Every finding on record at Craven Co Hlth Dept Hh & Hospice

Based on emergency preparedness review and staff interviews, the agency failed to include an all hazards risk assessment. Findings included: --- A review of the agencys emergencies preparedness program was conducted on 10/09/2024. There was no evidence of the required all hazards risk assessment. An interview conducted on 10/09/2024 at approximately 9:35 AM with quality assurance and performance improvement nurse #8 revealed that the all hazards risk assessment was under development and a meeting was scheduled to complete it.

Based on agency policy, record review, and staff interviews, the plan of care failed to include wound care orders for 1 of 3 patients with wounds (patient #3); and for tracheostomy care for 1 of 1 patient with a tracheostomy (artificial airway) (patient #8) in the plan of care. Finding included: --- A policy The Plan of Care (revised 02/2015) received on 10/07/2024 at approximately 12:00 PM from the agency director stated, ";The written plan of care will contain... Drugs and treatments. Physician (or other authorized licensed independent practitioner) orders." Patient #3, a facility resident, was admitted on 04/06/2024 with a diagnosis of Alzheimers disease. The plan of care for 07/05/24-10/02/24 included orders for skilled nurse (SN) visits 1 time a week for 12 weeks and 14 PRN (as needed). Review of the clinical record revealed registered nurse (RN) #10 documented the following information on 07/30/24, ";Skin integrity: Wounds/Lesions/Decubiti [pressure ulcer] assessed." Review of the plan of care revealed no order for wound care. RN #10 was not available for an interview. Patient #8 was admitted on 09/14/24 with a diagnoses of malignant neoplasm of larynx (cancer of the area of the throat used for breathing, swallowing, and talking) and encounter for attention to tracheostomy." During the registered nurse (RN) visit of 09/14/24 RN #3 stated, ";Tracheostomy in place. CG [care giver] is performing trach care/change inner canula daily." Review of the plan of care revealed no order for tracheostomy care. An interview conducted on 10/08/24 at approximately 4:00 PM with the clinical manager RN#3 revealed that the agency does not include orders for treatments in the plans of care that the caregiver, families, or facility staff are completing.

Based on direct observation, job description review, aide training handout review, agency policy review, clinical record review, and staff interview, the hospice aide failed to observe standard safety practices while providing care and performed tasks that were not on the aide care plan and for 1 of 1 observed aide visit (Patient #11). Findings included: --- 1. An aide education handout titled ";Assisting with ADLs [activities of daily living]" was received from the clinical manager on 10/09/24 at approximately 11:25 AM. This policy revealed, ";Assisting with mobility and bathing requires detailed attention to safety due to the risk of falls or injury..." A policy titled ";Hospice Aide Training" and revised 04/13 was received from the clinical manager on 10/09/24 at 11:37 AM. This policy revealed, ";The competency evaluation program will be conducted annually and will include observation of performance of the following skills...appropriate and safe techniques in personal hygiene and grooming..." Patient #11 was admitted to the agency 06/21/24 with a primary hospice diagnosis of prostate cancer. The Plan of Care (POC) from 09/19/24 to 12/17/24 revealed orders for skilled nursing one time per week for 13 weeks, medical social worker one time per month, hospice aide one time per week for 13 weeks, and respite aide one time per week for 13 weeks. On 10/08/24 at approximately 10:30 AM, Employee #7, hospice aide, conducted a home visit for Patient #11 which was observed. Employee #7 was observed leaving the room to obtain clean water while the patient was positioned to the right side of the bed, the right side rail was down, and the bed was in high position. While Employee #7 was out of the room, the patient was observed moving in bed as if he planned to get up. In an interview on 10/09/24 at approximately 10:15 AM, Employee #7 acknowledged that lowering the bed and putting the side rail up was ";overlooked" and should have been done prior to leaving the room. In an interview on 10/09/24 at approximately 10:20 AM, Employee #3, clinical manager, stated that the expectation would be ";...the bed is lowered, and the bed rail is up..." and ";That is a safety issue." 2. The Hospice II Position Description Form revised 09/24, was received from the agency director on 10/09/24 at 9:00 AM. This policy revealed, ";A written plan of care on each patient outlines specific procedures and activities to be performed. Special instructions are given for special tasks." On 10/08/24 at approximately 10:30 AM, Employee #7, hospice aide, conducted a home visit in which she was observed applying barrier cream to the patients coccyx (tailbone) area and a roll-on topical analgesic (pain medication) to the patient's left shoulder. In an interview on 10/09/24 at 10:15 AM, Employee #7 stated that instructions to reinforce the patients coccyx wound dressing was previously on the aide care plan but she did not know if the barrier cream was on the current aide care plan. Employee 7 stated, ";I dont make the care plan, so I dont know [if the barrier cream or topical analgesic application is on the care plan] ...He said his shoulder was hurting... He made the complaint about his joint hurting, and I put his [brand name of topical analgesic] on..." In an interview on 10/09/24 at approximately 10:20 AM, Employee #3, clinical manager, stated, ";Everything... should be on the med [medication] list because it [barrier cream and topical analgesic] is a topical medication and it should be on the aide care plan to use."

