Every finding on record at Moments Hospice

Based on observation, record review, interview, and policy review, the Hospice agency failed to ensure the plan of care (POC) and medication list were updated in the hospice binder located at the nursing desk at a skilled nursing facility during one patient (Patient (P)5) observation out of three total home care visits completed. The failure to provide the correct information for all disciplines providing care had the potential to result in medication errors or the provision of inadequate care and services.  Findings include: --- During P5's home visit observation on 04/28/26 at 12:40 PM, a review was completed of the hospice binder located at the facility nursing station. The binder did not include P5's current hospice POC. In addition, comparison of the hospice medication list with the facility medication list revealed the hospice list was not updated and did not match the facility list. The facility list included lorazepam (a medication for anxiety) 0.5 milligrams (mg) every four hours as needed for terminal agitation, morphine sulfate 0.25 milliliters (ml) every eight hours as needed for shortness of breath or pain, and morphine sulfate 0.25 ml every four hours as needed for shortness of breath or pain. The hospice medication list had morphine listed as only every four hours as needed. Morphine every eight hours and lorazepam were not on the hospice medication list.  During an interview on 04/28/26 at 2:00 PM, the Executive Director (ED) reviewed and confirmed that the medication list from the facility and the hospice medication list did not match and that the two lists should match. The ED stated the patient hospice POC is supposed to be in the binder at the nurse's station at the facility. The ED stated the POC is emailed to the facility and that the facility usually puts it in the binder. The ED did agree that this may not be the best approach to ensure coordination of services. Review of the hospice agency undated policy titled, "Interdisciplinary Group Coordination of Care," revealed, "[Agency] will utilize a case management system to guide an interdisciplinary group to provide comprehensive, coordinated health care to patients and families/caregivers services by the hospice … Continuity of care will be maintained throughout the patient's course with hospice."

Based on interview and document review, the hospice agency failed to report an allegation of abuse to the hospice administrator immediately after becoming aware of the situation and failed to report the incident to the state agency for 1 of 3 patients (P1) reviewed for abuse. --- Findings include: P1s plan of care, dated 7/2/24, indicated P1 was admitted to hospice on 7/1/24 with a primary diagnosis of metastatic prostate cancer and a secondary diagnosis of Alzheimers disease. During an interview on 11/20/24 at 12:57 p.m., registered nurse (RN)-A stated the first time she met P1, on 7/5/24, he appeared ";really lethargic", but it was not until her next visit on 7/8/24 that an assisted living (AL) nursing assistant (NA) told her an AL nurse gave P1 two medications (Seroquel and Haldol, both antipsychotic medications) that were not prescribed to him. RN-A stated it then made sense why P1 ";seemed so out of it" during her first visit with him. RN-A stated the AL nurse asked for an order for Seroquel or Haldol on 7/5/24 but the hospice doctor for P1 was not comfortable prescribing the medication at that time and did not order the medication. RN- A stated when she found out about the AL nurse giving P1 unprescribed medications she notified her team director and the AL director of nursing (DON). RN-A stated the AL DON stated she was going to report the incident. During an interview on 11/20/24 at 1:22 p.m., the team director (TD) stated he was aware P1 received medications that were not prescribed to him back in July and stated he believed it to be intentional, to ";control" P1s ";behaviors." The TD stated he completed a medication error report and updated the medical director but did not report the incident to the state agency or the hospice administrator because the facility told him they would report it. During an interview on 11/20/24 at 2:52 p.m., the DON stated she was not aware of the medication concern with P1 until that day. The DON stated the TD and medical director were the only hospice notifications made. During a follow up interview on 11/22/24 at 9:15 a.m., the DON confirmed the executive director and administrator were not made aware of the incident with P1 and that no internal investigation was made on their end.

