Every finding on record at Compassionate Care Hospice of Ohio, LLC

It is required that nursing care and services are provided by or under the supervision of a Registered Nurse and per the patient plan of care. Nursing services ensure that the nursing needs of the Patient are met as identified in the Patient's initial assessment, comprehensive assessment, and any updated assessments. This standard was not met as evidenced by the review of organizational policy, clinical record review, and an interview. Agency policy (SC-004), "Hours of Operation and On-Call Service" (Revised 4/2011) read in part, "After business hours and on weekend and holiday, coverage is available twenty-four (24) hours a day, seven (7) days a week through an answering service and on-call procedure." In 1 of 3 (33%) records reviewed for patients who had expired, the Registered Nurse failed to provide palliation and symptom management during the last hours of life as identified during ongoing clinical assessments. Record #27067: The Patient was an 85-year-old whose diagnoses included Alzheimer's, Stasis Dermatitis bilateral lower legs, impaired functional mobility, decreased endurance, and incontinence. The Patient resided at a private residence living with his wife and daughter. On 9/17/2021, on-call RN (Record #43273) documented in relevant part, "Upon arrival, the Patient was found in bed resting with his left eye open. The Patient did not respond to voice or gentle touch on shaking the Patient. The Patient responded by opening his eye and looking around but would go back to having one eye closed, and his breathing returned to a regular rhythm." Further documentation revealed the following: "Patients' daughter was worried that the Patient was not comfortable. The daughter states that she thought the Patient would just lay there and be comfortable. I didn't realize that he (Patient) would move around and act like that. The daughter was asked what she thought the signs of the Patient's discomfort were? She (daughter) states that the Patient has occasionally been coughing and noted to yell out during the visit." The RN performed pain assessment, rated at a 0, on a scale of 0-10, taught on medication regimens, notified the physician, and received an order for artificial tears." Another visit on 9/17/2021, at 2:47 PM, RNCM (Record #81432) during this visit, documented in relevant part, "Patient in hospital bed, unresponsive, HOB (head of bed) up at 35 degrees, audible rhonchi noted. Patient was administered Levsin due to audible rhonchi. Taught daughter and paid caregivers the importance of repositioning every 2 to 3 hours to maintain skin integrity. Both were able to voice back and demonstrate said education." According to the "Client Medication Report," "Levsin 0.125 mg tablet had been ordered on 9/10/2021 by mouth/sublingual every 6 hours as needed for secretions." Further investigation revealed, later in the day, that the complainant (daughter) had called the hospice regarding her father's (Patient) decline on 9/17/2021, at 8:02 PM (actual call). Triage RN (Record #32719) at 9:35 PM, documented, "Daughter has been texting the hospice nurse (Record #81432) about the patient's rattling." Daughter has been provided Morphine, Lorazepam, and Levsin. 2 PRN hospice visits have been made already today. Action taken: Notified on-call RN (Record #68032); she will call daughter back [and] RN (Record #10062) already has a visit scheduled for tomorrow." The triage RN (Record #32719) notified the local on-call RN (Record #68032) to call the daughter. On 9/17/2021. At 9:56 PM, the daughter received a call back from the Triage RN (Record #32719). The complainant stated, "nurse was very short, uncaring, and detached" while speaking with her. When she (complainant) tried to explain the problem, the nurse reminded the complainant that she (nurse) had been well-trained, [and] didn't understand what her problem was in administering medications. The nurse suggested that she call 911 or call the office the following morning, assuring her that they (agency) would not come out to help administer meds. She (complainant) stated that she asked the nurse to read the notes and reminded her that two previous nurses had put the Patient on "end of day's watch" and that she could call for assistance at any time and that a nurse would come out for an assessment. The nurse on the phone insisted there were no such notes and that she was not coming out. The complainant stated that on the night of 9/17/2021, it was horrific as the death rattle began. The Patient was in a lot of pain, his medication would