Every finding on record at Heartland Regional Medical Center

Based on policy review, record review, and interview, the hospice provider failed to ensure that the comprehensive assessment identified the physical needs (specifically pain) related to the terminal illness, that must be addressed in order to promote the hospice patients well-being in one of five records reviewed (Record/Patient #5). This deficient practice has the potential to adversely affect the pain management of all patients served by the provider. --- Findings included: Review of the providers policy titled, ";Scope of Assessment/Reassessment", approval date: 06/11/2020, showed: - Assessment and reassessment of the hospice patient includes a number of items standard to the assessment of the patient including pertinent physical findings; and - In addition, assessment and reassessment of the hospice patient and family includes these elements: * Severity of symptoms; and * Factors that alleviate or exacerbate physical symptom. RECORD/PATIENT #5: Review of the admission plan of care dated 08/29/2023 to 11/26/2023 showed the patient was admitted to hospice on 08/29/2023 with a primary diagnosis of esophageal necrosis (death of the cells of the esophagus (canal that connects the throat to the stomach)) and a history of alcoholism. Review of a SN (skilled nurse) encounter note dated 08/30/2023 showed under the pain assessment portion: - Patient has pain: yes; - Pain reported by: patient; - Pain details: left blank; - Location: generalized; - Frequency: intermittent; - Relieving factors: pain medication; - Severity, character, duration, exacerbating factors all left blank; and - The note failed to include a numerical description of the pain intensity. During an interview on 09/27/2023 at 12:20 PM the associate director stated that: - The pain assessment was not complete; - I can have the nurse do an addendum; and - He/she (the nurse) had it written down in their personal notes as an 8 that day.

Based on policy review, clinical record review, home visit observation, and interview, the hospice provider failed to maintain an accurate/updated medication profile/plan of care (POC) in one of five full records reviewed (Record/Patient #2).. This deficient practice has the potential to adversely affect the accurate administration of medications to all the providers patients. --- Findings included: Review of the providers policy titled, ";Medication Reconciliation," approval date: 02/27/2019, showed in part: - Purpose is to maintain and communicate accurate medication information; - Medication reconciliation is a process of comparing a patients current medications and previously prescribed medications with newly ordered medications; - When a patient is admitted from an outside facility (e.g. nursing home) and has a current facility medication list, this list is to be used to update the home medication list in the EMR (electronic medical record); - Through a good faith effort, the clinical caregiver reviews the electronic medication profile/medication list and verifies the current medication list with the patient/family member to include all prescription and over the counter medications noting compliance. A complete listing of the patients current medications includes the following for each medication: Drug name, dosage, route, frequency, compliance and date/time of last dose if available for inpatient; - The clinical caregiver updates the electronic medication list as appropriate using but not limited to the patient medication list; - Medication reconciliation: Admission Inpatient: * Once the patients current medication list is updated into the EMR, the attending/consulting provider completes the admission medication reconciliation process; * The attending/consulting provider reviews compliance information documented by caregiver. Medications may be discontinued or modified on the home medication list as necessary; * Each medication in the current medication list will have a corresponding order to either continue without modification, continue with modification, or do not continue; and * The nurse obtains clarification regarding any deferred medications. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice services on 08/29/2023 with a primary diagnosis of COPD (chronic obstructive pulmonary disease- a group of lung diseases that block airflow and make it difficult to breathe) and severe malnutrition. The patient resided in a LTCF (long-term care facility). Review of a physician order dated 08/29/2023 showed, in part, Morphine 20mg (milligram)/ml (milliliter) 0.25ml (5mg) PO/SL (by mouth or under tongue) every one hour as needed for pain rated 5-10/ SOA (short of air). Review of the admission POC, dated 08/29/2023 to 11/26/2023 showed, in part, Morphine 100mg/5ml, 20mg/ml 0.25ml (5mg) PO/SL every one hour as needed for pain rated 5-10/ SOA . Review of the POC, dated 09/14/2023 to 09/27/2023 showed, in part, Morphine 100mg/5ml, 