Every finding on record at Iowa City Hospice, Inc

Based on clinical record review, hospice wound job aid and staff interview, the hospice failed to ensure hospice nurse members of the Interdisciplinary Group failed to update the comprehensive assessment with changes to the patient condition regarding wound description and measurements for 2 of 4 sampled patients with a wound (Patients #1 and #16). Failure by the hospice Interdisciplinary Group (IDG) registered nurses to update the comprehensive assessment with complete wound descriptions and measurements placed the patient at risk for ineffective staff collaboration and communication regarding patient's wound status and effectiveness of treatments and interventions. --- 1.Patient #1 had a hospice admission date of 6/6/23 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The Interdisciplinary Group (IDG) meeting notes, dated 1/2/24, 1/16/24, 1/23/24, and 1/30/21, included orders for skilled nursing services 1 time per week. b. A comprehensive assessment, dated 1/11/24, included documentation the Registered Nurse (RN) assessed the patient had a wound that is open/pink and pea sized on the left buttock. The assessment failed to include a description of the measurements of the wound. c. Comprehensive assessments completed by the RN, dated 1/16/24, 1/30/24, and 2/6/24 included documentation of a wound to the right and left buttock. The documentation lacked wound measurements for the right and left buttock wounds. The hospice failed to document complete assessment including measurement of wounds. 2. Patient #16 had a hospice admission date of 10/5/23 and received hospice services while residing in a private residence. a. The IDG meeting notes, dated 12/13/23, 12/20/23, 12/27/23, 1/10/24, and 1/24/24, included orders for skilled nursing services 1 time per week. b. Comprehensive assessments completed by the RN, dated 12/18/23 and 1/2/24, included documentation the patient had wounds sites. The assessments failed to include identification of the wound sites and a description or measurements of the wounds. c. Comprehensive assessments completed by the RN, dated 12/29/23,1/19/24, and 2/2/24, included documentation the patient had wounds on the left lateral foot, posterior foot arch, right anterior lateral leg calf, right dorsal foot bottom of foot, and right hand thumb. The assessments lacked wound measurements for any of the identified wounds. Failure by the hospice nurses to update the comprehensive assessment with complete wound descriptions and measurements placed the patient at risk for ineffective staff collaboration and communication regarding wound status and effectiveness of treatments and interventions. The above findings were shared with the Administrator, Clinical Manager, and Quality Manager and the hospice provided no further information prior to the end of the survey. Findings include: According to hospice wound job aid, titled Wound Assessment and Documentation, dated 5/15/15, assess the wound location and size, measure the length, width and depth. The nurse must assess the patients wound every 2 weeks. During an interview on 2/26/24 4:19 PM, the Clinical Manager reported wounds should be assessed at least every comprehensive assessment, measurements include length, width and depth.

Based on hospice clinical record review, hospice policy review, home visit observation, nursing home record review, nursing home staff interview and patient interview, the hospice failed to ensure the Plans of Care for 2 of 4 home visits (Patients #2 and #3) identified all medical equipment and supplies necessary to meet identified patient needs. Failure to include all needed items of medical equipment and supplies the patient used on the Plans of Care placed the patients at risk of unanticipated decline or injury and of needs not met. Findings include: --- 2. Patient #2 had a hospice admission date of 1/5/24 and received hospice services while residing in a private home. a. Plan of Care, dated 1/5/24 to 4/3/24, identified the patient used the following medical equipment and supplies: overbed table, electric wheelchair, blue pads/chux, gloves, oxygen, pressure relief mattress, gait/transfer belt, bed rails, shower chair, hospital bed and ostomy bags. b. Interdisciplinary Group Update to the Plan of Care, dated 1/8/24, 1/15/24, 1/29/24 and 2/12/24, identified the patient used the following medical equipment and supplies: hospital bed with side rails, air mattress and pump, shower chair, CPAP (continuous positive air pressure), motorized wheelchair, overbed table, disposable chux, disposable wipes, gloves and ostomy supplies. c. On 2/20/24 at 12:25 PM, during a home visit observation with Staff H, Registered Nurse (RN), the surveyor identified the patient utilized a reacher that was on the bed next to the patient and the patient was wearing zippered compression knee high socks. The POC and IDG updates to the POC failed to identify all necessary medical equipment and supplies used by the patient, including the compression socks and reacher. The Administrator and Quality Manager received the above findings and no additional information was provided prior to the end of the survey. According to the hospice policy titled Plan of Care, dated 6/2023, the patient's plan of care specified the care and services necessary to meet the needs of the patient/caregiver as identified in the initial, comprehensive and updated assessments of the patient. 1. Patient #2 had a hospice admission date of 10/13/23 and received hospice services in a private residence. Review of the clinical record revealed the following: a. The Plans of Care (POC), dated 10/13/23 to 1/10/24, identified the patient had the following medical equipment and supplies: adult diapers, blue pads/chux, moisture barrier, walker, wheelchair, skin prep wipes, bed rails, bedside commode, hospital bed, overbed table, oxygen, shower chair. b. The Interdisciplinary Group (IDG) meeting, dated 12/27/, 1/3, 1/17, 1/31, 2/7 and 2/14/24, identified no additional medical equipment and supplies used by the patient. c. On 2/20/23 at 11:00 AM, during a home visit observation with Staff F, Registered Nurse (RN), the surveyor identified the patient also had a reacher and hand held shower. d. In an interview, during the same home observation, the patient's family stated he/she has used the equipment prior to the start of hospice services. The POC, and IDG meetings to update the POC, failed to identify all medical equipment and supplies used by the patient.

