Every finding on record at Masonicare Home Health and Hospice Inc

Based on clinical record review, review of agency documentation and interviews with hospice personnel, for one of three patients (Patient #1) who received hospice services, the hospice agency failed to manage the patient’s pain and symptoms related to the terminal illness in a timely manner. The findings include: --- Patient #1 elected the hospice benefit on 4/21/25 with diagnoses of end stage liver disease, hepatic cirrhosis and ascites. The physician's orders dated 4/21/25 included nursing services three times weekly for assessments and management of the left abdominal drain three times a week, home health aide services, social work and chaplain services. Physician’s orders included Hydromorphone 2 milligrams/mg by mouth three times a day for pain, Hydromorphone 1 milligram/milliliter (mg/ml) take 1ml by mouth every four hours as needed for pain, Atropine 1 % drops, 2 drops sublingually every two hours as needed for terminal secretions and Haloperidol Lactate 2mg/ml, take 0.5 ml by mouth every six hours as needed for agitation. Review of agency documentation dated 5/22/25 identified a concern from the next of kin indicating that Patient #1 suffered the last day of life, medications ran out, the Hospice nursing visit was delayed after a reported change in condition by the family and the family identified they did not feel supported by the Hospice team. Review of Registered Nurse/RN #1’s on-call communication note dated 5/22/25 at 5:09 AM indicated receiving a call from the spouse concerning increased bronchial congestion, with recommendations to administer atropine drops and a plan to have an on-call nurse visit for symptom management. On 5/22/25 at 5:31 AM, RN #2 conducted an on-call visit and documented that the patient was actively dying, moaning, restless, dyspneic at rest with labored breathing and mild congestion. RN #2 documented administering Haloperidol, Hydromorphone and Atropine drops with good effect and educated the spouse and next of kin on signs and symptoms of dying and repositioning of patient to alleviate secretions. Upon her departure, at 5:47 AM, the patient was resting comfortably. At approximately 7:45 AM, RN #2 received two additional calls from the spouse indicating symptoms of increased secretions, respirations and moaning had returned. RN #2 called MD #1 and Hydromorphone was increased to 6 mg every six hours around the clock for pain or shortness of breath, Lorazepam Intensol 2mg/ml, take 1 ml every 2 hours for anxiety and Haloperidol Lactate 2mg/ml, take 1 mg by mouth every six hours as needed for agitation. The medication orders were faxed to the Hospice pharmacy STAT at 8 AM (to be delivered within 4 hours). The spouse was notified of the updated medication orders, and a follow up nursing visit was requested. Interview and review of the Hospice pharmacy medication delivery receipt with the Hospice Program Director on 8/11/25 at 2:18 PM indicated that the medication receipt verified that the medications were delivered to the patient's home at 11:38 AM, but identified that the medications should have been ordered through the local pharmacy to ensure faster delivery to the patient residence and failed to ensure timely pain and symptom management.Patient #1 was pronounced on 5/22/25 at 12:39 PM by RN #3.

Based on clinical record reviews, review of agency policies, interviews with hospice personnel and review of agency documentation, for one of three patients (Patient #1) in the survey sample, the hospice nurse failed to provide the necessary assessment. The findings include: --- Patient #1 elected the hospice benefit on 4/21/25 with diagnoses of end stage liver disease, hepatic cirrhosis and ascites. The physician's orders dated 4/21/25 included nursing services three times weekly for assessments and management of the left abdominal drain three times a week, home health aide services, social work and chaplain services. Review of agency documentation dated 5/22/25 identified a concern from the next of kin indicating that Patient #1 suffered the last day of life, the requested nursing visit was delayed after a reported change in condition and the nurse inaccurately completed the death certificate. Review of RN #1’s on-call communication note dated 5/22/25 at 5:09 AM indicated receiving a call from the spouse concerning increased bronchial congestion, with recommendations to administer atropine drops and a plan to have on-call nurse visit for management. On 5/22/25 at 5:31 AM, RN #2 conducted an on-call visit and documented that the patient was actively dying, moaning, restless, dyspneic at rest with labored breathing and mild congestion. RN #2 documented administering Haloperidol, Hydromorphone