Every finding on record at Odyssey Healthcare Operating A, LP

Upon patient record review, 1 of 14 (Patient #2) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient#2: Upon review it was noted that the agency medication record did not match the SNF MAR. Both contained Breztri aerosphere inhalation 160-9-4.8. However, the agency medication record indicates the medication is administered 2 puffs twice a day. The facility MAR list this medication to be administered 1 puff daily.

Upon patient record review, 3 of 14 (Patient #1,#2,#6) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient#1: Upon record review, it is documented that patient had a wound to left heel from 7/23/24 until 9/10/24. There is no evidence of wound measurements the week of 8 /18, 8/25, 9/1/24. It is the policy of the agency for wound measurements to be completed weekly. Patient#2: Upon record review, it is documented that patient had a wound to buttocks from 5/16/25 until 6/24/25. There is no evidence of measurements for this wound the week of 5/18/25, 5/25, or 6/8. It is the policy of the agency for wound measurements to be completed weekly. Patient#6: Upon record review, it is documented that the aide reports noting a spot to the patients left big toe. She also notes that the facility LVN stated this was new. There is no evidence of any follow up that this was addressed.

Upon patient record review, 1 of 14 (Patient #8) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient#8: Pre-bereavement risk assessment was completed by the MSW on 11/12/25 was scored as high. No evidence that the bereavement care plan was updated to reflect the caregivers needs.

Upon client record review, 1 of 14 (Patient #2) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient#2: Upon review it is documented that volunteer plan of care was to begin on 3/12/25 1 x week tuck in calls. There are missed visit notes in the record for 3/21/25, 3/28, 4/5, and 4/11 stating visit missed due to volunteer unavailable. No evidence that the visits were missed due to patient/caregiver refusal or that an order was placed to change the visit frequency for the week. This patient was a home patient at the time of these visits.

Upon patient record review 1 of 14 (Patient #8) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Patient#8: Pre-bereavement risk assessment was completed by the MSW on 11/12/25 was scored as high. No evidence that a follow-up was completed or that anything was done to start supporting the high risk person at the time that the need was identified.

Upon patient record review, 1 of 14 (Patient #5) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient#5:Upon record review, the aide plan of care indicates patient to get a shower at each visit. Aide documents on 1/15/25, 1/20, 1/22, 1/29, and 2/3 that patient refused the shower. The aide documents that she contacted the RN and received verbal to give a bed bath which the patient accepted. There is no evidence that the RN followed up to address the patient needs and update the plan of care appropriately.

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. The agency had a volunteer utilization rate of 2.6% for 2025.

Upon patient record review 2 of 11 (Patient #3, 11) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient #3 The patient was admitted on 5/25/22, there is an order for spiritual care assessment, the services were declined in a phone call on 5/27/22, the spiritual care assessment was completed on 12/27/22 by the SW. Patient #11 The patient was admitted on 9/15/22, spiritual care services were declined, the spiritual care assessment was completed on 11/28/22 by the SW.

Upon patient record review, 2 of 11 (Patient #2, 7) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #2 The record indicates that the patient took Pepto-Bismol during a visit on 8/20/22, the medication was not listed on the medication profile during that time. Patient #7 The medication profile contains order for Beano 400 unit tablet, 2 tablets as needed for indigestion, it does not include a frequency of dosing. The medication profile contains an order for Pepto-Bismol 30ml by mouth as needed for gas, it does not include a frequency of dosing.

Upon patient record review, 1 of 11 (Patient #1) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient #1 Patient was admitted on 12/20/22, the initial bereavement assessment was completed on 12/28/22.

Upon patient record review, 2 of 11 (Patient #2, 7) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #2 The record indicates that the patient was given Pepto-Bismol for complaints of nausea/vomiting on a visit 8/20/22, there was no order received for the use of pepto-bismol in the patient record. Patient #7 The records indicates an order on 1/27/23 for Beano 400 unit, 2 tabs by mouth as needed per OTC package instructions. The order does not include a frequency of dosing. The records includes an order on 1/27/23 for Pepto-Bismol 30ml by mouth as needed per OTC package instructions. The order does not contain a frequency of dosing.

Upon client record review, 1 of 11 (Patient #8) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #8 The plan of care includes an order for "Physical Therapy: Evaluate and Treat" on 4/26/22, no evidence this evaluation was completed.

Upon patient record review, 1 of 11 (Patient #2) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #2 There is evidence in the patient record of decline, including bed bound status on or around 1/4/23, the hospice aide care plan was not updated and indicates that the patient was to receive a shower.

Upon patient record review, 1 of 11 (Patient #6) did not have evidence that the hospice provided the following information: • The most recent hospice plan of care specific to each patient • Hospice election form and any Advance Directives specific to each patient • Physician certification and recertification of the terminal illness specific to each patient • Names and contact information for hospice personnel involved in hospice care of each patient • Instructions on how to access the hospice's 24-hour on-call system • Hospice medication information specific to each patient • Hospice physician and attending physician (if any) orders specific to each patient Patient #6 During the home visit at the SNF for this patient, there was no evidence that the hospice has not provided the updated recertification of terminal illness since the initial certification on 3/24/21. This was corrected during the survey.

Based on interview and record review, the hospice failed to protect and promote the patient's right to be free from mistreatment and physical abuse by an agency employee for 1 of 3 (Patient #1) patient reviewed. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 12/13/21 after approval by CMS. While the IJ was removed on 12/13/21, deficient practice was present at a condition level. This failure resulted in Patient #1 experiencing pain, discomfort, and agitation and could result in other patients experiencing physical, mental, and emotional harm from abuse. Refer to L517 Based on interview and record review, the hospice failed to protect and promote each patient's right to receive effective pain management and symptom control from the hospice for 1 of 3 (Patient #1) patient reviewed. This failure resulted in Patient #1 experiencing continuing pain and discomfort and could result in other patients experiencing pain which is not effectively managed. Refer to L512 Based on interview and record review, the hospice failed to protect and promote the patient's right to refuse care or treatment for 1 of 3 (Patient #1) patient reviewed. This failure resulted in Patient #1 experiencing pain, discomfort, and agitation and could result in other patients experiencing physical, mental, and emotional harm related to a failure of the hospice to allow patients to refuse care and treatment. Refer to L514