Based on clinical record review, hospice policy review and hospice staff interview, the hospice failed to ensure the Interdisciplinary Group maintained a system for communication and integration of patient care and services to ensure hospice staff provided care in accordance with the plan of care for 6 of 6 sampled patients (Patients #1, #3, #5, #7, #10 and #15) with a missed visit. Failure of the hospice interdisciplinary group (IDG) members to maintain a system for communication and integration of patient care and services to ensure hospice staff provided care in accordance with the plan of care increased the risk that patients did not receive services to meet assessed needs. Findings --- 6. Patient #15 had a hospice admission date of 10/20/23, a death date of 11/20/23, and received hospice services while residing in a private home from 10/20/23 to 10/29/23 and 11/4/23 to 11/20/23 and residing in an inpatient facility from 10/30/23 to 11/3/23. Clinical record review revealed the following: a. The IDG update to the Plan of Care, dated 10/17/23 to 10/31/23, included IDG orders for hospice aide to provide services 2 times a week for 12 weeks, effective 10/29/23. b. The week of 10/29/23 to 11/4/23 lacked documentation of a completed hospice aide visit. c. The week of 11/5/23 identified a completed hospice aide visit on 11/7/23 but lacked a 2nd visit for the week. d. The IDG update to the Plan of Care, dated 10/30/23 to 11/13/23, lacked documentation the IDG was notified of missed hospice aide visits for the week of 10/29/23 and 11/5/23. The hospice failed to provide hospice aide visits as ordered per the IDG update to the Plan of Care. The Administrator and Quality Manager received the above findings and no additional information was provided prior to the end of the survey. 5. Patient #1 had a hospice admission date of 6/6/23 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The POC, dated 12/3/23 to 1/31/24, included IDG orders for hospice aide services 2 times a week. b. The clinical record lacked documentation of aide visits the weeks of 1/7/24 to 1/12/24 and 1/14/24 to 1/20/24. c. The IDG meeting notes, dated 1/16/24 and 1/23/24, lacked documentation of IDG member awareness of missed visits for hospice aide services. The hospice failed to include documentation the hospice notified IDG of hospice aide missed visits. 4. Patient #5 had a hospice admission date of 12/07/23, and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The POC, dated 12/7/2023 to 3/5/2024, included IDG orders for hospice aide services 1 time a week. b. The clinical record included documentation of a missed hospice aide visit, dated 1/6/24. c. The IDG meeting notes, dated 1/31/24, lacked documentation of IDG member awareness of missed visits for hospice aide services. The hospice failed to include documentation the hospice notified the IDG of hospice aide missed visits. According to the hospice policy titled Care Planning, dated 10/2023, the documentation of the IDG's care planning meetings reflects the ongoing reassessment of the patient/family's status and needs. 1. Patient #3 had a hospice admission date of 10/13/23 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 1/11/24 to 4/9/24, included IDG orders for hospice aide services 1 time a week. b. The clinical record laced documentation of a hospice aide visit the week of 1/28/24 to 2/3/24. c. The IDG meeting notes, dated 7/131/24 and 2/7/24, lacked documentation of IDG member awareness of missed visits for hospice aide services. The hospice failed to include documentation the hospice notified the IDG of hospice aide missed visits. 2. Patient #7 had a hospice admission date of 1/25/24 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The POC, dated 1/25/24 to 4/23/24, included IDG orders for hospice aide services 2 times a week. b. The clinical record lacked documentation of 2 hospice aide visits the week of 2/11/24 to 2/17/24. c. The IDG meeting notes, dated 2/20/24, lacked documentation of IDG member awareness of missed visits for hospice aide services. The hospice failed to include documentation the hospice notified the IDG of hospice aide missed visits. 3. Patient #10 had a hospice admission date of 12/15/24 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The POC, dated 12/15/23 to 3/13/23, included IDG orders for hospice aide services 2 times a week. b. The clinical record lacked documentation of 2 hospice aide visits the week of 12/24/23 to 12/30/24 and 2 hospice aide visits the week of 1/7/24 to 1/13/24. c. The IDG meeting notes, dated 1/2/24 and 1/9/24, lacked documentation of IDG member awareness of missed visits for hospice aide services. The hospice failed to include documentation the hospice notified the IDG of hospice aide missed visits.

Based on clinical record review, hospice policy review and home visit observation, the hospice failed to ensure staff performed tasks during home visits in a manner to prevent contamination and/ or the spread of infection. The survey identified concerns with 2 of 4 home visit observations (Patients #1 and #4). Failure to ensure services during home visits follow accepted standards of practice for infection control increased the risk of contamination during the home visit, the development of an infection and/or transmission of organisms from home to home. --- 1.Patient #1 had a hospice admission date of 6/6/23 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: The Plan of Care (POC), dated 2/1/24 to 3/31/24, included Interdisciplinary Group (IDG) orders for skilled nursing services. On 2/20/24 at 9:05 AM, during a home visit observation, Staff E, Registered Nurse (RN), completed an assessment of the patient in bed. Staff E, RN placed nursing bag on overbed table, checked patients pulse and oxygen with pulse oximeter, took patients temperature and blood pressure. Staff E documented in the notebook, placed dirty equipment on the notebook, and listened to patients lungs, abdomen, and heart. Staff E, utilized a wipe to clean equipment, placing clean thermometer on notebook before putting it in nursing bag with other cleaned equipment. The hospice nurse failed to wipe down all equipment and allow it to dry on a clean surface/barrier prior to putting it back in bag. 2. Patient #4 had a hospice admission start date of 5/25/23 and received hospice services while residing in a nursing home. The Plan of Care (POC), dated 1/20/24 to 3/19/24, included Interdisciplinary Group (IDG) orders for skilled nursing services. On 2/27/24 at 8:15 AM, during a home visit observation, Staff E, Registered Nurse (RN), completed an assessment of the patient in bed. Staff E, RN placed nursing bag on dresser with no barrier. She listened to patients lungs, abdomen, and heart and checked patients pulse, oxygen, and temperature. Staff E recorded vital signs on notebook and placed equipment on dresser prior to sanitizing it. She utilized a sanitizing wipe to clean equipment, placing clean oximeter on notebook before putting it in nursing bag with other cleaned equipment. The hospice nurse failed to wipe down all equipment and allow it to dry on a clean surface/barrier prior to putting it back in bag. The Administrator, Clinical Manager, and Quality Manager received the above findings and hospice staff provided no further information prior to the end of the survey. Findings include: According to the hospice policy titled Infection Control - Program, dated 12/2023, the agencys infection control program includes education and training for staff on the principles of infection identification, prevention and control, including the use of standard and transmission-based precautions.