and Atropine drops with good effect and educated the spouse and next of kin on signa and symptoms of dying and repositioning to alleviate secretions. Upon her departure, at 5:47 AM, the patient was resting comfortably. At approximately 7:45 AM, RN #2 received two calls from the spouse indicating symptoms of increased secretions, respirations and moaning had returned. RN #2 called MD #1 and Hydromorphone was increased to 6 mg every six hours around the clock for pain or shortness of breath, Lorazepam Intensol 2mg/ml, take 1 ml every 2 hours for anxiety and Haloperidol Lactate 2mg/ml, take 1 mg by mouth every six hours as needed for agitation. The medication orders were faxed to the Hospice pharmacy STAT at 8 AM (to be delivered within 4 hours). The spouse was notified of the updated medication orders, and a follow up nursing visit was requested. Review of the agency timeline documentation dated 5/22/25 identified at 8:03 AM, RN #3 was notified of the need to visit Patient #1 as soon as possible (ASAP), which was confirmed by RN #3 at 8:34 AM.  At 9 AM, Licensed Practical Nurse/LPN #1, who visited the patient frequently prior to 5/22/25, reported to RN #3 that she received a call from the next of kin that the patient was uncomfortable and may need continuous care. At 11 AM, the Hospice Program Director reassigned LPN #1 to the visit. . At 11:13 AM, the visit was removed from RN #3’s assignment to LPN #1’s assignment. Upon LPN #1 arrival at the residence, a review of the patient's communication notes was conducted and indicated that the patient had passed away while LPN #1 was in transit to the patient residence. LPN #1 notified the Hospice Program Director and at 12:02pm RN #3 was notified of the patient's passing. Subsequently RN # 3 had arrived at the patient's residence and was parked in the driveway, not entering the home until 12:26 PM. Interview with RN #3 on 8/12/25 at 11:19 AM identified never seeing the text from the office to visit Patient #1 "ASAP" (as soon as possible), and indicated that he/she already had Patient #1 on his/her visit schedule but was enroute to visit  patients in the skilled nursing facility first, and would see Patient #1 after. RN # 3 further identified that he/she arrived at Patient #1's home at 12:02 PM and was delayed in entering the patient's home until 12:26PM as he/she was on the phone in the driveway with the Hospice educator reviewing the pronouncement visit documentation process prior to entering the patient's home. Patient #1 was pronounced on 5/22/25 at 12:39 PM by RN #3. Interview and review of the agency documentation with the Hospice Program Director on 8/11/25 at 1:30 PM indicated that RN #3 should have seen Patient #1 as soon as she was notified on 5/22/25 at 8:03am of the urgent visit, but failed to ensure the timely arrival, assessment and management of the patients symptoms and families end of life needs. Review of agency policy for Hospice and Palliative Care Specialty Registered Nurse, directed ensure quality and safe delivery of hospice and palliative nursing services and can be depended upon to report to work on time.

Based on clinical record reviews, review of agency policies, interviews with hospice personnel and review of agency documentation, for one of three patients (Patient #1) in the survey sample, the hospice nurse failed to ensure a complete and accurate record. The findings include: --- Patient #1 elected the hospice benefit on 4/21/25 with diagnoses of end stage liver disease, hepatic cirrhosis and ascites. The physician's orders dated 4/21/25 included nursing services three times weekly for assessments and management of the left abdominal drain three times a week, home health aide services, social work and chaplain services. Review of agency documentation dated 5/22/25 identified a concern from the next of kin indicating that Patient #1 suffered the last day of life, the requested nursing visit was delayed after a reported change in condition and the nurse inaccurately completed the death certificate. Review of RN #3’s personnel file identified documentation dated 5/27/25 from Patient #1’s Funeral Home Director that RN #3 did not affirm/certify the death certificate (a box is on the death certificate to be checked off by the pronouncing nurse) and noted the wrong “Cause of Death” thus holding up the cremation of the patient. Interview and review of the agency documentation with the Hospice Program Director on 8/11/25 at 1:30 PM indicated that RN #3 failed to ensure accurate and complete information was documented on the death certificate. Review of agency policy for Hospice and Palliative Care Specialty Registered Nurse directed demonstrates timely and accurate computer documentation of patient information.