20mg/ml 0.25ml (5mg) PO/SL every one hour as needed pain rated 5-10/ SOA. Review of the LTCFs Physician order report dated 08/25/2023 to 09/25/2023 showed start date 08/29/2023 Morphine 20mg/5ml (4mg/ml), 0.25ml (1mg) every hour as needed. Review of the LTCFs medication administration record print out, dated 09/18/2023 to 09/25/2023 showed Morphine 20mg/5ml (4mg/ml), 0.25ml (1mg) every hour as needed. Observation on 09/25/2023 at 1:40 PM, during the patients home visit at the LTCF showed the following discrepancy with the hospice medication profile: The hospice medication profile showed the patient was on, Morphine 20mg/ml, 0.25ml (5mg) PO/SL every one hour as needed for pain rated 5-10/ SOA and the LTCFs medication profile showed Morphine 20mg/5ml (4mg/ml), 0.25ml (1mg) every hour as needed. During an interview on 09/25/2023 at 2:53 PM, the hospice RN stated that: - He/she agreed the orders did not match; - They (the orders) should match; and - It could be how they (the facility) put in the orders. During an interview with the LTCF RN on 09/25/2023 at 2:59PM he/she stated that: - The nurse put that order in incorrectly; - He/she was fixing the order right then; and - The patient hadnt used it, so no medication error had occurred.

Based on policy review, record review, and interview, the provider failed to ensure a revised plan of care (POC) included information from the patients updated assessment, in two of five full records reviewed (Records/Patients #1 and #3). This deficient practice has the potential to affect all patients served by the provider. --- RECORD/PATIENT #3 Review of the POC dated 08/24/2023 to 09/06/2023 failed to show: - Apply compression hose/socks (specialized socks that apply gentle pressure to your legs and ankles that can help improve blood flow from your legs to your heart) to patient during SN visit; - SN to prefill Morphine (opioid pain medication) and lorazepam (generic form of Ativan- medication utilized for anxiety) syringes; and - SN to set up weekly pill planner. Review of the POC dated 09/07/2023 to 09/20/2023 failed to show: - Apply compression hose/socks to patient during SN visit; - SN to prefill Morphine and lorazepam syringes; and - SN to set up weekly pill planner. Review of the POC dated 09/21/2023 to 10/04/2023 failed to show: - Apply compression hose/socks to patient during SN visit; - SN to prefill Morphine and lorazepam syringes; and - SN to set up weekly pill planner. Review of the clinical record showed: - SN visit note 08/31/2023 showed prefilled syringes for Morphine and Ativan during visit; - SN visit note 09/05/2023 showed: * The syringes were prefilled again for both Ativan and Morphine; and * Patient reports his/her support hose help his/her pain and keep edema controlled. * This nurse assisted patient with getting his/her hose on; - SN visit note 09/11/2023 showed: * Socks applied due to patient feels it helps; * Patient in agreement to set up weekly pill organizer. Nurse assisted with set up and patient did well; * Syringes pre-filled; - SN visit note 09/14/2023 showed compression socks applied and patient reports he can tell a difference already; - SN visit note 09/21/2023 showed socks applied during visit which he/she reports improves the discomfort. During an interview on 09/27/2023 at 12:15 PM the associate director stated that: - The compression hose should be on the POC; - Maybe it (the compression hose) was on in the old system; - We havent generally put filling syringes in the POC. Findings included: Review of the provider's policy titled, "Interdisciplinary Group (IDG) Coordination of Care," dated 06/09/2020, showed, in part: - The type and scope of services provided by the group is based upon the initial and ongoing assessments; - The group initiates change as the patient, family and caregiver needs evolve during the terminal illness; - It is the responsibility of the group to facilitate communication about changes in the patients status among assigned staff; - The group meets every 14 days or as often as the patient condition requires, evaluating plan of care and updating as needed; and - Team members are responsible for updating of the plan of care. Review of the provider's policy titled, "Scope of Assessment/Reassessment: Hospice," dated 06/11/2020, showed: - The update of the comprehensive assessment is done by the IDG, in collaboration with the patients attending physician, and/or hospice Medical Director and considers changes that have taken place since the initial assessment; - The IDG develops a comprehensive plan of care individualized to the patient and caregivers; - The plan of care is based on team assessments, strengths, limitations and needs; - The plan of care reflects patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessment, and includes all services necessary for the palliation and management of the terminal illness and related conditions; and - The plan of care includes scope and frequency of