Based on hospice policy review, clinical record review, review of employee personnel files, and hospice staff interview, the hospice failed to ensure 1 of 6 hospice aides (Staff G) demonstrated competency in the performance of any skills which exceed the level of basic hospice aide skills in the presence of a registered nurse with competency determined at a patient's bedside or using a real person (pseudo-patient) prior to being assigned to perform the task independently for 2 of 10 sampled patients who required an extra skill to be performed (Patients #4 and #13). Failure to ensure hospice aides have a competent ability to perform all skills above and beyond basic hospice skills increased the risk for patients to receive inadequate or inappropriate care. Findings include: --- The Medicare Conditions of Participation direct that the hospice aide may not independently provide any patient cares beyond the basic required skills without successful instruction and demonstration of competency in extra skills assigned on the aide care plan. Review of the hospices policy, titled, Hospice Aide Services, dated 11/20/08, the hospice ensures individuals who meet the personnel requirements specified in the hospice regulations and who have successfully completed a competency evaluation as required by regulations, provide hospice aide services under the supervision of a hospice registered nurse. During an interview on 12/27/24 at 2:05 PM, Clinical Manager reported no other skills competency forms that identified hoyer lift transfer, feeding patient, and weighing patient available for Staff G, Hospice Aide. 1.Patient #4 had a start of care date of 5/25/23, and received hospice services while residing in a nursing home. The aide care plan included Registered Nurse (RN) instructions to the aide to utilize the hoyer lift with transfers. The aide care plan included RN instructions for the aide to assist the patient to eat a regular diet. Review of the clinical record showed Staff G, Hospice Aide, provided aide services independently for Patient #4. Staff G, Hospice Aide, had a hire date of 1/15/24. Staff Gs personnel file lacked documentation RN had observed Staff G competently perform the tasks of transferring patient with hoyer lift and assisting the patient to eat a regular diet. 2. Patient #13 had a start of care date of 1/22/24, and received hospice services while residing at home. The aide care plan included RN instructions to obtain patients weight monthly. Review of the clinical record showed Staff G, Hospice Aide, provided aide services independently for Patient #13. Staff G, Hospice Aide, had a hire date of 1/15/24. Staff Gs personnel file lacked documentation RN had observed Staff G competently perform the task of weighing the patient. The above findings were reviewed with the Administrator, Clinical Manager, and Quality Manager. Hospice staff provided no further information prior to the end of the survey.

Based on clinical record review and staff interview, the hospice failed to ensure all documentation was included in the clinical record in a timely manner for 8 of 19 sampled patients (Patients #1, #3, #4, #7, #8, #9, #13 and #17). Failure to ensure all clinical record documentation, and each patient's clinical record was complete, timely and appropriately authenticated, decreased the ability of hospice staff to communicate and coordinate patient care effectively, and to provide safe, effective hospice services to its patients. Findings include: --- 7. Patient #1 had a hospice admission date of 6/6/23 and received services while residing in a nursing home. a. The hospice aide visit note, dated, 12/22/23, signed completed on 12/26/23 (3 days late). b. The hospice aide visit note, dated, 1/3/24, signed completed on 1/10/24 (6 days late). c. The hospice aide visit note, dated, 1/5/24, signed completed on 1/10/24 (4 days late). d. The hospice aide visit note, dated, 1/24/24, signed completed on 1/29/24 (4 days late). e. The hospice aide visit note, dated 1/26/24, signed completed on 1/29/24 (2 days late). f. The hospice aide visit note, dated 1/31/24, signed completed on 2/14/24 (13 days late). The hospice clinical record failed to include timely documentation. 8. Patient #9 had a hospice admission date of 1/18/24 and received services while residing at home. a. The skilled nurse visit note, dated 2/7/24, signed completed on 2/20/24 (12 days late). b. The skilled nurse visit note, dated 2/14/24, signed completed on 2/26/24 (11 days late). The hospice clinical record failed to include timely documentation. The above findings were shared with the Administrator, Clinical Manager, and Quality Manager and the hospice provided no further information prior to the end of the survey. During an interview on 2/26/24 at 4:19 PM the Clinical Manager stated the expectation for staff to complete documentation in 24 hours. 1. Patient #3 had a hospice admission date of 10/13/23 and received services while residing in a private home. a. The skilled nurse visit note, dated 1/16/24, signed completed on 1/21/24 (3 days late). b. The skilled nurse visit note, dated 2/13/24, signed completed on 2/19/24 (6 days late). The hospice clinical record failed to include timely documentation. 2. Patient #4 had a hospice admission date of 5/25/23 and received services while residing in a nursing home. a. The hospice aide visit note, dated 12/22/23, signed completed on 12/26/23 (3 days late). b. The hospice aide visit note, dated 1/3/24, signed completed on 1/10/24 (6 days late). c. The hospice aide visit note, dated 1/5/24, signed completed on 1/10/24 (4 days late). d. The hospice aide visit note, dated 1/17/24, dated completed on 1/29/24 (11 days late). e. The hospice aide visit note, dated 1/24/24, dated completed on 1/29/24 (4 days late). f. The hospice aide visit note, dated 1/31/24, dated completed on 2/14/24 (13 days late). The hospice clinical record failed to include timely documentation. 3. Patient #7 had a hospice admission date of 1/25/24 and received services while residing in a private residence. a. The hospice aide visit note, dated 2/15/24, signed completed on 2/19/24 (3 days late). 4. Patient #8 had a hospice admission date of 1/31/24 and received services while residing in a private residence. a. The skilled nurse visit note, dated 2/8/24, signed completed on 2/20/24 (11 days late). b. The skilled nurse visit note, dated 2/15/24, signed completed on 2/26/24 (10 days late). The hospice clinical record failed to include timely documentation. 5. Patient #13 had a hospice admission date of 1/22/24 and received services while residing in a private residence. a. The hospice aide visit note, dated 1/25/24, signed completed on 1/29/24 (3 days late). The hospice clinical record failed to include timely documentation. 6. Patient #17 had a hospice admission date of 10/13/23 and received services while residing in a private residence. a. The hospice aide visit note, dated 11/16/23, signed completed on 11/21/23 (4 days late). b. The hospice aide visit note, dated 11/21/23, signed completed on 11/27/23 (5 days late). The hospice clinical record failed to include timely documentation.