Based on clinical record review, review of agency policies and interview with hospice personnel, for one of three patients (Patient #1) in the survey sample, the hospice nurse failed to coordinate with the interdisciplinary group to provide supportive counseling services and effective symptom control for the terminally ill patient. The finding includes: Patient #1 elected the hospice benefit on 06/13/2023. Patient #1s diagnoses included malignant neoplasm of the pancreas, sepsis, and intestinal obstruction. The physicians orders dated 06/13/2023 included nursing services twice per week for pain and symptom management, social work services once a month and home health aide services once per week for assistance with activities of daily living. Physician's orders included Haloperidol Lactate 2 milligrams/milliliter (mg/ml) give 0.5 ml orally every six hours as needed for agitation, Hyoscyamine 0.125 mg sublingual give one tablet orally every four hours as needed for secretions, Lorazepam 0.5 mg give one tablet orally every six hours as needed for anxiety or agitation, Morphine Concentrate 100 mg/5 ml (20 mg/ml) oral solution give 0.25 ml every hour as needed for pain or shortness of breath and Oxycodone 5 mg give one tablet orally every four hours as needed for pain. Review of the case communication report dated 07/02/2023, identified Patient #1s caregiver called the hospice answering service around 01:00 AM to indicate the Patient woke in pain. The on-call nurse instructed the caregiver to administer Morphine 0.25 ml every hour as needed for pain or shortness of breath. Review of the case communication report dated 07/02/2023, identified Patient #1s caregiver called the hospice answering service at 06:47 AM indicating the Patient had increased congestion and Morphine 0.25 ml was ineffective for pain. The hospice physician was notified and increased the Morphine to 10 mg every hour. The caregiver was directed to administer Lorazepam for anxiety and Hyoscyamine for secretions as needed. Review of the case communication report dated 07/02/2023, identified Patient #1s caregiver called the hospice answering service at 07:07 AM and indicated the Patients pain and congestion had improved. Review of the as needed nursing visit note dated 07/02/2023, identified Patient #1 was lethargic, denied pain and cough was managed. The nurses note identified the Patient was administered 5 mg of Morphine four times in the last 24 hours and administered Lorazepam and Hyoscyamine as needed. The caregiver identified not wanting the Patient to begin coughing again which caused discomfort and shortness of breath. Additionally, the nurses note indicated the caregiver was tired, overwhelmed, asked about inpatient hospice options, and would benefit from a social work visit. Review of the case communication report dated 07/02/2023, identified the answering service received multiple calls from the Patients caregiver. The caregiver called the answering service at 10:19 PM, indicating the Patient was having trouble breathing, had a productive cough and gagging. Review of Patient #1s clinical documentation with the Hospice Supervisor of Clinical Services (SCS) on 10/26/2023 at 10:45 AM, identified Patient #1 was transported to the hospital for symptom management after the caregiver called the answering service at 10:19 PM on 07/02/2023. The Patients symptoms were treated, and he/she expired in the hospital on 07/03/2023. The SCS identified the nurse failed to communication with the interdisciplinary group on 07/02/2023, the need for on-call counseling services for the caregiver to minimize anxiety around Patient #1's impending death and failed to identify communicate with the hospice physician to seek an alternative route for Morphine and Lorazepam due to the Patients copious sputum production. Review of the Hospice Program policy identified the hospice is responsible for the coordination of care between the interdisciplinary team members, primary care professionals, patient physicians, and the staffs of designated facilities providing hospice care are available 24 hours per day, 7 days per week and continue without interruption. Additionally, counseling services for bereavement counseling is identified and planned for/provided during the illness of a patient and around the time of death. The nurse case manager is responsible for the professional management of the patient's plan of care. This includes, but is not limited to, coordination with other care providers and collaboration with the patient's physician regarding any medication changes and changes in the patient's condition related to the terminal illness and/or hospice plan of care.