Based on interview and record review, the hospice failed to protect and promote each patient's right to receive effective pain management and symptom control from the hospice for 1 of 3 (Patient #1) patient reviewed. This failure resulted in Patient #1 experiencing continuing pain and discomfort and could result in other patients experiencing pain which is not effectively managed. The findings included: Record review of the clinical record for Patient #1 indicated the patient had a start of care date with the hospice of 10/19/17 and indicated the patient had a primary diagnosis of Alzheimer's disease. Record review of the clinical record for Patient #1 included a Hospice POC Report, not dated, which indicated the patient had an identified problem of altered comfort. The Hospice POC Report indicated the patient had a skilled nursing need for observation and assessment of altered comfort. The Hospice POC Report indicated the skilled nurse would implement the following intervention: Monitor pain level using the appropriate pain scale. Record review of a physician's order, dated 09/17/21, indicated the client had the following medications ordered for pain: Gabapentin 300 mg three times a day by mouth; Hydrocodone 5mg/Acetaminophen 325 mg four times a day at 8:00 a.m., 12:00 p.m., 4:00 p.m., and 8:00 p.m. by mouth; Morphine Concentrate 100mg/5ml solution 1ml as needed [no other frequency is included] by mouth; and MS Contin 30 mg tablet, extended release, once a day at bedtime by mouth. Record review of a physician's order, dated 11/12/21, indicated the client had the following medications ordered for pain: Gabapentin 300 mg three times a day by mouth; Hydrocodone 5mg/Acetaminophen 325 mg four times a day at 8:00 a.m., 12:00 p.m., 4:00 p.m., and 8:00 p.m. by mouth; Morphine Concentrate 100mg/5ml solution 1ml as needed [no other frequency is included] by mouth; and MS Contin 30 mg tablet, extended release, once a day at bedtime by mouth. Record review of the clinical record for Client #1 indicated the client refused medications at times. Record review of the clinical record for Client #1 indicated the client did not have pain medication ordered via a route other than oral until 11/30/21. Record review of the clinical record for Patient #1 included skilled nurse's notes, for the dates of 09/20/21, 09/27/21, 10/04/21, 10/11/21, 10/18/21, 10/25/21, and 11/08/21, which indicated Patient #1's pain was rated at a 0 on these visits. Record review of the clinical record for Patient #1 included a skilled nurse's note, dated 11/03/21, signed by the RN D, which indicated the skilled nurse did not complete a comprehensive pain assessment, including use of a pain scale during this visit. There was no documentation to indicate if the patient was having pain during this visit. Record review of the clinical record for Patient #1 included a skilled nurse's note, dated 11/12/21, signed by the administrator/supervising nurse, which indicated the skilled nurse did not complete a comprehensive pain assessment, including use of a pain scale during this visit. The note indicated, "No acute distress at thisvtime (sic)." Record review of the clinical record for Patient #1 included a skilled nurse's note, dated 11/15/21, signed by the administrator/supervising nurse, which indicated the skilled nurse did not complete a comprehensive pain assessment, including use of a pain scale during this visit. The note indicated, "Patient denies pain or discomforts (sic)." Record review of the clinical record for Patient #1 included a skilled nurse's note, dated 11/18/21, signed by the administrator/supervising nurse, which indicated the skilled nurse did not complete a comprehensive pain assessment, including use of a pain scale during this visit. The note indicated, "No non-verbal S/S of pain noted." Record review of the clinical record for Patient #1 included an on-call nursing note, dated 11/21/21, signed by the RN H, which indicated the hospice's on-call nurse, the RN H, received a call from the ALF where Patient #1 resides reporting the patient fell out of bed to the floor with complaint of pain to her groin. The note indicated the call was received at 12:59 a.m. The note further indicated on 11/21/21 at 9:05 a.m. the hospice on-call nurse made a follow-up phone call with ALF staff. The note indicated the ALF staff reported the patient was still having pain but was refusing pain medication. The note indicated the patient reported she hurt from her head to her toes and was unable to be specific. The note indicated the patient's left groin/ left leg were in question and indicated no difference in size/length of legs and no internal or external rotation were noted. The note indicated no discoloration to the legs was noted. The note indicated the hospice on-call nurse advised the ALF to monitor the patient and notify the hospice of any changes. Record review of the clinical record for Patient #1 did not include documentation to indicate the hospice nurse conducted a visit with Patient #1 to assess the patient following the fall and complaint of pain on 11/21/21 or to indicate the physician was notified of the fall or complaints of pain on this date. Record review of the clinical record for Patient #1 included a skilled nurse's note, dated 11/22/21, signed by the administrator/supervising nurse, which indicated a comprehensive pain assessment, including use of the visual pain scale, was conducted during this visit. The note indicated the patient's pain during this visit was rated at a 4 - hurts a little more (the scale measures pain from no pain, hurts a little, hurts a little more, hurts even more, hurts a whole lot, hurts worst). The note further indicated, "Patient had falls over the weekend and some facial grimacing during assessment." Record review of the clinical record for Patient #1 did not include documentation to indicate the skilled nurse notified the physician of the falls over the weekend or the patient's complaint of pain during this visit. Record review of the clinical record for Patient #1 included a skilled nurse's note, dated 11/23/21, signed by the administrator/supervising nurse, which indicated a comprehensive pain assessment, including use of the pain scale for the cognitively impaired, was conducted during this visit. The note indicated the patient's pain during this visit was scored a 1 for displaying the following behaviors: occasional labored breathing, short period of hyperventilation, occasional moan or groan, low-level speech with negative or disapproving quality, sad and/or frightened facial expression or frown, tense body language with distressed pacing and/or fidgeting. The note further indicated, "Patient had a fall last night and has some facial grimacing during assessment." Record review of the clinical record for Patient #1 did not include documentation to indicate the skilled nurse notified the physician of the fall or the patient's signs of pain during this visit. Record review of the clinical record for Patient #1 included a hospice aide visit note, dated 11/24/21, signed by the hospice aide F, which indicated, "Pt is harder to transfer due to her left hip & thigh hurts when she puts her weight on it. It is from the recent falls she has had. ---------------- (name of the administrator/supervising nurse) RN administrator notified." Record review of the clinical record for Patient #1 included a skilled nurse's note, dated 11/24/21, signed by the RN D, which indicated a comprehensive pain assessment, including use of a pain scale, was not conducted during this visit. The note indicated, "On call visit ... patient requesting to go to hospital due to pain in hip." The note indicated the nurse advised the ALF to medicate the patient for pain and upon the nurse's arrival the patient's pain was improved and she was assisted back into bed. Record review of the clinical record for Patient #1 did not include documentation to indicate the skilled nurse notified the physician of the patient's complaint of pain or request to be transferred to the hospital due to the pain in her hip on this date. Record review of the clinical record for Patient #1 included a patient coordination note, dated 11/26/21, which indicated, "Received a call from ------------- (name of the ALF where Patient #1 resides), Patient is in pain. Stated patient is in bed sleeping but wanted to let us know she has been in pain. I [hospice nurse] asked if she was currently comfortable stated yes, but she [ALF staff member] knows the client likes to be around in her wheelchair and she could not get up this evening because of pain." Record review of the clinical record for Patient #1 included a hospice aide visit note, dated 11/26/21, signed by the hospice aide F, which indicated, "I arrived & Pt was sitting on her sofa. She said she needed me to help her to the restroom, but she would not allow me to transfer her to the wheelchair because she has somuch (sic) pain in her left hip & side. I called for an aide to help me & she still would not allow us to get her up off of the sofa. She started yelling help & get away, leave me alone, so she refused bath & all care. ------------- (name of the administrator/supervising nurse) RN administrator notified." Record review of the clinical record for Patient #1 included a skilled nurse's note, dated 11/29/21 (9 days after the patient first began consistently complaining of pain to her left hip/leg/side area), signed by the administrator/supervising nurse, which indicated a comprehensive pain assessment, including use of a pain scale, was not conducted during this visit. The note indicated, "Spoke with ----------- (name of an ALF employee) about patients (sic) care, she states patient has not been consistent on taking her routine medication and will frequently c/o pain and then not open her mouth to take the pain medication. Spoke with ---------- (name of the physician for Patient #1, the medical director E) about patient status, discussed switching patient to Fentanyl patch for more effective pain control, call placed to patients (sic) --------- (family member) to ask if he approves of medication change with no answer to phone call. Message left." Record review of the clinical record for Patient #1 included a skilled nurse's note, dated 11/30/21, signed by the RN D, which indicated a comprehensive pain assessment, including use of a pain scale, was not conducted during this visit. The note indicated, "States she hurts all the time ... CM is changing her medication to Fentanyl patch for consistent pain control." Record review of the clinical record for Patient #1 included a patient coordination note, dated 12/08/21, as a late entry for 11/30/21, which indicated the patient's family member returned the hospice's phone call regarding medication changes. The note indicated the patient's family member was reluctant to change the patient's medications because the last time she was prescribed Fentanyl she became very drowsy. The note indicated the patient's family member agreed to the medication changes but requested the patient be started at the lowest dose. Record review of the clinical record for Patient #1 indicated Patient #1 was started on a Fentanyl patch at 25 MCG/HR one patch to be applied every 72 hours on 11/30/21. Record review of the clinical record for Patient #1 did not include documentation to indicate the hospice had attempted to contact Patient #1's family member prior to 11/29/21 to discuss changing her pain medications. Record review of the clinical record for Patient #1 included a hospice aide visit note, dated 12/01/21, signed by the hospice aide F, which indicated, "Pt is complaining of pain when she puts weight on her left leg. She says it hurts up in her left abdomen & left side of hip & the pain goes down her left leg ... ---------- (name of the administrator/supervising nurse) RN administrator notified." Record review of the clinical record for Patient #1 included a social worker visit note, dated 12/02/21, signed by the social worker G, which indicated the patient was "uncomfortable because of pain." The note indicated the social worker G notified the RN D regarding the patient's complaint of pain during this visit. The note further indicated, "Patient complained of pain in her left leg. Social worker talk (sic) to med aide [ALF medication aide] who said she has her Fentanyl patch and she gave her some morphine earlier, said it does not always cure for pain." Record review of the clinical record for Patient #1 included a skilled nurse's note, dated 12/02/21, signed by the RN D, which indicated a comprehensive pain assessment, including use of the verbal pain scale, was conducted during this visit. The note indicated the patient rated her pain during this visit as a 7-8, hurts a whole lot. The note indicated the patient reported her pain in the last 24 hours as severe pain. The note indicated the patient reported her acceptable pain level would be mild pain. The note indicated the patient reported the pain was to her left hip. The note further indicated, "Patient states she hurts on her left side ... she is unable to get out of bed without maximal lift assist to chair. Patient is aware of this change. She states she is in pain." Record review of the clinical record for Patient #1 did not include documentation to indicate the skilled nurse notified the physician of the patient's complaint of pain during this visit. Record review of the clinical