Based on clinical record review and hospice policy review, the hospice failed to educate patients and/or family/caregivers on the hospice policy and procedure concerning the disposal of controlled substances for 1 of 2 sampled patients who received hospice services in a private residence after transferring out of a facility and had physician ordered controlled medications (Patient #11). Failure to educate hospice patients and/or family members/caregivers about the hospice protocol for disposal of controlled substances, increased the risk that the patient/caregiver discarded controlled substances in a way which might be hazardous for others. --- Findings include: The hospice policy, titled Medications – Labeling Disposing and Storing of Drugs and Biologicals, dated 08/2023, indicated at the time when controlled substances are first ordered, the hospice nurse, discusses the hospices policies and procedures for managing the safe use and disposal of controlled drugs with the patient or representative and documents in the patients clinical record that the written policies and procedures for managing controlled drugs were provide and discussed. Patient #11 had an admission to hospice on 10/27/23 and received services in a long term care facility from 10/27/23 to 2/7/24 and started in a private home on 2/8/24. Clinical record review revealed the following: a. The Plan of Care, dated 1/25/24 to 4/23/24, included orders for Morphine Sulfate and Lorazepam, both controlled substances. b. Skilled nursing visit note, dated 2/8/24, included documentation the nurse made a visit to the patients home to fill the medication planner and prefill syringes of morphine sulfate. The clinical record lacked documentation that the patient had received education on and a copy of the hospice policy for disposal of controlled medications. The Administrator and Quality Manager received the above findings and no additional information was provided prior to the end of the survey.

Based on clinical record review and hospice policy review, the hospice failed to maintain documentation in the patient clinical record as evidence that patients received a copy of the hospice policy concerning the disposal of controlled medications and hospice staff discussed this policy with the patient/caregiver for 1 of 2 sampled patients (Patient #11) who received routine home care while living in a private home residence after transferring out of a facility and had a physician ordered controlled medication. Failure to ensure patients and/or caregivers received adequate education on the use and disposition of controlled (medication whose manufacture, possession and use is controlled by the government) increased the risk of inappropriate use of narcotics and other controlled substances by individuals other than the patient for whom the medication was prescribed. --- Findings include: The hospice policy, titled Medications – Labeling Disposing and Storing of Drugs and Biologicals, dated 08/2023, indicated at the time when controlled substances are first ordered, the hospice nurse documents in the patients clinical record that the written policies and procedures for managing controlled drugs were provide and discussed. Patient #11 had an admission to hospice on 10/27/23 and received services in a long term care facility from 10/27/23 to 2/7/24 and started in a private home on 2/8/24. Clinical record review revealed the following: a. The Plan of Care, dated 1/25/24 to 4/23/24, included orders for Morphine Sulfate and Lorazepam, both controlled substances. b. Skilled nursing visit note, dated 2/8/24, included documentation the nurse made a visit to the patients home to fill the medication planner and prefill syringes of morphine sulfate. The clinical record lacked documentation that the patient had received a copy of the hospice policy for disposal of controlled medications. The Administrator and Quality Manager received the above findings and no additional information was provided prior to the end of the survey.

Based on clinical record review, policy review, staff interview and caregiver interview, the hospice failed to ensure the hospice registered nurse completed a comprehensive assessment which included assessment of the physical and emotional needs of the patient and caregiver related to the terminal illness as well as the complications and risk factors that affect care planning for 1 of 4 sampled patients (Patient #3) at time of admission to hospice services. Failure to complete an initial comprehensive physical and emotional assessment along with complications and risk factors that affect care planning increased the risk that patient's and caregivers needs would not be identified and/ or addressed appropriately and the hospice would have the potential for inadequate and/or inappropriate treatments and interventions. --- Findings include: According to the hospice policy, titled Initial Assessment, dated 06/23, the hospice RN (registered nurse) completes the initial assessment tool and ensures that orders for treatment and services are obtained to meet the immediate care and support needs of the patient. According to the hospice policy, titled Comprehensive Assessment – Content, dated 06/23, the interdisciplinary group uses information obtained from the comprehensive assessment tools to develop an effective plan of care with interventions that address the identified needs of the patient/family. During an interview on 9/12/23 at 4:36 PM, the Administrator reported at hospice admission the goal is to touch base with patient and caregiver, this can be done by a visit to the home or a phone call the day after the admission. The skilled nurse on call would use clinical judgement to determine if a home visit or phone call is needed to address the on-call issue. During an interview on 9/13/23 at 9:08 AM, the Clinical Manager reported after patient is admitted to hospice services, the admission nurse notifies the case manager of the new admit. The case manager is responsible for contacting the patient/caregiver the day after admit or the next day, this is the standard of practice for the hospice. The skilled nurse on call would use nursing judgement to determine if a home visit or phone call is needed to handle the on-call issue. During an interview on 9/13/23 at 11:50 AM, Staff C, RN, reported the case manager tries to see a new patient (make a home visit to new admitted patient) within 2 days of admission. If patient is admitted on a Friday, case manager will schedule a visit on the weekend for the on-call nurse to see. If Staff C receives an on-call phone call regarding a change in condition, a visit would be made and a visit would be made to allow the nurse to provide emotional support and helps alleviate the family concerns. During an interview on 9/12/23 at 2:00 PM, Staff D, RN, reported the follow up after hospice admission is usually a phone call the next day or a visit depending on what is going on in the home. Patient #3 had a hospice admission date of 4/27/23, a death date of 4/30/23 and received services while residing in a private home. Clinical record review revealed the following: a. The initial comprehensive assessment completed by an RN, dated 4/27/23, included documentation the patient was lethargic, easy to arouse; patient and caregiver were not talking about loss; and anticipated date for next follow up visit was 4/28/23. b. A skilled nursing phone call note, dated 4/27/23 at 11:55 PM, included documentation the patient spouse called to report difficulties toileting and repositioning patient in bed, had help to get patient comfortable