Based on clinical record review, review of agency policies and interview with hospice personnel for one of three patients (Patient #1) in the survey sample, the hospice nurse failed to provide effective symptom management education related to the terminal illness. The finding includes: Patient #1 elected the hospice benefit on 06/13/2023. Patient #1s diagnoses included malignant neoplasm of the pancreas, sepsis, and intestinal obstruction. The physicians orders dated 06/13/2023 included nursing services twice a week for pain and symptom management, social work services one time a month and home health aide services once a week for assistance with activities of daily living. Physician's orders included Haloperidol Lactate 2 milligrams/milliliter (mg/ml) give 0.5 ml orally every six hours as needed for agitation, Hyoscyamine 0.125 mg sublingual give one tablet orally every four hours as needed for secretions, Lorazepam 0.5 mg give one tablet orally every six hours as needed for anxiety or agitation, Morphine Concentrate 100 mg/5 ml (20 mg/ml) oral solution give 0.25 ml every hour as needed for pain or shortness of breath and Oxycodone 5 mg give one tablet orally every four hours as needed for pain. Review of the case communication report dated 07/02/2023, identified Patient #1s caregiver called the hospice answering service around 01:00 AM to indicate the Patient woke in pain. The on-call nurse instructed the caregiver to administer Morphine 0.25 ml every hour as needed for pain or shortness of breath. Review of the case communication report dated 07/02/2023, identified Patient #1s caregiver called the hospice answering service at 06:47 AM indicating the Patient was having increased congestion and Morphine 0.25 ml was ineffective. The hospice physician was notified and increased the Morphine to 10 mg every hour. The caregiver was directed to administer Lorazepam for anxiety and Hyoscyamine for secretions as needed. Review of the case communication report dated 07/02/2023, identified Patient #1s caregiver called the hospice answering service at 07:07 AM and indicated the Patients pain and congestion had improved. Review of the as needed nursing visit note dated 07/02/2023, identified Patient #1 was lethargic, denied pain and cough was managed. The Patient was administered 5 mg of Morphine four times in the last 24 hours, Lorazepam and Hyoscyamine as needed. The caregiver identified not wanting the Patient to begin coughing again which caused discomfort and shortness of breath. Additionally, the nurses note indicated the caregiver was tired, overwhelmed, asked about inpatient hospice options, and would benefit from a social work visit. Review of the case communication report dated 07/02/2023, identified the answering service received multiple calls from the Patients caregiver. The caregiver called the answering service at 10:19 PM, indicating the Patient was having trouble breathing, had a productive cough and gagging. Interview and review of Patient #1s clinical documentation with the Hospice Supervisor of Clinical Services (SCS) on 10/26/2023 at 10:45 AM, identified Patient #1 was transported to the hospital for symptom management after the caregiver called the answering service at 10:19 PM on 07/02/2023. The Patients symptoms were treated, and he/she expired in the hospital on 07/03/2023. The SCS identified the nurses note, failed to indicate the frequency of the Ativan and Hyoscyamine administered and failed to identify the caregiver was educated on relieving respiratory distress, coughing and secretions during the visit. Review of the Pain Management policy, identified routine documentation must reflect the patient's response to interventions/pain control efforts. When assessment shows pain that is not controlled per patient, documentation must reflect action taken to manage pain. The clinicians would coordinate care amongst themselves to develop a comprehensive approach to pain management and would coordinate the reporting of all episodes of increased pain to appropriate medical personnel. All clinicians are responsible for coordinated follow-through with instructions or suggestions as indicated, until it is at an acceptable level for the patient.

Based on clinical record review, review of agency policies and interview with hospice personnel, for one of one patient (Patient #9) who received continuous care, the hospice agency failed to provide effective pain management and symptom control for conditions related to the terminal illness. The finding includes: Patient #9 elected the Hospice benefit on 7/14/20. Patient #9's diagnoses included malignant neoplasm of the right and left lungs and malignant pleural effusion. The physician's orders dated 7/14/20 included nursing services 3 times a week for pain and symptom management and social work services 1 time a month. The patient declined hospice aide services and spiritual care services. Physician's orders included Lorazepam Intensol 2 milligrams/milliliter (mg/ml) give 0.5 ml orally every hour as needed for anxiety or agitation; Morphine 15 mg Immediate Release/IR orally give 45 mg every two hours as needed for pain or shortness of breath, and Morphine 200 mg orally every twelve hours. On 7/16/22 at 10:12 AM, RN #1 documented that the patient and family's wish was for the patient to die at home. A subsequent note on 7/16/22 indicated that the patient's symptoms were difficult to manage and required frequent assessment