record for Patient #1 included a skilled nurse's note, dated 12/04/21, signed by the RN D, which indicated a comprehensive pain assessment, including use of a pain scale, was not conducted during this visit. The note indicated, "Patient reports that she has pain always and cannot walk or sit in chair because of pain." Record review of the clinical record for Patient #1 did not include documentation to indicate the skilled nurse notified the physician of the patient's complaint of pain during this visit. Record review of the clinical record for Patient #1 included a skilled nurse's note, dated 12/06/21 (16 days after the documentation shows the patient began consistently complaining of pain to the left hip/leg/side area), signed by the administrator/supervising nurse, which indicated, "Patient continues to be in pain dispite (sic) medication, pain medication adjustments to be made." The note indicated a comprehensive pain assessment, including use of the pain scale for the cognitively impaired, was completed during this visit. The note indicated the patient's pain during this visit was scored a 6 indicating moderate pain. The note indicated the patient demonstrated the following signs of pain: occasional labored breathing and/or short periods of hyperventilation, repeated trouble calling out, loud moaning or groaning, crying, sad and/or frightened facial expression and/or frown, and tense body language, distressed pacing and/or fidgeting. The note further indicated, "Staff from ------------ (name of the ALF where Patient #1 resides) had notified hospice this morning that patient was still having pain to the left leg. ------------- (name of the medical director E) notified and xrays ordered ... During xrays ... patient moaning and showing facial grimacing ... Upon receiving final report, SN called results to ------------ (name of medical director E) and patient --------- (family member). Xrays showing fracture to left femoral neck into greater trochanter ... Son agreed to increased (sic) medication for pain." Record review of the clinical record for Patient #1 included a physician's order, dated 12/06/21, which indicated the physician ordered to increase the Fentanyl patch from 25 to 50 MCG and increased the morphine to 1 ml every 2 hours as needed for pain. Record review of the clinical record for Patient #1 indicated the previous order for morphine indicated the patient was to receive morphine 1ml as needed but did not include a frequency, such as every two hours. Record review of the clinical record for Patient #1 included a skilled nurse's note, dated 12/08/21, signed by the administrator/supervising nurse, which indicated during this visit the patient rated her pain as a 2 - hurts a little bit. The note indicated, "Patient is more alert this visit ... Patient smiles at SN and appears relaxed. No s/s non-verbal or verbal during this visit." During an interview conducted on 12/09/21, from 10:48 a.m. - 11:54 a.m., the RN D said she was a case manager with the hospice. The RN D said the administrator/supervising nurse is Patient #1's case manager. The RN D said she [RN D] was on-call on 12/04/21. The RN D said she received a call from the on-call service on 12/04/21 regarding Patient #1 indicating the patient's oxygen saturation levels were low. The RN D said when she arrived, she proceeded through the patient's apartment to her bedroom and found the patient on the floor. The RN D said she did not do an assessment or get the patient's vital signs until after the patient had been assisted back into bed. The RN D said the patient was complaining of pain while she was on the floor. The RN D said the patient has been complaining of pain to her left side and this was not a new complaint. The RN D said she was not sure when the patient had begun complaining of the pain to the left side and said the patient had multiple falls and while the complaint began after one of the falls she was not sure which fall. The RN D then said the patient had not complained of pain while on the floor but only complained of pain after she was in the bed. The RN D said she was speaking with the patient once she was in bed and the patient said she was hurting. The RN D said she could not recall if the patient stated verbally the location of her pain or indicated it with her hand, but the patient indicated she was having pain to her left hip. The RN D said the patient was not able to rate her pain using a 1-10 numerical scale. The RN D said the hospice did use a non-numerical scale for patients who were unable to use the numerical scale, but she did not ask the patient to rate her pain during the visit on 12/04/21. The RN D said the only indication she had regarding whether the patient's pain was improved, worsened, or the same by the end of the visit was that the patient appeared more comfortable and relaxed and was falling asleep. The RN D said she did not ask the patient if her pain was improved. The RN D said she did not get the patient's vital signs and didn't complete a full assessment. The RN D said the patient was breathing ok, and as far as she could tell the patient's leg was not rotated or shortened. The RN D said she did not manually move anything but just did a visual assessment and everything looked like it lined up ok. The RN D said she didn't try to move the leg to assess it. The RN D said she did not do a full skin assessment. The RN D said the patient had an abrasion on her knee, but it didn't look new. The RN D said the patient had experienced multiple previous falls. The RN D said she did not examine the patient's leg for injuries. The RN D said she did assist the ALF staff to change the patient's clothes and while they were doing this, she did look at the patient. The RN D said she did not go back and do an assessment after this. The RN D said she didn't do any physical manipulation of the patient's body to assess the patient but she did observe as the patient was changed which required pulling her up in bed and rolling her from side to side. The RN D said the patient's pain did not seem worse during this visit than previously to her. The RN D said it was difficult to tell with the patient. The RN D said the patient didn't cry out when they were changing her, but she kept grabbing things because she was afraid of falling. The RN D said the patient's only reaction was grabbing people or things due to her fear when they rolled her to the edge of the bed that she would fall. The RN D said she did contact the administrator/supervising nurse after the visit and sent a text to the medical director E reporting the patient had a fall with no apparent injuries. The RN D said no new orders were received. The RN D said she did not contact the patient's family as she assumed the ALF would do this. The RN D said she normally does not contact the families and usually would just notify the physician. The RN D said the medical director E did respond and said, ok. The RN D said she called the administrator/supervising nurse as she was this patient's case manager and told her the patient had been found soaked in urine and had fallen. The RN D said the administrator/supervising nurse did not give her any additional tasks to do regarding the patient. The RN, D, said the patient routinely refuses her medications from the ALF and this is the reason she is on a Fentanyl patch. Record review of a written statement, dated 12/07/21, signed by RN, D, indicated on 12/04/21 the RN, D, received a call from the ALF where Patient #1 resides reporting the patient's oxygen saturation level was low. The written statement indicated the RN, D, made a visit to the patient and indicated during the visit the patient was found on the floor and during the visit said her hip hurt. During an interview conducted on 12/09/21 at 2:26 p.m., with Patient #1, the patient was unable to answer questions about the hospice. The patient was observed to be calm. The patient was observed to touch her left leg and try to tell the surveyor something, but the surveyor was not able to make out what she was attempting to say. During an interview conducted on 12/09/21 at 2:28 p.m., the ALF medication aide L said on 12/04/21 the ALF medication aide M got a call from the hospice nurse, the RN D, who said Patient #1 was on the floor. The ALF medication aide L said when she and the ALF medication aide M arrived at the patient's room the hospice nurse, the RN D, had put the patient back into the bed. The ALF medication aide L said the ALF's policy is that they are supposed to get the patient's vital signs before picking the patient up off the floor. The ALF medication aide L said the patient was complaining of pain to her left side and she appeared to be in pain. The ALF medication aide L said she and the ALF medication aide M went to get pain medication for the patient. The ALF medication aide L said the ALF medication aide M attempted to give the patient the medication, but the patient moved her head away. The ALF medication aide L said the hospice nurse, the RN D, tried to hold the patient's head still and tried to force it in the patient's mouth. The ALF medication aide L said the medication they attempted to administer to Patient #1 was morphine and it was in a syringe. The ALF medication aide L said the ALF medication aide M put the syringe near the patient's mouth and the patient pulled her head away. The ALF medication aide L said because of this the ALF medication aide M gave up on trying to administer the medication. The ALF medication aide L said the hospice nurse, the RN D, then tried to administer the medication. The ALF medication aide L said the hospice nurse, the RN D, held the patient by her jaw and tried to put the medication in her mouth. The ALF medication aide L said the syringe was a couple of inches from the patient's mouth and the hospice nurse, the RN D, was trying to put the medication in the patient's mouth. The ALF medication aide L said the patient turned her head away or tried to but was unable because the hospice nurse, the RN D, was holding her head. The ALF medication aide L said when the patient tried to turn her head away the medication went half-way into her mouth and the rest got on the side of her mouth. The ALF medication aide L said the hospice nurse, the RN D, did not say anything to the patient about the medication to tell her what she was doing or ask her if she wanted it. The ALF medication aide L said the patient was in pain and she could see that the patient was in pain. The ALF medication aide L said the ALF staff asked the hospice nurse, the RN D, about getting an x-ray for the patient and the hospice nurse, the RN D, said she thought the patient only needed rest and pain medication. The ALF medication aide L said, however, the patient had refused the pain medication. The ALF medication aide L said it didn't seem like the hospice nurse cared. The ALF medication aide L said this was the first time she had seen the patient complain of pain like that. The ALF medication aide L said she thought the patient was in a lot of pain and said the patient usually doesn't complain of pain. During an interview conducted on 12/09/21 at 2:36 p.m., the ALF caregiver N said on 12/04/21 she was in the dining room at the ALF when Patient #1's light went off. The ALF caregiver N said when she got to the patient's room the patient was in bed. The ALF caregiver N said the ALF medication aides were trying to get the patient's vital signs but were unable to do so. The ALF caregiver N said the patient said her hip hurt, her hip hurt, and was complaining about it and yelling. The ALF caregiver N said it seemed like the hospice nurse wanted to leave. The ALF caregiver N said the patient doesn't complain of pain a lot and said the patient had never complained to her of pain. The ALF caregiver N said the whole time the patient was complaining and said usually when the patient says something is hurt something is hurt. During an interview conducted on 12/09/21 at 2:44 p.m., the ALF medication aide M said on Saturday 12/04/21 at around 12:45 to 12:50 p.m., she got a call from the hospice nurse, the RN D, saying Patient #1 had fallen. The ALF medication aide, M, said she asked the RN D, if she had gotten the patient's vital signs and asked her not to move the patient because the ALF's policy is for the staff to make sure the patient is in a somewhat comfortable position, get the patient's vital signs, ask the patient if they have any injuries or are hurt anywhere, and then notify the ALF's on-call medical staff before getting the patient up. The ALF medication aide M said she was just down the hall and was there in minutes, quickly, and as soon as she walked into the patient's room the RN D said she had put the patient in the bed. The ALF medication aide M said the patient was crying and she had never seen her cry before. The ALF medication aide M said the patient was begging to go to the hospital. The ALF medication aide M said the patient said her side hurt and was touching her hip indicating her hip was hurting. The ALF medication aide M said the patient refused vital signs when she tried to take them and asked her if she could send her to the hospital. The ALF medication aide M said she told the patient she did not have that authority, but the hospice nurse could make that decision. The ALF medication aide M said the hospice nurse, the RN D, said nothing could be done. The ALF medication aide M said it was not