tonight but would like more information on private caregivers, possible placement and respite care as patient progressed; and patient would need a urinal delivered tomorrow (4/28/23). c. A skilled nursing phone call note, dated 4/28/23 at 10:14 AM, included documentation the patient spouse called to report inability to get patient out of bed to place the air mattress on the bed that is expected to be delivered soon. RN reported a nurse would be sent out early afternoon to assist with transferring patient to a wheelchair, place air mattress on the bed and transfer patient back to bed. Patient spouse was in agreement with this plan. d. A skilled nursing phone call note, dated 4/28/23 at 11:37 AM, included documentation the RN was returning a call to patient spouse, spouse reported patient was having jerking movements while up on commode attempting to have a bowel movement. At this time, jerking had stopped, patient resting in bed, required help from friends to get patient back into bed. RN documented spouse needed teaching on how to reposition and change chux/linen in bed, requested LPN (licensed practical nurse) to deliver fracture bed pan, chux, wipes and urinal and LPN to call patient spouse with estimated time of arrival this afternoon. e. A skilled nursing visit note, dated 4/28/23 at 3:10 PM, included documentation the LPN went to home to assist spouse with placing an air mattress on the patient's bed. The LPN was unable to transfer patient out of the bed, hospice aide assisted with removing foam mattress and placing the air mattress on the bed. f. A skilled nursing phone call note, dated 4/29/23 at 7:11 PM, included documentation the patients spouse had a few questions about services like how frequently the hospice aide would visit. g. A skilled nursing phone call note, dated 4/29/23 at 7:20 PM, included documentation the patients spouse called to report she had forgot to mention earlier the patient had a change in condition with patient being restless. The nurse reported she could contact the on-call physician for medication such as Haldol or lorazepam, spouse reported not wanting to start medications with those types of side effects and questioned starting Ambien. The nurse educated spouse Ambien was a sleeping pill. Spouse reported must have thought of the wrong medication. h. A skilled nursing visit note, dated 4/29/23 at 10:30 PM, included documentation RN visit was made to the home. Patient resting comfortably, denied pain, lethargic, responds with minimal prompting and is non-ambulatory. Patient spouse very anxious about caring for patient. Patient had an episode of tremors earlier in evening but spouse declines wanting additional medications for patient. Spouse is aware of respite services available should she need it. i. A skilled nursing visit note, dated 4/30/23 at 7:45 AM, included documentation nurse made visit to home to pronounce patient and provide post mortem care. During an interview on 9/11/23 at 4:15 PM, the patient spouse reported the patients condition declined quickly and spouse had to call hospice to ask for help. The spouse reported being instructed there was no additional help that could be provided. During an interview on 9/13/23 at 4:10 PM, the Administrator reported this scenario is not what the hospice expects from the staff. The hospice failed to identify in the comprehensive assessment physical and emotional needs related to the terminal illness as well as the complications and risk factors that affect care planning. The above findings were shared with the Administrator and Clinical Manager, the hospice provided no further information prior to the end of the survey.

Based on hospice clinical record review, hospice admission packet review, assisted living clinical record review, assisted living staff interview and hospice staff interview, the hospice failed to ensure hospice staff provided effective symptom control management for conditions related to the terminal illness for 1 of 7 sampled patients (Patient #6). Failure to ensure hospice staff provided effective symptom control management for conditions related to the terminal illness placed patients at increased risk for uncontrolled emotional, physical or psychological pain. Findings include: Review of the hospice admission packet revealed a policy, titled Patient's Rights and Responsibilities, dated 11/20/08, revealed the patient had the right to receive effective pain management and symptom control. Review of the hospice's policy, titled E-Kit (Emergency) Process, dated 1/20/2022, identified the E-kit included bottled of liquid Morphine, liquid Haldol, Lorazepam tablets or liquid, Glycopyrrolate tablets or liquid, Hydromorphone tablets and DMD (Dexamethasone, Metoclopramide and Diphenhydramine) suppositories. The policy identified the hospice staff kept the E-kits in a double locked location with a pharmacy red tag lock. The policy identified hospice nursing staff were to use the E-kit medications for emergent patient symptoms for when the patient's need is too urgent to wait or for when the nurse is unable to obtain the medication from the pharmacy, such as after pharmacy hours. When hospice nursing staff need to use a medication from the E-kit, they need to break and remove the pharmacy red tag, take the needed medication from the bag, complete a form including the date, time, drug and patient name and signature of the nurse. Hospice staff notify the patient's physician or Medical Director for a E-kit fill order and deliver the E-kit to the pharmacy for refill and pick-up. The hospice Clinical Coordinator checks the E-kits to verify the lock is intact 2 times per day Monday through Friday. Patient #6 had a hospice admission date of 1/5/22, received hospice services while residing in an assisted living facility and died on 1/8/22. 1. Review of the hospice clinical record revealed the following: a. A communication note, dated 1/4/22 at 3:56 PM, included directions to "please pick up Tylenol, Morphine and Haldol comfort medications from a the local pharmacy used by the hospice for a tentative admit scheduled for 10:30 AM. b. A communication note, dated 1/5/22 at 9:41 AM, included documentation of medication changes and to pick up Morphine (medication used to treat pain), Lorazepam (medication used to treat anxiety, restlessness), Tylenol and Ondansetron (medication used to treat nausea) at the local pharmacy used by the hospice. c. The comprehensive assessment completed by Staff H, Hospice Registered Nurse (RN), dated 1/5/22 at 10:30 AM, included documentation the patient had a gastrointestinal bleed and dementia. The family was seeking comfort cares for the patient. Staff H, RN, assessed the patient had moderately impaired thought processes, confused and had mild pain associated with chronic back pain. Staff H, RN, documented the assisted living facility did not have Lorazepam available, but the medication had been ordered at the local pharmacy used by the hospice and needed to be delivered. d. The Plan of Care (POC), dated 1/5/22 to 4/4/22, included physician orders for Morphine 20 milligrams (mg) per milliliter (ml) oral concentrate 0.125 to 0.25 ml orally every 2 hours as needed for pain or dyspnea and Lorazepam 0.5 mg oral tablets take one-half tablet orally every 4 hours for anxiety or agitation. e. A skilled nursing visit completed by Staff J, Hospice RN and patient's Case Manager, dated 1/5/22 at 5:00 PM, included documentation the nurse had received a phone call from the assisted living facility staff who reported the patient had a fall, hit the patient's head and the patient had pulled his/her urinary