Every finding on record at Mayo Clinic Hospice

Observed in Record Review. In 18 of 18 patient records reviewed, for active hospice patients the nurse surveyor noted that the goals were not measurable or individualized. For example, “Patient/family/caregiver will verbalize satisfaction with the patient’s level of comfort and symptom control throughout hospice care” and “Patient/family/caregiver will verbalize management of edema”. Additionally, there were minimal short-term goals at start of care to address issues of immediate needs such as understanding medication management, symptom management, pain management, mobility, or safety, most had a long term timeframe for completion or none at all. Findings were verified by the hospice nurse managers and hospice quality coordinators who were present for the record reviews.

Observed in Record Review. In 2 of 18 patient records reviewed, for active patients, it was noted by the nurse manger that the plan of care did not include treatments/care being administered. For RRHV#3, upon admission, the patient had a G tube for feedings. Neither the feedings nor the site care was included in the patient’s Plan of Care. Additionally, the patient developed an open wound on her face due to tumor growth and this was not addressed in the plan of care. For RRNHV#1, the patient was admitted with a feeding tube and an arm cast, neither was addressed the plan of care. Findings were verified by the hospice nurse managers and hospice quality coordinators who were present for the record reviews.

Based on interview and record review, the agency failed to provide ongoing nursing assessment, physician involvement and coordination for 1 of 1 patient (P1) who displayed hypoglycemic symptoms and had a significant medication error related to narcotics. Findings include: Refer to L556 for additional information. The agency failed to identify and provide appropriate treatment and management based on patient assessment when P1 had seizures related to a hypoglycemic (low blood glucose) episode and received four times greater than the prescribed amount of morphine. --- Findings include: Refer to L556 for additional information. The agency failed to identify and provide appropriate treatment and management based on patient assessment when P1 had seizures related to a hypoglycemic (low blood glucose) episode and received four times greater than the prescribed amount of morphine.

Based on interview and document review, the facility failed to provide appropriate treatment and management based on patient assessment when P1 had seizures related to a hypoglycemic (low blood glucose) episode and received four times greater than the prescribed amount of morphine. This resulted immediate jeopardy to P1, who death was related to hypoglycemia. The immediate jeopardy which began on 8/5/2023 when P1 failed to receive appropriate hypoglycemia management and an opioid (narcotic) overdose. Mayo Clinic Hospice director and was notified of the immediate jeopardy on 9/20/23 at 8:46 a.m.. The immediate jeopardy was removed on 9/20/23 at 5:01 p.m. after verification of an acceptable removal plan was implemented. --- P1's certification of terminal illness dated 7/13/23, indicated P1 was admitted on 7/13/23 with a terminal diagnosis of severe protein calorie malnutrition. Other hospice diagnoses included: type two diabetes mellitus with hyperglycemia (high blood sugar), dysphagia oropharyngeal phase (swallowing problems in the mouth or throat), and P1 had a body mass index (BMI) 19.9 or less indicating P1 was underweight. P1's hospice plan of care (POC) dated 7/13/23, indicated P1 was alert and oriented to self, date, and place and had visual and auditory hallucinations. P1 was cachectic (loss of muscle loss) and had a poor appetite. P1's care plan indicated P1's wishes was to live out the remainder of her life in her home and did not want to be sent to the hospital any further. Additionally, the POC identified the patient and caregiver would verbalize a basic understanding of diabetes at end of life with interventions to education on signs and symptoms of hypoglycemia. P1's provider orders for life sustaining treatment (POLST) indicated P1 did not want resuscitation, however desired comfort focused treatment. The POLST indicated P1 wanted relief from pain and suffering through the use of any medication by any route and although P1 preferred no transfers to the hospital for life sustaining treatments, wanted to be transferred if comfort needs could not be met in her current location. P1's skilled nurse hospice admission progress note dated 7/13/23, indicated P1 had a poor appetite, was cachectic, had difficulty swallowing and was at risk for aspiration, and lost 10% of her body weight in the prior 6 months. The note further indicated P1 had dysphagia that led to recurrent aspiration and or inadequate oral intake. P1 weighed approximately 83 pounds. P1 had pneumonitis due to inhalation of food on 6/9/2023. The progress noted indicated the nurse reviewed P1's medications with the nurse practitioner