Based on interview and document review, the hospice agency failed to investigate an allegation of abuse after becoming aware of the situation for 1 of 3 patients (P1) reviewed for abuse. --- Findings include: P1s plan of care, dated 7/2/24, indicated P1 was admitted to hospice on 7/1/24 with a primary diagnosis of metastatic prostate cancer and a secondary diagnosis of Alzheimers disease. During an interview on 11/20/24 at 12:57 p.m., registered nurse (RN)-A stated the first time she met P1, on 7/5/24, he appeared ";really lethargic", but it was not until her next visit on 7/8/24 that an assisted living (AL) nursing assistant (NA) told her an AL nurse gave P1 two medications (Seroquel and Haldol) that were not prescribed to him. RN-A stated it then made sense why P1 ";seemed so out of it" during her first visit with him. RN-A stated the AL nurse asked for an order for Seroquel or Haldol on 7/5/24 but the hospice doctor for P1 was not comfortable prescribing the medication at that time. RN- A stated when she found out about the AL nurse giving P1 unprescribed medications she notified her team director and the AL director of nursing (DON). RN-A stated the AL DON stated she was going to report the incident, which is why she did not report or investigate the concern. During an interview on 11/20/24 at 1:22 p.m., the team director (TD) stated he was aware P1 received medications that were not prescribed to him back in July and stated he believed it to be intentional, to ";control" P1s ";behaviors." The TD stated a medication error report was created and the medical director was updated, but the incident was not reported or investigated because the AL DON stated they would report it. During an interview on 11/20/24 at 2:52 p.m., the DON stated she was not aware of the medication concern with P1 until that day. The DON stated the TD and medical director were the only hospice notifications made. During a follow up interview on 11/22/24 at 9:15 a.m., the DON confirmed the executive director and administrator were not made aware of the incident with P1 and that no internal investigation was conducted on their end.

Based on interview and document review, the hospice agency failed to ensure increasing medication doses and initiation of additional medications were based on corresponding objective assessments and reassessments of changes in conditions when requesting additional medications to manage P1s symptoms, resulting in harm when P1 became increasingly lethargic and sustained numerous falls. In addition, the hospice agency failed to coordinate care and communication with P1s assisted living facility to ensure accurate and comprehensive reassessments of P1s changes in condition and medication usage were communicated to P1s provider. This resulted in an immediate jeopardy when P1's increasing medications and dosage increases preceded P1's subsequent falls, hospitalization, and death. The immediate jeopardy began on 7/5/24 when the hospice agency prescribed scheduled morphine to P1 despite the hospice nurse's objective assessment which indicated P1 was in no distress, with no signs or symptoms of pain or shortness of breath. The director of nursing and executive director were notified of the immediate jeopardy on 11/22/24 at 9:32 a.m. The immediate Jeopardy was removed on 11/26/24, after verification of an acceptable removal plan was implemented, but noncompliance remained at the lower scope and severity of level D, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. --- Findings include: Refer to L556 for additional information. The hospice agency failed to ensure increasing medication doses and additional medications were based on corresponding objective assessments and reassessments of changes in conditions when requesting additional medications to manage P1s symptoms. In addition, the facility failed to coordinate care and communication with the P1s assisted living facility to ensure accurate and comprehensive reassessments of P1s changes in condition and medication usage were communicated to P1s provider. This resulted in an immediate jeopardy when P1's increasing medications and dosage increases preceded subsequent falls, hospitalization, and death.