catheter out. Staff J, RN, documented orders to reinsert the catheter. She documented the charge nurse at the assisted living facility requested Morphine and Lorazepam for the patient, and she would have on-call deliver the medications that night. f. A skilled nursing visit completed by Staff I, Hospice On-Call RN, dated 1/5/22 at 7:30 PM, documented she delivered Morphine and Lorazepam from the hospice's emergency kit (E-kit). She instructed the facility staff to crush the Lorazepam, as only tablets were available. g. A hospice's social worker (SW) visit note, dated 1/6/22 at 9:20 AM, included documentation the POA discussed concerns with the patient getting out of bed and falling the previous day and concerns with the patient maybe needing a medication to help the patient sleep better at night. The SW documented she discussed options of side rails on the bed, but thought this would be a restraint. She discussed with the POA the option of hiring a private duty caregiver and documented she would discuss the medication question with Staff I, RN. 2. Review of the assisted living facility progress notes revealed the following: a. A progress notes completed by an Assisted Living RN, dated 1/5/22 at 12:50 PM, included documentation the patient had a condition change and had been referred to hospice services. The RN documented the patient used a wheelchair for mobility and required the assistance of 2 persons for transfer. The patient needed reminders to not transfer without assistance and was a fall risk. b. A progress note completed by an Assisted Living Licensed Practical Nurse (LPN) on second shift, dated 1/5/22 at 3:30 PM, included documentation the patient had a fall and hit his/her head. The patient had pulled his/her urinary catheter out and hospice staff had been informed. c. A progress note, dated 1/5/22 at 5:00 PM, included documentation the hospice nurse was at the facility to assess the patient. d. A progress note completed by an Assisted Living LPN on first shift, dated 1/6/22 at 11:04 AM, which identified the patient was found on the floor after a fall while trying to get up at 7:30 AM on 1/6/22. e. A progress note completed by an Assisted Living RN Manager, dated 1/6/22 at 12:02 PM, included documentation the RN was following up on the patient fall from the previous day. The RN documented the patient had complaints of "crotch" pain due to pulling the catheter out on 1/5/22. The RN documented the patient had become increasingly restless. She documented the patient had a care conference that morning with the family member/POA present. The POA discussed concerns with the patient's increased restlessness. f. A progress note completed by an Assisted Living LPN on day shift, dated 1/6/22 at 1:30 PM, included documentation the LPN called the hospice on-call number at 7:40 AM due to the hospice having delivered Morphine and Lorazepam with another patient's name on the label on each of the bottles. She reported her inability to give the medications to the patient at that time due to the problem with the bottles. She documented the hospice on-call nurse would contact their office and someone would call back. On 1/26/22 at 2:54 PM, during an interview, the Assisted Living LPN on first shift reported on the morning of 1/6/22, the patient had a fall. She assessed the patient reported some "crotch" pain in relation to the patient having previously pulled out the urinary catheter and the patient was restless. She reported she went to give the patient Morphine for the pain and Lorazepam for restlessness, but the bottles provided by the hospice had other patient names on labels and the names had been blacked out, but still legible. The Assisted Living LPN on first shift reported she notified the Assisted Living RN Manager and the Assisted Living Director. She called the hospice on-call nurse around 7:40 AM to inform her of the concern and the inability to give the medications to the patient. According to the assisted living LPN, the hospice on-call nurse told her she got the Morphine and Lorazepam from the hospice's E-kit and it was okay for the Assisted Living LPN to give. The Assisted Living LPN reported the patient continued to be restless. At 9:37 AM, she reported the patient was restless and tried to get out of bed again. The hospice staff still had not delivered the right medications by then. On 1/26/22 at 3:32 PM, during an interview with the Assisted Living RN Coordinator and the Assisted Living LPN on first shift, the Assisted Living RN Coordinator reported the Assisted Living LPN on second shift accepted the Morphine and Lorazepam medications with the patient's names blacked out from the hospice nurse during the 3-11 PM shift. She reported receiving Morphine concentrate and Lorazepam 0.5 mg tablets with the patient's name on the label at 12:00 PM on 1/6/22. Someone from the hospice delivered the medications and removed the 2 bottles with the blacked out patient's names on them. The Assisted Living LPN on first shift and the Assisted Living RN Coordinator reported they assessed the patient was just restless at that time (12:00 PM 1/6/22) and not in pain. The Assisted Living LPN on first shift gave the patient Lorazepam 0.5 mg at 12:02 PM on 1/6/22. The patient had good relief from the restlessness with the Lorazepam. The Assisted Living LPN on first shift reported her assessment that the patient's restlessness contributed to the patient's fall on the morning of 1/6/22. On 1/26/22 at 4:26 PM, during an interview, the Assisted Living LPN on second shift reported the patient was very restless at times, but staff was often able to redirect the patient and talk to the patient into calming down. She reported she received the medications from hospice staff on 1/5/22. She put the medications in the nurses office and did not look at the labels until the end of her shift. She noticed at that time the liquid Morphine and Lorazepam tablets delivered by the hospice for the patient had labels with blacked out patient's names on them. She denied the patient had needed Lorazepam or Morphine during her shift. On 1/27/22 at 6:26 AM, during an interview, the Assisted Living Certified Medication Aide on third shift (11 AM to 7:00 AM) reported she worked the night of 1/5 into the morning of 1/6/22. She did not view the medication bottles brought in by the hospice and she did not remember the patient having any problems that night and morning. On 1/27/22 at 11:38 AM, during an interview, Staff I, Hospice On-Call RN, explained the local pharmacy used by the hospice filled the hospice's E-kit bags. The pharmacy puts a red tag lock on the E-kits. When a nurse needs a medication from the E-kit, she cuts the red tag, puts in the code to open the bag, removes the needed medication, fills out paperwork for the pharmacy and the hospice and also sends an email to the Clinical Manager and Staff L, RN. Staff I, Hospice On-Call RN, reported for Patient #6 on 1/5/22 the patient had medications waiting at the local pharmacy used by the hospice that did not get delivered. She did not know if hospice staff were supposed to have picked the medications up or if the pharmacy was supposed to deliver them. She reported by the time Staff J, RN and Case Manager for the patient, contacted her, the pharmacy was closed. She cut the pharmacy red lock tag off the hospice E-kit, removed Morphine and Lorazepam from the E-kit and took the medications to the patient's assisted living facility staff. She reported she did not look at the labels on the bottles. She reported patient names had never been on the medication bottles before. She first became