and medication adjustments. The Hospice Physician was notified and Continuous Care level of care was initiated for pain, shortness of breath and anxiety. On 7/16/22 at 4:45 PM - 12:24 AM (7/17/22), RN #2 documented arriving in the patient's home, indicated that the patient reported bad, generalized pain, feelings of panic secondary to shortness of breath and air hunger. RN #2 documented that the patient was in acute respiratory distress for the entire shift and had copious amounts of brown sputum. Additional physician's orders dated 7/16/22 at 2 PM included Lorazepam Intensol 2 mg/ml administer 0.5 ml - 1 ml orally every hour as needed for anxiety or agitation and Morphine Concentrate 20 mg/ml, administer 20 mg - 30 mg orally every hour as needed for pain or shortness of breath. At 5:00 PM, Morphine Concentrate 20 mg/ml was increased to 20 mg every 20 minutes x 3 doses then, at 7:30 PM, Morphine Concentrate 20 mg/ml was increased to 30 mg sublingually every 30 minutes as needed for pain, air hunger and respiratory distress. Interview and review of the Medication Administration Record/MAR with the Director of Hospice on 9/08/22 at 11 AM identified that Morphine Concentrate 20 mg was administered every 20 minutes from 5 PM to 5:40 PM (a total of 60 mg) then Morphine Concentrate 30 mg was administered every half hour from 6 PM to 12 AM (a total of 390 mg) and every 5 minutes from 12 AM to 12:20 AM (a total of 120 mg) until the patient died, and failed to identify communication with the physician for the need to increase the dosage of Morphine needed to relieve respiratory distress, air hunger and pain, and an alternate route needed to administer Morphine due to the copious amounts or oral secretions. Review of the agency policy on Pain Management directed all clinicians will continue to assess pain at regular intervals, when assessment shows pain that is not controlled per patient, documentation must reflect action taken to manage pain. The clinicians will coordinate the reporting of all episodes of increased pain to appropriate medical personnel. Review of agency policy for Pain Management guidelines for breakthrough pain dosing directed that patients on a long-acting opioid must have an order for breakthrough pain which is 10-20% of the oral 24-hour baseline dose. Peak effect of immediate-release opioid is 1 hour, a repeat does may be given every one hour if patient isn't overly sedated. Review of agency policy for guidelines for shortness of breath and air hunger directed that opioids are the first-line therapy, start with Morphine 2.5 mg-5 mg every hour and titrate up aggressively.

Based on clinical record review, review of agency policies and interview with hospice personnel, for one of sixteen patients (Patient #9) in the survey sample, the hospice nurse failed to follow the physician-certified plan of care. The finding includes: Patient #9 elected the Hospice benefit on 7/14/20. Patient #9's diagnoses included malignant neoplasm of the right and left lungs and malignant pleural effusion. The physician's orders dated 7/14/20 included nursing services 3 times a week for pain and symptom management and social work services 1 time a month. The patient declined hospice aide services and spiritual care services. Physician's orders included Lorazepam Intensol 2 milligrams/milliliter (mg/ml) give 0.5 ml orally every hour as needed for anxiety or agitation; Morphine 15 mg Immediate Release/IR orally give 45 mg every two hours as needed for pain or shortness of breath and Morphine 200 mg orally every twelve hours. On 7/16/22 at 10:12 AM, RN #1 documented that the patient and family wished for the patient to die at home. A subsequent note on 7/16/22 indicated that the patient's symptoms were difficult to manage and required frequent assessment and medication adjustments. The Hospice Physician was notified and Continuous Care level of care was initiated for pain, shortness of breath and anxiety. On 7/16/22 at 4:45 PM - 12:24 AM (7/17/22), RN #2 documented arriving in the patient's home, indicated that the patient reported bad, generalized pain, feelings of panic secondary to shortness of breath and air hunger. RN #2 documented that the patient was in acute respiratory distress for the entire shift and had copious amounts of brown sputum. Additional physician's orders dated 7/16/22 at 2 PM included Lorazepam Intensol 2 mg/ml administer 0.5 ml - 1 ml orally every hour as needed for anxiety or agitation, and Morphine Concentrate 20 mg/ml, administer 20 mg - 30 mg orally every hour as needed for pain or shortness of breath. At 5:00 PM, Morphine Concentrate 20 mg/ml was increased to 20 mg every 20 minutes x 3 doses then, at 7:30 PM, Morphine Concentrate 20 mg/ml was increased to 30 mg sublingually every 30 minutes as needed for pain, air hunger and respiratory distress. Interview and review of the Medication Administration Record/MAR with the Director of Hospice on 9/08/22 at 11 AM identified that Morphine Concentrate 20 mg was administered every 20 minutes from 5 PM to 5:40 PM (a total of 60 mg) then Morphine Concentrate 30 mg was administered every half hour from 6 PM to 12 AM (a total of 390 mg) according to physician's orders. Subsequently, RN #2 administered Morphine Concentrate 30 mg every 5 minutes from 12 AM to 12:20 AM (a total of 120 mg) until the patient died and failed to follow physician's orders for the Morphine to be administered every 30 minutes as needed.