Based on interview and document review, the hospice agency failed to ensure increasing medication doses and the initiation of additional medications were based on corresponding objective assessments and reassessments of changes in conditions when requesting additional medications to manage P1s symptoms. In addition, the facility failed to coordinate care and communication with the P1s assisted living facility to ensure accurate and comprehensive reassessments of P1s changes in condition and medication usage were communicated to P1s provider. This resulted in an immediate jeopardy when P1's increasing medications and dosage increases preceded subsequent falls, hospitalization, and death. The immediate jeopardy began on 7/5/24 when the hospice agency prescribed scheduled Morphine to P1 despite the hospice nurse's objective assessment which indicated P1 was in no distress, with no signs or symptoms of pain or shortness of breath. The director of nursing and executive director were notified of the immediate jeopardy on 11/22/24 at 9:32 a.m., The immediate Jeopardy was removed on 11/26/24, but noncompliance remained at the lower scope and severity of level D, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. --- Findings include: P1s plan of care, dated 7/2/24, indicated P1 was admitted to hospice on 7/1/24 with a primary diagnosis of metastatic (widespread) prostate cancer and a secondary diagnosis of Alzheimers disease. P1s electronic medical record (EMR) indicated he received the following skilled nursing visits and medication changes from 7/2/24 – 7/13/24: P1's visit note, dated 7/2/24, documented P1 was visited by registered nurse (RN)-B and was noted to be exhibiting agitation, restlessness, exit seeking, and hallucinations. P1s scheduled olanzapine (medication for treating severe agitation) was increased from 2.5 milligrams (mg) at bedtime to 10 mg twice a day, following a provider call associated with the visit. P1's visit note dated 7/4/24, documented an as needed (PRN) visit was made by RN-B for restlessness and agitation. P1s PRN olanzapine was increased from 2.5mg daily to 5mg twice a day following a provider call associated with the visit. P1's visit note dated 7/5/24, documented a visit was made by RN-A. The visit note documented P1 was very lethargic without documented concerns of pain or shortness of breath. However, scheduled morphine (opioid medication to treat pain and shortness of breath) was initiated at 5 mg scheduled every 8 hours that same day following a provider call associated with the visit. P1's visit note dated 7/8/24, documented a visit was made by RN-A. The note documented the RN-A was made aware that on 7/5/24, P1 was intentionally given two medications that were not prescribed to him (Seroquel and Haldol, both anti-psychotic medications used to treat agitation) by an assisted living staff member. Following the visit no medication changes were made. P1's visit note dated 7/10/24, documented a visit was made by RN-A and it was documented the assisted living (AL) nurse reported ";significant improvement" in P1s mood and behaviors since the last medication changes were made. No medication changes were made were made following this visit. On 7/11/24, no skilled nursing visit was made, and no triage calls received, for P1. A Chaplain visit note, dated 7/11/24, indicated a visit was made by chaplain (C)-A. C-A documented P1 was awake and in a good mood. However, P1's Hospice Physican Order, dated 7/11/24, documented a new order for clonazepam (medication to treat anxiety) 0.5 mg twice a day. P1's visit note dated 7/12/24, by RN-A documented P1 ";appeared calm and not in any immediate distress". It was also documented P1 had fallen earlier in the day and had been complaining of ankle pain and had been ";agitated and anxious". The visit note documented the assisted living (AL) facility nurse requested ABH gel (a gel consisting of Ativan, Benadryl, and Haldol which are compounded medications used to treat agitation). Despite P1 being documented as calm during the hospice skilled nursing visit, P1s morphine was increased from 5 mg every 8 hours to 10 mg every 6 hours, clonazepam was increased from 0.5 mg twice a day to three times a day and Haldol was initiated at 5 mg PRN for agitation every 4 hours following a provider call from RN-A. P1s Client Medication Report, printed 11/22/24, indicated P1 had orders for the following medications; clonazepam (medication to treat anxiety) 0.5 mg three times a day scheduled for agitation, Haldol 5 mg every 4 hours PRN for agitation, olanzapine 10 mg two times a day scheduled and 5 mg two times a day as needed (PRN) for agitation/restlessness, lorazepam (medication to treat anxiety) 0.5 mg every 4 hours PRN for agitation/restlessness, morphine 10 mg every 6 hours scheduled and every 3 hours PRN for pain/shortness of breath. With this change in medications P1 was then being administered two benzodiazepines (a class of prescription drugs that slow brain activity and produce a calming effect. Common side effects include respiratory depression, drowsiness, confusion, and syncope), two antipsychotics (a class of prescription drugs that treat symptoms of psychosis, such as hallucinations, delusions, and dementia. A common side effect is sedation) and an opioid medication (pain relieving medication with common side effects which include sedation, dizziness, nausea, vomiting, constipation, and respiratory depression). Review of P1's medication administration record (MAR) from 7/2/24 through 7/13/24, documented in addition to P1s scheduled medications, he also received the following PRN medications: On 7/2/24, P1 