aware of the problem with the medication bottle labels having other patient names on them blacked out on 1/6/22 around 7:00 AM or 7:30 AM when she received a call from an assisted living nurse. Staff I, Hospice On-Call RN, explained she then notified her supervisors and completed an incident report. She denied telling the assisted living nurse to use the medications. She reported she called the admission nurse (Staff H, RN, per the clinical record) and the admission nurse told her the patient's medications had been ready since the previous day and should have been delivered. On 1/27/22 at 12:38 PM, the hospice's Chief Operations Officer provided a copy of the incident report completed in relation to the blacked out patient names on the medication bottle labels that Staff I, Hospice On-Call RN, had delivered to the patient's assisted living facility from the hospice's E-kit. Review of the incident report revealed the following: Staff I, Hospice On-Call RN, documented she delivered Lorazepam and Morphine from the hospice's E-kit on 1/5/22 for Patient #6 to the assisted living facility. The assisted living staff reported both bottles had another patient's name on them crossed off with a black marker and were open. They identified the names on the bottles being Patient #5 and Patient #7, both hospice patients that had died the previous week. Staff I, Hospice On-Call RN, also went to deliver a bottle not in a box to another patient, but the patient died before she could deliver the medication. On 1/6/22, hospice staff spoke with pharmacy staff in regards to the labeling issue, and the pharmacy staff reported the need to fix the printer label issue so the labels did not have patient names on them. The incident reported identified a hospice aide delivered new medications to the hospice's assisted living, picked up the inappropriately labeled bottles and returned them to the hospice office. Hospice staff documented destroying those medications. On 1/18/22, Staff I, Hospice On-Call RN, reported finding another bottle of Morphine with a patient's name on it in the hospices E-kit. The name had not been marked out. Hospice staff documented talking with the pharmacy again about the labeling issue. According to incident report, the pharmacy discussed issues with getting supplies and having to label the bottles differently due to dispensing smaller quantities. The pharmacy had reported a printer/program issue with having to use the name of the last person to get that medication in order to get the label to print. On 1/19/22, the hospice's Clinical Manager attempted to reach pharmacy management, but that person was unavailable until 1/21/22. On 1/21/22, the hospice's Clinical Manager and Chief Operations Officer met with the pharmacy's owner to discuss labeling concerns of the medication bottles for the E-kits. On 1/24/22, the pharmacy owner confirmed the resolution of the labeling issue. On 1/31/22 at 9:45 AM, during an interview, Staff H, Hospice RN and the admitting nurse for Patient #6, reported the patient had not been restless on admission, but the physician had ordered Lorazepam from the local pharmacy to be available. When asked if she remembered talking with Staff I, Hospice On-Call RN, about the Lorazepam being available at the pharmacy for pick-up on 1/6/22. She explained hospice staff pick up the medications from the pharmacy. She explained the process of removing a medication from the hospice's E-kit included reading the bottle labels before signing the medications out from the E-kit. On 1/31/22 at 10:35 AM, during an interview, the Pharmacy Owner (of the local pharmacy used by the hospice) explained a pharmacy technician did not follow procedure and refill the hospice's e-kits correctly. He reported the technician was now on leave and he had rectified the problem. On 1/31/22 at 10:39 AM, during an interview, Staff J, Hospice RN and the patient's Case Manager, reported she remembered the patient and going to see the patient on 1/5/22 at 5:00 PM. She reported the patient had not been restless at that time, but the assisted living facility nurse asked to have Morphine and Lorazepam available. She described the procedure from removing medications from the hospice's E-kit and confirmed the nurse should read the medication bottle label prior to taking the medication. On 1/31/22 at 10:58 AM, during an interview, the hospice's Clinical Manager reported providing education to nursing staff to ensure no patient names had been put on the bottles by the pharmacy before taking the medications out of the E-kits. On 1/31/22 at 11:21 AM, during an interview, the hospice's Chief Operations Officer reported they resolved the issue with the pharmacy on 1/22/22. The hospice staff did not realize the pharmacy was labeling medication bottles with patient names and then marking them out to place in the E-kit. She reported reviewing the 2 medication bottles from this incident and couldn't make out full patient names, just some of the letters. She described the bottle labels as not easy to read, but regardless reported the bottles should not have gone out. She reported Staff I, Hospice On-Call RN, found another bottle in the E-kit after this incident with a former patient's name on the label before it could be delivered. On 1/31/22 at 2:16 PM, during an interview, the hospice's Clinical Manager reported the delivery of the Lorazepam and Morphine to the assisted living facility was delayed (on 1/6/22) due to concerns with the medication bottle labels. She also reported she did not think the pharmacy opened until 9:00 AM. When asked why hospice staff had not tried to replace the Morphine and Lorazepam needed by the patient from one of the other 4 remaining hospice E-kits, there was no response. During the same interview, the hospice's Administrator (Chief Executive Officer) reported hospice staff were responsible for picking up patient medications from the pharmacy and delivers them to the patients. At the time frame when this happened, the hospice had an increased number of staff out with the Covid-19 virus and hospice staff were just trying to get the basics done. They were trying to cover multiple positions. She confirmed a hospice aide picked up the medications from the local pharmacy used by the hospice and delivered them to the patient's assisted living facility. The same hospice aide picked up the medication bottles with the blacked out patient names on them from the assisted living facility and returned them to the hospice office. During the same interview, the hospice's Chief Operations Officer explained, during that time frame, the hospice only had 2 hospice nurses working and everyone else was off due Covid-19. 1/31/22 at 3:43 PM, during an interview, the Pharmacy Manager (for the local pharmacy used by the hospice) reported the pharmacy received an order for Lorazepam 0.5 mg tablets on 1/5/22 at 8:11 AM. The pharmacy filled the order and it was ready for pick-up at 11:54 AM on 1/5/22. She reported the pharmacy received a second order for Lorazepam 0.5 mg tablets and Morphine on 1/6/22. Hospice failed to ensure the patient received symptom relief in relation to restless associated with the patient's condition related to the terminal illness from when the hospice became aware of the medication issue on 1/6/22 at 7:40 AM (according to assisted living facility staff) until hospice staff delivered medication for the patient on 1/6/22 at 12:00 PM. The patient continued to be restless and attempted to get out of bed (according to assisted living facility staff) during this time frame, risking a potential fall and injury.

