Every finding on record at Hospice of the South Holdings LLC

Upon patient record review, 1 of 14 (Patient #2) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #2: Patient admitted 3/7/25. During home visit and medication review, patient has Morphine Concentrate in home, but it is not on hospice medication profile. Prescription bottle dated 4/15/25. Patient caregiver states she has not needed dose thus far.

Upon patient record review, 5 of 14 (Patient #1, 2, 3, 10, 11) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #1: Patient admitted 3/21/25 with Huntington's disease and dysphagia. No related problems, goals, interventions related to dysphagia. Patient #2: Patient has order for oxygen, but no related problems, goals interventions related to oxygen safety precautions. Patient #3: Patient admitted 3/19/25 with cirrhosis, pleural effusion, ascites, and DM. There are no problems, goals, interventions related to primary diagnoses of bleeding precautions. Patient #10: Patient admitted 4/2/25 with orders for Oxygen 4LPM NC continuous, but there are no problems, goals, interventions related to oxygen precautions. Patient #11: Patient admitted 6/8/24 with port-a-cath on admission, but no related problems, goals, interventions.

Upon patient record review, 2 of 14 (Patient #2,3) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient #2: Admitted 3/7/25. Patient treated with antibiotics for pneumonia 3/25/25 and for possible UTI 5/2/25. There were no updates to problems, goals, interventions for either. Patient #3: 5/6/25 order for Oxygen 2 LPM NC. There are no problems, goals, interventions related to oxygen therapy and/or precautions.

Upon patient record review, 3 of 14 (Patient #3,6,7) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #3: 3/19/25 order for MSW 1x/week for 2 weeks. The next order started on 5/4/25 order for MSW 4x/week for 4 weeks. For the weeks of April 11, 19, 21, 23, the patient was seen weekly with no orders. Staff interview with administrator identifies interim frequency order inadvertently discontinued during update. Patient #6: 4/15/25 order for SC 1/wkx13. There was is no documented visit week of 4/21/25. Patient #7: 2/1/25 order for MSW 1/mox2. There is no visit for March

Upon patient record review, 3 of 14 (Patient #2, 3, 8) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #2: Patient admitted 3/7/25. Hospice aide care plan includes assigned task to change linens each visit prn and ensure oxygen in place every visit after bathing prn. PRN is not qualified with specific circumstances and/or with statement of patient's cognitive ability to decide task. Patient #3: Patient admitted 3/19/25 with orders for oxygen therapy. Hospice aide care plan does not include oxygen related safety precautions. Patient #8: Patient admitted 4/19/25 with Eliquis prescribed and no related bleeding precautions included on the hospice aide care plan.

Upon patient record review 1 of 14 (Patient #10) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #10: Tasks assigned include provide ROM each visit and to notify RN after each visit for refused interventions. 4/23/25 ROM was not noted and various tasks including bath, shampoo, shave were documented as patient refused. There was no documented evidence RN was notified of refusal.

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. No evidence that the agency utilized volunteers at least 5% of the total patient care hours in 2024. (NC had a waiver in place for Hurricane Helene but the CMS waiver did not include volunteer services).

Upon observation, there was no evidence the hospice designates a physician to serve as Medical Director which includes: • The Medical Director must be a doctor of medicine or osteopathy who is an employee or is under contract. • When the Medical Director is not available, a physician designated by the hospice assumes the same responsibilities and obligations as the Medical Director. There is currently no physician designated to assume responsibility in absence of medical director. A candidate has been identified, but the contract is not duly executed at time of survey.

Upon patient record review, 1 of 14 (Patient #1) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #1: Hospice Aide supervisory visit documented in initial RN visit 3/21/25, with details including aide following care plan and family satisfied with aide. The aide had not yet provided services at that time.