Based on clinical record review and interview with hospice personnel, for one of sixteen patients (Patient #9) in the survey sample, the hospice nurse failed to communicate with the interdisciplinary group to provide effective pain management and symptom control for conditions related to the terminal illness. The finding includes: Patient #9 elected the Hospice benefit on 7/14/20. Patient #9's diagnoses included malignant neoplasm of the right and left lungs and malignant pleural effusion. The physician's orders dated 7/14/20 included nursing services 3 times a week for pain and symptom management and social work services 1 time a month. The patient declined hospice aide services and spiritual care services. Physician's orders included Lorazepam Intensol 2 milligrams/milliliter (mg/ml) give 0.5 ml orally every hour as needed for anxiety or agitation; Morphine 15 mg Immediate Release/IR orally give 45 mg every two hours as needed for pain or shortness of breath and Morphine 200 mg orally every twelve hours. On 7/16/22 at 10:12 AM, RN #1 documented that the patient and family wish for the patient to die at home. A subsequent note on 7/16/22 indicated that the patient's symptoms were difficult to manage and required frequent assessment and medication adjustments. The Hospice Physician was notified and Continuous Care level of care was initiated for pain, shortness of breath and anxiety. On 7/16/22 at 4:45 PM - 12:24 AM (7/17/22), RN #2 documented arriving in the patient's home, indicated that the patient reported bad, generalized pain, feelings of panic secondary to shortness of breath and air hunger. RN #2 documented that the patient was in acute respiratory distress for the entire shift and had copious amounts of brown sputum. Additional physician's orders dated 7/16/22 at 2 PM included Lorazepam Intensol 2 mg/ml administer 0.5 ml - 1 ml orally every hour as needed for anxiety or agitation and Morphine Concentrate 20 mg/ml, administer 20 mg - 30 mg orally every hour as needed for pain or shortness of breath. At 5:00 PM, Morphine Concentrate 20 mg/ml was increased to 20 mg every 20 minutes x 3 doses then, at 7:30 PM, Morphine Concentrate 20 mg/ml was increased to 30 mg sublingually every 30 minutes as needed for pain, air hunger and respiratory distress. Interview and review of RN #2's nursing note dated 7/16/22 and the MAR with the Director of Hospice on 9/08/22 at 11 AM identified that Morphine Concentrate 20 mg was administered every 20 minutes from 5 PM to 5:40 PM (a total of 60 mg) then Morphine Concentrate 30 mg was administered every half hour from 6 PM to 12 AM (a total of 390 mg) and every 5 minutes from 12 AM to 12:20 AM (a total of 120 mg) until the patient died and failed to identify communication with the interdisciplinary group for the need to increase the dosage of Morphine needed to relieve respiratory distress, air hunger and pain and/or seek an alternate route needed to administer Morphine due to the copious amounts or oral secretions.

