Every finding on record at Hartford Healthcare at Home

Based on clinical record review, review of agency policies and interview with hospice personnel, for one of one patient (Patient #1) who resided in an Assisted Living Facility/ALF, the hospice agency failed to ensure effective pain management and symptom control for conditions related to the terminal illness. The finding includes: --- Patient #1 elected the Hospice benefits on 1/31/23. The patients diagnoses included coronary artery disease, hypoxia, and dementia. The patient resided at an assisted living facility. The physician's orders dated 1/31/23 included nursing services one to three times a week for assessments, hospice aide services, social work services and chaplain services. Physicians orders directed to administer Morphine Concentrate 20 milligrams/milliliter (mg/ml) every three hours by mouth as needed for pain or shortness of breath. On 2/3/23 at 5:54 PM, RN #1s (on call) nursing noted identified a telephone call from the next of kin indicating that the patient was very uncomfortable and requested the patient receive pain medication. RN #1 indicated that the ALF nurse needed to administer the medications. RN #1 called the facility and requested ALF LPN #1 to administer Morphine 5 mg/milligrams as ordered. Interview with RN #1 on 4/04/23 at 2:30 PM indicated that s/he called the ALF staff to administer the Morphine 5 mg and discussed with ALF LPN #1 scheduling the Morphine or keeping it as needed and thought nursing staff or medication technicians were available throughout the night to administer medications. On 2/5/23, the agency on-call logs identified a call was dispatched to on call RN #2 at 6:02 AM from the next of kin reporting foam was coming out of the patients nose and gurgling from the mouth. Subsequently, at 6:53 AM, the next of kin called RN #2 to report that the patient had passed away. Interview with RN #2 on 4/05/23 at 9:45 AM identified after receiving the call from the next of kin on 2/05/23 at 6:02 AM, s/he called the ALF to speak to a nurse about administering medications for the secretions, and was informed that there wasnt a nurse in the building overnight. Additionally, RN #2 indicated that there was no access to medications, so s/he didnt make a visit and was unaware of any Comfort Pak medications available for the Hospice nurse to administer to the patient. Interview and review of RN #1s and RN #2s phone visit documentation and the clinical record with the Director of Quality on 4/04/23 at 11 AM identified that a Comfort Pak was ordered at the hospital prior to discharge and then cancelled, agency nurses should have confirmed delivery and availability of the Comfort Pak for the Hospice nurses to access after-hours, and failed to ensure adequate pain and symptom management. Interview with next of kin #2 on 4/05/23 at 12:40 PM indicated that next of kin #1 arrived at the ALF on Friday, 2/03/23 and stayed with Patient #1 through the weekend, until 2/05/23. Kin # 2 indicated that the last dose of Morphine was given on 2/04/23 at 8 PM. The patient woke on 2/5/23 at 6 AM and was uncomfortable, and if medications were available to give, s/he would have given them. Review of the Hospice Pain and Symptom Management policy directed that the hospice nurse assesses the patients pain management and other symptoms as part of the initial assessment.

Based on clinical record review, review of agency policies and interview with hospice personnel, for one of three patients (Patient #2) in the survey sample, the hospice agency failed to provide services in a timely manner. The finding includes: --- Patient #2 was scheduled for admission to home care services on 3/09/23 with diagnoses including status epilepticus. Upon admission, per RN #4s assessment, the patient was unable to walk and had a glazed look on his/her face. The next of kin was informed by RN #4 that a home care admission was not appropriate, and a hospice evaluation was agreed upon. On 3/09/23, RN #4 called the Clinical Manager to schedule a Hospice admission. Interview and review of the clinical record on 4/05/23 at 9:40 AM with the Director of Quality identified that the Intake Department was notified of the Hospice referral on 3/09/23 by the Clinical Manager, and the physician request for a Hospice referral was dated 3/15/23 (six days later), and failed to ensure a timely initial evaluation within 24-48 hours of receiving the referral according to agency policies. Review of the agency policy for Admission and Acceptance directed an initial evaluation for patient admission shall occur within 24-48 hours of receiving a referral unless a later date is arranged with the referral source or patient.

