, chest, left knee and abdomen. The note did not indicate the doctor was notified of patients pain or symptoms. The note also did not indicate that other interventions/treatments were attempted for pain/symptom relief. Record review of a Visit Note Report for Patient #11 dated 11/04/22 by RN H revealed a pain assessment and indicated pain was a 10 out of 10 on a numeric scale to chest and ribs. The pain section of the assessment revealed pain assessment findings were abnormal assessment findings this visit. The pain assessment indicated pain medications were morphine and fentanyl patch. The narrative section of the note revealed pain level had increased and patient said he had chronic depression from his pain. The note indicated patient was crying due to inability to breathe. The note revealed patients anxiety was at an all-time high from pain and inability to breathe. The note indicated patient had morphine and fentanyl patch for pain. The note did not indicate the doctor was notified of patients pain or symptoms. The note also did not indicate that other interventions/treatments were attempted for pain/symptom relief. The patients medication profile indicated patient was on Morphine Extended Release 60mg tablet, one tablet by mouth twice daily for pain and Fentanyl 25mcg/hour transdermal patch every 72 hours for pain. Record review of a clinical coordination note dated 11/07/22 for Patient #11 by RN H indicated patient reported pain was high at the time and a 9 out of 10 due to not being able to breathe and having continued left side pain in his chest, knee, back, gallbladder, right arm, and abdomen. The note indicated patients right abdomen was painful to light palpation. The note indicated patient reported lack of appetite due to pain. The note did not indicate the doctor was notified of patients pain or symptoms. The note also did not indicate that other interventions/treatments were attempted for pain/symptom relief. Review of a Physicians Order by MD N for Patient #11 dated 11/22/22 revealed an order for Fentanyl Transdermal Patch 50mcg/hour, 1 patch every 72 hours for pain with a start date of 11/21/22. The order revealed a discontinued order for Fentanyl 25mcg/hour transdermal patch. Record review of a Visit Note Report for Patient #11 dated 11/25/22 by RN H revealed pain assessment findings were documented as not applicable for routine visit. The narrative section of the visit note revealed patient was sitting in his hospital chair hunched over and said he had difficulty breathing. The note indicated patient said he lost consciousness before midnight and was up at 6:43 a.m. from pain unwitnessed. The note did not indicate the doctor was notified of patients pain or symptoms. The note also did not indicate that other interventions/treatments were attempted for pain/symptom relief. There was no evidence that RN H asked the patient about the effectiveness of the Fentanyl patch. Record review of a Visit Note Report for Patient #11 dated 11/28/22 by RN H revealed a pain assessment and indicated pain was a 9 out of 10 on a numeric scale with a goal of 3. The pain assessment indicated pain continuous, crushing, aching, and shooting in abdomen, back, chest, upper and lower extremities, and neck. The narrative section of the visit note revealed patient had right sided pain below his right breast and stomach. The note indicated RN noted patient was swollen in the area and upon light palpation it was painful to touch. The note did not indicate the doctor was notified of patients pain or symptoms. The note also did not indicate that other interventions/treatments were attempted for pain/symptom relief. There was no evidence that RN H asked the patient about the effectiveness of the Fentanyl patch. Record review of Hospice IDG (team which is responsible for development, review, and update of the patients plan of care) Comprehensive Assessment and POC Update Reports for Patient #11 dated 07/07/22 and 07/21/22 did not indicate patients pain was addressed or discussed. Further review revealed there was no documented evidence that the agency optimized comfort for the patient and addressed intervention/treatments as Patient #11 continued to have 8-10 out of 10 pain. Record review of a discharge report indicated Patient #11 expired at home on 11/30/22. During an interview on 03/09/23 at 8:51 a.m., RN H said Patient #11 was non-compliant with taking his pain medication. She said his opioid pain medication was left in a locked medication box and kept them at the office, and she left his other pills for him at his home. RN H said she would fill his medication planner every 3 days and she would transport the locked medication box that was stored in a locked closet at the Texarkana drop off site to his home and then back to the office. She said she did not remember if it was discussed in an IDG meeting or not about placing medications in a locked box and being kept at the office. During an interview on 03/09/23 at 11:08 a.m., the Supervising Nurse said Patient #11 medications were placed in a lock box and kept at the patients house. She said she did not remember if the lock box was kept in Texarkana. The Supervising Nurse said the agency did not continue to fill patients Oxycodone. During an interview on 03/09/23 at 12:42 p.m., the Supervising Nurse said Patient #11 was a trouble patient and lived in a bad neighborhood with previous break-ins. She said the medications were placed in a lock box in a locked room at the patients home after medication was missing. During an interview on 03/09/23 at 1:23 p.m., the Supervising Nurse said if the agency received a referral on a patient in area that was not good, they would put the patients medications in a lock box. During an interview on 03/09/23 at 2:30 p.m., the Administrator said the SN would lock up a patients medications with permission depending on the situation, such as abusing of medication or unsafe environment. During an interview on 03/09/23 at 3:45 p.m., the Supervising Nurse said no consent was signed or doctor order received when patients medications were locked up. She said the SN would just let the doctor know. During an interview on 03/09/23 at 3:47 p.m., RN H said Patient #11s medication lock box was stored in his house and when done she would store it in Texarkana office in a locked room between patients use. She said she went and filled patients medications 3 days at a time. She said medications were locked in a room or freezer and the medications never left the home. During an interview on 03/10/23 at 8:56 a.m., Patient #11s family member said Patient #11 was on oxycodone (pain reliever) for years and that was the only thing that kept him functioning and helped control his pain. She said his pain medication was stolen so RN H put his medications in a lock box at the house. She said the home was broken into and the medications were stolen again, so RN H had Patient #11 