not stay in his mouth, and blood was oozing from his mouth – all of which the Patient's wife had to witness." The on-call RN (Record #68032), on 9/17/2021, at 10:09 PM, documented, "Per discussions with Patient's daughter, Patient has had increased secretions. RN reviewed the administration of Levsin. RN provided emotional support and encouragement to daughter. Per discussion with daughter, she understands that Levsin can be given SL (sublingual, under the tongue) and will dissolve. RN reviewed 24-hour contact information and capabilities. RN encouraged daughter to call with any questions that arise or concerns of change of condition." Later that morning, the daughter called the agency on-call and spoke with another triage nurse. On 9/18/2021 at 7:48 AM, Triage RN (Record #81619) documented, "Actual Time of call: 6:28 AM. Purpose of Call: Requesting assistance in care and meds and notified RN (Record #68032). At 07:20 AM, on 9/18/2021, RN (Record #77660) and on-call RN (Record #10062) arrived at the Patient's home. The on-call RN (Record #10062) documented in part, "Visit requested due to change in patient status/secretions unmanaged. Patient's daughter called over concern with changes that her father was going through. She stated that he was seen by RN yesterday during the day, who verbalized that patent was beginning to transition. Upon arrival, an audible death rattle, friend at the bedside who just bathed the Patient, changed the pad and applied cool washcloth to the forehead. Asked daughter if we could move out of cramped room to speak freely. Reviewed with daughter changes from last night, acknowledged concerns while validating frustration, offered support, and let her know that this RN would assess patient to discuss next steps in care. Invited Patient's wife and daughter to sit with Patient next to him and explained that agonal breathing precedes death. Patient passed peacefully with daughter and Patient's wife next to bedside. Wife and daughters grieving appropriately. Patient's wife was able to verbalize wishes of how long to sit with Patient and where she wanted to be in the house when funeral home arrived. Postmortem care provided, Funeral Home, Medical Director, and DOO notified of patient passing. Family denies additional support at this time and verbalizes appreciation of support. Time of departure 10:45 AM." However, the daughter (complainant) stated, in the complaint submitted to CHAP, that the two nurses arrived at 8:00 AM. Instead of assessing the Patient right away, they pulled her into the bathroom (away from the cameras in her home) and began questioning her with an attitude. They insisted the Patient be moved to a facility if unable to administer the medication – all in the presence of a witness, who stood in shock." In an interview, the Administrator/DOO (Record #26188), on 12/14/2021 at approximately 4:00 PM, indicated that when a patient/family calls the hospice, the call is routed to a Triage Center that is out-of-state. In other words, the calls go to a centralized location. The Triage Nurse then calls the on-call nurse to the appropriate location. The Administrator/DOO indicated that the Triage Nurse (Record #32719) had assigned the on-call nurse (Record #68032) a "telephone visit." The on-call nurse (Record #68032), during the phone visit, indicated that the complainant had not requested a visit to the home after providing teaching regarding the medications. Additionally, the Administrator/DOO (Record #26188) felt that the Triage RN should have sent the on-call out, and the RN on-call should have documented that the family did not request a visit. Also, the medication regimen prescribed to alleviate terminal symptoms was inadequate to meet the client's needs. The prescribed medications were apparently inadequate to alleviate symptoms in the terminal phase and should have been adjusted. Directly, PO tablets should have been replaced by sublingual, fast-release, liquid options. Also, there seems to be a gap in expertise as relates to the teaching forwarded to the family regarding the process of "Active Dying." In addition, the Administrator/DOO stated that the complainant had filed a formal complaint during a phone call on 9/20/2021. The complainant was expressing loudly verbal dissatisfaction and indicated that she was sitting with an attorney. The Administrator/DOO had documented several calls to the daughter on 9/24/2021, 9/28/2021, and 9/29/2021. The daughter returned the call back on 9/29/2021 and initiated a transfer of her mother to another hospice, who had been on the same hospice as this Patient (father).