like the patient to even be crying. The ALF medication aide M said in the almost year she had worked at the ALF she had never heard the patient ask to go to the hospital before or ask for help or act like she did that day. The ALF medication aide M said the patient will sometimes complain of pain or make a crying sound, but she doesn't cry tears and, on this date, (12/04/21) the patient was crying tears. The ALF medication aide M said she could tell this was different from the patient's usual behavior. The ALF medication aide M said the patient specifically said she wanted to go to the hospital. The ALF medication aide M said she did not see the RN D assess the patient's leg or hip and said the RN D, said nothing could be done. The ALF medication aide M said she told the RN D there was something wrong and said the patient was crying and crying which was unusual for her. During an interview conducted on 12/10/21 at 10:02 a.m., the RN H said the weekend of 11/21/21 was her first-time taking call for the hospice. The RN H said she was assisting the hospice that weekend by taking call as the hospice had a nursing staff shortage. The RN H said Patient #1 had two falls on 11/21/21. The RN H said after the first fall on 11/21/21 there were no injuries. The RN H said after the second fall the patient was complaining of pain to the left groin/leg but no signs or symptoms of injuries were noted and the patient was able to move and just had some discomfort which was to be expected after the number of falls that weekend. The RN H said she did not notify the patient's physician regarding the falls or complaints of pain on this date because she didn't know who the physician was. The RN H said this was her first time working at this hospice and said there was a hiccup as she was not assigned to any patients and could not review their records in the electronic medical record at first. The RN H said she let the administrator/supervising nurse and her bosses at her primary agency know and the issue was corrected. The RN H said she believed she was able to access the patient records by 11/21/21 from her laptop but said she still couldn't get to all the information from her tablet which is where she knew how to do things. The RN H said she did notify the administrator/supervising nurse of the falls and she was sure of this because she was unable to do an occurrence report regarding the falls and usually she would do one so she contacted the administrator/supervising nurse who said she would do this. During an interview conducted on 12/10/21 at 10:14 a.m., the social worker G said on 12/02/21 she called the RN D to report the patient's complaints of pain and that the ALF staff said the pain medications were not always effective. The social worker G said the patient's family member can be very difficult to get a hold of and said she knew they had been trying to reach him regarding this, but it was several days before he called back. During an interview conducted on 12/10/21 at 10:30 a.m., with the hospice aide F when presented with the findings regarding Patient #1 which indicated the patient had a change in the amount of pain she experienced and in her functional status beginning on or around 11/21/21, the hospice aide F said this was correct. The hospice aide F said the patient became harder to transfer around this time and said previously the patient had been able to help more but she could tell it was a lot harder for the patient. The hospice aide F said around this time the patient had experienced several falls. The hospice aide F said the patient was consistently complaining of pain to the left hip/leg/side area. The hospice aide F said on 11/26/21 the patient was sitting on the sofa in living room and said she needed to go to the bathroom but when she went to assist her up the patient began crying and holding her side like she was in pain. The hospice aide F said she pulled the call light for assistance but when the ALF aide came to assist her the patient would not allow them to assist her. The hospice aide F said she had notified the RN of the patient's complaints of pain. The hospice aide F said she couldn't recall the exact dates but around 12/06/21 - 12/07/21 the patient had refused care. The hospice aide F said on one visit the patient held onto her blanket and wouldn't even let her check to see if she had been incontinent and needed to be changed. The hospice aide F said the patient had a scared look on her face during this visit. During an interview conducted on 12/10/21 at 10:43 a.m., the RN D said she could not recall if she notified the physician of Patient #1's complaint of pain and request to go to the hospital on 11/24/21. The RN D said she could not recall if she notified the administrator/supervising nurse, Patient #1's case manager, of the patient's complaint of pain and request to go to the hospital o n 11/24/21. The RN D said she could not recall if she notified the physician or the administrator/supervising nurse regarding the ALF's report that Patient #1 was unable to get up in her wheelchair due to pain on 11/26/21. The RN D said she could not recall if she notified the physician or the administrator/supervising nurse of Patient #1's complaint of pain on 12/02/21. The RN D said the patient had multiple falls and had an increase in pain around that time. The RN D said the patient often refused medications from the ALF staff. The RN D said they changed the patient's pain medications from oral medications to a Fentanyl patch around this time. The RN D said she texted the physician that the patient had a fall with no injuries regarding the visit on 12/04/21. The RN D said her process for completing pain assessments depends on how well the patient can vocalize. The RN D said if the patient was able to use the numerical scale she would use this and said if the patient was not able to do this, for example Patient #1, she would use the scale that says it hurts a little, hurts a lot, hurts a whole lot. The RN D said if she documented that no comprehensive pain assessment was completed during a visit it was because the patient wasn't complaining of pain. During an interview conducted on 12/10/21 at 1:30 p.m., the administrator/supervising nurse said she couldn't be 100% sure that the physician was notified of the patient's falls and complaint of pain on 11/21/21. The administrator/supervising nurse said it was the responsibility of the on-call nurse to notify the physician. When presented with the findings indicating the on-call nurse had reported she did not contact the physician but had notified the administrator/supervising nurse, the administrator/supervising nurse said she (the administrator/supervising nurse) did not notify the physician of the falls or the patient's complaint of pain on this date. The administrator/supervising nurse said the physician was probably not notified of the patient's complaint of pain on 11/22/21 because the pain on that date was generalized soreness and the patient was not super specific about the location of the pain. The administrator/supervising nurse said she was not sure if the physician was notified of the patient's fall and complaint of pain on 11/23/21. The administrator/supervising nurse said she was not sure if the physician was notified of the patient's request to go to the hospital due to her pain on 11/24/21. The administrator/supervising nurse said she had read the nurse's note for this visit and it doesn't say. The administrator/supervising nurse said she was not sure if the physician was notified that the patient was unable to get up to her wheelchair or that the patient had refused hospice aide services on 11/26/21 due to complaints of pain. The administrator/supervising nurse said Patient #1's family member was called regarding the patient's pain prior to 11/29/21. The administrator/supervising nurse said the family member was called several times and several messages were left. The administrator/supervising nurse said the patient's family is very particular with what he will allow for the patient's care. The administrator/supervising nurse said she would have to ask to determine if the physician was informed of the patient's complaint of pain on 12/01/21. The administrator/supervising nurse said she did not know if the patient's complaint of pain, her pain medications not always being effective, and her need for additional assistance and decreased functional status were reported to the physician on 12/02/21. The administrator/supervising nurse said she would look to see if the physician was notified of the patient's complaint of pain on 12/04/21. The administrator/supervising nurse said there is always room to improve and she thought the hospice could do a better job of ensuring documentation of coordination of care with family members and the physician was included in the clinical record. The administrator/supervising nurse said Patient #1's family member usually does not want aggressive treatment or surgery for the patient and said it is difficult to get him to agree to allow the patient to go to the ER. The administrator/supervising nurse said Patient #1's plan of care didn't change that much after the x-rays were obtained and the fracture was identified. The administrator/supervising nurse said the hospice did increase the dosage of the patient's pain medications following identification of the fracture. The administrator/supervising nurse said the staff absolutely should have notified the physician of the issues identified during the investigation and documented above. The administrator/supervising nurse said the timeframe for staff to report to the physician would depend on the issue but should be reported quickly. The administrator/supervising nurse said most reports should be made the same day. The administrator/supervising nurse said the hospice's policy regarding documentation of coordination of care should indicate the hospice would document this in the patient's clinical record but she would have to review the written policy to determine if this was included in the policy or not. The administrator/supervising nurse said she didn't think RN D's statement that if she documented that she had not conducted a comprehensive pain assessment during a visit that this meant the patient did not have any pain on this visit was accurate based on her review of the records. The administrator/supervising nurse said in the hospice's electronic medical record system if you select, yes, to indicate the clinician is conducting a comprehensive pain assessment, the clinician can select the type of pain scale being used to conduct the assessment. The administrator/supervising nurse said she would expect the nurse to utilize a pain scale of some type to assess the patient's pain during each skilled nurse visit when the patient experienced pain. The administrator/supervising nurse said she would expect the clinician to assess a patient for injuries after a fall prior to getting the patient up to the bed from the floor. During an interview conducted on 12/10/21 at 9:31 a.m., the medical director E said she did not receive a call from the nurse regarding Patient #1` on 11/21/21. The medical director E said she did receive a call on 11/22/21 and they discussed pain medications and looked at changing her to a pain patch. The medical director E they were unable to get ahold of the patient's family member to get approval. The medical director E said she also had text messages on 11/29/21 and 11/30/21 where they were still discussing changing her medications and getting her pain under better control. The medical director E said she was never informed of the patient's request to go to the hospital due to pain on 11/24/21. The medical director E said on 12/04/21 she was notified of the fall, but she was just told the patient scraped her knee. The medical director E said on 12/06/21 they decided to do the x-rays. The medical director E said she was not notified that the ALF staff had reported the patient's pain medications were not always effective at controlling her pain. The medical director E said if she had known the patient was consistently complaining of pain to the same area and had a change in her functional status this could have affected her decisions to order additional interventions and said she might have ordered x-rays sooner if she had been notified of this information. Record review of a hospice policy titled, "Hospice Nursing Care," dated November 2020, indicated, "--------------- (name of hospice) ... nursing services will be provided in accordance with physician's order, the patient plan of care, and accepted standards of practice by or under the supervision of a registered nurse ... The hospice nurse will play a key role in easing physical and psychosocial symptoms and initiating communication with the interdisciplinary group to establish the plan of care ... Duties will include the responsibility for coordination of care, fostering communication between the patient and the interdisciplinary group ... The hospice nurse will ... report the condition of patient and family/caregiver to the attending physician, Medical Director, and interdisciplinary group on a regular basis, as well as changes in the plan of care ... The hospice nurse will ... Manage discomfort and provide symptom relief according to physician orders ... Provide an ongoing evaluation of the patient and family/caregiver response to care ..."