Based on clinical record review, review of agency policies and interview with hospice personnel, for one of one patient (Patient #1) who resided in an Assisted Living Facility/ALF, the hospice agency failed to ensure that the primary caregivers received education and training about their responsibilities for care and services identified in the plan of care. The finding includes: --- Patient #1 elected the Hospice benefits on 1/31/23. The patients diagnoses included coronary artery disease, hypoxia, and dementia. The patient resided at an assisted living facility. The physician's orders dated 1/31/23 included nursing services one to three times a week for assessments, hospice aide services, social work services and chaplain services. Physicians orders directed to administer Morphine Concentrate 20 milligrams/milliliter (mg/ml) every three hours by mouth as needed for pain or shortness of breath. On 2/3/23 at 5:54 PM, RN #1s (on call) nursing notes identified a telephone call from the next of kin indicating that the patient was very uncomfortable and requested the patient receive pain medication. RN #1 indicated that the ALF nurse needed to administer the medications, and failed to identify care giver teaching for the administration of as needed medications, to manage pain and end of life symptoms. On 2/5/23, the agency on-call logs identified a call was dispatched to on call RN #2 at 6:02 AM from the next of kin reporting foam was coming out of the patients nose and gurgling from the mouth, and failed to identify care giver teaching for the administration of as needed medications to manage pain, and end of life symptoms including excess secretions. Subsequently, at 6:53 AM, the next of kin called RN #2 to report that the patient had passed away. Interview with RN #2 on 4/05/23 at 9:45 AM identified after receiving the call from the next of kin on 2/05/23 at 6:02 AM, s/he call the ALF to speak to a nurse about administering medications for the secretions and was informed that there wasnt a nurse in the building overnight. Interview and review of the clinical record on 4/05/23 at 12:00 PM with the Director of Quality identified that the hospice personnel failed to document/ensure caregiver teaching for medication and symptom management. Interview with next of kin #2 on 4/05/23 at 12:40 PM indicated that next of kin #1 arrived at the ALF on Friday, 2/03/23 and stayed with Patient #1 through the weekend, until 2/05/23 and if medications were available to give, s/he would have given them. Review of agency policies for patient/caregiver education directed members of the Inter-Disciplinary Team/IDT assess the patient and caregivers education and training needs based on the care being provided to the patient, as appropriate to each patient and caregiver. Verbal or written information may be provided related to hospice philosophy and benefit, the plan of care including services and treatments, signs and symptoms of approaching death, effective pain management, safe and effective use of medications including side effects, preparation and storage and disposal.

Based on clinical record review, review of agency policies and interview with hospice personnel for two of three patients (Patients #1 & #3) in the survey sample, the hospice agency failed to ensure the availability of nursing services on a 24-hour basis 7 days a week. The finding includes: --- 1. Patient #1 elected the Hospice benefits on 1/31/23. The patients diagnoses included coronary artery disease, hypoxia, and dementia. The patient resided at an assisted living facility. The physician's orders dated 1/31/23 included nursing services one to three times a week for assessments, hospice aide services, social work services and chaplain services. On 2/3/23 review of the on-call logs identified the next of kin requesting a call from the nurse ASAP, indicating 4 calls were made, and at 5:54 PM, RN #1s (on-call) nursing noted identified a telephone call from the next of kin indicating that the patient was very uncomfortable and requested the patient receive pain medication. RN #1 indicated that the ALF nurse needs to administer the medications. On 2/04/23, the agency on-call logs identified a call was dispatched to (on-call) RN #2 at 4:09 PM from the next of kin questioning when a nurse was coming to visit, but failed to identify documentation that RN #2 responded to the next of kin with the visit concerns. Subsequent interview with RN #2 on 4/05/23 at 9:45 AM indicated that the next of kin called, waiting for a nursing visit and indicated that nursing hadnt visited in a couple of days. RN #2 indicated that the next of kin didnt sound urgent for a visit and agreed to a visit the next day, 2/05/23. On 2/04/23, the agency on-call logs identified a call was dispatched to (on-call) RN #2 at 5:06 PM from the next of kin that s/he couldnt wake the patient up, but failed to identify a return call to the next of kin. On 2/5/23, the agency on-call logs identified a call was dispatched to on call RN #2 at 6:02 AM from the next of kin reporting foam was coming out of the patients nose and gurgling from the mouth. Subsequently, at 6:53 AM, the next of kin called RN #2 to report that the patient passed away. Interview with RN #2 on 4/05/23 at 9:45 AM identified after receiving the call from the next of kin on 2/05/23 at 6:02 AM, s/he call the ALF to speak to a nurse about administering medications for the secretions and was informed that there wasnt a nurse in the building overnight. Additionally, RN #2 indicated that there was no access to medications, so s/he didnt make a visit. Interview and review of the call logs and the clinical record on 4/05/23 at 11:40 AM with the Director of Quality identified that RN #1 and #2 should have made a visit to Patient #1 on 2/04/23 and 2/05/23, and failed to follow agency policies for on-call services available to the patient 24 hours a day. 2. Patient #3 elected the Hospice benefits on 1/6/23. The patients diagnoses included Alzheimers disease and dementia. The physician's orders dated 1/6/23 included nursing services one to two times a week for assessments, hospice aide services, social work services and chaplain services. On 2/04/23 at 10: 39 AM, the agency on-call log identified a call from next of kin #2 identifying that the patient passed away last night, s/he tried calling all night with no answer, so the police were called and the funeral home. Interview and review of the call logs and the clinical record on 4/05/23 at 12:40 PM with the Director of Quality identified that the agency was having issues with calls getting though and failed to ensure on-call services 24-hours a day. Review of the policy for On-Call services directed that patients have access to hospice services 24 hours per day, seven days a week and receive prompt telephone response when accessing On-Call services.