services to be provided, measurable outcomes anticipated from implementing and coordinating the plan of care, drugs and treatments, medical supplies and appliances necessary to meet the needs of the patient and the IDGs documentation of the patient or representatives level of understanding, involvement and agreement with the plan of care. RECORD/PATIENT #1: Review of the Plan of Care, dated 08/30/2023 to 09/13/2023, showed: - SN (skilled nurse) to instruct patient and caregiver in medication administration, purpose, dosages, preparation, scheduling, side effects, food/drug interactions, storage, and potential complications, with a starting date of, 03/09/2023 (No intervention for SN to fill the patients medication box); - SN to initiate oxygen, obtain order, contact DME (durable medical equipment) company to arrange delivery, enter oxygen information under miscellaneous item on the meds (medications) task, instruct patient/family regarding safety precautions and oxygen use, and O2 (oxygen) oximeter (measures how much oxygen is in the blood) use PRN (as needed) with a starting date of 03/07/2023 listed; and - Oxygen was not listed in the medications section of the POC. Review of the clinical record, showed: - SN visit note, dated 08/08/2023 showed: * The patient was wearing oxygen at 3.5 L (liters) per nasal cannula (a thin, flexible tube that goes around your head and into your nose to deliver supplemental oxygen); * SN filled the patients med (medication) box (No interventions/orders on the POC for SN to fill the med box); - SN visit note, dated 08/15/2023 showed: * The patient was wearing oxygen at 3.5 L per nasal cannula; * SN ordered more oxygen during the visit (Oxygen orders were not included in the interventions/orders and/or the medication section of the POC); * SN filled the patients med box; - SN visit note, dated 08/22/2023 showed: * The patient was wearing oxygen at 3.5 L per nasal cannula; * Medications set up by the nurse; - SN visit note, dated 08/29/2023 showed: * The patient was wearing oxygen at 3.5 L per nasal cannula; * ";Medication review completed and patient is taking a new inhaler that this nurse did not know (he/she) was taking, will review with (named physician) and add to the medication list if (he/she) is ok with that," was documented in the encounter notes section; - SN visit note, dated 09/05/2023 showed: * The patient was wearing oxygen at 3.5 L per nasal cannula; * SN filled med box with patient/caregiver; - SN visit note, dated 09/12/2023 showed: * The patient was wearing oxygen at 3.5 L per nasal cannula; * Med box filled for pt (patient); - SN visit note, dated 09/19/2023 showed: * The patient was wearing oxygen at 3.5 L per nasal cannula; * ";Meds ordered today. No supplies needed. During next med box fill, pt will need to start (his/her) bumex (a medication that reduces extra fluid in the body) on Wednesday. Meds that (he/she) takes are kept in fed ex bag next to (his/her) chair," was documented in the encounter notes section (No documentation of the POC being updated to include this SN intervention); - SN visit note, dated 09/22/2023 showed: * ";Tuck in visit made" after patient arrived at a facility for respite care; * The patient was wearing oxygen at 3 L per nasal cannula; * ";CNA stated patient has a diarrhea problem and patient is very gualded on bottom and scrotum areas," was documented in the encounter notes section (The skin assessment section failed to show documentation regarding bottom and scrotum assessment after the reported concern); - SN visit note, dated 09/24/2023 showed, the patient was wearing oxygen at 3 L per nasal cannula; - SN visit note, dated 09/25/2023 showed, the patient was wearing oxygen at 4 L per nasal cannula; - The medication profile, dated 09/25/2023, showed, Oxygen (O2) gas, inhale 3.5 L/min (liters per minute) continuously for shortness of air, with a start date of 09/15/2023 listed; and - Patient was already receiving oxygen therapy prior to 09/15/2023. Review of the clinical record failed to show: - Orders for oxygen to be administered at 3 L and/or 4 L; - SN interventions to titrate oxygen; and - SN interventions to fill the patients medication box. During an interview on 09/27/2023, at 12:40 PM, the associate director, stated that: - The POC does not have interventions for the SN to fill the med box; and - Med box fill should be on the POC. During an interview on 09/27/2023, at 1:00 PM, the associate director, stated that: - The POC is not updated; - Interventions will only fall off the POC if an end date is entered; and - Interventions on the POC should have been updated during the patients recertification. During an interview on 09/27/2023, at 1:15 PM, the associate director, stated that: - The oxygen order is for 3.5 Lt; - Usually there are orders to titrate to maintain oxygen sats (oxygen saturation- the oxygen level of the blood) above 91%; and - There are no orders to titrate this patients oxygen.