taken off Oxycodone and put him on a Fentanyl patch that did not help with the pain at all. She said RN H also put Patient #11s medications in a lock box and took them to the agencys office and kept them and would fill his medication box every 3 days. Patient #11s family member said Patient #11 got a small dose of Morphine in his box every 3 days, but it did not help his pain. Patient #11s family member said she nor the patient agreed with placing the medications in a lock box at the office but was told patient would be taken off hospice if they did not allow it. She said called the agency several times after hours because patient would be in so much pain and he was told almost every time to take deep breaths and a shower. She said there were no in person visits to assess the pain. Patient #11s family said RN H would not allow patient to be put back on Oxycodone and the family member and patient asked over and over because of his severe pain. The family member said the day before patient died RN H put 2 Fentanyl patches on him. During an interview on 03/15/23 at 12:38 p.m., RN H said Patient #11 was a complicated case and he had major anxiety. She said she felt like he was always in some kind of pain, but it was always controlled. RN H said Patient #11 had severe pain in his chest, back, and he hurt all over and couldnt function or get out of bed. She said he always had pain which was the reason from switching patient from Oxycodone to the Fentanyl patch. During an interview on 03/15/23 at 12:42 p.m., MD N said medications would not be locked up under any circumstance except maybe in a pain control kit. She said the medications went straight from the pharmacy to the patients home and were not kept in the office. MD N said the nurses give the medications to the patient and did not keep them. MD N said the nurses have never told her they locked up a patients medications and she was not sure the protocol on that. She said she was not aware that Patient #11s medications were being locked up and that she knew the nurses were counting his medications and prefilling a planner for a certain number of days due to a history of some issues with the patient. MD N said the agency often had difficulty controlling Patient #11s pain and tried alternate treatments. She said patient had a history of drug abuse and medications missing but the agency wanted to treat pain the best they could without discriminating. She said she could not remember why he was taken off Oxycodone and put on a Fentanyl Patch since it had been some time ago. She said maybe it was because he would run out before his refill was due, so the medication didnt seem to control his pain. MD N said she believed she did order PRN medications but couldnt remember. MD N said Patient #11s pain was discussed during IDG meetings. She said Patient #11 had all over body pain and the agency tried different treatments for physical and emotional pain and wanted to manage the pain the best they could. During an interview on 03/15/23 at 1:06 p.m., RN H said Patient #11 was taken off Oxycodone and put on a Fentanyl patch. She said if one medication was not working the agency would try something different. During an interview on 03/15/23 at 1:09 p.m., NP O said only completed patients face to face visits and did not write orders, she said MD N did that. NP O said medications would be locked up if patient lived in an unsafe home, unstable home, the patient was taking more than they should. She said it was a trust thing honestly. NP O said some patients neighborhoods are not the best and they have to lock the medications up. She said she was pretty sure needed a doctor order to lock up medications because it was part of patients rights. NP O said she was pretty sure the POC would reflect if a patient had a medication lock box. NP O said she knew Patient #11s medications were locked up, but she was not sure if that was just the agencys decision. NP O said medications would never be taken from a patients home and she had never seen or heard of the nurses doing that. NP O said Patient #11 was a difficult patient. She said nurses would notify MD N for any issues because she did not write orders or prescriptions. NP O said she only saw Patient #11 one to two times and he did not appear to be in distress or pain that medication could not control, she said she would have notified MD N if so. NP O said she did not attend IDG meetings. During an interview on 03/15/23 at 1:37 p.m., RN H said she called the doctor about Patient #11s pain level and he was put on a Fentanyl patch to try to control the pain. She said patients pain was always 10 out of 10 and she notified the doctor each time. RN H said she documentation may have been in IDG, but she did not really know. She said Patient #11s medication lock box consisted of everything but patients normal medications. She said medications locked up were opioids and pain medications, and medications that could be stolen because he did not live in the best neighborhood. RN H said she never dealt with a patients medications being locked up before and this was her first interaction with that. She said she was just doing what she was told to do and did not know what the protocol was. RN H said Patient #11 would say this is what I live with (regarding pain) and he knew he was always going to be in that type of pain due to his condition. RN H said patients pain was always the same and patient was very aware of his condition. During an interview on 03/15/23 at 2:05 p.m., the Supervising Nurse said the doctor was notified anytime a new order was needed or there was a change in the patient. She said Patient #11's POC should have included any updates and changes in patient. She said the POC was patient specific and should include a pain assessment including type, frequency, location, duration, what the agency was doing to keep patient comfortable to manage pain. She said interventions listed on Patient #11's POC should have included pain medications, when to call the doctor, ensuring patient was comfortable, and if the patient was on oxygen. The Supervising Nurse said measurable outcomes on Patient #11's POC should have included how to rate the pain, including a pain scale. She said goals should include goals the agency can meet, and the patient was comfortable with. The Supervising Nurse said a medication lock box should be on the POC, but it was not. Review of a Clients Rights and Responsibilities – Texas policy dated 04/27/20 indicated ";...3. The notice of the clients rights and responsibilities includes, but is not limited to, the clients right... f. to receive effective pain management and symptom control..." Review of a Pain and Symptom Management policy dated 04/27/20 indicated ";1. Policy: The interdisciplinary team ensures the clients right to receive effective pain management and symptom control from the hospice for conditions related to the terminal illness... 6. If the client is not receiving relief from the current pain medication or dosage, the nurse notifies the Hospice Medical Director, and/or attending physician or allowed practitioner, and cries out the recommended action(s) ordered by the physician or allowed practitioner... 8. Guidelines and/or protocols are developed for the assessment and management of common physical symptoms that are addressed by the interdisciplinary team in the clients plan of care, including, but not limited to: a. dyspnea; b. nausea and vomiting; c. anorexia and weight loss; d. anxiety and confusion; e. pressure ulcers; f. constipation; g. fatigue; h. restlessness and agitation; and i. sleep disorders..."

