Every finding on record at Ivory Hospice, Inc

Based on interview and record review, the hospice agency (HA) failed to ensure the emergency preparedness plan/drill for field staff were completed on an annual basis. This failure had the potential for the staff to lack the knowledge to respond effectively during an emergency/disaster situation. Findings: During a review of the emergency preparedness plan of the HA on 4/14/22 at 11:30 a.m., the HA did not have evidence of Emergency Preparedness training/disaster drill for all field staff. During an interview with the Administrator and Director of Patient Care Services, on 4/14/22 at 11:35 a.m., they stated they could not provide evidence of the field staff receiving Emergency Preparedness training/disaster drill training. The HA's undated policy and procedure titled, "Emergency Management Policy No. 7-001.8," indicated the agency conducts an additional exercise every 2 years, on the year opposite of the full scale community-based exercise or individual facility-based functional exercise which includes a mock disaster drill.

Based on observation, interview and record review, the hospice agency (HA) failed to maintain an accurate, current medication profile for four of seven patients (Patients 1, 4 ,8 and 9). This failure has the potential in placing the patient at risk for medication errors and adverse drug reactions. Findings: a. A review of Patient 1's Patient Profile indicated, a start of care (SOC) date of 12/9/21, with a diagnosis that included Alzheimer's disease (it is a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment). During a review of Patient 1's Plan of Care (POC), for the re-certification period from 2/6/22 to 4/12/22, included an order for skilled nurse (SN) to visit 2-3 times a week and as needed for nine weeks. Patient 1's physician's order dated 4/12/22, indicated to administer Amlodipine (used for high blood pressure) 2.5 milligrams (mg- unit of measurement) 1 tablet by mouth every morning after breakfast and one tab by mouth every evening after dinner, to hold if SBP (systolic blood pressure) is below 105 and HR (heart rate) is below 60. On 4/13/22, at 11:30 a.m., a home visit was conducted at Patient 1's residence with Licensed Vocational Nurse (LVN 2). Patient 1 was observed lying on her bed, LVN 2 proceeded to render care. During a review of Patient 1's medications, on 4/13/22 at 12 p.m., there was a bottle of Amlodipine 2.5 mg that had a label of 1 tablet by mouth every morning after breakfast and one tab by mouth every evening after dinner, to hold if SBP (systolic blood pressure) is below 105 and HR (heart rate) is below 60. On 4/13/22, at 12:15 p.m., during an interview with Caregiver 1, when asked on how she administer the Amlodipine medication, she stated she takes the patient's blood pressure reading first, and if the SBP was below 100 and HR was below 50, she would not administer the medication to Patient 1. On 4/14/22, at 11 a.m., during an interview with the DPCS, she stated LVN 2 should have asked and re-assessed the patient's caregiver knowledge regarding the patient's medication regime during their visits. b. A review of Patient 4's admission record indicated the patient was admitted to the HA on 3/17/22, with a primary diagnosis of Alzheimer's disease. During a home visit on 4/12/22, at 1:00 p.m., with Registered Nurse 1 (RN 1), Patient 4 was observed lying in bed. During the visit, RN 1 did not review the medications Patient 4 was taking. During an interview, on 4/12/22 at 1:55 p.m., RN 1 stated, "I checked the medications yesterday morning. I am supposed to check the medications every visit. I forgot." A review of Patient 4's medical record titled, "Initial Orders and Plan of Care," for certification period 2/26/22-5/26/22, indicated "Orders for discipline and treatments skilled nursing (SN) visits ...2 visits/week and 1 PRN (as needed) visits/week for symptom management." c. A review of Patient 8's Patient Profile indicated, a start of care (SOC) date of 9/14/21, with a diagnosis that included Alzheimer's disease. During a review of Patient 8's Plan of Care (POC), for the re-certification period from 3/13/22 to 5/11/22, included an order for SN to visit 2-3 times a week and as needed for nine weeks. Patient 8's physician's order dated 4/11/22 indicated to administer Temazepam 15 milligrams (mg- unit of measurement) 1 tablet every 12 hours as needed for anxiety and agitation during the day and night as evidenced by removing the nasal cannula, pulling shirt and involuntary arm movements and difficulty sleeping at night. On 4/13/22, at 11:00 a.m., a home visit was conducted at Patient 8's residence with LVN. Patient 8 was observed lying on her bed, LVN proceeded to render care. During a review of Patient 8's medications, on 4/13/22 at 11:30 a.m. the patient's medication profile was not updated. Temazepam 15mg in liquid form was found inside patient medication box. Patient's son stated that it was changed last 3/22/22. LVN stated that he should be checking the medications to ensure the medication profile is up to date. d. A review of Patient 9's Patient Profile indicated, a start of care (SOC) date of 3/21/22, with a diagnosis that included Alzheimer's disease. During a review of Patient 9's POC, for the re-certification period from 3/21/22 to 6/18/22, included an order for SN) to visit -3 times a week and as needed for nine weeks. On 4/12/22, at 11:00 a.m., a home visit was conducted at Patient 9's residence with Director of Patient Care Services (DPCS). Patient 9 was observed lying on her bed, DPCS proceeded to render care. During a review of Patient 9's medications, on 4/12/22 at 12:30 p.m. the patient's medication profile was not updated. Hydrocodone 5/325mg 1 tablet (tab) by mouth every four hours as needed for moderate to severe pain. Patient 9's son stated they give it three times a day and as needed for wound care and repositioning. Seroquel 25 mg 1 tab by mouth as needed daily for psychosis (a condition that affects the brain to process information), Lactulose 10 mg per 15 milliliters (ml- unit of liquid measurement) for severe constipation and Collagen powder for wound were not listed in the medication profile. The DPCS stated the medication should be checked to ensure the medication profile is up to date. A review of the HA's policy and procedure titled, "Medication Profile", dated April 2020, indicated "Patients receiving medications administered by the hospice will have a current, accurate medication profile in the clinical record ...A comparison of the medications ordered for the patient while under the organization's care will be made to those on the list."

