Every finding on record at Drc Health Systems LP

Based on record review and interview the agency did not ensure that the nursing needs of the client were met as identified in the patients initial assessment, comprehensive assessment, and updated assessments in that the nurse did not ensure that the foley catheter was in the bladder of the patient upon insertion before inflating the balloon in 1 of 4 patients reviewed. (Patient #1). This failure could lead to urethral injury to the client, including bleeding and pain. --- Review of patient #1s clinical record it was revealed that the patient was a 79 year old man with a diagnosis of Malignant Neoplasm of Right Bronchus (a passage or airway in the lower respiratory tract that conducts air into the lungs) with metastasis (cancer has spread to a different part of the body part than where it started) to brain and bone. He was admitted to hospice on 10/01/23 from the hospital. Patient #1 came to the Hospice from the hospital with a Foley catheter in place (a medical device that helps drain urine from the bladder). A review of the clinical record revealed an order dated 10/03/23 from the physician to change the Foley catheter every 30 days. Review of the SN clinical note dated 10/11/23 revealed a statement by RN A as follows: ";RN changed 16 F (French gauge is commonly used to measure the size of a catheter) coude (a curved tip or slightly angled catheter that is sometimes needed when a straight tip catheter is not easily inserted) with 15 cc. Pt tolerated well." Review of literature: Academy of Medical-Surgical Nurses, November 16, 2016. ";Record the date and time of insertion, size and type of catheter used, and amount of sterile water used to inflate the balloon." In a telephone interview with RN A on 10/18/23 at 1:30 pm, she stated that on the skilled nursing visit on 10/09/23 a family member requested the catheter be changed on the next visit. RN A stated that she checked with the medical director and he told her it was ok to change the catheter early. She stated she removed the old catheter and placed the patient in a prone position. She then inserted the foley until it would advance no further. She then inflated the balloon with 15 cc of sterile water. Surveyor inquired if there was any return urine in the tube when the catheter was inserted. She stated no, there was no urine return. She stated she has inserted many catheters in her career. She stated that she had never had any problem. She stated if she does not get urine return she would turn the patient on his side but she did not turn the patient this time as he was in too much pain. She stated she did not notify the doctor or the nursing supervisor. RN A stated she did tell the family member if no urine had drained in the bag by later in the day to call the agency. Review of skilled nursing note of RN B written on 10/11/23 at 11:00 PM revealed that patient was experiencing pain and there was no urine output in the foley bag. RN B noticed there was blood around the tip of the catheter. She deflated the balloon and removed the foley and blood clots came out. RN B tried to reinsert the catheter but was unable to, she notified the physician and was told to send the patient to the hospital. In an interview with RN B on 10/18/23 at 2:00 PM she stated that she received a call from the triage nurse that the patient was in lots of pain. She arrived around 11:00 pm on 10/11/23. The family member told her she thought the pain was because of the catheter. She noticed there was no urine in the bag. She stated she deflated the balloon and removed the catheter. She stated she saw blood clots then but no return of urine. She tried to reinsert the foley but was unable to, she stated there was too much resistance. She stated that the family member told her the patient had prostate problems. She called the physician and he told her to send the patient to the hospital. Review of literature: Dr. Lewis Porter. OSCE , February 23, 2014, updated October 22, 2023 ";Once the catheter is fully inserted, inflate the catheter balloon with the ordered amount of sterile water to secure it within the bladder. Before doing this, ask the patient to let you know immediately if they experience any discomfort as you inject the water. If the patient begins to experience discomfort during the injection of the water stop immediately as this may indicate the tip of the catheter is within the urethra." Agency Nursing Procedure entitled ";Indwelling Urinary Catheter (Foley) insertion," dated November 27, 2022, stated in part: ";Clinical alert: Never inflate a balloon without first establishing urine flow, which ensures that the catheter is in the bladder."