Based on interview and record review, the governing body failed to ensure the administrator managed the daily operations of the hospice in that: 1. The hospice failed to protect and promote each patient's right to receive effective pain management and symptom control for conditions related to a terminal illness for Patient #11. 2. The hospice failed to provide care that optimized comfort and dignity and was consistent with patient and family needs and goals for Patient #11. 3. The hospice failed to develop a written plan of care that included all services necessary for the palliation and management of the terminal illness and related conditions for Patient #11. 4. The hospice failed to ensure ongoing sharing of information for Patient #11. These failures resulted in administrative oversite and led to Patient #11 experiencing continued pain and discomfort and could result in other patients experiencing pain which is not effectively managed and unmet needs. --- Findings included: Review of an Administrator policy dated 04/27/20 indicated ";The Governing Body appoints a qualified individual with appropriate education and experience to serve as the Administrator... and assume responsibility for the day-to-day administration of the hospice program... 6. The hospice Administrator, with the Governing Body, ensures that all care, treatment, and services provided by the hospice are in accordance with Federal, State, and local laws and regulations and consistent with accepted standards of practice..." Review of an Administrator Job Description dated 12/2020 indicated ";The Hospice Administrator/Regional Director is responsible for the overall operation and services for the assigned hospice provider. The Hospice Administrator/Regional Director organizes and directs the hospice's ongoing day to day operations, maintains ongoing liaison among the Governing Body and personnel, employs qualified personnel..." Record review of the Administrators personnel record revealed a date of hire as 04/07/16. A signed job description for the Administrator position was dated 02/02/23. Record review of Patient #11s POC dated 06/29/22 – 08/27/22 indicated a SOC date of 06/29/22 and indicated he was a 40-year-old with diagnoses including heart failure (condition that develops when your heart doesn't pump enough blood for your body's needs), chronic (persisting for a long time) kidney disease (your kidneys are damaged and can't filter blood the way they should) stage 4 (severe ), atherosclerotic heart disease (thickening or hardening of the arteries caused by a buildup of plaque), acute pancreatitis (inflammation of the pancreas), calculus of gallbladder (gallstones), and do not resuscitate (a medical order written by a doctor that instructs health care providers not to do cardiopulmonary resuscitation (CPR) if a clients breathing stops or heart stops beating). The POC indicated Patient #11 was ordered skilled nursing visits two times a week for 1 week, then one time a week for 8 weeks, and 3 PRN visits for medical needs. The POC revealed a medication order for Oxycodone (used to relieve moderate to severe pain) Extended Release 10mg tablet, by mouth 4 times daily for pain. This was the only medication listed on the POC. Further review of the plan of care failed to reveal the plan addressed pain and failed to reveal pain parameters were provided to guide the patient/caregiver. The POC also did not include all services necessary for the palliation and management of the terminal illness including other interventions to manage pain and symptoms. There was no order or no documented evidence that the agency was to place the patients pain medication in a lock box or to perform refills every three days. The POC did not include outcomes that were measurable or patient specific. Record review of a Physicians Order by MD N for Patient #11 dated 06/29/22 revealed an order for Oxycodone HCL 30mg tablet by mouth four times daily and Morphine (pain medication) 100mg Extended Release by mouth two times daily. Further review revealed an order for Morphine Extended Release 60mg tablet by mouth twice daily for pain. The POC dated 06/29/22 – 08/27/22 did not reflect these orders. Record review of a certification of terminal illness order for Patient #11 dated 06/29/22 and electronically signed by NP O and MD N and revealed a narrative that indicated the patient said he was taking 30mg of oxycodone (prior to admission). The note indicated the hospice switched client to 10mg due to him not having any narcotics for 2 weeks prior to admission. The note indicated patient was still having significant pain, but the agency was slowly increasing and requiring patient to responsibly manage medications via pill box before willing to prescribe more. Record review of Patient #11s readmit from hospital POC dated 07/13/22 – 09/10/22 indicated he was a 40 year old with diagnoses including chronic congestive heart failure, chronic kidney disease stage 4, atherosclerotic heart disease, ischemic cardiomyopathy (heart's decreased ability to pump blood properly), duodenal ulcer with hemorrhage (upper GI bleeding), liver disease, anxiety, chronic pain, dependance on supplemental oxygen, presence of automatic cardiac defibrillator (send an electric pulse or shock to the heart to restore a normal heartbeat). The POC indicated Patient #11 was ordered skilled nursing visits two times a week for 1 week, then one time a week for 8 weeks, and 3 PRN visits for medical needs. The POC indicated Orders of Discipline and Treatments was Hospice nurse to evaluate patient and develop POC to be signed by physician, hospice nurse to monitor pain level using pain scale of 0-10 with 0 being the lowest at each visit and report changes in pain level to physician... Further review of the POC revealed goals listed: a nursing POC will be established that meets the patients needs, client/caregiver will understand the pain scale, how to manage pain and report changes to hospice. The POC revealed a medication order for Oxycodone 10mg tablet, by mouth 4 times daily for pain and Morphine Extended Release 60mg tablet by mouth two times daily. Further review of the plan of care failed to reveal the plan addressed pain and failed to reveal