Based on interview and record review, the HA failed to ensure physician orders were implemented for one of 11 sample selected patient (Patient 4). This deficient practice resulted in delay of care. Findings: A review of Patient 4's admission record indicated the patient was admitted to the HA on 3/17/22, with a primary diagnosis of Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). Further review of Patient 4's medical record titled, "Physician Orders," dated 4/6/22, indicated "Patient was seen by Wound specialist today with recommendation for nutrition consult ...Refer patient to Dietitian for nutrition consult ...Wound specialist ordered to obtain wound culture of left hip wounds." During an interview, on 4/13/22 at 1:41 p.m., the administrator (ADM) stated the agency's process when receiving a physician's order is to carry out the order the same day. The ADM stated the reason why the wound culture was not done on 4/6/22 was due to patient's family refusal. The ADM stated the agency received family approval for the wound culture on 4/13/22, during the survey. The ADM stated, "No, I did not follow up with nutritional consult. Yes, it was ordered on 4/6/22. We followed up last night. I should have followed up right away." A review of the HA's policy and procedure titled, "Physician Orders Communications and Implementation," dated 3/15/19, indicated, "Procedure ...4. Implementing orders received and updating the plan of care. 5. Ivory Hospice & Palliative Care will make follow-ups and monitoring if the order was carried out or implemented. 6. Collaborate with assigned discipline and patient/family representative regarding orders received and document."

Based on interview and record review, the Hospice Agency (HA) failed to ensure care plans were reviewed by the interdisciplinary team (IDT) as frequently as the patient's condition requires, but no less frequently than every 15 calendar days for four of 11 sample selected patients (Patients 1, 4, 8 and 9). This deficient practice had the potential for patient's care not being evaluated timely to ensure it meets their needs. Findings: a. A review of Patient 1's Patient Profile indicated, a start of care (SOC) date of 12/9/21, with a diagnosis that included Alzheimer's disease (it is a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment). During a review of Patient 1's Plan of Care (POC), for the re-certification period from 2/6/22 to 4/12/22, included an order for skilled nurse (SN) to visit 2-3 times a week and as needed for nine weeks. A review of Patient 1's IDT Plan of Care & Review of Comprehensive Assessment, indicated the medical director (MD), medical social worker (MSW), registered nurse (RN) and chaplain (SC) did not attend the IDT meetings on 3/11/22 and 3/25/22. On 4/14/22, at 11:30 a.m., during an interview with the administrator (ADM), she stated the agency holds IDT meetings every two weeks and the IDT members are expected to sign for attending the meeting. b. A review of Patient 4's admission record indicated the patient was admitted to the HA on 3/17/22, with a primary diagnosis of Alzheimer's disease. Further review of Patient 4's medical record titled, "IDT Plan of Care & Review of Comprehensive Assessment," indicated the Medical Director, MSW, RN, and Chaplain do not attend the IDT meetings on 3/25/22 and 4/8/22. During an interview on, 4/13/22 at 10:54 a.m., the ADM stated the agency holds IDT meetings every two weeks. The ADM stated the IDT members attending the meetings include the RN, MSW, MD, and SC. The ADM stated the IDT members are expected to sign the IDT Plan of Care & Review of Comprehensive Assessment after the meeting because their signature means they attended the meeting. c. On 4/14/22, during a review of Patient 8 and 9 Interdisciplinary Team Meeting dated 4/8/22 showed no electronic signatures for Registered Nurse (RN) and Physician to validate they attended the IDT meeting A review of the HA's policy and procedure titled, "Interdisciplinary Group Meeting", dated 11/2018, indicated " ...The hospice Medical Director and all hospice interdisciplinary group members will be present ...Procedure 1. Members at the interdisciplinary group meeting sill sign an attendance form that will be kept by the hospice Clinical Supervisor/Nursing Supervisor."

