Every finding on record at Mercy Hospital Jefferson

Based on policy review, record review, observation, and interview the hospice provider failed to ensure that medication reconciliation was completed in, but not limited to, two of five full records reviewed (Records/Patients #2 and #4). This deficient practice has the potential to affect all patients served by the hospice provider. --- RECORD/PATIENT #4: Review of the clinical record showed patient was admitted to hospice services on 03/01/2023 with a terminal diagnosis of late onset Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions) with a secondary diagnosis of type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar). The patient resided in a skilled nursing facility (SNF). Review of the SNF medication list showed the following medication orders: -Glipizide (a medication used to treat type 2 diabetes) 5 mg tablet: take one tablet by mouth in the evening; -Linagliptin (a medication used to lower the blood sugar levels in patients with type 2 diabetes) 5 mg tablet: take 5 mg by mouth one time a day; and -The agency's medication list failed to contain orders for these medications. Review of the agency's medication listed showed the following medication orders: -Olanzapine (a medication used to treat mental disorders, including schizophrenia and bipolar disorder) 5 mg tablet: take 5 mg by mouth every 8 hours as needed for anxiety or delirium; and -The SNF medication list failed to contain an order for this medication. During an interview on 03/29/2023, the clinical manager stated that he/she would expect the medications to match between the agency and the facility. Findings included: Review of the hospice provider's policy titled, "Medication Reconciliation Medication Regime Review Policy," dated 09/23/2022, showed in part a periodic "Medication Regime Review" will occur every two weeks as part of the ongoing comprehensive assessment. This will include a thorough review of all medications, including prescribed, over-the-counter (OTC), or herbal preparations the patient is using. RECORD/PATIENT #2: Review of the clinical record showed: - The patient was admitted on 01/19/2022; - The medication list printed on 03/27/2023 included the following medications: * Albuterol sulfate (a medication to help breathing) 90 micrograms (mcg) inhaler take two puffs every six hours as needed for shortness of breath; * Xanax (a medication for anxiety) one milligram (mg) take one tablet by mouth ever six hours as needed for anxiety; * Tylenol (a medication for pain) take 650mg every six hours as needed for pain; * Buspar (a medication for anxiety) take 10mg by mouth every 12 hours; * Calcium carbonate with Vitamin D3 (a medication for bone health) take one tablet daily with breakfast; * Mucinex DM (a medication for cough and congestion) 1200mg take one tablet every 12 hours as needed for cough; * Voltaren (a medication for pain) 1% apply two grams to the affected area four times per day as needed for pain; * Pepcid (a medication for GI upset) take 20mg two times per day; * Trelegy Ellipta disk (a medication to help breathing) one puff every day; and * Duoneb (a medication to help breathing) take 3 milliliters (ml) by inhalation two times per day. Observation on 03/27/2023 beginning at 11:45 AM, during the patient's home visit, showed that the patient reported the following changes to his/her medication list: * He/she is taking the Albuterol sulfate inhaler every four hours; * He/she is taking one-half tab of Xanax every six hours as needed; * He/she is not taking or using Tylenol, Buspar, Calcium carbonate with Vitamin D3, Mucinex DM, Voltaren, or Trelegy Ellipta; * He/she is taking Pepcid daily; and * He/she is taking Duoneb by inhalation four times per day. During an interview on 03/29/2023 beginning at 11:55 AM, the administrator designee stated that he/she would expect the medication list to match what the patient is taking.