pain parameters were provided to guide the patient/caregiver. The POC also did not include all services necessary for the palliation and management of the terminal illness including other interventions to manage pain and symptoms. There was no order or no documented evidence that the agency was to place the patients pain medication in a lock box or to perform refills every three days. The POC did not include outcomes that were measurable or patient specific. Record review of Patient #11s medication report printed on 03/07/23 revealed an order for Morphine Extended Release 60mg tablet, one tablet by mouth twice daily for pain with a start date of 06/29/22. The medication report revealed the client was ordered Fentanyl 25mcg/hour transdermal patch every 72 hours for pain with a start date of 09/06/22 and discontinued date of 11/21/22. The medication report revealed a new order for a Fentanyl 50mcg/hour transdermal patch every 72 hours for pain with a start date of 11/21/22. Further review of the medication report revealed an order for Oxycodone 10mg tablet, 1 tablet by mouth 4 times daily as needed for pain with a start date of 06/29/22 and a discontinued date of 08/27/22. The medication report did not indicate any other pain medications were ordered for pain control between 08/27/22 – 09/06/22 (10 days), the time frame from when the Oxycodone was discontinued, and when the Fentanyl patch was first ordered. There was no evidence of any other medications ordered for pain control between start of care on 06/29/22 and patients death on 11/30/22. Record review of a Visit Note Report for Patient #11 dated 06/29/22 indicated a SOC visit was completed by RN H. The vital signs section indicated pain was a level 10. The pain section of the assessment indicated pain was severe, continuous, burning, shooting and tender in abdomen, back, chest, lower & upper extremity, and neck. The pain section also indicated the pain was all the time and nothing relieved the pain. Further review of the pain section indicated ";yes" to ";is pain an active problem for the patient?" Review of the narrative section of the visit note indicated patient had been off all his medications for 30 days and pain was a 10 out of 10 all over his body. Record review of a clinical coordination note dated 06/29/22 for Patient #11 by NP O indicated patient was uncomfortable during visit with severe pain and was hypertensive with a blood pressure of 167/123 per RN. Record review of a Visit Note Report for Patient #11 dated 07/06/22 by RN H revealed a pain assessment and indicated pain was a 10 out of 10 on a numeric scale with a goal of 1. The pain section of the assessment revealed ";no" to ";is the patients pain medication regimen effective". Further review of the pain assessment indicated pain was described as continuous, crushing, and shooting in the abdomen, back, chest, lower and upper extremities, head, and hip. The assessment revealed ";nothing" relieved the pain. Review of the narrative section of the visit note revealed patient said his mind was ready to fracture because of the pain and it hadnt been that long with no relief. The note revealed pain was a 10 out of 10 in neck, back, head, chest, down his arm. The note indicated patient didnt know what to do because his neck and back were crushing pain, left arm was a shooting pain, and right knee cracked and popped. The note indicated pain took patients breath away. The note also revealed RN observed patient needing help just to get out of the chair. Further review of the narrative revealed patient was taking 30mg of Oxycodone (prior to admission) and agency switched him to 10mg (upon admission) but the 30mg worked. Patient #11s medication report printed on 03/07/23 revealed an order for Morphine Extended Release 60mg tablet, one tablet by mouth twice daily for pain and Oxycodone 10mg tablet, by mouth 4 times daily for pain with a start date of 06/29/22. The note did not indicate the doctor or Supervising Nurse was notified of patients pain or symptoms. The note also did not indicate that other interventions/treatments were attempted for pain/symptom relief. Record review of a clinical coordination note dated 07/13/22 for Patient #11 by RN H indicated patients pain level was 8 out of 10 in stomach, backside of left arm which was sharp and stabbing pain, right side of body and chest and left back pain were a crushing pain. The note indicated RN H brought over all medications the patient was on in a pill planner along with a pill lock box for the following week. The note indicated RN would continue to monitor medications due to patient running out of pain medications. The note did not indicate the doctor or Supervising Nurse was notified of patients pain or symptoms. The note also did not indicate that other interventions/treatments were attempted for pain/symptom relief. The patients medication profile indicated patient was on Morphine Extended Release 60mg tablet, one tablet by mouth twice daily for pain and Oxycodone 10mg tablet, by mouth 4 times daily for pain. Record review of a clinical coordination note dated 07/15/22 for Patient #11 by RN H indicated patients pain level was 8 out of 10 in stomach, shoulder, neck, left arm, and back. The note did not indicate the doctor or Supervising Nurse was notified of patients pain or symptoms. The note also did not indicate that other interventions/treatments were attempted for pain/symptom relief. The patients medication profile indicated patient was on Morphine Extended Release 60mg tablet, one tablet by mouth twice daily for pain and Oxycodone 10mg tablet, by mouth 4 times daily for pain. Record review of a clinical coordination note dated 07/20/22 for Patient #11 by RN H indicated patients pain level was 10 out of 10 started from left shoulder to chest, left knee, right arm and down to back. The note did not indicate the doctor or Supervising Nurse was notified of patients pain or symptoms. The note also did not indicate that other interventions/treatments were attempted for pain/symptom relief. The patients medication profile indicated patient was on Morphine Extended Release 60mg tablet, one tablet by mouth twice daily for pain and Oxycodone 10mg tablet, by mouth 4 times daily for pain. Record review of a clinical coordination note dated 07/27/22 for Patient #11 by RN H indicated patients pain level was 10 out of 10 in right arm, back, chest and neck described as dull crushing pain. The note indicated patient reported left side shooting pain. The note did not indicate the doctor or Supervising Nurse was notified of patients pain or symptoms. The note also did not indicate that other interventions/treatments were attempted for pain/symptom relief. The patients medication profile indicated patient was on Morphine Extended Release 60mg tablet, one tablet by mouth twice daily for pain and Oxycodone 10mg tablet, by mouth 4 times daily for pain. Record review of