Based on record review and interview, the hospice failed to respect the client's right to participate in planning care or treatment and be told of any change in care or treatment for 1 of 1 active patient (#2) whose record was reviewed, in that: The hospice changed the hospice aide visits from 3 visits per week to 2 visits per week for patient #2 without notifying the client or family. This failure has the potential of the hospice not meeting the needs of the client by not involving the client and family members in the developing of the patient's plan of care. --- Findings included: Patient #2 Review of the physician order #1105863, dated 9/1/2022 for certification period 9/3/2022 to 11/1/2022 showed a terminal diagnosis of Alzheimers disease. The physician order showed the following calendar frequency for HHA of 3wk8 (three times per week for eight weeks) and 1wk1 effective 09/04/2022. The physician order was electronically signed by MD A. Review of the physician order #1112288, dated 9/9/2022 and signed by the DON and MD A showed HHA 2x1wk (twice a week for 1 week) per family request. Review of the physician order #1112993, dated 9/12/2022 and signed by the DON and MD A showed HHA 2x1wk (twice a week for 1 week) per family request. Review of the physician order #1114357, dated 9/15/2022 and signed by the DON and MD A showed HHA 2xwk (twice a week). Review of the HHA clinical notes showed the following: For the week of 9/4/22 to 9/10/22 Patient #2 received 1 HHA visit. For the week of 9/11/22 to 9/17/22 Patient #2 received 0 HHA visit. For the week of 9/18/22 to 9/24/22 Patient #2 received 2 HHA visit. For the week of 9/25/22 to 10/1/22 Patient #2 received 2 HHA visit. For the week of 10/9/22 to 10/15/22 Patient #2 received 2 HHA visit. For the week of 10/16/22 to 10/22/22 Patient #2 received 2 HHA visit. For the week of 10/23/22 to 10/29/22 Patient #2 received 1 HHA visit. During interview on 11/29/22 at 12:50 p.m. with Family Member B, she was asked for the HHA visit frequency for Patient #2. Family Member B stated that initially, the hospice stated it was Monday, Wednesday, and Friday then it changed to Tuesday and Thursday. Family Member B was asked if the family requested the HHA visit frequency to twice a week and Family Member B stated ";no, we never did. We want her to be bathe three times a week." During interview on 11/29/22 at 1:50 p.m. with the DON, she was asked why the HHA visit frequency was changed for Patient #2. The DON stated that it was per family request. The DON was asked if she talked to the family about decreasing the visit frequency for the aide and the DON stated no, she believed she talked to HHA A. The DON stated that she didnt have documentation about speaking with HHA regarding decreasing the visit frequency for Patient #2. During interview on 11/29/22 at 2:52 p.m. with HHA A, she was asked why the HHA visit frequency was changed to twice a week for Patient #2. HHA A stated that she was not sure why. HHA A was asked if the family requested a change in the HHA visit frequency and HHA A stated ";I dont know, I was only covering that area at that time." Record review of the hospice policy titled "Service Delivery Patient Rights" with a reviewed date of 11-03-2022 reads in part: "Exercise these rights any time as a patient of the Agency. Or have the person appointed by law exercise these rights when the patient has been judged incompetent...... Participate in planning the care and treatment and any changes. Be informed, in advance of the care to be provided, the disciplines who will provide the care, the frequency of the visits proposed, and Hospice levels of care (for Hospice patients only), any changes in the care before the change is made, expected outcomes of the care provided and barriers to treatment."

Based on record review and interview, the hospice did not make sure care was provided according to the IDT written plan of care for 1 of 3 discharged patients (#1) whose records were reviewed. The hospice failed to meet the patient physical and psychological needs and place his family in distress. --- Findings included: Record review of HHSC Consumer Rights and Services Complaint Investigation Worksheet #384337 noted in TULIP dated 10/21/2022 read in part: ";PATIENT #1 WAS NEVER SEEN BY A CHAPLAIN, WHO WAS NEWLY HIRED AND SUGGESTED TO CONDUCT AN OVER THE PHONE VISIT. [FAMILY MEMBER] INSTEAD OPTED TO OBTAIN A PERSONAL CHAPLAIN. THE SOCIAL WORKER RESIGNED AND WAS NOT ABLE TO INTERVENE. CONCERNS WERE ADDRESSED WITH THE ADMINISTRATOR WHO NEVER MADE CHANGES, ALONG WITH ADMITTING THE AGENCY WAS SHORT STAFFED." Patient #1 Record review of the IDT written plan of care for benefit period 6/9/22 to 9/6/22 showed a start of care date of 6/9/22 and the diagnoses of heart failure, hypertension, respiratory failure.... The plan of care showed the following orders for frequency /duration of visits: SN 2wk13 (twice a week for thirteen weeks) and 1wk1 (once a week for one week) MSW 1 evaluation visit to assess psychosocial needs CH 1 evaluation visit to assess spiritual needs The plan of care showed the following orders for discipline and treatments: Hospice nurse to observe and assess psychological, cognitive, and behavioral symptoms, and instruct patient/caregiver on