Based on policy review, record review, and interview the hospice provider failed to ensure that an individualized plan of care was developed for each patient in two of five full records reviewed (Records/Patients #2 and #4). This deficient practice has the potential to affect all patients served by the hospice provider. --- Findings included: Review of the agency's policy titled, "Hospice Plan of Care Policy," dated 06/15/2022, showed the following: -All hospice care and services furnished to patients and their families must follow an individualized written plan of care (POC) established by the hospice interdisciplinary group (IDG) in collaboration with the attending physician, the patient representative, and the primary caregiver in accordance with the patient's needs if any of them so desire; and -The hospice will develop an individualized written POC for each patient. RECORD/PATIENT #4: Review of the clinical record showed the patient admitted to hospice services on 03/01/2023 with a terminal diagnosis of Alzheimer's Disease with secondary diagnoses of seizure disorder and type 2 diabetes mellitus. The patient resided in a facility. Review of the document titled, "Skilled Nurse (SN) Hospice Initial Assessment," dated 03/01/2023, showed the following: -The patient was at an increased risk for falls; -The patient was incontinent of bowel and bladder; and -The patient was at an risk for skin breakdown. Review of the documents titled, "Hospice Plan of Care," dated 03/01/2023, 03/07/2023, and 03/21/2023, showed the following: -The agency failed to include interventions related to the patient's seizure disorder; -The agency failed to include interventions related to the patient's type 2 diabetes; -The agency failed to include interventions related to the increased risk for falls; -The agency failed to include interventions related to the increased risk for skin breakdown; and -The agency failed to include interventions related to the patient's incontinence. During an interview on 03/29/2023 at 11:45 AM, the clinical manager stated that he/she would expect the POC to be individualized to the patient's needs and contain interventions related to issues discovered during the initial comprehensive assessment RECORD/PATIENT #2: Review of the clinical record showed: - The patient was admitted to hospice services on 01/19/2022 with a primary diagnosis of decompensated chronic obstructive pulmonary disease (a chronic disease of the lungs that affects breathing) and a secondary diagnosis of type 2 diabetes mellitus (a disease of the pancreas that affects the level of blood sugar in the body); - The updated plan of care dated 03/21/2023, showed the following: * The patient is a fall risk and the hospice provider failed to include any goals or interventions related to falls; * The patient requires oxygen and the hospice provider failed to include any goals or interventions related to oxygen safety; and * The patient is diabetic and the hospice provider failed to include any goals or interventions related to diabetes. During an interview on 03/29/2023 beginning at 11:55 AM, the administrator designee stated that he/she would expect that the plan of care would be individualized for each patient.

Based on policy review, record review, and interview the hospice provider failed to ensure that the physician was notified of changes in the patient's condition in three of five full records reviewed (Records/Patients #2, #3, and #5). This deficient practice has the potential to affect all patients served by the hospice provider. --- Findings included: Review of the hospice provider's policy titled, "Plan of Care Change of Orders Policy," dated 06/15/2022, showed in part, that the physician shall be notified/alerted of any changes in the patient's condition which may indicate needed changes to the plan of care. RECORD/PATIENT #2: Review of the clinical record showed: - The skilled nurse's (SN) note dated 03/13/2023, showed that the patient complained of his/her right elbow being tender and swollen; - The SN note dated 03/16/2023, showed that the patient complained of pain in the left breast and into his/her shoulder rating 2/10 on pain scale, no redness noted, mild swelling noted. His/her right elbow remained swollen and tender. The registered nurse (RN) encouraged the patient to take Ibuprofen routinely for several days to help with inflammation; - The SN note dated 03/20/2023, showed that the patient complained of his/her right elbow being sore. The right elbow was red and swollen from the elbow extending down the mid arm. A new order was received to start Keflex (a medication used for bacterial infections) 500 milligrams (mg) four times per day for 7 days; and - The hospice provider failed to notify the physician of a change in the patient's condition on 03/13/2023 and 03/16/2023. During an interview on 03/29/2023 beginning at 11:55 AM, the administrator designee stated that he/she would expect the nurse to call the physician with a change in condition. Review of the agencys policy titled, ";Medication Administration Policy," dated 08/08/2022, showed: - RN (registered nursing) co-workers or the patient/caregiver, according to policy, administers medications in the home in accordance with physician orders and pharmacy label instructions; - The RN case manager or designee provides instruction to the patient/caregiver on the proper administration of medications; and - Any questionable dose or medication should be discussed with the supervisor and/or the physician. RECORD/PATIENT #3: Review of the patients medication profile showed the patient takes dexamethasone (a steroid medication taken relieve inflammatory conditions that occur with the skin, joints, lungs and other organs) 4 milligrams (mg) by mouth four times daily for swelling. Review of the skilled nursing (SN) visit notes, dated 02/06/2023, showed in part: - Due to the patients sleeping habits, the caregiver is unable to give the patient his/her dexamethasone more than two or three times daily; - The RN discussed the dexamethasone and strongly encouraged the caregiver to give it at least three times daily (the physicians order is to give dexamethasone four times daily); and - The note failed to contain any documentation that the physician was notified the patient was not receiving the medication as ordered or a new order to take the medication three times daily was received. During an interview on 03/29/2023 at 11:35 AM, the clinical supervisor stated that he/she would expect the RN to notify the physician that the patient was not receiving their medication at the ordered frequency and the nurse should not be suggesting alternate dosing of the patients medication without getting a physicians order. RECORD/PATIENT #5: Review of the clinical record showed patient was admitted to hospice services on 03/02/2022 with a terminal diagnosis of malignant neoplasms (disease in which abnormal [cancerous] cells divide uncontrollably and destroy body tissue) of the lower esophagus. The patient resided in a skilled nursing facility (SNF). Review of the document titled, ";Telephone Encounter," dated 03/21/2023, showed: -The long term care facility nurse called the agency and reported the patient had ";cracks" to his/her buttocks from ";poor hygiene" and a barrier cream was applied; and -The encounter failed to contain documentation that the physician was notified of the cracks in the patients buttocks. Review of the SN note, dated 03/23/2023, showed: -An assessment of the skin showed temperature, moisture level, and skin turgor (the degree of elasticity of the skin) were all within normal limits; -The skin color was documented as pale; -The SN note to contain documentation of an assessment of the ";cracks" on the patients buttocks; and -The SN note failed to contain documentation that the physician was notified of the ";cracks" on the patients buttocks. During an interview on 03/29/2023 at 11:45 AM, the clinical manager stated that he/she would have expected the patient's skin to be assessed and the changes reported to the physician.

