Every finding on record at Hospice of Henderson County

Observed in Individual Tracer. In 1 of 2 records reviewed, the surveyor noted that 3 pain assessments were not completed and documented as defined by the organization's policy. Two of the pain assessments did not contain a pain score as required. The organization's policy states that the pain assessment will include a score. Two of the assessments did not include a pain scale score. This finding was discussed with the Director of Accreditation.

Observed in Record Review. In 4 of 8 patient records reviewed, for active patients in home hospice, it was noted by the nurse surveyor that the comprehensive assessment was not completed within five calendar days of the election of hospice care. For RRNHV#11, the chaplain completed his initial assessment 10 days late. There was no documentation to explain the delay. For RRNHV#12, the chaplain documented an initial phone call to the patient 13 days after the election of hospice care at which time the patient refused spiritual care. For RRNHV#13, the chaplain called the patient on day 2 after admission and left a message. There was no other documentation in the record until the spiritual assessment was documented 2 months later. For RRNHV#14, the chaplain’s initial assessment was completed on day 6 after the election of the benefit. There was no documentation as to why the visit was delayed. Findings were verified by the Team Leader assisting with record review. Observed in Record Review. In 2 of 12 patient records reviewed, The hospice’s interdisciplinary group, in consultation with the patient’s attending physician, if any, did not complete the comprehensive assessment no later than five calendar after the election of hospice care. During review of the record associated with hospice home visit 6 and hospice record 3, it was noted that the social worker did not make a visit within five days of the admission in record 3 and the chaplain did not make a visit with in five days in the record associated with hone visit 6. This was confirmed by the Team Lead.

Observed in Tracer Activities. In 1 of 4 bereavement records reviewed, the pre-bereavement assessment had not been documented as required by the organization's Bereavement Risk Assessment Policy. This finding was validated by the Grief Services Coordinator at the time of the observation.

Observed in Record Review. The written plan of care was not based on the patient’s goals and the time frames, settings, and services required to meet those goals. During review of the record associated with hospice home visit 5 it was noted that goals were not in place for findings in the comprehensive assessment. For example, the patient had an arm wound documented at admission but there were no goals or interventions related to wound in the initial plan of care, and the patient had decreased nutritional intake and nausea and vomiting assessed but there were no nutritional goals or interventions in the initial plan of care. This was confirmed by the team leader. Observed in Record Review. In 2 of 12 patient records reviewed, The written plan of care was not based on the patient’s goals and the time frames, settings, and services required to meet those goals. During review of the record associated with hospice home visit 5 and hospice record associated with home visit 6 it was noted that goals related to pain were not appropriate. In the record associated with home visit 5 the patient reported a pain level of 8 at admission with a patient goal of a pain level five. The only goal related to pain for the initial assessment stated that the patient will continue to report that her pain is well controlled with a date of two weeks hence. There was no documentation that the patient had reported her pain to be well controlled and the patient's pain was still at an 8 on the second visit two days later. In the record associated with home visit 6 the patient's pain was rated at a 6 on admission, and the goal stated that the patient's pain would be at the patient's goal of 4 in 15 days. This was confirmed by the team leader.

Observed in Record Review. In 4 of 12 patient records reviewed, The plan of care includes all services needed for the palliation and management of the terminal illness and related conditions, including the following: interventions to manage pain and symptoms. During review of the record associated with hospice home visit 5 it was noted that although the patient consistently reported moderate to severe pain, the only intervention in the care plan stated assess for pain and initiate pain interventions as needed. There were no specific interventions as to pharmacological or non pharmacological approaches. In the record associated with home visit 6 it was noted that although the patient had a new PEG tube requiring dressing changes, there were no interventions or goals in the care plan related to the tube. In record 1 the patient was noted to have oral thrush and was on Diflucan at admission but there was nothing in the plan of care relating to oral thrush management. In record 5 it was noted that the patient had a diagnosis of ALS and had dyspnea at 3 on admission but there was nothing in the plan of care for dyspnea until one month after admission. This was confirmed by the team leader. Observed in Record Review. In 2 of 12 resident records reviewed, The organization did not implement interventions to reduce falls based on the patient’s assessed risk. In the records associated with records 2 and 3 there were no interventions related to falls based on falls risk assessment. For example, in record 3 the fall risk was scored at 7, but there was no fall care plan for 28 days after admission, and in record 2 the fall risk was scored at 8, but there was no fall care plan until 2 and 1/2 months after admission. This was confirmed by the team lead. Observed in Record Review. In 2 of 3 patient records reviewed, for patients located in the inpatient hospice house, it was noted by the nurse surveyor that for RRIPU#2, the patient was admitted to the hospice house GIP for pain and agitation. Agitation was not included in the care plan, but the patient was receiving pharmacological interventions. Additionally, a foley catheter was inserted but not added to the care plan. For RRIPU#3, the patient had a foley inserted and her breast tumor erupted and became an open area requiring dressing changes. Both were being addressed and cared for but had not been added to the plan of care. Findings were verified by the Team Leader assisting with record review.