Based on policy review, home visit observation, clinical record review, and patient and staff interview, all medications and treatments were not included in the Plan of Care for 2 of 3 patients who received a home visit (#2 and 5). Findings included: --- Patient # 5 had a Start of Care date of 4/11/23 with a diagnosis of Congestive Heart Failure [CHF-heart doesnt pump adequately]. The Plan of Care [POC] for the certification period 7/10/23 to 10/7/23 included orders for SN [skilled nursing] 1 time a week for 13 weeks. A joint visit was conducted with the hospice aide on 8/1/23 at approximately 9 am. During the visit a medication review was conducted using the POC provided by the agency. The following discrepancies were noted: The medications on the POC included: - Colestipol [used to treat high cholesterol] 1 gram. 1-6 tablets daily. - Farxiga [used to treat kidney disease] 5 mg. 1 tablet per day. - Milk Thistle [supplement] 1 tablet daily. - Nystatin Powder [treats fungal or yeast infections] 10000 units per gram. Use 1 application four times a day. - Nystatin Mouth Suspension 100000 units per ml. Take 5 ml three times per day. An interview was conducted with the caregiver during the visit. The caregiver reported," She hasnt taken the Farxiga since she came home from the hospital in April. We stopped the Milk Thistle a while back too. I was trying to cut down on her medications. She used all the Nystatin last month [6/23]". During an interview with the administrator on 8/1/23 at approximately 11:30 am, the administrator confirmed the POC did not include current/correct medications. A policy, ";Medication Profile" (no date), was provided by the clinical manager on 8/1/23 at 12:30 p.m. The policy stated, ";A drug regimen review will be performed at the time of initial and comprehensive assessment...During subsequent hospice visits, the medication profile will be used as a care planning and teaching guide to ensure that the patient and family/caregiver, as well as other clinicians, understand the medication regimen..." 1. Patient #2 was admitted on 7/3/19 with diagnoses of senile degeneration of the brain and dementia. The Plan of Care (POC) for 6/12/23-8/10/23 included orders for skilled nursing visits weekly. The POC also included orders for Ondansetron 4 mg sublingual (under the tongue) every six hours as needed for nausea. A joint visit to was conducted with RN #1 on 7/31/23 at approximately 3:20 p.m. The patient resided in an assisted living facility (ALF). The ALF provided a ";Physician Order Report" during the visit. The ALF order for Ondansetron was 4 mg every four hours as needed for nausea. The ALF order date was 4/24/23. An interview with the agency director on 8/1/23 at approximately 12:00 p.m. confirmed medication should be reviewed each visit and the POC updated.

Based on policy review, clinical record review, the agency ";Bereaved List", and staff interviews, the agency failed to follow the bereavement plan of care for 1 of 2 bereavement clients (#7). Findings include: --- A policy, ";Bereavement Services" (no date), was provided by the agency director on 8/1/23 at 12:30 p.m. The policy stated, ";Bereavement interventions will reflect the family/caregivers choices to participate in the bereavement program...The Bereavement Counselor will evaluate each bereaved person on a case-by-case basis and evaluate the needed for individual counseling..." Patient #7 was admitted on 6/6/23 with a diagnosis of end stage heart failure. The Plan of Care for 6/6/23-9/3/23 included orders for skilled nursing visits. The patient died on 6/8/23. A bereavement assessment was conducted on 6/9/23. The agency ";Bereaved List" identified two bereaved clients, the patients spouse and child. An email from the Regional Bereavement Coordinator was provided by the agency director on 8/1/23 at 11:00 a.m. The email stated, ";We typically only send mailings to the PCG [primary caregiver]. In this case that would be [patients wife] ..." An interview with the agency director on 8/1/23 at 11:00 a.m. confirmed the patients son was listed as a bereaved caregiver, but no interventions were provided.