a clinical coordination note dated 08/03/22 for Patient #11 by RN H indicated patients pain level was 10 out of 10 due to gallstones, right arm, neck, lower back below coccyx. The note indicated pain was described as stabbing and crushing pain. The note did not indicate the doctor or Supervising Nurse was notified of patients pain or symptoms. The note also did not indicate that other interventions/treatments were attempted for pain/symptom relief. The patients medication profile indicated patient was on Morphine Extended Release 60mg tablet, one tablet by mouth twice daily for pain and Oxycodone 10mg tablet, by mouth 4 times daily for pain. Record review of a clinical coordination note dated 08/05/22 for Patient #11 by RN H indicated patients pain level was 7 out of 10. The note did not indicate the doctor or Supervising Nurse was notified of patients pain or symptoms. The note also did not indicate that other interventions/treatments were attempted for pain/symptom relief . The patients medication profile indicated patient was on Morphine Extended Release 60mg tablet, one tablet by mouth twice daily for pain and Oxycodone 10mg tablet, by mouth 4 times daily for pain. Record review of a clinical coordination note dated 08/10/22 for Patient #11 by RN H indicated patients pain level was 10 out of 10 because he was out of his medication. The note indicated RN H was there to fill patients pill planner. The note did not indicate the doctor or Supervising Nurse was notified of patients pain or symptoms. The note also did not indicate that other interventions/treatments were attempted for pain/symptom relief. Record review of a clinical coordination note dated 08/12/22 for Patient #11 by RN H indicated patient reported pain in the bottom lower right of his back which was a stabbing pain and level was 8 out of 10 intermittently. The note indicated the patient told RN H he took a pain pill (unspecified) and the level went down to 5 out of 10. The note did not indicate the doctor or Supervising Nurse was notified of patients pain. The note also did not indicate that other interventions/treatments were attempted for pain/symptom relief. Record review of a clinical coordination note dated 08/17/22 for Patient #11 by RN H indicated patient reported pain daily 6 out of 10 in his right knee, back, neck, and right shoulder from where he fell in the shower 2 weeks prior. The note indicated RN H filled patients medications for the week from the lock box. The note did not indicate the doctor or Supervising Nurse was notified of patients pain or symptoms. The note also did not indicate that other interventions/treatments were attempted for pain/symptom relief. Record review of a clinical coordination note dated 08/20/22 for Patient #11 by RN H indicated patient had taken all his pain medications from his pill planner and refill was not due until 08/24/22. The note indicated patient was upset that he had no more pain medications, and he said he was desperate and asked the RN if she knew of anyone that sold oxycodone. The note did not indicate the doctor or Supervising Nurse was notified of patients pain or symptoms or that patient was out of his medications. The note also did not indicate that other interventions/treatments were attempted for pain/symptom relief. Record review of a clinical coordination note dated 08/23/22 for Patient #11 by RN H indicated patients pain level was 10 out of 10 and patient reported he had thrown up 5 times since prior Sunday due to the pain. The note indicated pill planner was empty and patient had been out of pain medication and all other medications since prior Friday. The note did not indicate the doctor or Supervising Nurse was notified of patients pain or symptoms. The note also did not indicate that other interventions/treatments were attempted for pain/symptom relief. Record review of a clinical coordination note dated 08/30/22 for Patient #11 by RN H indicated patient continued to have pain 10 out of 10 in knee, back, neck, and left side due to multiple heart attacks and a blocked carotid artery. The note indicated chest pain was 6 out of 10 and patient could not take deep breaths and had shortness of breath. The note indicated RN observed patient did get short of breath holding a conversation and short of breath at rest. The note indicate patient took Morphine and Oxycodone for pain. The patients medication profile indicated patient was on Morphine Extended Release 60mg tablet. The medication profile indicated Oxycodone was discontinued by RN H on 08/27/22. The note did not indicate the doctor or Supervising Nurse was notified of patients pain or symptoms. The note also did not indicate that other interventions/treatments were attempted for pain/symptom relief. Record review of a clinical coordination note dated 09/02/22 for Patient #11 by RN H indicated patient reported pain 10 out of 10 under his right axillary (armpit) and was painful to touch. The note indicated RN palpated (examination by pressing on the surface of the body) and patient winced in pain, and under axillary was slightly inflamed compared to left side. The note indicated RN would monitor and inform MD N if pain or inflammation became worse. The note did not indicate the doctor or Supervising Nurse was notified of patients pain or symptoms. The note also did not indicate that other interventions/treatments were attempted for pain/symptom relief. Record review of a clinical coordination note dated 09/12/22 for Patient #11 by RN H indicated patient reported pain 10 out of 10 all over and couldnt sleep and had slept possibly 2 hours over the previous 2 days. The note indicated patients pain was in his lower back, left arm, and knee. The note indicated patients caregiver reported patient had restless leg syndrome since RN had changed his pain medication to a patch. The note did not indicate the doctor or Supervising Nurse was notified of patients pain or symptoms. The note also did not indicate that other interventions/treatments were attempted for pain/symptom relief. The patients medication profile indicated patient was on Morphine Extended Release 60mg tablet, one tablet by mouth twice daily for pain and Fentanyl 25mcg/hour transdermal patch every 72 hours for pain with a start date of 09/06/22. There was no evidence that RN H asked the patient about the effectiveness of the Fentanyl patch. Record review of a clinical coordination note dated 09/15/22 for Patient #11 by RN H indicated patient reported he was extremely tired and in pain. The note indicated patients blood pressure was extremely high due to stress and pain level. The note did not indicate the doctor or Supervising Nurse was notified of patients pain or symptoms. The note also did not indicate that other interventions/treatments were attempted for pain/symptom relief. There was no evidence that RN H asked the patient about the effectiveness of the Fentanyl patch. Record