Observed in Record Review. It was noted by the nurse surveyor that for RRIPU#3, the patient had a foley inserted and her breast tumor erupted and became an open area requiring dressing changes. Both were being addressed and cared for but had not been added to the plan of care. Findings were verified by the Team Leader assisting with record review.

Observed in Record Review. In 2 of 12 patient records reviewed, The organization did not provide the patient with care, treatment, or services according to the patient's individualized plan of care. During review of records 4 and 6 it was noted that visits were not provided according to orders. In record 4 nursing visits were ordered for 1x week but no visits were provided in the first week after the admission visit. In record 6 nursing was ordered once per week but no visits were provided in a one week period. this was confirmed by the team lead.

Observed in Patient Home. In 1 of 6 home visits conducted, it was observed by the Nurse Surveyor that the organization did not implement the infection prevention and control activities it had planned per policy “Hand Hygiene Policy During RRHV#2 the Social Worker did not hand sanitize upon entry into the patient’s room or before and after assisting the patient with sending an email on the patient’s own tablet. Finding was verified by the Spiritual Care Team Leader who was present on the home visit. Observed in Individual Tracer. The organization did not implement the infection prevention and control activities it has planned. During hospice home visit 5 it was observed that the nurse did not cleanse her hands before entering the nursing bag per policy. This was confirmed by the team leader. Observed in Individual Tracer. The organization did not implement the infection prevention and control activities it has planned. During hospice home visit 5 it was observed that the nurse did not cleanse her hands after doffing gloves per policy. This was confirmed by the team leader. Observed in Individual Tracer. The organization did not implement the infection prevention and control activities it has planned. During hospice home visit 5 it was observed that the nurse cleansed her hands, then grasped the would solution bottle that was kept in the patient's home before donning gloves on two occasions. This did not follow organizational policy. This was confirmed by the team leader. Observed in Individual Tracer. The organization did not reduce the risk of infections associated with medical equipment, devices, and supplies. During hospice home visit 5 it was observed that the nurse her notebook computer directly on the patient's table. She then placed patient pill bottles on the computer during the pill box fill. The nurse did not cleanse the computer per policy upon leaving the patient's home. This was confirmed by the team leader. Observed in Individual Tracer. The organization did not implement infection prevention and control activities when doing the following: Cleaning and performing disinfection of medical supplies and devices. During hospice home visit 5 it was observed that sani-wipe disinfecting wipes were used to clean equipment used to take vital signs. The nurse removed one sani-wipe from its package and used it to clean equipment prior to use. The wipe was left open during the visit was then used to clean equipment after use. The wipe was no longer wetting the equipment. This was confirmed by the team leader.

Observed in Record Review. In 1 of 8 patient records reviewed, for active patients, It was noted by the surveyor that for RRNHV#13, one Hospice Aide Supervisory visit was completed 15 days apart, not the required 14 days. Finding was verified by the Team Leader assisting with record review. Observed in Record Review. In 2 of 12 patient records reviewed, The registered nurse did not supervise the hospice aide during an on-site visit to the patient’s home no less frequently than every 14 days. During review of records 4 and 6 it was noted that aide supervision was not documented every 14 days or less. For example in record 4 there was no supervisory visit documented for 4 1/2 weeks and in record 6 there was no supervision documented for 8 1/2 weeks. This was confirmed by the team lead.

Observed in Individual Tracer. The surveyor reviewed the information provided to hospice patients at the time of admission. The surveyor noted that the organization does not a provide a copy of its written policies and procedures on the management and disposal of controlled medications to the patient or the patient's representative and family when controlled medications are ordered. This finding was discussed with the Director of Accreditation.