received 2 doses of PRN lorazepam 0.5 mg and 1 dose of PRN olanzapine 2.5 mg. On 7/3/24, P1 received 1 dose or PRN lorazepam 0.5 mg. On 7/4/24, P1 received 2 doses of PRN morphine 5 mg, 2 doses of PRN lorazepam 0.5 mg, and 2 doses of PRN Olanzapine, 2.5 mg. On 7/5/24, P1 received 2 doses of PRN morphine 5 mg, 3 doses of PRN lorazepam 0.5 mg, and 1 dose of PRN olanzapine 2.5 mg. (In addition to a dose of unprescribed Haldol and Seroquel of unknown doses taken from another resident without an order). On 7/6/24, P1 received 2 doses of PRN lorazepam 0.5 mg. On 7/7/24, P1 received 1 dose of PRN morphine 5 mg and 1 dose of PRN lorazepam 0.5 mg. On 7/8/24, P1 received 1 dose of PRN morphine 5 mg, 1 dose of PRN lorazepam 0.5 mg, and 1 dose of PRN olanzapine 2.5 mg. On 7/9/24, P1 received 2 doses of PRN morphine 5 mg, 2 doses of PRN lorazepam 0.5 mg, and 1 dose of PRN olanzapine 2.5 mg. On 7/10/24, P1 received 3 doses of PRN morphine 5 mg, 3 doses of PRN lorazepam 0.5 mg, and 1 dose of PRN olanzapine 2.5 mg. On 7/11/24, P1 received 2 doses of PRN morphine 5 mg, 2 doses of PRN lorazepam 0.5 mg, and 2 doses of PRN olanzapine 2.5 mg. On 7/12/24, P1 received 2 doses of PRN morphine 5 mg, 2 doses of PRN lorazepam 0.5 mg, and 3 doses of PRN olanzapine 2.5 mg. On 7/13/24, P1 received 3 doses of PRN morphine 5 mg, 4 doses of PRN lorazepam 0.5 mg, and 1 dose of PRN Haldol 5 mg. P1S Hospice electronic medical record (EMR) documented between 7/4/24 and 7/13/24, P1 sustained 10 falls. Two falls on 7/4/24, one fall on 7/8/24, one fall on 7/12/24 and six falls on 7/13/24 resulting in a head strike and hospitalization. P1's hospital Death Summary, dated 7/23/24 documented P1 passed away nine days later in the hospital. During an interview on 11/21/24 at 10:00 a.m., FM-A stated P1 was admitted to the AL facility on 7/1/24 and at the time P1 was walking and able to carry on conversation. FM-A stated P1 would wander at times, looking for her but was not agitated or aggressive in nature. FM-A further stated after the incident on 7/5/24, when P1 received two medications that were not prescribed to him he was ";never the same" and seemed overly sedated from that point forward. FM-A voiced distressed in P1 passing away in the hospital, stating ";he should not have had to die in that way." During an interview on 11/20/24 at 12:57 p.m., registered nurse (RN)-A stated the first time she met P1, on 7/5/24, he was observed ";really lethargic", but it was not until her next visit on 7/8/24 that an assisted living (AL) nursing assistant (NA) told her an AL nurse gave P1 two medications, Seroquel and Haldol, that were not prescribed to him and were taken from another AL resident. RN-A stated it then made sense why P1 ";seemed so out of it" during her first visit with him. RN-A stated the AL nurse asked for an order for Seroquel or Haldol on 7/5/24 but the hospice doctor for P1 was not comfortable prescribing the medication at the time. RN-A stated she made ";a lot" of medication changes with P1 despite her never seeing him aggressive or agitated, stating he was always calm and eating well during her visits. RN-A further stated the medication changes made for P1 were ";all based on what the facility reported" stating ";I think they [the AL facility] just wanted meds [medication] to knock him [P1] out." RN-A further stated the AL facility had threatened to switch P1 to their hospice agency if they did not prescribe medications they were requesting. RN-A stated P1 died in the hospital and his spouse was ";very upset" he died in the hospital. During an interview on 11/20/24 at 1:22 p.m., the team director (TD) stated he was aware P1 received medications that were not prescribed to him in July and stated he believed it to be intentional by the AL staff, to ";control" P1s ";behaviors." The TD stated he completed a medication error report and updated the medical director but did not report the incident to the state agency because the facility told him they would report it to the state agency. The TD stated P1s family member (FM)-A reported P1 wanted to get up and walk around and was not aware of his surroundings, because he was new to the facility, but FM-A did not report any agitation. The TD also stated RN-A would call and report that the facility was asking for increased medications to manage agitation and RN-A reported P1 was not assessed to be agitated according to the assessment from RN-A. The TD stated it was expected that RN-A ensured the medical director was aware they were not seeing any behaviors in P1. The TD further stated the multiple medication changes very much felt to be ";facility driven." TD further explained they generally only use lorazepam for end-of-life agitation and that should have been explained to the AL facility to ensure it was not being used as a maintenance medication due to the medication causing an increased risk for falls. During an interview on 11/20/24 at 2:17 