Based on policy review, home visit observation, clinical record review, and patient and staff interview, all medications and treatments were not included in the Plan of Care for 4 of 14 patients (#1, 10, 13, and 14). Findings included: --- A policy, ";Plan of Care" (updated 4/15/23), was provided by the agency director on 5/15/23 at 2:00 p.m. The policy stated, ";The plan of care is revised as needed...The Hospice interdisciplinary plan of care is developed and individualized for each patient and family...and includes all services necessary for palliation and management of the terminal illness and related conditions including...Treatments, drugs, and interventions to manage pain and symptoms of the terminal illness...interventions to manage pain and symptoms..." 1. Patient #1 was admitted on 3/17/23 with a diagnosis of acute systolic (congestive) heart failure. The Plan of Care (POC) for 3/17/23-6/14/23 included orders for skilled nursing one time. A supplemental order on 3/18/23 was obtained for skilled nursing weekly for 12 weeks. The nurse note on 3/18/23 stated, ";Small reddened around navel noted. Calazime cream (protective cream) given at visit with instructions to cleans [sic] with soap and water, pat/air dry then apply cream. Cleanse and reapply daily." Calazime cream not on the POC. An interview with the agency director on 5/17/23 at 9:20 a.m. confirmed Calazime was not on the POC. A nurse note on 4/4/23 revealed the patient had a fungal rash to the left breast fold, and the patient used an antifungal cream daily. The POC did not include an antifungal cream. An interview with the agency director on 5/17/23 at 9:20 a.m. confirmed an antifungal cream was not on the POC. On 5/16/23 at approximately 9:30 a.m., a joint home visit was conducted with RN #4. A review of the patients medication during the visit revealed the patient was taking an iron supplement 325 mg daily. No iron supplement was on the POC. During the visit the patient confirmed she was taking the iron supplement prior to the hospice admission. 2. Patient #10 was admitted on 3/29/23 with a diagnosis of senile degeneration of the brain. The Plan of Care (POC) for 3/29/23-5/27/23 included an order for skilled nursing one time for one week. A supplemental order on 4/2/23 was obtained for skilled nursing visits weekly for eight weeks. The nurse note on 3/29/23 stated, ";Bandage is removed from the left elbow and small skin tear measuring 0.3x0.3 and bandage is replaced [sic]." There was no order on the POC for a dressing to the left elbow. An interview with the agency director on 5/17/23 at 10:22 a.m. confirmed there was no order for the dressing. 3. Patient #13 was admitted on 6/2/22 with a diagnosis of malignant neoplasm upper lobe (lung cancer). The Plan of Care (POC) included orders for skilled nursing one visit for the initial assessment, then weekly for 13 weeks. On 6/6/22, the nurse visit note stated, ";Has skin tear to [right] upper arm. Cleansed, applied ABT [antibiotic] ointment and covered with island dressing." There was no order on the POC for a dressing. An interview with the agency director on 5/17/23 at 10:32 a.m. confirmed there was no order for the dressing. 4. Patient #14 was admitted on 5/13/22 with a diagnosis of ischemic cardiopathy (disease that affects the heart muscles). The Plan of Care (POC) for 5/13/22-8/10/22 included orders for skilled nursing for the initial visit, twice weekly for 12 weeks, then one time for one week. The initial nurse visit stated, ";6 months ago patient was on lasix [sic] [fluid pill] 20 mg per day and has slowly had to increase the dose to 120 mg per day." The POC did not include Lasix. An interview with the agency director on 5/17/23 at 10:38 confirmed Lasix was not included in the POC.