Observed in Patient Home. In 1 of 6 home visits conducted, it was noted by the nurse surveyor that for RRHV#1, the patient did not have a completed individualized emergency plan in her home folder. There was some general information related to emergency planning but nothing regarding what to do if care, treatment, or services are disrupted by a natural disaster or emergency. Finding was verified by the Director of Hospice Clinical Services who was present during the home visit. Observed in Individual Tracer. The organization did not document procedures to follow if care, treatment, or services are disrupted by a natural disaster or an emergency. During hospice home visits 5 and 6 it was observed that there was no emergency plan in place at the patient's home or in the patient record. This was confirmed by the Team Leader.

Observed in Tracer Activities. During a review of contracted services, the surveyor noted that the contracts for durable medical equipment (DME) and therapy did not include the following: a stipulation that the outside agency will complete criminal background checks on contracted employees who provide direct patient care or have access to patient records. This finding was discussed with the Director of Accreditation at the time of the observation.

Based on a review of the patient and caregiver handbook, clinical record review and staff interviews the agency did not obtain an order or assure access to medication for pain and symptom management in a timely manner for 1 of 1 [#1] patient with complaint of pain, nausea and vomiting. The findings included: --- A review of the patient and caregiver handbook, Confident Caregiving: a resource for patients and families: patient rights and responsibilities, provided by the Chief Clinical Operations Officer [CCOO] on 11/29/22 at 3:18 pm, stated, ";[patient] to receive effective pain management and symptom control from [agency name] for conditions related to the terminal illness." The handbook also stated, ";[patient] to receive reasonable response to my requests of the agency." Patient #1 had a Start of Care of 6/18/22 with diagnoses of malignant neoplasm [cancer] of the Pancreas with metastasis [secondary malignant growths at a distance from a primary site of cancer]; neoplasm related pain; anxiety disorder and nausea. A review of the Plan of Care for certification period 9/16/22 to 12/14/22 included orders for skilled nursing [SN] visits 1 time per week for 14 weeks with 5 PRN [as needed] for symptom management. A coordination note by the LPN #8 on 9/22/22 reported that the facility medication technician [MT] had called and reported patient had back, buttock and abdominal pain. Also reported patient #1 daughter had visited and requested liquid morphine [pain medication] ...the daughter ";does not want the patient to mess with having to take pills so she wants liquid pain medication." The LPN documentation, reviewed medications and LPN instructed MT that the patient had oxycodone [pain medication] ordered and ";to crush and mix with a small amount of water and make it a liquid." The LPN also stated, ";their pharmacy would not be able to deliver morphine tonight." The LPN documented that a message was sent to the case manager [primary registered nurse] to follow up. Further review revealed SN #6 made a visit on 9/27/22 and documented patient #1 reported pain that morning. Patient #1 had stated the pain ";was unbearable...burning 10/10 [ numerical pain scale; 0= no pain, 10= worst pain] ..." Documentation by SN#6 reported an order was obtained for morphine 5 mg [milligrams] every 2 hours PRN [sic]. Documentation showed the order was obtained 5 days after it had originally been requested on 9/22/22. SN #1 made a routine visit on 10/3/22 at 9:10 am. Documentation showed that the patient had complained of nausea and vomiting, had refused scheduled medications and wanted only comfort medications [medications to relieve symptoms]. SN #1 stated that an order was obtained for Haldol [medication for nausea/vomiting] 0.5 mg by mouth 4 times per day, Haldol 1 mg every 2 hours and Fentanyl 12 mcg patch [pain medication/ micrograms] every 72 hours. There is no evidence the hospice verified that the facility had received the new mediations. On 10/3/22 at 8:20 p.m., SN #1 documented a telephone call that stated, ";patient #1 son called requesting update on [patient] he feel ... needs continuous drip of morphine {sic}...son not present at bedside." SN#1 documented a telephone call was made to the facility on 10/3/22, [no time documented], SN spoke with a MT #1 and asked about the patients pain... stated that [MT #1] ";feels as if it could be controlled better." SN #1 stated that the MT #1 was instructed to administer medications for pain that included oxycodone, morphine and Ativan [doses were not documented in clinical note]. On 10/3/22 at 9:11 pm it was documented by SN #1 that MT #2 had called and was ";upset that pain was not handled...this nurse informed [MT#2] what was given and what could be done to get pain under control... informed...that if patient was still in pain when [MT #2] got there ... could call back for further interventions." There was no evidence a nurse visited the patient to assess the report of uncontrolled pain. SN documented that on 10/3/22 at 10:15 pm that MT #1 called and requested additional interventions for pain. SN #1 also stated that the MT reported that terminal secretions [ occur when mucous and saliva build up in the patients throat] had started and that the facility did not have medications for this symptom. SN#1 instructed the medications would be ordered. There was no evidence the facility had received the new medications. On 10/3/22 at 10:27 pm, SN #1 was notified the patient had died. An interview with SN#1 on 11/29/22 at 3:45 pm verified the patient did not receive the Fentanyl patch or Haldol that had been ordered on 10/3/22 during the SN visit at 9:10 am.