Based on policy review, clinical record review, and employee interview, the agency failed to provide an accurate medication list to the skilled nursing facility during a respite stay for 1 of 3 patients (Patient #2). Findings included: Policy H:2-030.1 titled The Plan of Care was received from the Employee #1, the Clinical Manager, on 12/07/21 at 1:54 PM and revealed, "The Case Manager (or admitting registered nurse) will then notify the attending physician ...of the initial assessment findings, the identification of patient needs and the recommended services to meet those needs. The plan of care will be reviewed prior to care being delivered ...Care provided to the patient will be in accordance with the plan of care." Policy H:2-014.1 titled Physician Services-Attending Physician Role was received from Employee #1, the Agency Director, on 12/07/21 at 11:54 PM and revealed, "Communication between the attending physician and other members of the interdisciplinary group will be ongoing and documented in the hospice clinical record ...The plan of care will be developed by the hospice registered nurse, the patient and family/caregiver, attending physician, and the hospice Medical Director after the initial assessment is performed and prior to start of care." Patient #2 was a transfer from another hospice agency and was admitted on 09/03/21 with a principal diagnosis of Alzheimer's disease. Hospice Certification and Plan of Care from 09/03/21 to 10/04/21 revealed orders for skilled nursing 1 time per week for 9 weeks, social work 1 time to evaluate and assess for emotional support and community resources, and chaplain 1 time for assessment of spiritual needs. Hospice admission narrative note of 09/03/21 revealed, "Medications reviewed with husband/CG (caregiver), profiled with [name of pharmacy], and no meds (medications) ordered at this time. [Patient #2's spouse's name] states he does not use any medications previously ordered and that [Patient #2] takes no medications on a daily basis." Medications on the Hospice Certification and Plan of Care from 09/30/21 to 10/04/21 include the following: acetaminophen 650 milligram suppository per rectum every 6 hours as needed for fever; bisacodyl 10 milligram suppository insert 1 suppository per rectum daily as needed for constipations [sic] if no BM (bowel movement) 3 days; haloperidol 2milligrams per milliliter, give 0.5 milliliter sublingual every 6 hours as needed for agitation, hyoscyamine 0.125 milligram tablet every 4 hours as needed for excess secretions; ibuprofen 600 milligram tablet, take 1 tablet by mouth every 8 hours as needed for pain; lorazepam 0.5 milligrams every 6 hours as needed for anxiety; methocarbamol 500 milligram tablet by mouth three times daily; morphine concentrate 20 milligrams per milliliter solution, take 0.25 milliliters by mouth every hour as needed for pain or shortness of breath; prochlorperazine maleate 10 milligrams by mouth every 6 hours as needed for nausea/vomiting; quetiapine 25 milligram tablet by mouth two times daily The agency coordinated a respite stay for Patient #2 from 09/20/21 to 09/27/21 with a contracted skilled nursing facility. The NC Medicaid Long Term Care FL2 Form which contains the admitting orders was provided to the skilled nursing facility prior to the respite stay and included the aforementioned medications. The Medication Administration Record from the skilled nursing facility for dates 09/01/21 to 09/30/21 revealed that Patient #2 received the following medications during the respite stay: quetiapine 15 total doses received 09/20/21 through 09/27/21 methocarbamol 23 total doses received 09/20/21 through 09/27/21 lorazepam 7 total doses received 09/20/21 through 09/25/21 and 09/27/21 haloperidol 5 total doses received 09/20/21 through 09/23/21 and 09/27/21 ibuprofen 1 total dose received 09/23/21 A PRN (as needed) On-Call SN (skilled nursing) visit note of 09/27/21 revealed, "Patient's husband called to report patient had returned from [name of skilled nursing facility] and had multiple wounds and medications. SN arrived and found patient on the floor in the living room. Husband reports patient was brought into the house in a wheelchair and placed on the couch. Patient then fell off of couch and crawled across floor ...Patient noted to have multiple skin tears on bilateral calves and right elbow. +3 bilateral lower leg and pedal edema noted with weeping coming from wound on back of left leg. Patient also noted to have multiple bruises on left arm. Patient was seen on Friday where +1 edema was noted at ankles and 1 small, nickel sized blister was noted on back of right knee and skin tear to right elbow was noted. Patient was able to ambulate through her home before going to the facility and had to have maximum assistance getting into bed at this time ..." In an interview on 12/07/21 at approximately 1:00 PM, Employee #2, the Clinical Manager, stated, "Medication review should be done every visit ...when he [Patient #2's spouse] said that he was not giving the medication, they should not have been a medication list." In an interview on 12/07/21 at 2:38 PM, Employee #4, the Medical Director, stated, "The assumption is that the medications are assisting in keeping the patient in a stable state. If she [Patient #2] was in a stable state without taking the medications but they were still on her list, that would be a problem." In an interview on 12/07/21 at 4:35 PM, Employee #3, the Registered Nurse Case Manager, stated, "The medications profiled were received from the previous hospice's paperwork. I may have mentioned it [Patient #2's spouse was not giving her any medication on a regular basis] in report but I did not specifically seek out a doctor ...I did call and speak to the facility nurse to give report [prior to respite stay] ...I did tell her [the skilled nursing facility nurse] that she [Patient #2] wasn't taking any medications and the nurse said, 'oh I remember her' ...Now, I know that I should go to the doctor and discuss the medications, as needed ones as well, if I don't believe they're appropriate."