and P1's metformin and sliding scale insulin was discontinued by the nurse practitioner. P1's telephone note dated 7/16/23, indicated P1's family member contacted hospice regarding P1's diabetes management and recalled a discussion of stopping medications and blood sugar checks for diabetes. The note indicated P1's metformin (a medication to lower blood glucose) was discontinued on admission and P1 continued on Glipizide 10 mg daily (a medication to lower blood glucose) and NPH insulin 5 units daily. P1's nursing progress note dated 7/17/23, indicated P1 had a poor appetite and ate approximately 10 to 30 bites per day and was on a dysphagia diet and was at risk for aspiration. The note also indicated P1 completed an antibiotic for a urinary tract infection on 7/15/23. Additionally, blood sugars (BG) were reviewed with the physician and P1's NPH insulin was increased from 5 units to 10 units every a.m. BG readings since previous the nurse visit ranged from 177 to 225 in the a.m., and 255 to 455 prior to supper. P1's nursing progress note dated 7/20/23 indicated P1's BG levels ranged from 211-275 in the a.m., and 405-502 at bedtime. Per the progress note, P1's NPH insulin was subsequently increased to 15 units every a.m.. P1's nursing progress note dated 7/24/23, indicated P1 had difficulty swallowing and was at risk for aspiration. P1 ate a pancake during nursing visit and a family member reported P1 was eating a little better the past couple of days. The progress note indicated P1 had approximately 10-30 bites per day. P1's BG levels ranged 270-302 in the a.m., and 285-527 in the p.m. Per the progress note, P1's NPH insulin was subsequently increased to 20 units every a.m.. P1's nursing progress note dated 7/27/23, indicated P1's BG levels ranged from 234 to 317 in the a.m., and 404 to 555 at bedtime and new orders were received to increase P1's NPH insulin to 25 units every a.m.. P1's nursing progress note dated 7/31/23, indicated P1 ate 100% of breakfast and a family member stated P1 ate well the last three days. P1's BG levels ranged from 97 to 235 in the a.m., and 115-544 at bedtime and new orders were received for a sliding scale insulin due to continued elevated glucose levels. P1's nursing progress note dated 8/3/23, indicated P1's BG readings were reviewed with the NP along with urinary symptoms and no new orders were received. P1's BG levels ranged from 351 to 413 in the a.m., and there were no recorded BG readings recorded at bedtime on 7/31/23 and 8/1/23. The note further indicated the reading of the meter on the evening of 8/2/23, indicated "HI". Further, the note indicated the caregiver contacted the facility director of nursing (DON) who, per the note, did not have access to a computer to verify the sliding scale insulin dose and instructed the aide to administer seven units of insulin. P1's telephone contact note dated 8/5/23 at 5:40 a.m., indicated the assisted living facility (ALF) called to report P1 had increased shortness of breath and chest tightness after ambulating to the bathroom and hospice instructed staff to administer morphine 7.5 mg table, which was then given at 5:00 a.m. and contact hospice if no improvement. P1's telephone contact note dated 8/5/23 at 8:36 a.m., indicated ALF staff called hospice to report P1's continued shortness of breath. P1's insulin was held due to a low blood glucose reading (unspecified number) and requested further instruction. The nurse directed the ALF staff to administer morphine (unspecified dose) and if ineffective, lorazepam (unspecified dose) could be given at 9:30 a.m. The hospice care coordinator was updated regarding the low BG level and planned to follow up. P1's nurse visit note dated 8/5/23 at 12:35 p.m., indicated P1 was in bed and had involuntary repetitive eye movements consistent with seizure activity. P1's body was rigid and had clenched fists and teeth and her pupils were non-reactive. The note indicated orders were received to administer 2 milligrams (mg) or lorazepam every 5 minutes times two doses for seizure activity. The first dose was administered at 1:00 p.m., without a change in symptoms. At 1:15 p.m. it was documented the doses were repeated however the ALF staff stated to the registered nurse (RN)-A that she had retrieved morphine from the medication cart instead of lorazepam and had given morphine to the nurse to administer. P1 inadvertently received 4.5 tablets of morphine which equaled 30 mg of morphine. Further, the RN-A notified the nurse practitioner (NP)-B at 1:22 p.m., and lorazepam 2 mg was ordered and given at 1:30 p.m., for continued seizure activity. RN-A's visit ended at 3:34 p.m., and the progress note indicated seizure activity had subsided by the end of the visit. The visit lacked documentation regarding ongoing monitoring related to P1 receiving 4 times the ordered morphine dose, additionally, P1's respirations were documented as 26 at 1:35 p.m., Staff were instructed to hold oral pills as long as P1 was unresponsive, and the DON was instructed on new orders for scheduled morphine. Additionally, the