Based on clinical record review, review of agency policies and interview with hospice personnel for one of one patient (Patient #1) who resided in an Assisted Living Facility/ALF, the hospice agency failed to maintain professional management of the hospice care. The findings include: --- Patient #1 elected the Hospice benefits on 1/31/23. The patients diagnoses included coronary artery disease, hypoxia, and dementia. The patient resided at an assisted living facility. The physician's orders dated 1/31/23 included nursing services one to three times a week for assessments, hospice aide services, social work services and chaplain services. On 2/3/23 at 5:54 PM, RN #1s (on call) nursing noted identified a telephone call from the next of kin indicating that the patient was very uncomfortable and requested the patient receive pain medication. RN #1 indicated that the ALF nurse needed to administer the medications. RN #1 called the facility and requested ALF LPN #1 to administer Morphine 5 mg/milligrams as ordered but failed to inquire about the availability of 24-hour nursing in the ALF and/or availability of a primary caregiver to ensure adequate pain management throughout the night. On 2/5/23, the agency on-call logs identified a call was dispatched to on call RN #2 at 6:02 AM from the next of kin reporting foam was coming out of the patients nose and gurgling from the mouth. Subsequently, at 6:53 AM, the next of kin called RN #2 to report that the patient passed away. Interview with RN #2 on 4/05/23 at 9:45 AM identified after receiving the call from the next of kin on 2/05/23 at 6:02 AM, s/he call the ALF to speak to a nurse about administering medications for the secretions and was informed that there wasnt a nurse in the building overnight. Additionally, RN #2 indicated that there was no access to medications, so s/he didnt make a visit and was unaware of any Comfort Pak medications available for the Hospice nurse to administer to the patient. Interview and review of the clinical record on 4/05/23 at 10:40 AM with the Director of Quality failed to identify a Memorandum of Understanding/MOU was developed to address the hospices professional management of hospice services, the need for emergency medications available (Comfort Pak) for administration of medications after hours and the availability of a primary care giver. Interview with next of kin #2 on 4/05/23 at 12:40 PM indicated that next of kin #1 arrived at the ALF on Friday, 2/03/23 and stayed with Patient #1 through the weekend, 2/05/23 and if medications were available to give, s/he would have given them. Review of agency policies for hospice care for Nursing Facility residents directed that hospice assumes full responsibility for the professional management of the facility patients hospice care and routinely provides all core services.

Based on clinical record review, review of agency policies and interview with agency personnel for one of three patients (Patient #1) the hospice agency failed to follow agency policies and the Regulations of Connecticut State Agencies. The finding includes. --- Patient #1 elected the Hospice benefits on 1/31/23. The patients diagnoses included coronary artery disease, hypoxia, and dementia. The patient resided at an assisted living facility. The physician's orders dated 1/31/23 included nursing services one to three times a week for assessments, hospice aide services, social work services and chaplain services. Interview and review of the clinical notes with the Director of Quality on 4/05/23 at 10 AM failed to identify a Memorandum of Understanding/MOU between the assisted living facility staff and the hospice agency staff, to delineate responsibility for the patient ' s care and methods of communication to ensure coordination of care, in accordance with the Regulations of Connecticut State Agencies Section 19-13-D77 Administrative organization and records (g) (2). Review of agency policy for Memorandum of Understanding/MOU directed to the purpose of the policy is to assure delivery of the right service at the right time to the right patient. To assure service and treatments are in accord with systematic assessment of the patient and physicians orders. To delineate the expectations of each party involved in the patients care whenever there are two or more providers.

Based on clinical record review, review of agency policies and interview with hospice personnel, for one of three patients (Patient #1) in the survey sample, the hospice agency failed to provide services in a timely manner. The finding includes: --- Patient #1 elected the Hospice benefits on 9/08/22. The patient's diagnoses included bladder mass suspect malignant, weakness and renal insufficiency. Interview and review of the clinical record on 9/19/22 at 1PM with the Director of Quality, identified that the physician's referral was dated 8/29/22 (ten days earlier) and failed to ensure a timely initial evaluation within 24-48 hours of receiving the referral according to agency policies.Review of the agency policy for Admission and Acceptance directed an initial evaluation for patient admission shall occur within 24-48 hours of receiving a referral unless a later date is arranged with the referral source or patient.