review of a clinical coordination note dated 09/19/22 for Patient #11 by RN H indicated patient reported pain and anxiety level 10 out of 10 and was throwing up at least two times daily. The note indicated RN would consult with MD. Patients medical record did not indicate the MD or Supervising Nurse was notified. The note did not indicate that other interventions/treatments were attempted for pain/symptom relief. There was no evidence that RN H asked the patient about the effectiveness of the Fentanyl patch. Record review of a clinical coordination note dated 09/26/22 for Patient #11 by RN H indicated patient reported he continued to have pain 10 out of 10 in his knees, back, and neck and reported the pain medication was not working. The note indicated patients blood pressure was high even after taking blood pressure medication. The note did not indicate the doctor or Supervising Nurse was notified of patients pain or symptoms. The note also did not indicate that other interventions/treatments were attempted for pain/symptom relief. Record review of a clinical coordination note dated 10/03/22 for Patient #11 by RN H indicated patient reported pain was as usual 10 out of 10 in his back, left side and knee. The note did not indicate the doctor or Supervising Nurse was notified of patients pain or symptoms. The note also did not indicate that other interventions/treatments were attempted for pain/symptom relief. Record review of a clinical coordination note dated 10/10/22 for Patient #11 by RN H indicated patient reported pain was in the center of his chest and patient took 3 nitroglycerins (medication used to treat chest pain) due to dizziness of the pain. The note did not indicate the doctor or Supervising Nurse was notified of patients pain or symptoms. The note also did not indicate that other interventions/treatments were attempted for pain/symptom relief. Record review of a clinical coordination note dated 10/17/22 for Patient #11 by RN H indicated patient had decline in ability to care for self and energy and patient continued to have pain 10 out of 10 in knee, back, neck and left side. The note indicated patient continued to be weak and had extreme anxiety related to pain and aggravation. The note indicated patient took morphine and had a fentanyl patch for pain. The note did not indicate the doctor or Supervising Nurse was notified of patients pain or symptoms. The note also did not indicate that other interventions/treatments were attempted for pain/symptom relief. Record review of a clinical coordination note dated 10/24/22 for Patient #11 by NP O indicated patient continued to have pain 10 out of 10 in knee, back, neck, and left side due to multiple heart attacks and a blocked carotid artery. The note indicated patient continued to have increased pain and difficulty taking deep breaths. The note indicated patient had extreme anxiety 9 out of 10 related to pain and aggravation due to health. The note indicated patient continued to decline physically. Record review of a clinical coordination note dated 10/24/22 for Patient #11 by RN H indicated patient reported anxiety and pain 10 out of 10. The note did not indicate the doctor or Supervising Nurse was notified of patients pain or symptoms. The note also did not indicate that other interventions/treatments were attempted for pain/symptom relief. Record review of a clinical coordination note dated 10/28/22 for Patient #11 by RN H indicated patient reported pain 7 out of 10 due to health and moving. The note indicated RN changed out pain patch. The note did not indicate the doctor or Supervising Nurse was notified of patients pain or symptoms. The note also did not indicate that other interventions/treatments were attempted for pain/symptom relief. Record review of a clinical coordination note dated 10/31/22 for Patient #11 by RN H indicated patient reported pain 10 out of 10 in lower back, kidneys, neck, chest, left knee and abdomen. The note did not indicate the doctor or Supervising Nurse was notified of patients pain or symptoms. The note also did not indicate that other interventions/treatments were attempted for pain/symptom relief. Record review of a Visit Note Report for Patient #11 dated 11/04/22 by RN H revealed a pain assessment and indicated pain was a 10 out of 10 on a numeric scale to chest and ribs. The pain section of the assessment revealed pain assessment findings were abnormal assessment findings this visit. The pain assessment indicated pain medications were morphine and fentanyl patch. The narrative section of the note revealed pain level had increased and patient said he had chronic depression from his pain. The note indicated patient was crying due to inability to breathe. The note revealed patients anxiety was at an all-time high from pain and inability to breathe. The note indicated patient had morphine and fentanyl patch for pain. The note did not indicate the doctor or Supervising Nurse was notified of patients pain or symptoms. The note also did not indicate that other interventions/treatments were attempted for pain/symptom relief. The patients medication profile indicated patient was on Morphine Extended Release 60mg tablet, one tablet by mouth twice daily for pain and Fentanyl 25mcg/hour transdermal patch every 72 hours for pain. Record review of a clinical coordination note dated 11/07/22 for Patient #11 by RN H indicated patient reported pain was high at the time and a 9 out of 10 due to not being able to breathe and having continued left side pain in his chest, knee, back, gallbladder, right arm, and abdomen. The note indicated patients right abdomen was painful to light palpation. The note indicated patient reported lack of appetite due to pain. The note did not indicate the doctor or Supervising Nurse was notified of patients pain or symptoms. The note also did not indicate that other interventions/treatments were attempted for pain/symptom relief. Review of a Physicians Order by MD N for Patient #11 dated 11/22/22 revealed an order for Fentanyl Transdermal Patch 50mcg/hour, 1 patch every 72 hours for pain with a start date of 11/21/22. The order revealed a discontinued order for Fentanyl 25mcg/hour transdermal patch. Record review of a Visit Note Report for Patient #11 dated 11/25/22 by RN H revealed pain assessment findings were documented as not applicable for routine visit. The narrative section of the vi sit note revealed patient was sitting in his hospital chair hunched over and said he had difficulty breathing. The note indicated patient said he lost consciousness before midnight and was up at 6:43 a.m. from pain unwitnessed. The note did not indicate the doctor or Supervising Nurse was notified of patients pain or symptoms. The note also did not indicate that other interventions/treatments were attempted for pain/symptom relief. There was no evidence that RN H asked the patient about the effectiveness of the Fentanyl patch. Record