Based on policy review, record review, and interview the hospice provider failed to ensure that physician's orders were part of the patient's record in, but not limited to, two of five full records reviewed (Records/Patients #2 and #3).This deficient practice has the potential to affect all patients served by the hospice provider. --- Review of the agencys policy titled, ";Plan of Care Policy," dated 06/15/2022, showed: - All hospice care and services furnished to patients and their families must follow an individualized written plan of care (POC); and - The POC must include all services necessary for the palliation and management of the terminal illness and related conditions. Review of the agencys policy titled, ";Plan of Care Change of Orders Policy," dated 06/15/2022, showed in part: - The agency will provide care and services consistent with the plan of care; and - Drugs, services, and treatments are administered only as ordered by a physician. RECORD/PATIENT #3: Review of the SN visit notes showed visits were made on 03/06/2023 and on 03/09/2023. Review of the POC dated 02/03/2023 through 02/13/2023 showed an order for two skilled nursing (SN) visits every week for 02/05/2023 through 03/04/2023. Review of the POC updates with dates ranging from 02/14/2023 through 03/13/2023, showed: - An order for two SN visits every week from 02/26/2023 to 03/04/2023; and - The POC failed to contain an order for the two SN visits for the week of 03/05/2023 through 03/11/2023 (visits were made by the nurse on 03/06/2023 and 03/09/2023). During an interview on 03/29/2023 at 11:35 AM, the clinical supervisor and clinical manager stated that the clinicians do visits a month at a time and it must have been a data entry error that caused them to miss the order. Both agreed the clinical record should have contained an order for the SN visits on 03/06/2023 and 03/09/2023. Findings included: Review of the hospice provider's policy titled, "Plan of Care Change of Orders Policy," dated 06/15/2022, showed in part: - Verbal and changed orders shall be maintained in the electronic record (EPIC); and - Drugs, services, and treatments are administered only as ordered by a physician. RECORD/PATIENT #2: Review of the clinical record showed: Review of a hospice aide visit dated 03/10/2023, showed that the patient complained of chest pain and felt like, "a mack truck was sitting on his chest; - The hospice aide notified the office and spoke to a registered nurse (RN). During a telephone call with the RN the patient reported heaviness in the chest and mild aching pain. He/she stated that since he/she started a new nebulizer on Wednesday he/she has been having episodes of chest pain; - The RN notified the nurse practitioner (NP) who ordered "an extra dose of Terazosin, as well as encourage to take Xanax, and stop Budesonide nebulizer until further notice,"; and - The hospice provider failed to produce a written order from the NP for the medication orders. Review of a skilled nurse's (SN) note dated 03/16/2023, showed that the patient complained of pain in the left breast and into his/her shoulder rating 2/10 on pain scale, no redness noted, mild swelling noted. His/her right elbow remained swollen and tender. The RN encouraged the patient to take Ibuprofen routinely for several days to help with inflammation. The hospice provider failed to produce a written order from the physician to change the frequency of the Ibuprofen. Review of a SN note dated 03/27/2023, showed that during the visit the patient stated to the RN that he/she was no longer taking Buspar. The RN documented that the medication was removed from the patient's medication list. The hospice provider failed to produce a written order from the physician to remove the medication. During an interview on 03/29/2023 beginning at 11:55 AM, the administrator designee stated that he/she would expect an order to be written for medication changes.