Based on policy review, record review, and interview, the provider failed to maintain a system of communication and integration, in accordance with the hospices own policies and procedures in, two of five full records reviewed (Records/Patients #1 and #5). This deficient practice has the potential to affect the care provided to all patients on service with the hospice provider. --- Findings included: Review of the provider's policy titled, "Interdisciplinary Group (IDG) Coordination of Care," dated, 06/09/2020, showed: - It is the responsibility of the group to facilitate communication about changes in the patients status among assigned staff; - The group communicates changes via telephone, one-on-one meetings, care conferences, e-mail report and home visits; - Documentation shall include the date and time of the communication, individuals involved with the communication, information discussed and the outcome of the communication; - The team documents their discussions in the patients clinical record in the EMR (electronic medical record); and - Written evidence of care coordination is found in the plan of care and/or IDG meeting notes/patient summary or in the patients clinical record. RECORD/PATIENT #1: Review of the clinical record showed: - Skilled nurse visit note, dated, 08/29/2023, showed, ";patient is taking a new inhaler that this nurse did not know that (he/she) was taking, will review with (named physician) and add to the medication list if (he/she) is ok with that;" - The clinical record failed to show documentation of communication with the physician regarding the new inhaler; and - No new medications were added to the medication profile for a new inhaler. During an interview on 09/27/2023, at 1:15 PM, the associate director, stated that: - He/she was unable to find any documentation of follow up with the physician regarding the inhaler; - The physician likes to communicate by secure email, so if the nurse sent an email regarding the inhaler, nobody else had access to it unless they are included in that email; and - A communication note should be entered with details of the communication.

Based on policy review, clinical record review and interview, the hospice provider failed to ensure that the providers policies and procedures were being followed regarding nursing supervision and wound measurements. The registered nurse (RN) failed to document monthly supervision of the licensed practical nurse (LPN) in one of five applicable records (Record/Patient #1) and failed to document wound measurements in one of five applicable records (Record/Patient #5). This deficient practice has the potential to affect any patient receiving LPN services and/or wound care from the provider. --- Findings included: Review of the hospice providers policy titled, ";General Wound Standard for Home Health/Hospice," approval date: 05/16/2019, showed: - Wounds are assessed weekly or with changes and the wound as well as any drainage description is documented in the medical record; - The RN or PT (physical therapist) performs skin re-assessment at regular intervals per plan of care or as needed by wound status change; and - Evidence of treatment efficacy and/or progression of wound healing are documented in the patient record. RECORD/PATIENT #1 (Melissa) RECORD/PATIENT #5: Review of SN (skilled nurse) dated 09/13/2023, showed: - Under the integumentary section (skin) new wounds to coccyx (tailbone area) and left heel; and - In the narrative section: I found a DTI (deep tissue injury) on her left heel, see LDA for description and picture; two wounds found on coccyx. See LDA for updated picture and description. Review of a telephone order dated 09/13/2023, showed in part: - Left heel DTI, spray skin protectant weekly with compression dressing changes; and - Coccyx: cleanse with wound cleanser, pat dry, spray skin protectant, apply foam dressing and change weekly. Further review of the clinical record failed to show and documentation of wound