Based on policy, clinical record review and staff interviews, there was no evidence the LPN (licensed practical nurse) communicated to the RN (registered nurse) case manager for 1 of 1 patients a request for medication change by patient/caregiver. The findings included: --- A policy provided by Director of Compliance on 11/30/22 at 11:54 am, Coordination of Care, approved 3/22 stated, ";[agency] maintains a system of communication and integration to ensure the IDG (interdisciplinary group) directs, coordinates... care and services provided." Patient #1 had a Start of Care of 6/18/22 with diagnoses of malignant neoplasm [cancer] of the Pancreas with metastasis [secondary malignant growths at a distance from a primary site of cancer]; neoplasm related pain; anxiety disorder and nausea. A review of the Plan of Care (POC) for certification period 9/16/22 to 12/14/22 included orders for skilled nursing [SN] visits 1 time per week for 14 weeks with 5 PRN [as needed] for symptom management. The patient had an order for Oxycodone 5 mg (milligrams) tablet PRN (as needed) every 4 hours for pain/ shortness of breath. LPN #8 documented on 9/22/22 at 4:30 pm that MT (medication technician) #2 from the assisted living facility called and reported that patient #1s daughter requested the pain medication be changed to liquid morphine. LPN #8 also documented MT #2 reported, ";patients daughter does not want patient to mess with having to take pills, so she wants liquid pain medication." LPN #8 documented an email had been sent to SN #1 to follow up. Further investigation revealed an order for liquid morphine had not been obtained until 9/27/22, 5 days after the daughters initial request on 9/22/22. SN #1 stated in an interview on 11/29/22 at 3:50 pm, he/she had not been notified that patient #1 daughter requested liquid morphine.