p.m., P1s provider and medical director (MD) stated it was not uncommon for AL facilities to struggle with taking care of patients who were restless or agitated, stating they either ";cant or dont have the patience" to properly manage them. The MD stated he only had the nurses assessment of P1 to go off and had he known P1 was receiving PRN Lorazepam he would not have increased the second benzodiazepine (clonazepam), stating the PRN Lorazepam should have only been used for end-of-life agitation and he would not be expecting it to be administered to P1. MD confirmed he was unaware that P1 was receiving any lorazepam and was concerned that he was getting it daily, stating it would be a fall risk to have P1 taking Lorazepam daily along with his scheduled clonazepam. MD stated prescribing the second anti-psychotic (Haldol) was not something he agreed with but did it because the facility was continually asking for medications to control P1s agitation. MD stated he was unaware P1 was not displaying behaviors during the hospice nurse visits, and was unaware the reports of behavioral symptoms were from the facility staff and were not based off the hospice nurse assessments. During an interview on 11/20/24 at 2:40 p.m., P1s pharmacist (P)-A stated P1 was consuming ";a lot" of highly sedative medications and stated with a diagnosis of Alzheimer's disease, benzodiazepines are often contraindicated because they can lead to increased confusion and agitation. P-A also stated concern with P1's high dose of morphine and stated she would have liked to see a decrease in P1s benzodiazepines or anti-psychotics with a morphine dose that high. P-A further stated P1s medications put him at a high fall risk due to them being highly sedative, stating generally with older adults Seroquel is preferred over olanzapine and lorazepam is preferred over clonazepam as they are less sedating. During an interview on 11/20/24 at 2:52 p.m., the hospice director of nursing (DON) stated the indication for the lorazepam order in P1s EMR was missing the word ";terminal" from an indication of use for terminal agitation and the indication was instead listed as only "agitation/restlessness" which could have led to the confusion of it being used as a maintenance medication by the AL facility. The DON further stated it would be expected that the hospice team had objective assessments and reasonings on why P1s medications were increased or changed based on symptoms observed by the hospice, not solely based on what the AL facility was reporting. The DON further stated she was not aware of the incident on 7/5/24 when P1 intentionally received two anti-psychotic medications that were not prescribed to him until that day's interview on 11/20/24. The immediate jeopardy that began on 7/5/24, was removed on 11/26/24, upon verification of implementation of the removal plan and when the facility provided education to all staff on serious adverse event reporting, abuse reporting, and incident reporting prior to returning to work for their next shift and provided education to all licensed staff (registered nurse case managers, licensed practical nurses, nurse practitioners, medical providers and the medical director) on the following policies; Comprehensive Assessment Policy, Ongoing Assessment Policy, Pain Assessment Policy, Identification, Prevention, and Treatment of Secondary Symptoms Policy, Monitoring Patient's Response/Reporting to Physician Policy, Medication Monitoring Policy, Safe/Effective Use of Medication Policy, and Provision of Care to Residents of SNF/NF (skilled nursing facility/nursing facility).

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. In 3 of 23 (13%) clinical records reviewed, the hospice did not ensure that the Interdisciplinary Group completed the comprehensive assessment within five (5) calendar days after the election of hospice care. Clinical Record 9: The patient elected the hospice benefit on 5/5/23. The need for a spiritual care assessment was documented in the comprehensive assessment. The chaplain completed the initial spiritual assessment on 5/12/23, seven (7) days after the election of hospice care. Clinical Record 15: The patient elected the hospice benefit on 4/20/23. On 4/27/23, the chaplain documented that the visit was “not in my schedule until today.” The chaplain completed the initial spiritual assessment on 4/28/23, eight (8) days after the election of hospice care. On 5/1/23, the Medical Social Worker (MSW) documented the visit was “added to my schedule late.” The MSW completed the initial psychosocial assessment on 5/1/23, eleven (11) days after the election of benefits. Clinical Record 20: The patient elected the hospice benefit on 3/14/23. The MSW completed the initial psychosocial assessment on 3/20/23, six (6) days after the election of hospice care. During an interview on 7/17/23, the Vice President (VP) of Clinical Operations confirmed this finding.