review of a Visit Note Report for Patient #11 dated 11/28/22 by RN H revealed a pain assessment and indicated pain was a 9 out of 10 on a numeric scale with a goal of 3. The pain assessment indicated pain continuous, crushing, aching, and shooting in abdomen, back, chest, upper and lower extremities, and neck. The narrative section of the visit note revealed patient had right sided pain below his right breast and stomach. The note indicated RN noted patient was swollen in the area and upon light palpation it was painful to touch. The note did not indicate the doctor or Supervising Nurse was notified of patients pain or symptoms. The note also did not indicate that other interventions/treatments were attempted for pain/symptom relief. There was no evidence that RN H asked the patient about the effectiveness of the Fentanyl patch. Record review of Hospice IDG (team which is responsible for development, review, and update of the patients plan of care) Comprehensive Assessment and POC Update Reports for Patient #11 dated 07/07/22 and 07/21/22 did not indicate patients pain was addressed. Further review revealed there was no documented evidence at the IDG meetings that the patients medication was to be stored in a lock box, that agency RN was to refill it every three days, and there was no discussion about the patients pain medication and/or pain. Further review revealed there was no documented evidence that the agency optimized comfort for the patient and addressed intervention/treatments as Patient #11 continued to have 8-10 out of 10 pain. Record review of a discharge report indicated Patient #11 expired at home on 11/30/22. During an interview on 03/09/23 at 8:51 a.m., RN H said Patient #11 was non-compliant with taking his pain medication. She said his opioid pain medication was left in a locked medication box and kept them at the office, and she left his other pills for him at his home. RN H said she would fill his medication planner every 3 days and she would transport the locked medication box that was stored in a locked closet at the Texarkana drop off site to his home and then back to the office. She said she did not remember if it was discussed in an IDG meeting or not about placing medications in a locked box and being kept at the office. During an interview on 03/09/23 at 11:08 a.m., the Supervising Nurse said Patient #11 medications were placed in a lock box and kept at the patients house. She said she did not remember if the lock box was kept in Texarkana. The Supervising Nurse said the agency did not continue to fill patients Oxycodone. During an interview on 03/09/23 at 12:42 p.m., the Supervising Nurse said Patient #11 was a trouble patient and lived in a bad neighborhood with previous break-ins. She said the medications were placed in a lock box in a locked room at the patients home after medication was missing. During an interview on 03/09/23 at 1:23 p.m., the Supervising Nurse said if the agency received a referral on a patient in area that was not good, they would put the patients medications in a lock box. During an interview on 03/09/23 at 2:30 p.m., the Administrator said the SN would lock up a patients medications with permission depending on the situation, such as abusing of medication or unsafe environment. During an interview on 03/09/23 at 3:45 p.m., the Supervising Nurse said no consent was signed or doctor order received when patients medications were locked up. She said the SN would just let the doctor know. During an interview on 03/09/23 at 3:47 p.m., RN H said Patient #11s medication lock box was stored in his house and when done she would store it in Texarkana office in a locked room between patients use. She said she went and filled patients medications 3 days at a time. She said medications were locked in a room or freezer and the medications never left the home. During an interview on 03/10/23 at 8:56 a.m., Patient #11s family member said Patient #11 was on oxycodone (pain reliever) for years and that was the only thing that kept him functioning and helped control his pain. She said his pain medication was stolen so RN H put his medications in a lock box at the house. She said the home was broken into and the medications were stolen again, so RN H had Patient #11 taken off Oxycodone and put him on a Fentanyl patch that did not help with the pain at all. She said RN H also put Patient #11s medications in a lock box and took them to the agencys office and kept them and would fill his medication box every 3 days. Patient #11s family member said Patient #11 got a small dose of Morphine in his box every 3 days, but it did not help his pain. Patient #11s family member said she nor the patient agreed with placing the medications in a lock box at the office but was told patient would be taken off hospice if they did not allow it. She said called the agency several times after hours because patient would be in so much pain and he was told almost every time to take deep breaths and a shower. She said there were no in person visits to assess the pain. Patient #11s family said RN H would not allow patient to be put back on Oxycodone and the family member and patient asked over and over because of his severe pain. The family member said the day before patient died RN H put 2 Fentanyl patches on him. During an interview on 03/15/23 at 12:38 p.m., RN H said Patient #11 was a complicated case and he had major anxiety. She said she felt like he was always in some kind of pain. RN H said Patient #11 had severe pain in his chest, back, and he hurt all over and couldnt function or get out of bed. She said he always had pain which was the reason from switching patient from Oxycodone to the Fentanyl patch. During an interview on 03/15/23 at 12:42 p.m., MD N said medications would not be locked up under any circumstance except maybe in a pain control kit. She said the medications went straight from the pharmacy to the patients home and were not kept in the office. MD N said the nurses give the medications to the patient and did not keep them. MD N said the nurses have never told her they locked up a patients medications and she was not sure the protocol on that. She said she was not aware that Patient #11s medications were being locked up and that she knew the nurses were counting his medications and prefilling a planner for a certain number of days due to a history of some issues with the patient. MD N said the agency often had difficulty controlling Patient #11s pain and tried alternate treatments. She said patient had a history of drug abuse and medications missing but the agency wanted to treat pain the best they could without discriminating. She said she could not remember why he was taken off Oxycodone and put on a Fentanyl Patch since it had been some time ago. She said maybe it was because he would run out before his refill was due, so the medication didnt seem to control his pain. MD N said she