Based on interview and record review, the Hospice Agency (HA) failed to ensure clinical records accurately reflected the care being provided for 1 of 11 sampled patients (Patient 4). This deficient practice had the potential to increase the risk of error due to incorrect information. Findings: A review of Patient 4's admission record indicated the patient was admitted to the HA on 3/17/22, with a primary diagnosis of Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). During an interview on, 4/14/22 at 10:00 a.m., the Director of Patient Care Services (DPCS) stated the wound care orders on the care plan where the initial physician orders given on admission. The DPCS stated the new order should have been updated to reflect in the plan of care. The DPCS stated it is important to update the information because it is important the record is accurate, so the nurses administer the right order. Further review of Patient 4's medical record titled, "Initial Orders and Plan of Care," for certification period 2/26/22-5/26/22, indicated "Wound Care/Treatment-Wound Care Order #1: Cleanse Sacrum (tail bone) with normal saline (salt water), pat dry, apply Santyl (helps treat wounds) ointment at area, cover with bordered foam dressing, change dressing every 1-2 days or as needed if soiled. Wound Care Order #2 Cleanse right hip with apply Santyl ointment at area, secure with bordered foam dressing daily and as needed if soiled. Wound Care Order #3 Cleanse left hip with apply Santyl ointment at area, secure with bordered foam dressing daily and as needed if soiled. A review of Patient 4's medical record titled, "Physician Order Details," dated 3/23/22, indicated "discontinue previous wound treatment on left hip, sacrum, right hip. New Order by PAS Wound Care Specialist: 1) Left Hip Superior pressure ulcer (PU, injuries to the skin and underlying tissue due to prolong pressure on the skin) Stage 4: Cleanse with sterile wound cleanser. Apply hydrogel with silver (help heal). Pack tunneling with gauze. Cover with island dressing. Change Dressing Daily and as needed when soaked or soiled. 2) Left Hip Inferior PU stage 4: Cleanse with sterile wound cleanser. Apply hydrogel with silver. Pack tunneling with gauze. Cover with island dressing. Change dressing daily and as needed when soaked or soiled. 3) Sacrum PU Stage 4 Cleanse with sterile wound cleanser. Apply hydrogel with silver. Loosely pack with gauze. Cover with island dressing. Change dressing daily and as needed when soaked or soiled. 4) right hip PU Stage 3: Cleanse with sterile wound cleanser. Apply hydrogel. Cover with island dressing. Change 2-3 times per week and as needed when soaked or soiled." A review of Patient 4's medical record titled, "Physician Order Details," dated 3/23/22, indicated "discontinue previous wound treatment on left hip, sacrum, right hip. New Order by PAS Wound Care Specialist: 1) Left Hip Superior PU Stage 4: Cleanse with sterile wound cleanser. Apply hydrogel with silver. Pack tunneling with gauze. Cover with island dressing. Change Dressing Daily and as needed when soaked or soiled. 2) Left Hip Inferior PU stage 4: Cleanse with sterile wound cleanser. Apply hydrogel with silver. Pack tunneling with gauze. Cover with island dressing. Change dressing daily and as needed when soaked or soiled. 3) Sacrum PU Stage 4 Cleanse with sterile wound cleanser. Apply hydrogel with silver. Loosely pack with gauze. Cover with island dressing. Change dressing daily and as needed when soaked or soiled. 4) right hip PU Stage 3: Cleanse with sterile wound cleanser. Apply hydrogel. Cover with island dressing. Change 2-3 times per week and as needed when soaked or soiled". A review of the HA's policy and procedure titled, "Entries into the Clinical Record," dated 11/2020, indicated "Documentation in the clinical record will be timely, detailed, accurate, and reflect the care or services provided. The record format will be reviewed and updated as necessary".