Based on interview and record review, the hospice failed to protect and promote the patient's right to refuse care or treatment for 1 of 3 (Patient #1) patient reviewed. This failure resulted in Patient #1 experiencing pain, discomfort, and agitation and could result in other patients experiencing physical, mental, and emotional harm related to a failure of the hospice to allow patients to refuse care and treatment. The findings included: Record review of a self-reported incident, reported by the hospice administrator/supervising nurse, to HHSC, on 12/07/21, indicated the administrator of the ALF where Patient #1 resides reported to the hospice administrator/supervising nurse on 12/06/21 an allegation that on 12/04/21 the hospice RN D had grabbed Patient #1's face and forced her to take medication and had held the patient's arm down while obtaining vital signs. Record review of the hospice's complaint/incident documentation for the incident with Patient #1 on 12/04/21 indicated the administrator of the ALF contacted the hospice on 12/06/21 at 10:30 a.m. and reported two ALF employees were reporting on 12/04/21 at 12:30 p.m. they witnessed the hospice nurse, the RN D, hold Patient #1's arm down while attempting to obtain vital signs and observed the RN D, grab the patient's face and attempt to force the patient to take medication. Record review of the PIR for this incident, dated 12/07/21, signed by the hospice administrator/supervising nurse, indicated Patient #1 was not able to be interviewed, indicated the RN D denied the allegations, indicated two ALF employees, a caregiver and a medication aide, reported they observed the RN D to hold the patient's arm down while ALF staff attempted to obtain her vital signs and held the patient's face and attempted to force the patient to take medication. The PIR indicated police were notified of the incident by ALF staff. During an interview conducted on 12/08/21 at 4:29 p.m., the law enforcement officer investigating this incident said he believed the RN D caused pain and harm to Patient #1 by grabbing her face to administer medications. The law enforcement officer said law enforcement would be proceeding with pressing criminal charges against the RN D due to this incident for harm to an elderly person. The law enforcement officer said he believed the witnesses at the ALF where Patient #1 resides did a good job in reporting the incident. The law enforcement officer said the ALF did have policies regarding administering medications and said what the RN D did was not by the facility's policies. During an interview conducted on 12/09/21 at 9:41 a.m., Patient #1's family member said he was notified of the incident by the ALF staff. Patient #1's family member said he is currently out of town, and travels frequently out of town, but he visits the patient at the ALF every weekend. Patient #1's family member said he visited the patient on 12/04/21 but was not present at the time the incident occurred. Patient #1's family member said he has not seen the client since 12/04/21. Patient #1's family member said he was told the ALF had contacted the hospice nurse on that weekend and said the nurse who made the visit on 12/04/21 was not the patient's regular nurse but was the weekend nurse. Patient #1's family member said the hospice nurse told the ALF attendant to give the patient morphine for breakthrough pain, but the client resisted. Patient #1's family member said he was told the hospice nurse grabbed the patient by the face, forced open her mouth, and forced the medication into the patient's mouth. Patient #1's family member said the patient ended up spitting the medication out. Patient #1's family member said he was also told the hospice nurse held the patient's arm down. Patient #1's family member said the surveyor could make a visit to the patient but said she sleeps a lot and it depends on the day whether she would talk to the surveyor or not. Patient #1's family member said she probably would not be able to answer questions about the incident and probably doesn't remember it as she has issues with her memory. During an interview conducted on 12/09/21 at 10:48 a.m. - 11:54 a.m., the RN D said she was a case manager with the hospice. The RN, D, said the administrator/supervising nurse is Patient #1's case manager. The RN, D, said she [the RN D] was on-call on 12/04/21. The RN D said she received a call from the on-call service on 12/04/21 regarding Patient #1. The RN D said the ALF medication aide was trying to get the patient's vital signs but could not. The RN D said she held the patient's hand and began speaking with her in an attempt to calm her down and comfort her. The RN D said the patient obviously recognized her and she thought this might help to keep the patient still. The RN D said the patient was moving her hand around and said the patient's elbows were on the bed and the movement was from the hand not the shoulder. The RN D said she explained to the patient they were trying to get her blood pressure and told her she would be ok and tried to calm her down. The RN D said the ALF medication aide was still unable to get the patient's blood pressure. The RN D said part of the reason the ALF medication aide was unable to get the patient's blood pressure was that the patient was not being still. The RN D said she did not try to get the patient's blood pressure herself. The RN D said she was speaking with the patient and the patient said she was hurting. The RN D said she asked the ALF medication aide to give the patient morphine. The RN D said the morphine was liquid and was ordered to be given orally. The RN D said the ALF medication aide asked someone in the room (another ALF employee) to go with her and went and got the morphine. The RN D said when the ALF medication aide returned with the morphine, she [the ALF medication aide] stepped up to the patient's bed and then stepped away. The RN D said the ALF medication aide did not attempt to administer the morphine. The RN D said she then said let me see if she will take it for me. The RN D said she told the patient she had something to give her for pain and attempted to give the patient the medication. The RN D said the patient turned her face away and didn't take it. The RN D said the morphine was in a syringe. The RN D said she attempted to give the morphine by leaning over the bed and squirting it. The RN D said the patient turned her head and didn't take it. The RN D said she did not touch the patient's head or face during this process. The RN D said she didn't hold the patient's neck. The RN D said she didn't try to forcefully give the medication. The RN D said the patient had her mouth open and she tried to give the morphine. The RN D said she wasn't close enough to the patient to put the syringe in the patient's mouth because there was someone in front of her. The RN D said she just squirted the morphine and when she did the patient turned her head and didn't take it. The RN D said she didn't have the syringe in the patient's mouth. The RN D said she didn't believe the medication had gone into the patient's mouth, but she couldn't say for certain. The RN D said the patient didn't say if she did or didn't want the medication and didn't address this. The RN D said she did not ask the patient if she wanted the medication and said she told the patient she had it and was going to give it to her. The RN D said the patient routinely refuses her medications from the ALF and this is the reason she is on a Fentanyl patch. The RN D said she wouldn't have shoved the medication down the patient's throat. The RN D said she was trying to make the patient understand the morphine would help her pain. The RN D said this is the reason she was talking to the patient. The RN D said the ALF medication aide did not attempt to give the patient the morphine or ask the patient about taking the morphine. The RN D said it was obvious the patient didn't want the medication. The RN D said she didn't remember the patient spitting. The RN D said the medication was on the patient's face and the patient was trying to get it off her face. The RN D said there was no second attempt to administer the morphine to the patient after this attempt. The RN D said during the attempt to get the patient's blood pressure she was holding the patient's hand to comfort her and was leaning over the patient so she could see her face and focus on her. The RN D said the patient did not resist this contact. The RN D said the patient was holding her hand up in the air and she [RN D] took it. The RN D said she did not hold the patient's hand down on the bed. The RN D said she explained to the patient she needed to be still and asked her to keep still. The RN D said the patient didn't resist that and said the patient never resisted her. The RN D said she didn't think it would be accurate to say she held the patient's arm down. The RN D said she didn't feel this contact was restraining to the patient as the patient could have pulled her hand away. The RN D said the patient wasn't struggling with her. The RN D said the patient was lying in bed moving her hand around and she took it and told the patient to hold still. The RN D said the visit on 12/04/21 was her last contact with the patient. The RN D said the patient fell asleep and she left the room. The RN D said the call regarding the patient came in around 12:00 p.m. and she arrived at the facility around 12:15 p.m. The RN D said the incident occurred at lunch time. The RN D said the ALF did not call back regarding the patient that day or during the rest of that weekend. The RN D said on the following Monday (12/06/21) she learned of the allegations. The RN D said she was told she was physically restraining the patient and that she tried medicating the patient against the patient's will. The RN D said this was not accurate at all. The RN D said she felt like the ALF staff made these allegations against her in retribution because she had documented in the patient's folder that she found her on the floor soaking wet. The RN D said after the allegations were made the hospice asked for her statement regarding the incident. The RN D said she provided a written statement and said she wrote it on Monday (12/06/21) and came back on Tuesday (12/07/21) as she had not thought to sign and date it on Monday. Record review of a written statement, dated 12/07/21, signed by RN D indicated on 12/04/21 the RN D received a call from the ALF where Patient #1 resides reporting the patient's oxygen saturation level was low. The written statement indicated the RN D made a visit to the patient and noted upon arrival a strong odor of urine in the room. The written statement indicated the patient was found on the floor, wet from her knees to upper back with her incontinent underwear soaked. The written statement indicated the patient's bed was wet as well. The written statement indicated the RN D called for assistance and they assisted the patient back into bed, changed her clothes and linens and wiped her down. The written statement indicated the patient said her hip hurt and the RN D asked the ALF medication aide to medicate the patient with liquid morphine, but the patient was resistant to the ALF medication aide. The written statement indicated the RN D attempted to medicate the patient who refused and spit out the medication. The written statement indicated the ALF medication aide tried to talk to the patient and the patient reached up and grabbed the ALF medication aide's neck and dug her nails in. The written statement indicated the ALF medication aide attempted to get the patient's vital signs and the patient was resistant. The written statement