Based on clinical procedure policy review, clinical record review and staff interview, the agency failed to follow the agency's clinical procedure and failed to document a physician's order regarding a needle change, administration set change, or a dressing change for 1 of 1 patients with an implantable vascular access device (Patient #8). Findings included: Clinical procedure policies titled Management of Implantable Vascular Access Devices (IVAD) and Intravenous Pain Management were received from the Clinical Manager on 10/20/21 at 9:35 AM. These policies revealed, "Connect IV (implantable vascular) infusion tubing to extension tubing, open clamp and regulation IV infusion as ordered ...Change the needle every 7 days" and "Change peripheral and central primary administration sets (the tubing used to connect the medication and the patient) every 72 hours, immediately upon suspected contamination or when there is question of system integrity" respectively. Patient #8 was admitted to the agency on 10/05/20 with malignant neoplasm of head of pancreas (pancreatic cancer). Plan of Care dated 10/05/21 to 01/02/22 revealed an order for skilled nursing 1 time per week for 13 weeks with 14 PRN (as needed) for crisis intervention. The skilled nursing visit note of 10/05/21 revealed that the Employee # 3, the admitting registered nurse, connected the patient to the hydromorphone (pain medication) using a portable infusion pump. The medication was being administered into the patient's implantable vascular access device. "I (Employee # 3) flushed and attached the (name of device) pump to begin PCA (patient controlled analgesic, which allows the patient to press a button on the portable infusion pump to receive additional doses of pain medication as needed) availability of hydromorphone." A PRN skilled nursing visit note of 10/17/21 made by Employee #3 revealed, "My primary purpose for visit is to change medication bag [sic]." There is no evidence in the clinical record of a needle change or a change to the administration set prior to the 10/17/21 visit and there is no evidence in the clinical record of a physician's order for the needle change, administration set change or dressing change. In an interview with Employee #2, the Clinical Manager, on 10/19/21 at approximately 3:25 PM, Employee #2 stated, "The nurse (Employee #4, the nurse case manager) talked to the doctor and he told her that it could be changed every 30 days but she didn't document it. She should have documented it." In an interview with Employee #3, the nurse who made the 10/05/21 and 10/17/21 visits, on 10/19/21 at approximately 4:10 PM, she sated "Yes, the tubing was changed at the time (the visit of 10/17/21) and as far as the physical order ...we discussed it in meeting Friday morning and I was on call so I had a verbal order ...the dressing and the (brand name) needle were intact and everything was running fine. The wife did not want it changed at the time. I don't know if I put it in the note or not. I don't see it in the note right now." In an interview with Employee #4, the Nurse Case Manager, on 10/20/21 at 8:45 AM, Employee #4 stated, "We were going to change the tubing when we changed the bag. We were going to reaccess his port and everything at that time. After discussion with the wife and assessing his condition, she did not want us to reaccess (change the needle) the site because he also had agitation and changing the needle would have been uncomfortable. I did not put it in the chart."

Based on clinical record review and staff interview, the agency failed to increase the visit frequency order for 1 of 13 records reviewed (Patient #8). Findings included: Patient #8 was admitted to the agency on 10/05/20 with malignant neoplasm of head of pancreas (pancreatic cancer). Clinical record review revealed the Plan of Care dated 10/05/21 to 01/02/22 with an order for skilled nursing 1 time per week for 13 weeks with 14 PRN (as needed) for crisis intervention and an order effective 10/10/21 for skilled nursing 3 times per week and 14 PRN for crisis intervention for remaining certification period. Patient #8 received skilled nursing visits on the following dates: 10/05/21 x2, 10/06/21, 10/07/21, 10/08/21, 10/10/21, 10/11/21 x3, 10/12/21, 10/13/21, 10/14/21, 10/16/21, 10/17/21, 10/18/21. In an interview on 10/20/21 at 8:45 AM, Employee #4, the Nurse Case Manager, stated, "I had not quite officially increased his visit frequency because I planned to get him (Patient #8's nursing visit frequency) down to 3 days a week . Last week (Employee #2, the Clinical Manager's name) and I had a discussion about it (Patient #8's nursing visit frequency). In an interview on 10/20/21 at 9:00 AM, Employee #2, the Clinical Manager, stated that she had noted how frequently Patient #8 was receiving skilled nursing visits and had advised Employee #4 that she should increase Patient #8's visit frequency due to the number of nursing visits that he was receiving.