Every finding on record at Hospice of Cumberland County Inc

Based on agency policy review, medical record review, and interview the agency failed to update the medication profile for 1 patient (#3) of 3 patients reviewed with home visits. The findings include: Review of the agency's policy titled, "Comprehensive And Ongoing Assessment," effective 4/7/2015, showed "...The comprehensive assessment shall take into account the following...Drug profile...A review of all of the patient's prescription and over-the-counter drugs...This includes...effectiveness of drug therapy...Actual or potential interactions...During each home visit, Hospice staff will reevaluate the patient according to the problems identified during the initial visit and afterwards...Reassessment...shall consider....Changes that have taken place since the initial assessment....patient's response to care, treatment and services..." Review of the agency's policy titled, "Content of the Clinical Record," effective 4/7/2015, showed "...The clinical record will contain...accurately document care, treatment and/or service provided...The Minimum Content of the Clinical Record Includes...Medication allergies or sensitivities...Updated medication profile, including dosage..." Medical record review revealed Patient #3 was admitted to the agency on 5/13/2021 with diagnoses including Acute and Chronic Respiratory Failure with Hypercapnia, Chronic Obstructive Pulmonary Disease with Exacerbation, and Chronic Kidney Disease, Stage 3. Medical record review of Patient #3's Combined Disciplinary Plan of Care dated 12/29/2021, showed "...Medication profile reviewed on: Dec [December] 29, 2021..." Medical record review of Patient #3's Face Sheet dated 1/10/2022, showed the patient was allergic to Fenofibrate (a cholesterol medication) and Gabapentin (a medication used for nerve pain). Medical record review of Patient #3's agency medication profile dated 1/10/2022, showed the patient had orders for the following medications: Melatonin (an herbal supplement used for sleep) 5 mg (milligram) capsule with instructions to take 1 by mouth at night with an order date of 6/25/2021, Temazepam (a medication used for sleep) with instructions to take 15-30 mg as needed at bedtime for sleep with an order date of 9/8/2020, Fentanyl 25 mcg/hr (micrograms per hour) transdermal patch (adhesive patch placed on the skin to deliver medications) with instructions to apply 1 patch every 72 hours and to notify nurse if initiated with an order date of 9/8/2020, and Ambien (a medication used for sleep) with an order date of 8/26/2021. Further review showed the patient was allergic to Fenofibrate and Gabapentin. During an interview on 9/11/2022 at 11:30 AM, Patient #3's Family Member stated the Patient had not taken the Melatonin or Temazepam since the initiation of Ambien and the Patient was allergic to the Fentanyl. The Family Member stated the Patient had attempted to use Fentanyl "a couple of years ago" but he was allergic. The Family Member stated the patient attempted to use the Fentanyl patch "again a few months ago" but had another allergic reaction and it had been stopped. During an interview on 1/11/2022 at 11:40 AM, Registered Nurse (RN) #2 stated the agency medication profile and the home medications were to be reconciled every 2 weeks during the patient's comprehensive assessment. RN #2 confirmed the Melatonin, Temazepam, and Fentanyl had not been removed from the agency's medication profile list after the patient had stopped taking the medications. Further interview confirmed RN #2 had been aware of Patient #3's allergy to Fentanyl and the medication had been stopped. During an interview on 1/12/2022 at 12:42 PM, RN #1 confirmed the agency had not reconciled Patient #3's medication profile list to remove the Melatonin, Temazepam, and Fentanyl after the resident had stopped taking those medications. She further confirmed the Fentanyl had not been added to Patient #3's allergy list.