progress note indicated at 1:29 p.m., P1's BG was 27, at 2:02 p.m., BG was 24, at 2:35 p.m., BG was 37, and at 3:09 p.m., BG was 52. Further, the family member (FM)-A reported P1's BG was 29 upon return to the facility approximately 12:00 p.m. and a repeat BG check was 24. The progress note indicated ALF staff tried crushing glucose tabs mixed with orange juice and administering when the hospice nurse arrived. The note indicated 1 milliliter of glucagon was administered at 2:22 p.m., by the facility nurse. The note lacked additional information regarding further treatment of the low blood glucose. P1's nurse postmortem hospice visit dated 8/5/23 at 9:25 p.m., indicated P1 expired at 7:35 p.m. During interview on 9/18/23 at 1:29 p.m., the hospice administrator stated P1's event wasn't fully finished. The hospice administrator stated P1 resided at an assisted living facility (ALF) and P1's family took her out on an outing and P1 had a seizure in the car due to a hypoglycemic episode and family brought P1 back to the ALF. The administrator further stated P1 had a hypoglycemic seizure and should have received Ativan for the seizures, however an unlicensed staff from the ALF had put morphine in a medication cup and gave the medication to RN-A to administer. During interview on 9/19/23 at 9:04 a.m., FM-A stated P1 was picked up from the ALF on 8/5/23 in the morning and started to have a seizure in the car and was brought back to the ALF. FM-A stated P1 that morning received morphine inadvertently instead of lorazepam. FM-A stated P1 should not have had to struggle because she was on hospice and further stated it was traumatic for her and P1. FM-A stated when they arrived at the facility, P1 did not eat much that a.m., was alert and awake, and added they would have reconsidered taking her out if they knew P1 received morphine. FM-A stated the hospice agency did not talk about a general inpatient level of care or going to the hospital to treat low blood sugars or seizures. During interview on 9/19/23 at 10:29 a.m., RN-B stated if a patient's symptoms were not managed, she provided direction or called the patient back and would send a nurse to see the patient. RN-B stated ALF staff called and reported P1 complained of shortness of breath and morphine was provided. Additionally, P1's insulin was held that morning. RN-B stated she instructed staff at the ALF to administer morphine and instructed the staff to administer lorazepam if the morphine was not effective. RN-B further stated she ended the call and thought she should have asked what P1's blood sugar was and when RN-B tried to call the facility back, RN-B received no answer. Additionally, RN-B stated she did not provide any instruction to the ALF staff regarding P1's insulin that was held. During interview on 9/19/23 at 11:01 a.m., RN-A stated if a patient's symptoms were not managed, she would utilize orders a patient currently had and contact the provider to obtain new orders if needed. RN-A further stated P1 was alert and oriented to place and self and on the day P1 expired, P1 had a significant change and RN-A was notified by a triage nurse that family took P1 out of the facility to go to an event, was not responsive and P1's family brought P1 back to the facility. RN-A stated she arrived at 12:35 p.m., P1 was in bed and was not responding, had repetitive rapid eye movements and was very hypoglycemic and added family was overly excited trying to wake P1 up. RN-A stated the ALF staff were trying to intervene with glucose tablets and orange juice because P1's blood glucose was only 29 when P1 returned from the facility. RN-A stated her concern was P1's safety and addressing P1's low blood sugar and stated she suspected the seizure was due to hypoglycemia and further stated P1 did not have a history of having seizures. RN-A stated she observed P1 lying in bed with no response, with repetitive eye movements, and her fists and teeth were clenched tightly and she was moaning. RN-A stated she contacted NP-B at 12:45 p.m., and received an order to administer Ativan 2 mg every five minutes times two doses for seizures. RN-A stated she administered the first dose of Ativan at 1:00 p.m., and there was no change in P1's response. RN-A directed ALF staff to obtain a second dose of Ativan 2 mg. The ALF staff brought a cup of crushed medication to RN-A who administered the medication at 1:15 p.m., without verifying the medication type or medication dose. RN-A further stated the ALF staff informed RN-A at approximately 1:22 p.m., they crushed four tablets of morphine 7.5 mg (30mg) instead of intended intended four tablets of ativan 0.5 mg to total ativan 2 mg. This constituted four times the amount morphine that was prescribed for P1. RN-A stated she notified NP-B immediately of the medication error and was instructed to administer the second dose of Ativan 2mg. RN-A administered the second dose of Ativan at 1:30 p.m., and stated P1 continued to have the repetitive eye movement but P1's fists and teeth were not as tight as they had been. RN-A further