Based on policy, clinical record review and staff interviews the nurse failed to assess change in patient condition for 1 of 3 patients [ #1] with a complaint of pain during after hours, conduct as visit as communicated to the skilled nursing facility for 1 of 3 patients (#3); and to assess for 1 of 1 patients with new wounds reported (#3). The findings included: --- 2A. Patient #3 was admitted on 8/18/21 with a diagnosis of Alzheimer's disease. The Plan of Care for 8/13/22-10/11/22 included orders for skilled nursing visits weekly for 10 weeks and five (5) visits as needed. On 8/23/22, LPN #9 documented a call from the skilled nursing facility (SNF) that the patient was declining and asked for a hospice nurse to visit. On 8/23/22 RN #2 conducted a visit and stated that the patient had a decline and was non-verbal and unable to swallow. On 8/24/22, RN #2 called the SNF ";to check on [patient] status...Advised faiclity [sic] i [sic] would make another visit on Friday..." On Friday, August 26, 2022, a call was documented. The note stated, ";Call to facillitiy [sic] to get update and take care of needs..." There was no evidence the nurse visited the patient as indicated to the SNF on 8/24/22. On 8/27/22 at 10:48 p.m., the SNF called the hospice agency to update on the patients decline and need for comfort medication: morphine (pain) and levsin (secretions). The patient died on 8/28/22 at 12:50 a.m. There was no evidence of a skilled nursing visit since 8/23/22. In an interview with RN #2 on 11/29/22 at 10:44 a.m., the nurse stated that she could not remember why she did not visit the patient on 8/26/22. 2B. Patient #3 was admitted on 8/18/21 with a diagnosis of Alzheimer's disease. The Plan of Care for 8/13/22-10/11/22 included orders for skilled nursing visits weekly for 10 weeks and five (5) visits as needed, and hospice aide visits weekly for 10 weeks. On 8/17/22, two hospice aides made a visit at 8:20 a.m. Hospice aide #10 visit note stated, ";...we collaborated with pts [patients] hospice nurse_______ [name of nurse] about a couple of pressure sore [sic] on pts buttock and coax [sic—coccyx-tailbone] area we applied barrier cream to those areas." Hospice aide #4 visit note stated, ";Joint visit with ___ [hospice aide #10] open sore on scrotum [sic] patch on coccyx [sic] and red area on right buttocks nurse notified." On 8/18/22 at 10:00 a.m. RN #3 conducted a visit. There was no evidence the nurse assessed the wounds the aides reported. An interview with RN #2 on 11/30/22 at 10:43 revealed the RN was unable to recall if the new wounds were reported to RN #3. In an interview with RN #3 on 11/30/22 at 11:20 a.m. it was revealed the nurse was unable to recall if the new wounds were assessed. An interview with Chief Clinical Operations Officer on 11/30/22 at 10:56 a.m. confirmed there was no evidence that the wounds were assessed by the RN on 8/18/22. A policy, ";After hours services" (approved 3/22) provided on 11/29/22 at 3:18 pm by Chief Clinical Operations Officer [CCOO], stated, ";patients and their caregivers have access to [agency name] nursing and medical services 24 hours per day, 7 days a week...after hours clinical staff provide follow-up to each call..." A policy, Reassessment of Patients (approved 9/22), was provided on 11/30/22 at 11:54 a.m. by the Director of Compliance. The policy stated, ";Each patient is reassessed as necessary based on his or her plan of care or changes/anticipated changes..." A policy, Coordination of Services (approved 3/22), was provided on 11/30/22 at 11:54 a.m. by the Director of Compliance. The policy stated, ";An RN that is a member of the IDG [interdisciplinary group] is designated to provide coordination of care and to ensure continuous assessment of each patients and familys needs and implementation of the interdisciplinary plan of care...The designated RN coordinates the patients plan of care and facilitates communication with the attending physician, contracted facilities, vendors, and other members of the interdisciplinary team." 1. Patient #1 had a Start of Care of 6/18/22 with diagnoses of malignant neoplasm [cancer] of the Pancreas with metastasis [secondary malignant growths at a distance from a primary site of cancer]; neoplasm related pain; anxiety disorder and nausea. A review of the Plan of Care for certification period 9/16/22 to 12/14/22 included orders for skilled nursing [SN] visits 1 time per week for 14 weeks with 5 PRN [as needed] for symptom management. On 10/3/22 at 8:20 p.m., SN #1 documented a telephone call that stated, ";patient #1 son called requesting update on [patient] he feel ... needs continuous drip of morphine {sic}...son not present at bedside." SN#1 documented a telephone call was made to the facility on 10/3/22, [no time documented], SN spoke with a medication technician [MT #1] and asked about the patents pain... stated that [MT #1] ";feels as if it could be controlled better." There was no evidence a nurse conducted a visit to assess patient needs. SN #1 stated that the MT #1 was instructed to administer medications for pain that included oxycodone, morphine and Ativan [doses were not documented in clinical note]. On 10/3/22 at 9:11 pm it was documented by SN #1 that MT #2 had called and was ";upset that pain was not handled...this nurse informed [MT#2] what was given and what could be done to get pain under control... informed...that if patient was still in pain when [MT #2] got there ... could call back for further interventions." There was no evidence a nurse visited the patient to assess the report of uncontrolled pain. SN documented that on 10/3/22 at 10:15 pm that MT #1 called and requested additional interventions for pain. SN #1 also stated that the MT reported that terminal secretions [ occur when mucous and saliva build up in the patients throat] had started and that the facility did not have medications for this symptom. SN#1 instructed the medications would be ordered. There was no evidence a conducted a visit to assess the patient. On 10/3/22 at 10:27 pm, SN #1 was notified the patient had died. SN dispatched a nurse to pronounce [patients date and time of death]. Patient #1 death was pronounced on 10/4/22 at 00:05 am by the hospice nurse. In an interview with SN#1 on 11/29/22 at 3:45 pm, SN reported that if, ";they [patient and/or caregiver] call back the third time, then we send someone out." The CCOO stated in an interview no 11/29/22 at approximately 4:09 pm, that the expectation for after-hours was to dispatch a nurse after the second call from the patient or caregiver. An interview with SN#1 on 11/29/22 at 3:45 pm verified a nurse had not been sent prior to patients death.