Based on policy and procedure, clinical record review and staff interview the agency failed to have visit frequency projections for the chaplain IDG (interdisciplinary group) for 7 of 14 records reviewed (#3, 4, 5, 6, 8, 9 and 10) and frequency projections for the social work IDG for 8 of 14 records reviewed (#1, 3, 4, 5, 6, 8, 9, and 10). Findings included: --- 8. Patient #10 was admitted on 3/29/23 with a diagnosis of senile degeneration of the brain. The Plan of Care (POC) for 3/29/23-5/27/23 included order for chaplain services monthly. Between 3/29/23 and 5/9/23, there were no visit frequency projections for 3 of 3 interdisciplinary group meetings (IDG). The medical social worker (MSW) conducted the initial assessment on 4/24/23 with a plan to visit monthly. Between 4/24/23 and 5/9/23, there were no MSW visit frequency projections for 3 of 3 IDG meetings. An interview with the clinical director at 9:30 a.m. on 5/17/23 revealed, ";I dont see where they are projecting the frequency for the IDG meetings." Review of a policy ";Plan of Care", revised 04/15/23 was received from the agency director on 05/15/23 at 2:00 p.m. The policy stated," ...the written plan is reviewed every 15 days or more frequently as dictated by the patients condition..." 1.Patient #1 was admitted on 05/05/21 with diagnoses of senile degeneration of brain (decrease in the cognitive abilities), unspecified dementia, and unspecified severe protein-calorie malnutrition. The Plan of Care for 01/31/23 -04/31/23 included orders for skilled nursing 1 time a week for 9 weeks, home health aide 3 times a week for 8 weeks, and medical social work 1 time a month 1. The IDG meetings between 04/25/23-05/10/23 did not include a projected individualized plan for the next 2 weeks for the medical social worker for 2 of 2 meetings. 2.Patient #3 had a Start of Care date of 06/24/22 which included diagnoses of Huntingtons disease (incurable neurodegenerative disease), and dementia. The Plan of Care for certification period 04/20/23 to 06/18/23 included orders for skilled nursing 1 time a week for 9 weeks, and home health aide 6 times a week for 8 weeks, medical social work 1 time a month for 1 month, and chaplain 1 time a month for 3 months. The IDG meetings between 04/25/23-05/10/23 did not include a projected individualized plan for the next 2 weeks for the medical social worker or the chaplain for 2 of 2 meetings. 3.Patient #4 was admitted on 03/08/23 with diagnoses of senile degeneration of brain, not elsewhere classified, and chronic kidney disease stage 3. Review of the Plan of Care for 03/08/23 to 06/05/23 had orders for skilled nursing 1 time a week for 1 week, and 2 times a week for 12 weeks, home health aide 2 times a week for 12 weeks, and chaplain 1 time a month for 1 month. The IDG meetings between 03/08/23-05/10/23 did not include a projected individualized plan for the next 2 weeks for the chaplain for 5 of 5 meetings. 4.Patient #5 was admitted on 04/24/23 with diagnoses of malignant neoplasm of unspecified part of the left lung, and secondary malignant neoplasm of bone. The Plan of Care for certification period of 04/24/23 to 07/22/23 included orders for skilled nursing 1 time a week for 1 week, and 2 times a week for 12 weeks, home health aide 2 times a week for 12 weeks, and chaplain 1 month 1, and medical social work 1 month 1. The IDG meetings between 04/25/23-05/10/23 did not include a projected individualized plan for the next 2 weeks for the medical social worker or the chaplain for 2 of 2 meetings. 5. Patient #6 was admitted on 05/01/23 with diagnoses of malignant neoplasm of spinal cord, acute embolism and thrombosis of unspecified deep veins (blood clots). The Plan of Care for 05/01/23 to 07/29/23 had orders for skilled nursing 1 time a week for 13 weeks, medical social work 1 time a month for 1 month, and chaplain 1 time a month for 1 month. The IDG meetings between 05/05/23-05/10/23 did not include a projected individualized plan for the next 2 weeks for the medical social worker or the chaplain for 1 of 1 meetings. 6. Patient #8 was admitted on 04/27/23 with diagnoses of chronic heart failure and chronic obstructive pulmonary disease. The Plan of Care for 04/27/23 to 07/25/23 had orders for 2 times a week for 12 weeks and medical social worker 1 time a month for 1 month and chaplain 1 time a month for 1 month. The IDG meetings between 05/05/23-05/10/23 did not include a projected individualized plan for the next 2 weeks for the medical social worker or the chaplain for 1 of 1 meetings. 7. Patient #9 was admitted on 02/25/23 with diagnoses of chronic heart failure, heart disease, and chronic kidney failure stage 4. The Plan of Care for 03/02/23 to 05/30/23 had orders for skilled nursing 2 times a week for 12 weeks, home health aide 3 times a week for 11 weeks, medical social worker for 1 time a month for 1 month, and chaplain for 1 time a month for 1 month. The IDG meetings between 03/13/23-05/10/23 did not include a projected individualized plan for the next 2 weeks for the medical social worker or the chaplain for 4 of 4 meetings.