stated P1's blood glucose levels were not resolved and provided the following readings: 1:29 p.m., BG was 27, at 202 p.m. BG was 24, at 2:35 p.m. BG was 37, and at 3:09 BG was 52. RN-A stated orange juice and crushed glucagon tablets were administered in the side of P1's mouth. RN-A further stated the ALF director of nursing inquired why they couldn't administer a glucagon intramuscular (IM) injection and RN-A stated hospice did not have an active order for IM glucagon. RN-A stated she obtained an order for the IM or subcutaneous glucagon injection and the DON administered the medication at 2:22 p.m. RN-A stated P1 was very thin and was 63 inches tall and weighed 83 pounds and stated the first time P1 consumed morphine was on 8/5/23 at 5:40 a.m., and had not consumed the medication previously. RN-A stated P1 never regained consciousness following the episode and stated after this happened, a reporting system was initiated and further stated she expressed concern there was a gray area in managing hypoglycemic episodes and stated since this happened, she had been educated further that 911 could be utilized to administer emergency medications. During interview on 9/19/23 at 12:51 p.m., NP-B stated a blood sugar in the 20's would cause a seizure. NP-B stated if there is no glucose gel, to crush tablets, mix with juice and administer slowly and it should be started right away and administered every 30 minutes. Once a blood sugar was above 90, the glucose would be stopped and she would re-check a blood sugar an hour later. NP-B stated if P1 was opioid naive (having never received and opioid such as morphine) and received 30 mg of morphine, it would probably make her sleepy and stated she was not aware P1 was given 30 mg of morphine in error. During interview on 9/19/23 at 1:07 p.m., the hospice medical director (MD) stated he was familiar with P1 and they were investigating the situation as a sentinel event and were looking for opportunities for improvement. MD stated P1's seizures were due to having blood glucose in the 20's and further stated glucagon should be started as immediately as possible and added if a patient is not responsive but is able to swallow glucose gel and apple juice could be given, and if a patient was not able to swallow the role would be to call emergency medical services (EMS) for help. If P1 was seizing, the seizure would make it impossible to give anything orally and is an indication the glucose is needed parenterally (through an intravenous line). MD stated they were looking into informal education regarding that calls to EMS are appropriate in emergent situations, medication management, diabetes management, management of hypoglycemia, but was all these interventions were preliminary and had not been fully implemented. MD further stated P1 had severe hypoglycemia on the day of death and which should be added on the death certificate. MD further stated if P1 had respiratory depression, he would give Narcan to reverse symptoms. The nursing progress note lacked information monitoring was completed. During interview on 9/19/23 at 1:55 p.m., the hospice administrator stated they were awaiting further incident review before completing diabetic education to hospice nursing staff and the clinical nurse specialist was completing research on diabetic assessment and reassessment. The hospice administrator further stated there were opportunities with the episode where it should not have taken that long to recover P1's blood sugar levels and wondered if they could have reversed the hypoglycemia when P1's blood sugar was 24. The administrator further stated she spoke with RN-A regarding not administering medications in a facility without first verifying the correct patient, medication route, medication dose, medication amount and administration time which are the fundamentals for safe medication administration. During interview on 9/19/23 at 2:29 p.m., the hospice administrator stated they had not provided any education to staff on what to do with a suspected over-dose, but was something they should add. The immediate jeopardy which began on 8/5/2023 when P1 failed to receive appropriate hypoglycemia management and an opioid (narcotic) overdose. Mayo Clinic Hospice director was notified of the immediate jeopardy on 9/20/23 at 8:46 a.m.. The immediate jeopardy was removed on 9/20/23 at 5:01 p.m. after verification of an acceptable removal plan was implemented. The IJ was removed on 8/5/23, at 5:01 p.m. when the hospice submitted and implemented an acceptable removal plan. This included reviewing medication protocol policies and procedures, developing procedures for emergency diabetic management of hospice patients, training of nurses to ensure proper medication administration and review of patient management for an opioid overdose. Review of policy and procedure revisions was completed and hospice management was then interviewed on implemention of the aforementioned changes in policy and education. This was then verified through on-site document review, observation, and interview.