indicated the RN D held the patient's hand to calm her. The written statement indicated during the visit when the patient said she was hurting the RN D asked the ALF medication aide to medicate her and indicated the ALF medication aide walked up to the patient's bed with the syringe then stepped back. The written statement indicated the RN D asked if she could try to administer the medication and the ALF medication aide handed her the syringe. The written statement indicated the RN D attempted to medicate the patient, but she turned her head and the medication went in the bed. The written statement indicated the RN D did not hold the patient except to hold her hand to calm her while taking her blood pressure. During an interview conducted on 12/09/21 at 2:26 p.m., with Patient #1, the surveyor attempted to interview Patient #1, but the patient was unable to answer questions about the incident or the hospice. During an interview conducted on 12/09/21 at 2:28 p.m., the ALF medication aide L said the ALF medication aide M got a call from the hospice nurse, the RN D, who said Patient #1 was on the floor. The ALF medication aide L said they attempted to get the patient's vital signs, but the patient was refusing. The ALF medication aide L said the patient was complaining of pain to her left side and she appeared to be in pain. The ALF medication aide L said she and the ALF medication aide M went to get pain medication for the patient. The ALF medication aide L said the ALF medication aide M attempted to give the patient the medication, but the patient moved her head away. The ALF medication aide L said the hospice nurse, the RN D, tried to hold the patient's head still and tried to force it in the patient's mouth. The ALF medication aide L said when she arrived at the patient's room on 12/04/21 the hospice nurse, the RN D, was in the room with another ALF employee. The ALF medication aide L said while they were trying to get the patient's vital signs the patient wouldn't keep the pulse oximeter on and kept moving her arm. The ALF medication aide L said the hospice nurse, the RN D, held the patient's arm to keep it still. The ALF medication aide L said she [the ALF medication aide L] was holding the patient's hand but the patient refused to keep still and the hospice nurse, RN D, held her arm down on the bed. The ALF medication aide L said the medication they attempted to administer to Patient #1 was morphine and it was in a syringe. The ALF medication aide L said the ALF medication aide M put the syringe near the patient's mouth and the patient pulled her head away. The ALF medication aide L said because of this the ALF medication aide M gave up on trying to administer the medication. The ALF medication aide L said the hospice nurse, the RN D, then tried to administer the medication. The ALF medication aide L said the hospice nurse, the RN D, held the patient by her jaw and tried to put the medication in her mouth. The ALF medication aide L said the syringe was a couple of inches from the patient's mouth and the hospice nurse, the RN D, was trying to put the medication in the patient's mouth. The ALF medication aide L said the patient turned her head away or tried to but was unable because the hospice nurse, the RN D, was holding her head. The ALF medication aide L said when the patient tried to turn her head away the medication went half-way into her mouth and the rest got on the side of her mouth. The ALF medication aide L said the hospice nurse, the RN D, did not say anything to the patient about the medication to tell her what she was doing or ask her if she wanted it. During an interview conducted on 12/09/21 at 2:36 p.m., the ALF caregiver N said on 12/04/21 she was in the dining room at the ALF when Patient #1's light went off. The ALF caregiver N said when she got to the patient's room the patient was in bed. The ALF caregiver N said the ALF medication aides were trying to get the patient's vital signs but were unable to do so. The ALF caregiver N said the patient said her hip hurt, her hip hurt, and was complaining about it and yelling. The ALF caregiver N said the ALF medication aides couldn't get her vital signs and the hospice nurse, the RN D, tried. The ALF caregiver N said the hospice nurse, the RN D, kind of grabbed the patient's arm and it appeared to her [the ALF caregiver N] that this hurt the patient. The ALF caregiver N said the hospice nurse, the RN D, tried to hold the patient's arm down on the bed but was unable to get it all the way onto the bed. The ALF caregiver N said the hospice nurse, the RN D, was unable to get the patient's vital signs. The ALF caregiver N said the ALF medication aide M went to get the patient pain medication and this medication was liquid morphine. The ALF caregiver N said the ALF medication aide M tried to give the medication but the patient kept refusing, saying no and get away The ALF caregiver N said the ALF medication aide M tried to put the syringe next to the patient's mouth but the patient was not having it. The ALF caregiver N said the hospice nurse, the RN D, took the syringe and grabbed the patient by the face and squirted the morphine in the patient's mouth quick. During an interview conducted on 12/09/21 at 2:44 p.m., the ALF medication aide M said on Saturday 12/04/21 at around 12:45 to 12:50 p.m., she got a call from the hospice nurse, the RN D, saying Patient #1 had fallen. The ALF medication aide M said the patient was crying. The ALF medication aide M said the patient was begging to go to the hospital. The ALF medication aide M said the patient said her side hurt and was touching her hip indicating her hip was hurting. The ALF medication aide M said the patient refused vital signs when she tried to take them and asked her if she could send her to the hospital. The ALF medication aide M said she told the patient she did not have that authority, but the hospice nurse could make that decision. The ALF medication aide M said the hospice nurse, the RN D, said nothing could be done. The ALF medication aide M said she asked the medication aide L to go with her to get the morphine for the patient and when she returned she explained to the patient that she had pain medication for her and the patient refused. The ALF medication aide M said she explained a couple of times to the patient what the medication was for, but the patient refused. The ALF medication aide M said the hospice nurse, the RN D, told her to make the patient take it. The ALF medication aide M said she told the hospice nurse, the RN D, they could make another attempt to get her to take it, but they could not force the patient to take it. The ALF medication aide M said the hospice nurse, the RN D, took the syringe from her hand and grabbed the patient's face and squirted the medication from the syringe into the patient's mouth. The ALF medication aide M said most of the medication didn't make it into the patient's mouth and the patient was making a spitting noise. The ALF medication aide M said the patient spit it right back out. The ALF medication aide M said the patient was very upset. The ALF medication aide M said the hospice nurse, the RN D, held the patient's arm down to get the patient's blood pressure. The ALF medication aide M said she had her blood pressure cuff on the left side of the patient's bed and the ALF medication aide L was on the right side of the patient's bed. The ALF medication aide M said the hospice nurse, the RN D, gave the ALF medication aide L her [RN D] blood pressure cuff and pulse oximeter to see if the ALF medication aide L could get it on the patient's right side. The ALF medication aide M said the patient was in pain and the hospice nurse, the RN D, grabbed her arm and told her to stay still. The ALF medication aide M said the patient said, ow, please stop when this occurred. The ALF medication aide M said once the patient refuses, she refuses. The ALF medication aide M said during the incident when the hospice nurse, the RN D, attempted to give the patient the morphine the patient reacted by reaching up and scratching her [the ALF medication aide M] neck. The ALF medication aide said she thought the patient was confused as to who had done that and thought it was her [the ALF medication aide M]. Record review of the client record for Patient #1 indicated the patient had a start of care date with the hospice of 10/19/17 and indicated the patient had a primary diagnosis of Alzheimer's disease. Record review of the clinical record for Patient #1 also included a skilled nurse's note, dated 12/04/21, signed by the RN D, which indicated a PRN skilled nurse visit was conducted on this date due to a report of low oxygen saturation levels. The note indicated the patient was demonstrating anxiety and agitation during the visit. The note indicated the patient said her hip hurt her. The note indicated the RN D asked the ALF medication aide to medicate the patient with liquid morphine, but the patient was resistant to the ALF medication aide. The note indicated the RN D attempted to administer the morphine and the patient refused and spit the medication out. The note indicated the ALF medication aide attempted to talk to the patient and the patient reached up grabbed her neck and dug her nails in. Record review of the clinical record for Patient #1 also included a hospice aide visit note, dated 12/06/21, signed by the hospice aide F which indicated on this date Patient #1 only allowed the hospice aide to provide peri-care, a brief change, application of lotion, and to brush the patient's hair. Record review of the clinical record for Patient #1 included a hospice aide visit note, dated 12/07/21, signed by the hospice aide F which indicated on this date the patient refused a bath and all other care. The note indicated the patient held onto her blanket and kept saying no. The note indicated the patient had a scared look on her face. During an interview conducted on 12/10/21 at 10:30 a.m., the hospice aide F said she couldn't recall the exact dates, but it was around 12/06/21 - 12/07/21, when the patient had refused care. The hospice aide F said the patient had held onto her blanket and wouldn't even let her check to see if she had been incontinent and needed to be changed. The hospice aide F said the patient had a scared look on her face. During an interview conducted on 12/10/21 at 12:08 p.m., the administrator/supervising nurse said if a patient refuses staff cannot force the patient to take medication and said touching the patient's face to give the medication was crossing the line. The administrator/supervising nurse said even if the nurse did not hold the patient's face it is still unacceptable to give a medication after the patient has said no or turned her head away indicating she is refusing the medication. The administrator/supervising nurse said she received the call from the ALF administrator where Patient #1 resides on 12/06/21 at 10:30 a.m. The administrator/supervising nurse said the ALF administrator told her when she [the ALF administrator] got to work that day two ALF employees reported they witnessed what they reported as abuse by the RN, D. The administrator/supervising nurse reported one of the ALF staff members said the RN D tried to force medications and the other ALF staff member said the RN D held Patient #1's arm down while the ALF staff were trying to get vital signs. Record review of a hospice policy titled, "Patient Bill of Rights," dated November 2020, indicated, "Each patient will be an active, informed participant in his/her plan of care ... The Patient Bill of Rights statements defines the right of the patient to ... have the right to refuse care or treatment."