interventions designed to properly palliate symptoms. MSW to evaluate patient and develop plan of care to be signed by physician. Chaplain/clergy to evaluate patient and develop plan of care to be signed by the physician. The plan of care was electronically signed by RN A and MD A. Review of physicians order #1084621 and dated 6/10/22 read in part: ";assess emotional/spiritual preparation of imminent death, provide hospice team support as needed. CH effective 06/09/2022 2M3 (twice a month for three months). The order was signed by Chaplain A and MD A. Review of physicians order #1085654 and dated 6/14/2022 read in part: ";SN effective 06/12/2022 5wk1 (five times for one week), 2wk11 (twice a week for eleven weeks), 1wk1, 1 PRN for symptom management. Review of physicians order #1090837 and dated 6/30/22 read in part: ";Telehealth visit MSW visit x1 (one visit). The order was signed by RN B and MD A. Review of physicians order #1095244 and dated 7/15/22 read in part: ";Received a call from [family member] Add social worker visits and update chaplain schedule per [family member] request. MSW effective 07/01/2022 2M1 (twice a month for one month) 5M1 (five times a month for 1 month), 1M1 (one time per month for 1 month) CH effective 06/09/2022 1M1, 5Q2M2 (five times every 2 month), 1M1. The order was signed by the Administrator and MD A. Review of the MSW clinical notes showed services were provided in person on 06/13/22 and 07/19/22. Review of a MSW phone visit dated 07/19/22 signed by MSW A read in part: ";Social worker called [family member]. She expressed disappointment that Social Worker is not ";walking her thru this process". Social Worker has explained to [family member] twice now that this social worker is not assigned to [Patient #1], but is assisting the team with coverage and helping PRN. She did not appear satisfaction with this but social worker will continue to address issue as needed." Family member requested increase MSW visits for July of 2022 and Patient #1 and Family Member did not receive more MSW visits. Review of the Chaplain clinical notes showed an initial evaluation was conducted in 06/10/22. And a chaplain phone visit was conducted in 07/20/22 by Chaplain B. Further review of the chaplain phone visit read in part: ";family member voicemail stated that phone visits are not appropriate to patient due to mental capabilities, in person visits are needed, and her dissatisfaction with caregiving." Initial chaplain visit frequency of twice a month was not follow for June 2022. Also increase visit frequency was not follow for July of 2022 and the chaplain did not conduct in-person visits in July of 2022. Record review of the SN clinical notes for the week of 6/12/22 to 6/18/22 showed Patient #1 received 4 SN visits instead of 5 SN visits. Record review of SN note dated 07/22/22 signed by RN C read in part: ";Patient pronounced on 7/22/22 @1437. [Family Member] at bedside angry, crying, yelling at this nurse." During interview on 11/28/22 at 9:11 a.m. with Family Member A stated that she and Patient #1 needed more chaplain and social worker visits for end of life guidance. Family Member A stated that the chaplain requested for a telephone visit because she was in training but this was not acceptable to the family. Family Member A stated that these concerns were discussed with the hospice administrator. During interview on 11/29/22 at 9:24 a.m. with Chaplain B, she was asked why a telephone visit was made on 07/20/22 instead of an in-person visit to Patient #1. Chaplain B stated that the Houston office requested a phone visit to Patient #1. Chaplain B stated ";Im sure Houston location got approval from the family to do a phone visit." Chaplain B stated that she was filling in for Houston but worked at the Woodlands location. During interview on 11/29/22 at 9:35 a.m. with MSW A, she was asked why the visit frequency was not increased for Patient #1. MSW A stated that she was doing initial patient assessments in person for the Houston location. And she was doing regular visits as PRN or by telephone. MSW A stated, that in theory, she was supposed to do initial patient assessments and the other social worker was supposed to do the regular visits but she was the only social worker at the time. During interview on 11/29/22 at 10:05 a.m. with the Administrator and the DON, they were asked why the visit frequency was not followed for Patient #1 for the MSW, SN and the chaplain. The Administrator stated that they didnt have a chaplain at the time for the Houston location. The Administrator stated that at the time they lost their MSW and two chaplain quit at the same time. The Administrator stated that she notified the [family member] and the physician that they didnt have a social worker or a chaplain. The DON stated that she didnt recall why SN visits were not 5 times for that week [6/12/22 to 6/18/22]. No additional documentation was provided. Record review of the hospice policy titled ";Physicians role" with a reviewed date of 11-11-2022 reads in part: ";Staff develops and maintains the plan of care in consultation with the physician and follows established procedures. Care delivery follows the plan of care. Staff administers medications and treatments only as ordered by the physician."