measurements. Melissas interview During an interview on 0927/2023 at 12:15 PM the associate director stated that: - The best the nurse was able to do was pictures; and - The providers policy is to do wound measurements weekly, unless explainable by documentation why unable. During an interview on 0927/2023 at 12:17 PM, the RN stated that he/she agreed the wounds should have been measured on the thirteenth. RECORD/PATIENT #1: Review of the clinical record showed: - Review of a skilled nursing visit, dated, 07/12/2023, showed the nursing visit was completed by a LPN (licensed practical nurse); and - The clinical record failed to show a RN (registered nurse) completed a monthly LPN supervisory visit. During an interview on 09/27/2023, at 12:30 PM, the associate director, stated that: - LPN supervisory visits are to be completed every 30 (thirty) days; - There was no LPN supervisory visit made for this patient and there should have been; - The previous charting system generated supervisory visits every 30 days and this was does not; and - A ticket has been created for LPN supervisory visits to automatically generate every 30 days so they do not get missed.

Based on policy review, clinical record review, and interview, the hospice provider failed to ensure that the written patient care instructions from the registered nurse for the hospice aide were appropriate and accurate in one of four applicable records reviewed (Patient/Record #5). This deficient practice has the potential to adversely affect all patients served by the provider receiving aide services. --- Findings included: Review of the hospice providers policy titled, ";Interdisciplinary Group (IDG) Coordination of Care," approval date: 06/09/2020 showed: - Purpose: To ensure the coordination of services for each patient; - Hospice uses a comprehensive, coordinated healthcare process and an interdisciplinary group to provide services and aid patients, families or caregivers; - The IDG consists of physicians, registered nurses (RN), social workers, aides, chaplains, volunteer coordinators, pharmacist, dietician and therapists; - The IDG team meets every 14 days or less; - A registered nurse (Case Manager) is designated to coordinate the implementation of the plan of care for each patient; - Each team consists of an RN case manager, social worker, chaplain, and Hospice aide; - The type and scope of services provided by the group is based upon the initial and ongoing assessments; - The comprehensive plan of care (POC) defines patient, family, and caregiver problems, goals, and interventions; - The patients plan of care is established by the team within five days of admission; - The team decides the number of needed visits, symptom management needs, spiritual needs, and family caregiver needs; - The group initiates change as the patient, family, and caregiver needs evolve during the terminal illness; - It is the responsibility of the group to facilitate communication about changes in the patients status among assigned staff; and - The group meets every 14 days or as often as the patient condition requires, evaluating the plan of care and updating as needed. RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to hospice on 08/29/2023 with a primary diagnosis of esophageal necrosis (death of the cells of the esophagus (canal that connects the throat to the stomach)) and a history of alcoholism. Review of a physicians order dated 09/13/2023 2:35PM showed, in part, coccyx (tailbone area)- cleanse with wound cleanser, pat dry, spray skin protectant, apply foam dressing and change weekly. Review of the POC dated 09/07/2023 to 09/20/2023 failed to include documentation in the aide plan of care portion that a dressing was now present on the patients coccyx or give instruction for how the aide should provide care. During an interview on 09/27/2023 at 12:24 PM the associate director stated that he/she could not see where the aide POC had been updated regarding the new coccyx dressing.