Based on interview and record review, the hospice failed to protect and promote the patient's right to be free from mistreatment and physical abuse by an agency employee for 1 of 3 (Patient #1) patient reviewed. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 12/13/21 after approval by CMS. While the IJ was removed on 12/13/21, deficient practice was present at a condition level. This failure resulted in Patient #1 experiencing pain, discomfort, and agitation and could result in other patients experiencing physical, mental, and emotional harm from abuse. The findings included: Record review of a self-reported incident, reported by the hospice administrator/supervising nurse, to HHSC, on 12/07/21, indicated the administrator of the ALF where Patient #1 resides reported to the hospice administrator/supervising nurse on 12/06/21 an allegation that on 12/04/21 the hospice RN D, had grabbed Patient #1's face and forced her to take medication and had held the patient's arm down while obtaining vital signs. Record review of the hospice's complaint/incident documentation for the incident with Patient #1 on 12/04/21 indicated the administrator of the ALF contacted the hospice on 12/06/21 at 10:30 a.m. and reported two ALF employees were reporting on 12/04/21 at 12:30 p.m. they witnessed the hospice nurse, the RN D, hold Patient #1's arm down while attempting to obtain vital signs and observed the RN D, grab the patient's face and attempt to force the patient to take medication. Record review of the PIR for this incident, dated 12/07/21, signed by the hospice administrator/supervising nurse, indicated Patient #1 was not able to be interviewed, indicated the RN D denied the allegations, indicated two ALF employees, a caregiver and a medication aide, reported they observed the RN D to hold the patient's arm down while ALF staff attempted to obtain her vital signs and held the patient's face and attempted to force the patient to take medication. The PIR indicated police were notified of the incident by ALF staff. During an interview conducted on 12/08/21 at 4:29 p.m., the law enforcement officer investigating this incident said he believed the RN D caused pain and harm to Patient #1 by grabbing her face to administer medications. The law enforcement officer said law enforcement would be proceeding with pressing criminal charges against the RN D due to this incident for harm to an elderly person. The law enforcement officer said he believed the witnesses at the ALF where Patient #1 resides did a good job in reporting the incident. The law enforcement officer said the ALF did have policies regarding administering medications and said what the RN D did was not by the facility's policies. During an interview conducted on 12/09/21 at 9:41 a.m., Patient #1's family member said he was notified of the incident by the ALF staff. Patient #1's family member said he visited the patient on 12/04/21 but was not present at the time the incident occurred. During an interview conducted on 12/09/21 at 10:48 a.m. - 11:54 a.m., the RN D said she was a case manager with the hospice. The RN D said the administrator/supervising nurse is Patient# 1's case manager. The RN D said she [RN D] was on-call on 12/04/21. The RN D said she received a call from the on-call service on 12/04/21 regarding Patient #1. The RN D said when she arrived, she proceeded through the patient's apartment to her bedroom and found the patient on the floor. The RN D said she did not do an assessment or get the patient's vital signs until after the patient had been assisted back into bed. The RN D said the patient was complaining of pain while she was on the floor. The RN D said the patient has been complaining of pain to her left side and this was not a new complaint. The RN D said she was not sure when the patient had begun complaining of the pain to the left side and said the patient had multiple falls and while the complaint began after one of the falls she was not sure which fall. The RN D then said the patient had not complained of pain while on the floor but only complained of pain after she was in the bed. The RN D said when the patient was placed back into the bed there were 3-4 other people in the room besides herself and the patient. The RN D said the ALF medication aide was trying to get the patient's vital signs once she was back in the bed but could not. The RN D said she offered the ALF medication aide her blood pressure cuff. The RN D said the patient was obviously scared, after falling in the floor and with all of the people in the room, and said she held the patient's hand and began speaking with her in an attempt to calm her down and comfort her. The RN D said the patient obviously recognized her and she thought this might help to keep the patient still. The RN D said the patient was moving her hand around and said the patient's elbows were on the bed and the movement was from the hand not the shoulder. The RN D said she explained to the patient they were trying to get her blood pressure and told her she would be ok and tried to calm her down. The RN D said the ALF medication aide was still unable to get the patient's blood pressure. The RN D said part of the reason the ALF medication aide was unable to get the patient's blood pressure was that the patient was not being still. The RN D said she did not try to get the patient's blood pressure herself. The RN D said she offered the ALF medication aide her blood pressure cuff when the ALF medication aide could not get the blood pressure with her own cuff. The RN D said the ALF medication aide could not get the patient's blood pressure with either cuff. The RN D said she was speaking with the patient once she was in bed and the patient said she was hurting. The RN D said she asked the ALF medication aide to give the patient morphine. The RN D said the morphine was liquid and was ordered to be given orally. The RN D said the ALF medication aide asked someone in the room (another ALF employee) to go with her and went and got the morphine. The RN D said when the ALF medication aide returned with the morphine, she [the ALF medication aide] stepped up to the patient's bed and then stepped away. The RN D said the ALF medication aide did not attempt to administer the morphine. The RN D said she then said let me see if she will take it for me. The RN D said she told the patient she had something to give her for pain and attempted to give the patient the medication. The RN D said the patient turned her face away and didn't take it. The RN D said the morphine was in a syringe. The RN D said she attempted to give the morphine by leaning over the bed and squirting it. The RN D said the patient turned her head and didn't take it. The RN D said she did not touch the patient's head or face during this process. The RN D said she didn't hold the patient's neck. The RN D said she didn't try to forcefully give the medication. The RN D said the patient had her mouth open and she tried to give the morphine. The RN D said she wasn't close enough to the patient to put the syringe in the patient's mouth because there was someone in front of her. The RN D said she just squirted the morphine and when she did the patient turned her head and didn't take it. The RN D said she didn't have the syringe in the patient's mouth. The RN D said she didn't believe the medication had gone into the patient's mouth, but she couldn't say for certain. The RN D said the patient didn't say if she did or didn't want the medication and didn't address this. The RN D said she did not ask the patient if she wanted the medication and said she told the patient she had it and was going to give it to her. The RN D said the patient routinely refuses her medications from the ALF and this is the reason she is on a Fentanyl patch. The RN D said she wouldn't have shoved the medication down the patient's throat. The RN D said she was trying to make the patient understand the morphine would help her pain. The RN D said this is the reason she was talking to the patient. The RN D said the ALF medication aide did not attempt to give the patient the morphine or ask the patient about taking the morphine. The RN D said during her attempt to administer the morphine to Patient #1 the syringe was never in the patient's mouth. The RN D said there was a coffee table near the head of the bed, then the ALF medication aide, and possibly another person and said she was a good way away from the patient. The RN D said she reached up and leaned over and the syringe was approximately 6-8 inches from the patient's mouth when she attempted to administer the medication. The RN D said it was obvious the patient didn't want the medication. The RN D said she didn't remember the patient spitting. The RN D said the medication was on the patient's face and the patient was trying to get it off her face. The RN D said there was no second attempt to administer the morphine to the patient after this attempt. The RN D said during the attempt to get the patient's blood pressure she was holding the patient's hand to comfort her and was leaning over the patient so she could see her face and focus on her. The RN D said the patient did not resist this contact. The RN D said the patient was holding her hand up in the air and she [RN D] took it. The RN D said she did not hold the