Based on policy review, record review, and interview the hospice provider failed to ensure that documentation was clear, complete, and appropriately authenticated and dated in accordance with the hospice provider's policy in three of five full records reviewed (Records/Patients #2, #3, and #4). This deficient practice has the potential to affect all patients served by the hospice provider. --- RECORD/PATIENT #2: Review of the clinical record showed: - A skilled nurse's (SN) visit note dated 02/09/2023 and completed on 02/13/2023; - A SN visit note dated 02/13/2023 and completed on 02/15/2023; - A SN visit note dated 02/16/2023 and completed on 02/20/2023; - A SN missed visit note dated 02/24/2023 and completed on 03/03/2023; - A SN visit note dated 03/02/2023 and completed on 03/06/2023; -A SN visit note dated 03/16/2023 and completed on 0320/2023; -A SN visit note dated 03/22/2023 and completed on 03/24/2023; and -A social worker missed visit note dated 02/27/2023 and completed on 03/22/2023. During an interview on 03/29/2023 at 11:35 AM, the clinical supervisor and clinical manager stated that they expect all documentation to be completed promptly and according to policy. Findings included: Review of the agencys policy titled, ";Clinical Records Policy," dated 03/16/2023, showed: -An electronic medical record containing pertinent past and current findings is maintained for each patient receiving hospice services; -The electronic medical record must contain correct clinical information that is available to the patients attending physician and hospice co-workers and should be easily obtainable; -Routine notes and visits should be completed and closed within 24 hours of visit; and -Admissions and initial visits should be completed and closed within 72 hours of visit. RECORD/PATIENT #3: Review of the hospice aide care plan, with an admission date of 02/03/2023, showed the special instructions to notify the nurse if vital signs readings were outside of the following parameters: - Blood pressure greater than 160/90 millimeters of mercury (mm/Hg) or less than 70/40 mm/Hg; - Pulse greater than 110 beats per minute or less than 50 beats per minute; - Temperature greater than 100 degrees Fahrenheit or less than 96 degrees Fahrenheit; and - Respirations greater than 110 breaths per minute or less than 12 breaths per minute (normal respiratory rate range is 12 to 20 breaths per minute). Review of the hospice aide visit note, dated 03/07/2023, showed the aide documented the patient was outside on the deck with a gait belt around the patient and chair to keep him/her from sliding out of the chair. The patients family stated that the patient slid onto the wheelchair foot rests prior to the aides arrival. Review of the hospice aide visit note, dated 03/10/2023, showed the aide documented the patient was outside on the deck with a gait belt around the patient and chair to keep him/her from sliding out of the chair. The patients family stated that the patient slid onto the wheelchair foot rests prior to the aides arrival. During an interview on 03/29/2023 at 11:35 AM, the clinical supervisor and clinical manager stated that they absolutely expected entries into the clinical record to be accurate. They did not think that respirations of greater than 110 breaths per minute were appropriate and the defined parameter was excessive and they hoped it was just a data entry error. They would expect the hospice aide to enter accurate documentation and that it sounded like the aide copied the note from the previous visit and did not edit the information. RECORD/PATIENT #4: Review of the clinical record showed the following: -A SN visit note dated 03/04/2023 completed on 03/13/2023; -A SN visit note dated 03/14/2023 completed on 03/17/2023; -A SN visit note dated 03/17/2023 completed on 03/21/2023; -A SN visit note dated 03/21/2023 completed on 03/26/2023; and -A SN visit note dated 03/23/2023 completed on 03/29/2023. During an interview on 03/29/2023 at 11:35 AM, the clinical supervisor and clinical manager stated that they expect all documentation to be completed promptly and according to policy.

Based on contract review and interview, the hospice provider failed to include the verbiage within their general inpatient contract that if at least one patient in the hospice facility is receiving general inpatient care, then each shift must include a registered nurse who provides direct patient care in one of one general inpatient contract reviewed. This deficient practice has the potential to affect all patients served by the hospice provider. --- Findings included: Review of the general inpatient contract provided by the hospice provider showed that the hospice provider failed to include the verbiage that each shift will contain a registered nurse who provides direct patient care. During an interview on 03/29/2023 at 11:45 AM, the clinical manager stated that he/she could not find that verbiage within the contract and he/she would expect it to be contained in the contract.