Based on policy review, record review, and interview, the provider failed to ensure all record entries were legible, clear, complete, and appropriately authenticated and dated in accordance with the providers policy, in two of five full records reviewed (Records/Patients #1 and #4). This deficient practice has the potential to adversely affect the quality of care provided to all patients served by the provider. --- Findings included: Review of the provider's policy titled, "Interdisciplinary Group (IDG) Coordination of Care," dated, 06/09/2020, showed, in part: - The type and scope of services provided by the group is based upon the initial and ongoing assessments; - The comprehensive plan of care defines patient, family or caregiver problems, goals and interventions; - Each member is responsible for adding their note into the patient summary for the team; - Hospice staff submits documentation of services provided including clinical notes, the schedule of visits and patient evaluations and participate in interdisciplinary group meetings; and - Hospice patients and families receive quality holistic care from an interdisciplinary group who coordinates treatments and services with a team approach. Review of the provider's policy titled, "Medication Administration, Disposition, Including the Delivery of Medication and Medical Provider Orders for Home Health and Hospice," dated, 04/28/2021, showed, in part: - Current medications, including vitamins, supplements, and herbal therapies are listed on the medication profile; - Patients have a current medication profile in the medical record; and - The medication profile is updated as new orders are received automatically through the EMR (electronic medical record) interface. RECORD/PATIENT #1: Review of the skilled nurse visit note, dated, 09/19/2023, showed: - The patient ";could not remember where (his/her) medications are and would not allow this nurse to look for them in (his/her) piles of trash in (his/her) home;" - ";Pt (patient) complains of nausea when (he/she) goes in to have a BM (bowel movement). Zofran (medication to treat nausea and vomiting) is now in the home and (he/she) has been encouraged to use. Pt now taking Zofran up to 3 (three) times a day. Offered to place in med (medication) box but (he/she) adamantly refused;" - ";Pt states (he/she) had not taken a breathing treatment for several days now because (he/she) has stayed in bed. This nurse moved (his/her) nebulizer machine to where (he/she) can reach it next to (his/her) bed and (he/she) took a treatment at visit." Review of the skilled nurse visit note, dated 09/22/2023, showed, ";tuck in visit made," after the patient arrived to a facility for respite care. Review of the skilled nurse visit note, dated 09/23/2023, showed: - The patient ";could not remember where (his/her) medications are and would not allow this nurse to look for them in (his/her) piles of trash in (his/her) home" (The patient was in respite at this time); - ";Pt complains of nausea when (he/she) goes in to have a BM. Zofran is now in the home and (he/she) has been encouraged to use. Pt now taking Zofran up to 3 times a day. Offered to place in med box but (he/she) adamantly refused;" - ";Pt states (he/she) had not taken a breathing treatment for several days now because (he/she) has stayed in bed. This nurse moved (his/her) nebulizer machine to where (he/she) can reach it next to (his/her) bed and (he/she) took a treatment at visit" (This is the same documentation from the nursing visit made on 09/19/2023). During an interview on 09/27/2023, at 1:30 PM, the associate director, stated that: - The notes in the comment sections automatically pull over from the previous visit; and - The staff should have deleted them but didnt. RECORD/PATIENT #4: Review of the skilled nurse visit note, dated, 09/23/2023, showed, in part: - The skilled nurse made a visit to assess the patient for unrelieved pain; - The patient rated his/her pain at 8 out of 10 (0 being no pain and 10 being the worst pain); - The skilled nurse contacted the physician on-call and received an order to increase Morphine Sulfate (pain medication) to 0.75 ml (milliliters) every hour PRN (as needed) from 0.25 ml (The previous order was for Morphine sulfate 20mg/ml (milligrams per milliliter), patient to take 5mg (0.25ml) every hour as needed for pain); - The patients pain was reassessed after receiving additional Morphine and the patient reported ";now just barely" any pain; and - The skilled nurse entered a telephone order for the Morphine sulfate into the electronic medical record. Review of the medication profile, dated, 09/25/2023, failed to show the most current medication order for the Morphine Sulfate 0.75ml every hour as needed. During an interview on 09/27/2023, at 12:40 PM, the associate director, stated that: - The morphine order was entered into the EMR (electronic medical record) orders section with an orders type of ";other" selected; - The EMR has a medication orders section; - Medication orders have to be entered into the EMR in the medication order section in order for the medication profile to update; and - The medication profile did not update automatically with the morphine order due to the way the order was entered into the EMR.