Based on agency policy review, medical record review, and interview the facility failed to implement interventions for the assessment of pain for 2 patients (#5 and #6) of 13 patients reviewed. The findings include: Review of the agency policy titled, "PLAN OF CARE," effective 4/7/2015, showed "...PURPOSE...To provide direction to Hospice staff providing direct patient care...during Hospice assessments...team members develop a list of patient problems...with interventions..." Review of the agency policy titled, "PAIN ASSESSMENT, REASSESSMENT AND MANAGEMENT," effective 4/7/2015, showed "...The patient will undergo reassessment of pain at each visit..." Medical record review showed Patient #5 was admitted to the agency on 6/5/2021 with diagnoses to include Congestive Heart Failure, Hypertensive Heart Disease, and Dementia. Medical record review of Patient #5's Disciplinary Plan of Care with a review date of 12/29/21 showed "...Pain...Intervention...Assess patient for pain at each nurse visit..." Medical record review showed Patient #5 received Skilled Nursing (SN) visits on 12/3/2021, 12/10/2021, and 1/11/2022 and pain assessments had not been completed. Medical record review showed Patient #6 was admitted to the agency on 8/27/2021 with diagnoses to include Severe Protein Calorie Malnutrition, Pressure Ulcer of Sacral Region, and Iron Deficiency Anemia. Medical record review of Patient #6's Disciplinary Plan of Care with a review date of 12/29/2021, showed "...Pain...Intervention...Assess patient for pain at each nurse visit..." Medical record review showed Patient #6 received SN visits on 11/26, 12/1, 12/3, 12/6, 12/10, 12/20, 12/24, and 12/31/2021 with no pain assessments completed. Further review showed SN visits on 1/3/2022 and 1/7/2022, and pain assessments had not been completed. During an interview on 1/11/2022 at 4:40 PM, Registered Nurse (RN) #1 stated pain was to be assessed with every SN visit. During an interview on 1/12/2022 at 1:15 PM, RN #1 confirmed Patient #5's pain had not been assessed during SN visits on 12/3/2021, 12/10/2021, and 1/11/2022. Further interview confirmed Patient #6's pain had not been assessed during SN visits on 11/26, 12/1, 12/3, 12/6, 12/10, 12/20, 12/24, 12/31/2021, 1/3/2022 and 1/7/2022.

Based on agency policy review, medical record review, and interview, the facility failed to follow the Plan of Care related to visit frequency for 4 patients (#1, #5, #6, and #11) of 13 patients reviewed. The findings include: Review of the agency policy titled, "PLAN OF CARE," effective 4/7/2015, showed "...The plan of care shall state in detail the scope and frequency of services needed to meet the patient's...needs..." Medical record review showed Patient #1 was admitted to the agency on 10/29/2021 with diagnoses to include Waldenstrom Macroglobulinemia (a type of Leukemia), Hypertension, and Type 2 Diabetes. Medical record review of a Combined Disciplinary Plan of Care with a review date of 12/29/2021, showed "...Nurse visit frequency...Twice weekly..." Medical record review showed Patient #1 had a missed nurse visit the week of 12/27/2021-1/2/2022. Medical record review showed Patient #5 was admitted to the agency on 6/5/2021 with diagnoses to include Chronic Heart failure, Hypertensive Heart Disease with Heart Failure, and Dementia. Medical record review of a Combined Disciplinary Plan of Care with a review date of 12/29/2021, showed "...Nurse visit frequency...Twice weekly...Hospice Aide visit frequency...Twice weekly..." Medical record review showed Patient #5 had a missed hospice aide visit the week of 12/20/2021-12/26/2021 and a missed nurse visit the week of 12/27/2021-1/2/2022. Medical record review showed Patient #6 was admitted to the agency on 8/27/2021 with diagnoses to include Severe Protein Calorie Malnutrition, Pressure Ulcer of Sacral Region, and Iron Deficiency Anemia. Medical record review of a Combined Disciplinary Plan of Care with a review date of 12/29/2021, showed "...Hospice Aide visit frequency...Twice weekly..." Medical record review showed Patient #6 had a missed hospice aide visit the week of 12/20/2021- 12/26/2021 and the week of 12/27/2021- 1/2/2022. Medical record review showed Patient #11 was admitted to the agency on 12/3/2021 with diagnoses to include Chronic Obstructive Pulmonary Disease, Hypertension, and Type 2 Diabetes. Medical record review of a Combined Disciplinary Plan of Care with a review date of 12/29/2021, showed "... Nurse visit frequency...Twice weekly..." Medical record review showed Patient #11 had a missed nurse visit the week of 12/27/2021- 1/2/2022. During an interview on 1/12/2022 at 1:50 PM, Registered Nurse (RN) #1 confirmed Patients #1, #5, and #11 had a missed nurse visit the week of 12/27/2021- 1/2/2022. Further interview confirmed Patient #5 had a missed hospice aide visit the week of 12/20/2021-12/26/2021. RN #1 further confirmed Patient #6 had a missed hospice aide visit the week of 12/20/2021-12/26/2021 and the week of 12/27/2021-1/2/2022.