Based on policy review, client record review, direct observation and staff interview the agency staff failed to use proper hand hygiene for 2 of 3 home visits (#3 and 1). Findings included: --- 2. Patient #1 was admitted on 3/17/23 with a diagnosis of acute systolic (congestive) heart failure. The Plan of Care (POC) for 3/17/23-6/14/23 included orders for skilled nursing one time. A supplemental order on 3/18/23 was obtained for skilled nursing weekly for 12 weeks. On 4/4/23 an order was received to apply betadine daily to bilateral foot ulcers. On 5/16/23 at approximately 9:30 a.m., a home visit was conducted with RN #4. The RN cleansed feet with gauze soaked with wound cleanser. The RN reached into plastic bag of clean gauze to remove additional gauze without removing gloves and performing hand hygiene. Additionally, the RN assessed the patients buttocks then placed clean supplies in plastic bag with same gloves worn when buttocks were assessed. An interview with the RN immediately following the visit confirmed gloves should have been removed and hand hygiene completed. Review of policy ";Infection Control Hand Hygiene and Bag Technique", dated 2018 was received from the agency director on 05/17/23 at 11:30 a.m. The policy stated," ...use of alcohol based hand sanitizer is preferred...before and after caring for patients..." Patient #3 had a Start of Care date of 06/24/22 which included diagnoses of Huntingtons disease (incurable neurodegenerative disease), and dementia. The Plan of Care for certification period 04/20/23 to 06/18/23 included orders for skilled nursing 1 time a week for 9 weeks, and home health aide 6 times a week for 8 weeks, medical social work 1 time a month for 1 month, and chaplain 1 time a month for 3 months. A home visit was conducted on 05/13/23 at 9:45 a.m. with the chaplain. Employee #3 was observed to not clean his hands upon entering the facility or leaving the facility to visit the patient. Interview with Employee #3 on 5/17/23 at 10:45 a.m. revealed, ";I keep that sanitizer in my car, and I do it pretty religiously".

Based on policy review, clinical record review and staff interviews, the agency failed to follow the bereavement plan of care for 1 of 2 bereavement clients (#12). Findings included: --- A policy, ";Bereavement-Services" (dated 2018), was provided by the agency director on 5/17/23 at 12:20 p.m. The policy stated, ";Bereavement counseling services are provided in accordance with the plan of care...Bereavement services provided include...Development of a bereavement plan of care, reflecting the bereaved needs and frequency of services..." Patient #12 was admitted on 10/13/22 with a diagnosis of senile degeneration of the brain. The Plan of Care for 10/13/22-1/10/23 included orders for skilled nursing, hospice aide, medical social work, and chaplain. The patient died on 10/25/22. The chaplain conducted a bereavement call on 10/26/22. The assessment on 10/26/22 stated that the caregiver was ";interested in receiving...Telephone calls..." The note stated that ";Bereavement Staff is Offering...Telephone calls..." On 11/16/22, a call was made to the patients spouse and daughter. The bereavement risk level was scored as low risk. The note on 11/16/23 stated that the caregiver was ";interested in receiving...Telephone calls" and the bereavement staff would off telephone calls. There was no evidence that a telephone call was made after 11/16/22. An interview with the agency director on 5/17/23 at 10 a.m. revealed that there was no evidence of a telephone call after 5/17/23, and bereavement services were centralized through a corporate office.

Based on policy review, clinical record review, patient/caregiver interview, and staff interview, the chaplain documentation was inaccurate for 1 of 1 patients (#1) with documentation that the chaplain visited, but did not receive a chaplain visit. Findings included: --- A policy, ";Clinical Records" (dated 2018) was provided by the agency director on 5/17/23 at 11:30 a.m. The policy stated, ";The record is complete, promptly and accurately documented..." Patient #1 was admitted on 3/17/23 with a diagnosis of acute systolic (congestive) heart failure. The Plan of Care (POC) for 3/17/23-6/14/23 did not include orders for spiritual care services. On 3/20/23, the chaplain noted the patient/caregiver declined spiritual care at this time. The interdisciplinary group (IDG) meeting note by the chaplain on 3/28/23, 4/11/23, 4/25/23, and 5/9/23 stated, ";SC [spiritual care] visits PT [patient] at her home in ______, NC to assess needs and provide spiritual support..." A joint home visit was conducted with the RN #4 on 5/16/23 at approximately 9:30 a.m. An interview with the patient and her daughter revealed the chaplain had called in March, and they declined chaplain services at that time. During the home visit, the patient and caregiver revealed they were receptive to spiritual care at that time. An interview with the chaplain on 5/17/23 at ___ confirmed the chaplain had not made home visits. The chaplain stated, ";I probably should have worded that different [IDG notes]."