Based on clinical record review, review of agency policies and interview with hospice personnel for one of one patient (Patient #9) who received continuous care, the hospice nurses failed to provide effective pain management and symptom control for conditions related to the terminal illness. The finding includes: Patient #9 elected the Hospice benefit on 7/14/20. Patient #9's diagnoses included malignant neoplasm of the right and left lungs and malignant pleural effusion. The physician's orders dated 7/14/20 included nursing services 3 times a week for pain and symptom management and social work services 1 time a month. The patient declined hospice aide services and spiritual care services. Physician's orders included Lorazepam Intensol 2 milligrams/milliliter (mg/ml) give 0.5 ml orally every hour as needed for anxiety or agitation; Morphine 15 mg Immediate Release/IR orally give 45 mg every two hours as needed for pain or shortness of breath and Morphine 200 mg orally every twelve hours. On 7/16/22 at 10:12 AM, RN #1 documented that the patient and family wish for the patient to die at home. A subsequent note on 7/16/22 indicated that the patient's symptoms were difficult to manage and required frequent assessment and medication adjustments. The Hospice Physician was notified and Continuous Care level of care was initiated for pain, shortness of breath and anxiety. On 7/16/22 at 4:45 PM - 12:24 AM (7/17/22), RN #2 documented arriving in the patient's home, indicated that the patient reported bad, generalized pain, feelings of panic secondary to shortness of breath and air hunger. RN #2 documented that the patient was in acute respiratory distress for the entire shift and had copious amounts of brown sputum. Additional physician's orders dated 7/16/22 at 2 PM included Lorazepam Intensol 2 mg/ml administer 0.5 ml - 1 ml orally every hour as needed for anxiety or agitation and Morphine Concentrate 20 mg/ml, administer 20 mg - 30 mg orally every hour as needed for pain or shortness of breath. At 5:00 PM, Morphine Concentrate 20 mg/ml was increased to 20 mg every 20 minutes x 3 doses then, at 7:30 PM, Morphine Concentrate 20 mg/ml was increased to 30 mg sublingually every 30 minutes as needed for pain, air hunger and respiratory distress. Interview and review of the Medication Administration Record/MAR with the Director of Hospice on 9/08/22 at 11 AM identified that Morphine Concentrate 20 mg was administered every 20 minutes from 5 PM to 5:40 PM (a total of 60 mg) then Morphine Concentrate 30 mg was administered every half hour from 6 PM to 12 AM (a total of 390 mg) and every 5 minutes from 12 AM to 12:20 AM (a total of 120 mg) until the patient died and failed to identify communication with the physician for the need to increase the dosage of Morphine needed to relieve respiratory distress, air hunger and pain and/or an alternate route needed to administer Morphine due to the copious amounts or oral secretions. Review of the agency policy on Pain Management directed all clinicians will continue to assess pain at regular intervals, when assessment shows pain that is not controlled per patient, documentation must reflect action taken to manage pain. The clinicians will coordinate the reporting of all episodes of increased pain to appropriate medical personnel. Review of agency policy for Pain Management guidelines for breakthrough pain dosing directed that patients on a long-acting opioid must have an order for breakthrough pain which is 10-20% of the oral 24-hour baseline dose. Peak effect of immediate-release opioid is 1 hour, a repeat does may be given every one hour if patient isn't overly sedated. Review of agency policy for guidelines for shortness of breath and air hunger directed that opioids are the first-line therapy, start with Morphine 2.5 mg-5 mg every hour and titrate up aggressively.

Based on review of the clinical records, review of agency policies and interview with hospice personnel, for one of sixteen patients (Patient #9) in the survey sample, the hospice nurses failed to follow policies and procedures for the management of controlled drugs to prevent misuse or discrepancies. The finding includes: Patient #9 elected the Hospice benefit on 7/14/20. Patient #9's diagnoses included malignant neoplasm of the right and left lungs and malignant pleural effusion. The physician's orders dated 7/14/20 included nursing services 3 times a week for pain and symptom management and social work services 1 time a month. The patient declined hospice aide services and spiritual care services. Physician's orders included Lorazepam Intensol 2 milligrams/milliliter (mg/ml) give 0.5 ml orally every hour as needed for anxiety or agitation; Morphine 15 mg Immediate Release/IR orally give 45 mg every two hours as needed for pain or shortness of breath and Morphine 200 mg orally every twelve hours. On 7/16/22 at 10:12 AM, RN #1 documented that the patient and family wish for the patient to die at home. A subsequent note on 7/16/22 indicated that the patient's symptoms were difficult