believed she did order PRN medications but couldnt remember. MD N said Patient #11s pain was discussed during IDG meetings. She said Patient #11 had all over body pain and the agency tried different treatments for physical and emotional pain and wanted to manage the pain the best they could. During an interview on 03/15/23 at 1:06 p.m., RN H said Patient #11 was taken off Oxycodone and put on a Fentanyl patch. She said if one medication was not working the agency would try something different. During an interview on 03/15/23 at 1:09 p.m., NP O said only completed patients face to face visits and did not write orders, she said MD N did that. NP O said medications would be locked up if patient lived in an unsafe home, unstable home, the patient was taking more than they should. She said it was a trust thing honestly. NP O said some patients neighborhoods are not the best and they have to lock the medications up. She said she was pretty sure needed a doctor order to lock up medications because it was part of patients rights. NP O said she was pretty sure the POC would reflect if a patient had a medication lock box. NP O said she knew Patient #11s medications were locked up, but she was not sure if that was just the agencys decision. NP O said medications would never be taken from a patients home and she had never seen or heard of the nurses doing that. NP O said Patient #11 was a difficult patient. She said nurses would notify MD N for any issues because she did not write orders or prescriptions. NP O said she only saw Patient #11 one to two times and he did not appear to be in distress or pain that medication could not control, she said she would have notified MD N if so. NP O said she did not attend IDG meetings. During an interview on 03/15/23 at 1:37 p.m., RN H said she called the doctor about Patient #11s pain level and he was put on a Fentanyl patch to try to control the pain. She said patients pain was always 10 out of 10 and she notified the doctor each time. RN H said she documentation may have been in IDG, but she did not really know. She said Patient #11s medication lock box consisted of everything but patients normal medications. She said medications locked up were opioids and pain medications, and medications that could be stolen because he did not live in the best neighborhood. RN H said she never dealt with a patients medications being locked up before and this was her first interaction with that. She said she was just doing what she was told to do and did not know what the protocol was. RN H said Patient #11 stated this is what I live with (regarding pain) and he knew he was always going to be in that type of pain due to his condition. RN H said patients pain was always the same and patient was very aware of his condition. RN H said Patient #11's POC should have included a pain assessment, if patient was on oxygen, bowel and nutrition status, respiratory and skin status. She said Patient #11's POC should have included for the patient to notify if pain was out of control and when to notify the agency. She said the POC should be specific to each patient. During an interview on 03/15/23 at 2:05 p.m., the Supervising Nurse said the doctor was notified anytime a new order was needed or there was a change in the patient. She said Patients 11's POC should have included any updates and changes in patient. She said the POC was patient specific and should include a pain assessment including type, frequency, location, duration, what the agency was doing to keep patient comfortable to manage pain. She said interventions listed on Patient #11's POC should have included pain medications, when to call the doctor, ensuring patient was comfortable, and if the patient was on oxygen. The Supervising Nurse said measurable outcomes on Patient #11's POC should have included how to rate the pain, including a pain scale. She said goals should include goals the agency can meet, and the patient was comfortable with. The Supervising Nurse said the POC was created by the SN that did the admission and then she would approve the POC. She said updates to the POC were made by the SN who saw the patient and was updated with each change. Review of a Clients Rights and Responsibilities – Texas policy dated 04/27/20 indicated ";...3. The notice of the clients rights and responsibilities includes, but is not limited to, the clients right... f. to receive effective pain management and symptom control..." Review of a Pain and Symptom Management policy dated 04/27/20 indicated ";1. Policy: The interdisciplinary team ensures the clients right to receive effective pain management and symptom control from the hospice for conditions related to the terminal illness... 6. If the client is not receiving relief from the current pain medication or dosage, the nurse notifies the Hospice Medical Director, and/or attending physician or allowed practitioner, and cries out the recommended action(s) ordered by the physician or allowed practitioner... 8. Guidelines and/or protocols are developed for the assessment and management of common physical symptoms that are addressed by the interdisciplinary team in the clients plan of care, including, but not limited to: a. dyspnea; b. nausea and vomiting; c. anorexia and weight loss; d. anxiety and confusion; e. pressure ulcers; f. constipation; g. fatigue; h. restlessness and agitation; and i. sleep disorders..." Review of a Plan of Care policy dated 04/27/20 indicated ";1. Policy Overview: The care and services provided to clients and their families are in accordance with an individualized, written plan of care established by the hospice IDG in collaboration with the clients attending physician... 2. Procedures: 1... The clients plan of care specifies the care and services necessary to meet the needs of the client/family as identified in the initial, comprehensive and updated assessments of the client..." Review of a Plan of Care – Content policy dated 04/27/20 indicated ";1. Policy Overview: The plan of care reflects client and family goals and interventions that are based on the problems identified in the initial, comprehensive and updated assessments. 2. Procedures: The clients plan of care includes all services necessary for the palliation and management of the terminal illness and its related conditions. 2. The plan of care includes, but is not limited to: a. interventions to manage pain and symptoms... c. measurable outcomes anticipated from implementing and coordinating the plan of care..." Review of a Coordination of Services policy dated 04/27/20 indicated ";The IDG ensures that there is a coordinated and effective ongoing sharing of information amongst and between all disciplines, with all contracted services provided and in all settings... 2. An assigned hospice RN coordinates the clients plan of care and facilitates the ongoing sharing of information with the attending physician or allowed practitioner..."