Based on policy and procedure, and clinical record review the agency failed to have an accurate order for home health aide services for 4 of 8 patients with home health aide services (#3, 6, 7, and 10); and failed to document an order to discontinue an indwelling urinary catheter for 1 of 1 patient with an indwelling urinary catheter (#1). Findings included: --- 3. Patient #7 was admitted 4/1/23 with a diagnosis of abnormal weight loss. The Plan of Care (POC) for 4/1/23-6/29/23 included orders for skilled nursing weekly for 13 weeks and hospice aide weekly for 13 weeks. There were no aide visits after 4/13/23. An interview with the agency director on 5/17/23 at 9:50 a.m. revealed aide services were discontinued on 4/22/23, but no order to discontinue was in the record. 4. Patient #10 was admitted on 3/29/23 with a diagnosis of senile degeneration of the brain. The Plan of Care (POC) for 3/29/23-5/27/23 included order for skilled nursing one time for one week. A supplemental order on 4/2/23 was obtained for skilled nursing visits weekly for eight weeks. The POC also included hospice aide orders twice weekly for eight weeks. Between the weeks of 4/2/23 and 5/7/23, aide visits were weekly. Interview with the agency director on 5/17/23 at 10:11 a.m. revealed that two aides provide service at each visit. The agency director said they had to enter the orders that that way. 5. Patient #1 was admitted on 3/17/23 with a diagnosis of acute systolic (congestive) heart failure. The Plan of Care (POC) for 3/17/23-6/14/23 included orders for skilled nursing one time. A supplemental order on 3/18/23 was obtained for skilled nursing weekly for 12 weeks. On 4/4/23, an order was received to insert an indwelling urinary catheter. On 4/12/23, the catheter became dislodged, and the nurse contacted the physician for an order to discontinue the catheter. According to documentation, the nurse received an order to discontinue the urinary catheter. There was no evidence of the order in the clinical record. An interview with the agency director on 5/17/23 at 9:33 a.m. confirmed there was no order in the record. A policy, ";Clinical Records" dated 2018 was provided by agency director on 05/17/23 at 11:30 a.m. The policy stated, ";...the record is complete, promptly, and accurately documented..." 1.Patient #3 had a Start of Care date of 06/24/22 which included diagnoses of Huntingtons disease (incurable neurodegenerative disease), and dementia. The Plan of Care for certification period 04/20/23 to 06/18/23 included orders for skilled nursing 1 time a week for 9 weeks, and home health aide 6 times a week for 8 weeks, medical social work 1 time a month for 1 month, and chaplain 1 time a month for 3 months. Review of the clinical record revealed Patient #3 was seen by 2 home health aides 3 times a week for the weeks of 4/17/23, 4/24/23, 5/1/23, and 5/8/23. 2. Patient #6 was admitted on 05/01/23 with diagnoses of malignant neoplasm of spinal cord, acute embolism and thrombosis of unspecified deep veins (blood clots). The Plan of Care for 05/01/23 to 07/29/23 had orders for skilled nursing 1 time a week for 13 weeks, medical social work 1 time a month for 1 month, home health aide 4 times a week for 13 weeks, and chaplain 1 time a month for 1 month. Review of the clinical record revealed Patient #6 was seen by 2 home health aides 2 times a week for the weeks of 5/1/23 and 5/8/23.

Based on clinical record review and staff interviews the agency failed to inform the physician when pain medication was not available for 1 of 1 patients [#1]. The findings included: --- Patient # 1 had a Start of Care date of 4/28/22 and a terminal diagnosis of Congestive Heart Disease [CHF]. A review of the Plan of Care for the certification period 4/28/22 to 7/27/22 included orders for skilled nursing 1 time a week for 1 week, 1 time a week for 13 weeks, 2 PRN [as needed] for decline in condition. The clinical record revealed on 7/14/22 the caregiver called the agency to advise the nurse the patient needed a refill on ";morphine tabs" [Morphine Sulfate ER 15 mg]. The caregiver called the agency on 7/15/22 to report the patient was completely out of Morphine Sulfate ER 15 mg tablets. RN # 1 made a routine visit on 7/16/22. The caregiver voiced concern the Morphine Sulfate ER had still not been delivered. The caregiver called the agency on 7/18/22 and again on 7/19/22 to report the patient had not received the Morphine Sulfate ER 15 mg tablets from the pharmacy. On 7/19/22, RN # 2 notified the physician to request prescription for the Morphine Sulfate ER be called into a local pharmacy so Patient # 1s caregiver could pick the medication up. An interview was conducted with RN # 3 on 10/4/22 at approximately 9:30 am. During the interview, RN # 3 confirmed the physician should have been contacted prior to 7/19/22.