to manage and required frequent assessment and medication adjustments. The Hospice Physician was notified and Continuous Care level of care was initiated for pain, shortness of breath and anxiety. On 7/16/22 at 4:45 PM - 12:24 AM (7/17/22), RN #2 documented arriving in the patient's home, indicated that the patient reported bad, generalized pain, feelings of panic secondary to shortness of breath and air hunger. RN #2 documented that the patient was in acute respiratory distress for the entire shift and had copious amounts of brown sputum. Additional physician's orders dated 7/16/22 at 2 PM included Lorazepam Intensol 2 mg/ml administer 0.5 ml - 1 ml orally every hour as needed for anxiety or agitation and Morphine Concentrate 20 mg/ml, administer 20 mg - 30 mg orally every hour as needed for pain or shortness of breath. At 5:00 PM, Morphine Concentrate 20 mg/ml was increased to 20 mg every 20 minutes x 3 doses then, at 7:30 PM, Morphine Concentrate 20 mg/ml was increased to 30 mg sublingually every 30 minutes as needed for pain, air hunger and respiratory distress. Interview and review of the Medication Administration Record/MAR with the Director of Hospice on 9/08/22 at 11 AM identified that Morphine Concentrate 20 mg was administered every 20 minutes from 5 PM to 5:40 PM (a total of 60 mg) then Morphine Concentrate 30 mg was administered every half hour from 6 PM to 12 AM (a total of 390 mg) and every 5 minutes from 12 AM to 12:20 AM (a total of 120 mg) until the patient died and Lorazepam Intensol 2 mg/ml, 1 mg was administered 7 times from 5 PM to 12 AM but failed to identify the documentation of a beginning amount of Morphine and Lorazepam solutions, a remaining balance of the solutions after the nurse accessed the controlled substance to prevent misuse and discrepancies according to agency policies. Review of agency policies for Medication Management directed to implementing mandatory controlled substance counts and document them at every visit to ensure that medication administration is no more than the prescribed dosage.

Based on clinical record review, review of agency policies and interview with hospice personnel, for one of one patient (Patient #9) who received continuous care, the hospice nurse failed to follow the agency documentation policy. The finding includes: Patient #9 elected the Hospice benefit on 7/14/20. Patient #9's diagnoses included malignant neoplasm of the right and left lungs and malignant pleural effusion. The physician's orders dated 7/14/20 included nursing services 3 times a week for pain and symptom management and social work services 1 time a month. The patient declined hospice aide services and spiritual care services. Physician's orders included Lorazepam Intensol 2 milligrams/milliliter (mg/ml) give 0.5 ml orally every hour as needed for anxiety or agitation; Morphine 15 mg Immediate Release/IR orally give 45 mg every two hours as needed for pain or shortness of breath and Morphine 200 mg orally every twelve hours. On 7/16/22 at 10:12 AM, RN #1 documented that the patient and family wish for the patient to die at home. A subsequent note on 7/16/22 indicated that the patient's symptoms were difficult to manage and required frequent assessment and medication adjustments. The Hospice Physician was notified and Continuous Care level of care was initiated for pain, shortness of breath and anxiety. On 7/16/22 at 4:45 PM - 12:24 AM (7/17/22), RN #2 documented arriving in the patient's home, indicated that the patient reported bad, generalized pain, feelings of panic secondary to shortness of breath and air hunger. RN #2 documented that the patient was in acute respiratory distress for the entire shift and had copious amounts of brown sputum. Additional physician's orders dated 7/16/22 at 2 PM included Lorazepam Intensol 2 mg/ml administer 0.5 ml - 1 ml orally every hour as needed for anxiety or agitation and Morphine Concentrate 20 mg/ml, administer 20 mg - 30 mg orally every hour as needed for pain or shortness of breath. At 5:00 PM, Morphine Concentrate 20 mg/ml was increased to 20 mg every 20 minutes x 3 doses then, at 7:30 PM, Morphine Concentrate 20 mg/ml was increased to 30 mg sublingually every 30 minutes as needed for pain, air hunger and respiratory distress. Interview and review of the clinical note dated 7/16/22 by RN #2 and the Medication Administration Record/MAR with the Director of Hospice on 9/08/22 at 11 AM identified that Morphine Concentrate 20 mg was administered every 20 minutes from 5 PM to 5:40 PM (a total of 60 mg) then Morphine Concentrate 30 mg was administered every half hour from 6 PM to 12 AM (a total of 390 mg) and every 5 minutes from 12 AM to 12:20 AM (a total of 120 mg) until the patient died and failed to identify hourly documentation by RN #2 to document assessments, interventions and outcomes according to agency continuous care policy. Review of the agency policy for Continuous Care directed that the paper shift nursing visit record be updated hourly to document assessments, interventions and outcomes.