Based on clinical record review, hospice policy review and staff interview, the hospice failed to ensure the coordination and collaboration among Interdisciplinary Group (IDG) members to ensure hospice staff provided treatment and services to the patients according to team decisions. The survey identified this concern with 2 of 7 sampled patients (#2 and #4). Failure of the hospice IDG members to communicate and collaborate with each other to update the plan of care increased the risk that patients did not receive services and treatments to meet the needs of the patients. Findings include: Review of the hospice policy, titled Coordination of Services, dated 11/20/08, identified the nurse care team manager coordinates the patient's plan of care and assumes overall responsibility for ensuring there are effective methods of communication that allows for the coordination of care and services. Review of the hospice policy, titled Plan of Care (POC), dated 11/20/08, revealed hospice staff provide care and services in accordance with an individualized written POC established by the IDG in collaboration with the patient's attending physician. IDG members document and communicate reviews and changes to the POC every 15 days or more frequently as needed. 1. Patient #2 had a hospice admission date of 10/13/21 and received hospice services while residing in an assisted living apartment. Review of the clinical record revealed the following: a. The POC, dated 1/11/21 to 4/10/22, included IDG orders for skilled nursing services. b. A skilled nursing visit completed by Staff E, Registered Nurse (RN), dated 1/8/22, included documentation the hospice nurse completed a telehealth visit with the patient and assisted living facility nurse. The facility nurse reported the patient had a new skin tear to the left lower leg. The hospice nurse assessed the skin tear measured 5 centimeters (cm) in length and 1 cm in width. The hospice nurse instructed the facility nurse to apply a thin layer of Neosporin ointment, cover the wound with a non-adherent dressing and secure with a gauze wrap. c. The clinical record lacked documentation of contact with a physician prior to 1/11/22 regarding wound care for the left lower leg skin tear. d. A physician order, dated 1/11/22, included orders for the hospice nurse or assisted living facility nurse to complete wound care every 3 days or as needed for a left lower leg skin tear by cleansing the area with Saline, pat dry, cover with a hydrocellular dressing, wrap with Kerlix and secure with tape. On 1/31/22 at 12:35 PM, during an interview, Staff E, RN, explained she completed the as needed telehealth visit in the evening. She reported she used her knowledge base for directing the assisted living facility nurse in wound care on 1/8/22. She reported she did not contact a physician for wound care orders and explained she relied the "regular" hospice staff to take care of contacting the physician to get a wound care order. The hospice nurse instructed the assisted living nurse on wound care with obtaining and collaborating with the patient's physician or hospice Medical Director. 2. Patient #4 had a hospice admission date of 10/8/21 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The POC, dated 12/7/21 to 2/4/22, included IDG orders for skilled nursing services one time per week and a physician order for oxygen 1 to 4 liters per minute intranasal as needed for shortness of breath, titrate for comfort. b. A skilled nursing communication note, dated 12/9/21, included documentation RN had assessed the patient on 12/9/21 to be using 5 liters of oxygen. The visit notes lacked documentation the RN discussed with the patient the patient's use of oxygen at a higher rate than what the physician had ordered. c. The skilled nursing visits, dated 12/14/21, 12/20/21, 12/27/21, 1/3/22, 1/10/22 and 1/17/22, included documentation the nurse assessed the patient was using oxygen at a rate of 5 liters per minute. The accompanying communication notes lacked documentation of the patient's use of oxygen at higher rate. d. The IDG meeting notes, dated 12/14/21, 12/28/21, 1/11/22 and 1/25/22, continued to orders for oxygen 1 to 4 liters per minute as needed and to titrate for comfort. The IDG meeting notes lacked documentation of a discussion of the patient's use of oxygen at a rate higher than what the physician ordered. On 1/27/22 at 12:03 PM, during an interview, Staff G, RN, confirmed she was the patient's RN Case Manager. She explained the patient used oxygen at whatever rate the patient wanted to use it. The patient turned the oxygen up and down depending on how the patient felt. Staff G, RN, reported the patient told her the patient had the oxygen turned up to 6 liters per minute over the weekend. The patient reported speaking with the hospice's Advanced Registered Nurse Practitioner (ARNP) about the increased oxygen rate setting, and the ARNP told the patient to turn the oxygen down. Staff G, RN, confirmed she had not communicated or coordinated the patient's continued use of oxygen at a rate higher than what the physician had ordered and stated, "that's on me." On 1/27/22 at 12:16 PM, during an interview, Staff K, RN, who documented she provided hospice skilled nursing services on 12/14/21, reported she was not aware the patient had an order for 1 to 4 liters of oxygen. On 1/31/22 at 11:21 AM, during an interview, the hospice's ARNP reported he recently had a face to face visit through telehealth with the patient. He reported the patient chronically used oxygen at 3 to 4 liters per minute and had shortness of breath with activity. He reported the patient had the oxygen at 5 liters and he told the patient to titrate the oxygen back down, as he did not want the patient to become dependent on the oxygen at a higher rate. Hospice nursing staff failed to communicate and coordinate the patient's continued use of oxygen at a higher rate with the IDG than what the physician ordered. The hospice Administrator and Clinical Manager received the above findings and provided no further information prior to the end of the survey.