Based on NC Board of Nursing Physician Statement and staff interviews the RN [registered nurse] failed to obtain an order for the as needed medication to be given in place of the extended-release medication for 1 of 1 patients [#1]; and failed to provide correct education related to pain medication for 1 of 1 patient [#1]. The findings included: --- Review of the North Carolina Board of Nursing Physician Orders Communication and Implementation Position Statement for RN and LPN Practice [revised 9-2018] stated, ";...Nurse has no authority to prescribe or make medical judgements...Nurse has no authority to change the medical management plan or orders..." 1A. Patient # 1 had a Start of Care date of 4/28/22 and a terminal diagnosis of Congestive Heart Disease [CHF]. A review of the Plan of Care [POC] for the certification period 4/28/22 to 7/27/22 included orders for skilled nursing 1 time a week for 1 week, 1 time a week for 13 weeks, 2 PRN [as needed] for decline in condition. The POC also included orders for the following medications, ";Morphine Sulfate ER [extended release] 15 mg every 12 hours and Morphine Sulfate 20 mg/ml administer 0.25 milligram PRN every hour pain/shortness of breath. Review of the clinical record revealed the caregiver called the agency on 7/14/22 to inform the agency the patient only had 2 ";morphine tabs" [Morphine sulfate ER 15 mg] left. The agency contacted ______ pharmacy on 7/14/22 and requested the refill. On 7/15/22 the caregiver called the agency again to report the patient was completely out of the Morphine Sulfate ER [medication the patient used routinely for pain control]. RN # 1 called the caregiver back on 7/15/22 and advised the patient to use Morphine Sulfate 20 mg/ml administer 0.25 milligram PRN [as needed] for shortness of breath or pain every 4 hours. Further review of the POC revealed no order for the Morphine Sulfate 20 mg/ml administer 0.25 milligram PRN [as needed] for shortness of breath or pain every 4 hours. RN # 1 was not available for interview. An interview was conducted with RN # 3 on 10/4/22 at approximately 12 p.m. During the interview the RN stated, ";There is no physicians order for Morphine Sulfate 20 mg/ml administer 0.25 milligram PRN [as needed] for shortness of breath or pain every 4 hours." RN # 3 confirmed RN # 1 did not obtain the order for Morphine Sulfate 20 mg/ml administer 0.25 milligram PRN [as needed] for shortness of breath or pain every 4 hours to be given to the patient until the Morphine Sulfate ER was available. 1B. Patient # 1 had a Start of Care date of 4/28/22 and a terminal diagnosis of Congestive Heart Disease [CHF]. A review of the Plan of Care [POC] for the certification period 4/28/22 to 7/27/22 included orders for skilled nursing 1 time a week for 1 week, 1 time a week for 13 weeks, 2 PRN [as needed] for decline in condition. The POC also included orders for the following medications, ";Morphine Sulfate ER [extended release] 15 mg every 12 hours and Morphine Sulfate 20 mg/ml administer 0.25 milligram PRN every hour pain/shortness of breath." The clinical record revealed on 7/14/22 the caregiver called the agency to advise the nurse the patient needed a refill on ";morphine tabs" [Morphine Sulfate ER 15 mg]. The caregiver called the agency on 7/15/22 to report the patient was completely out of Morphine Sulfate ER 15 mg tablets. RN # 1 documented the following information, ";...Dtr [daughter] instructed to use PRN Morphine Sulfate as prescribed every 4 hours PRN until Morphine ER arrives..." RN # 1 was not available for interview. RN # 3 was interviewed on 10/4/22 at 11:30 am. During the interview, RN # 3 confirmed RN # 1 provided the wrong education related to the frequency of the Morphine Sulfate in the absence of the Morphine Sulfate ER.