patient's hand down on the bed. The RN D said she explained to the patient she needed to be still and asked her to keep still. The RN D said the patient didn't resist that and said the patient never resisted her. The RN D said she didn't think it would be accurate to say she held the patient's arm down. The RN D said she didn't feel this contact was restraining to the patient as the patient could have pulled her hand away. The RN D said the patient wasn't struggling with her. The RN D said the patient was lying in bed moving her hand around and she took it and told the patient to hold still. The RN D said the visit on 12/04/21 was her last contact with the patient. The RN D said the patient fell asleep and she left the room. The RN D said the call regarding the patient came in around 12:00 p.m. and she arrived at the facility around 12:15 p.m. The RN D said the incident occurred at lunch time. The RN D said the ALF did not call back regarding the patient that day or during the rest of that weekend. During an interview conducted on 12/09/21 at 2:26 p.m., with Patient #1, the surveyor attempted to interview Patient #1, but the patient was unable to answer questions about the incident or the hospice. During an interview conducted on 12/09/21 at 2:28 p.m., the ALF medication aide L said the ALF medication aide M got a call from the hospice nurse, the RN D, who said Patient #1 was on the floor. The ALF medication aide L said when she and the ALF medication aide M arrived at the patient's room the hospice nurse, the RN D, had put the patient back into the bed. The ALF medication aide L said the ALF's policy is that they are supposed to get the patient's vital signs before picking the patient up off the floor. The ALF medication aide L said they attempted to get the patient's vital signs, but the patient was refusing. The ALF medication aide L said the patient was complaining of pain to her left side and she appeared to be in pain. The ALF medication aide L said she and the ALF medication aide M went to get pain medication for the patient. The ALF medication aide L said the ALF medication aide M attempted to give the patient the medication, but the patient moved her head away. The ALF medication aide L said the hospice nurse, the RN D, tried to hold the patient's head still and tried to force it in the patient's mouth. The ALF medication aide L said when she arrived at the patient's room on 12/04/21 the hospice nurse, the RN D, was in the room with another ALF employee. The ALF medication aide L said while they were trying to get the patient's vital signs the patient wouldn't keep the pulse oximeter on and kept moving her arm. The ALF medication aide L said the hospice nurse, the RN D, held the patient's arm to keep it still. The ALF medication aide L said she [the ALF medication aide L] was holding the patient's hand but the patient refused to keep still and the hospice nurse, RN D, held her arm down on the bed. The ALF medication aide L said the medication they attempted to administer to Patient #1 was morphine and it was in a syringe. The ALF medication aide L said the ALF medication aide M put the syringe near the patient's mouth and the patient pulled her head away. The ALF medication aide L said because of this the ALF medication aide M gave up on trying to administer the medication. The ALF medication aide L said the hospice nurse, the RN D, then tried to administer the medication. The ALF medication aide L said the hospice nurse, the RN D, held the patient by her jaw and tried to put the medication in her mouth. The ALF medication aide L said the syringe was a couple of inches from the patient's mouth and the hospice nurse, the RN D, was trying to put the medication in the patient's mouth. The ALF medication aide L said the patient turned her head away or tried to but was unable because the hospice nurse, the RN D, was holding her head. The ALF medication aide L said when the patient tried to turn her head away the medication went half-way into her mouth and the rest got on the side of her mouth. The ALF medication aide L said the hospice nurse, the RN D, did not say anything to the patient about the medication to tell her what she was doing or ask her if she wanted it. During an interview conducted on 12/09/21 at 2:36 p.m., the ALF caregiver N said on 12/04/21 she was in the dining room at the ALF when Patient #1's light went off. The ALF caregiver N said when she got to the patient's room the patient was in bed. The ALF caregiver N said the ALF medication aides were trying to get the patient's vital signs but were unable to do so. The ALF caregiver N said the patient said her hip hurt, her hip hurt, and was complaining about it and yelling. The ALF caregiver N said the ALF medication aides couldn't get her vital signs and the hospice nurse, the RN D, tried. The ALF caregiver N, said the hospice nurse, the RN D, kind of grabbed the patient's arm and it appeared to her [the ALF caregiver N] that this hurt the patient. The ALF caregiver N said the hospice nurse, the RN D, tried to hold the patient's arm down on the bed but was unable to get it all the way onto the bed. The ALF caregiver N said the hospice nurse, the RN D, was unable to get the patient's vital signs. The ALF caregiver N said the ALF medication aide M went to get the patient pain medication and this medication was liquid morphine. The ALF caregiver N said the ALF medication aide M tried to give the medication but the patient kept refusing, saying no and get away The ALF caregiver N said the ALF medication aide M tried to put the syringe next to the patient's mouth but the patient was not having it. The ALF caregiver N said the hospice nurse, the RN D, took the syringe and grabbed the patient by the face and squirted the morphine in the patient's mouth quick. The ALF caregiver N said most of the medication came out and did not go in the patient's mouth. The ALF caregiver N said she felt the behavior she observed by the hospice nurse, the RN D, was out of the ordinary. During an interview conducted on 12/09/21 at 2:44 p.m., the ALF medication aide M said on Saturday 12/04/21 at around 12:45 to 12:50 p.m., she got a call from the hospice nurse, the RN D, saying Patient #1 had fallen. The ALF medication aide M said she asked the RN D if she had gotten the patient's vital signs and asked her not to move the patient because the ALF's policy is for the staff to make sure the patient is in a somewhat comfortable position, get the patient's vital signs, ask the patient if they have any injuries or are hurt anywhere, and then notify the ALF's on-call medical staff before getting the patient up. The ALF medication aide M said she was just down the hall and was there in minutes, quickly, and as soon as she walked into the patient's room the RN D said she had put the patient in the bed. The ALF medication aide M said the patient was crying and she had never seen her cry before. The ALF medication aide M said the patient was begging to go to the hospital. The ALF medication aide M said the patient said her side hurt and was touching her hip indicating her hip was hurting. The ALF medication aide M said the patient refused vital signs when she tried to take them and asked her if she could send her to the hospital. The ALF medication aide M said she told the patient she did not have that authority, but the hospice nurse could make that decision. The ALF medication aide M said the hospice nurse, the RN D, said nothing could be done. The ALF medication aide M said it was not like the patient to even be crying. The ALF medication aide M said she asked the medication aide L to go with her to get the morphine for the patient and when she returned she explained to the patient that she had pain medication for her and the patient refused. The ALF medication aide M said she explained a couple of times to the patient what the medication was for, but the patient refused. The ALF medication aide M said the hospice nurse, the RN D, told her to make the patient take it. The ALF medication aide M said she told the hospice nurse, the RN D, they could make another attempt to get her to take it, but they could not force the patient to take it. The ALF medication aide M said the hospice nurse, the RN D, took the syringe from her hand and grabbed the patient's face and squirted the medication from the syringe into the patient's mouth. The ALF medication aide M said most of the medication didn't make it into the patient's mouth and the patient was making a spitting noise. The ALF medication aide M said the patient spit it right back out. The ALF medication aide M said the patient was very upset. The ALF medication aide M said the hospice nurse, the RN D, held the patient's arm down to get the patient's blood pressure. The ALF medication aide M said she had her blood pressure cuff on the left side of the patient's bed and the ALF medication aide L was on the right side of the patient's bed. The ALF medication aide M said the hospice nurse, the RN D, gave the ALF medication aide L her [RN D] blood pressure cuff and pulse oximeter to see if the ALF medication aide L could get it on the patient's right side. The ALF medication aide M said the patient was in pain and the hospice nurse, the RN D, grabbed her arm and told her to stay still. The ALF medication aide M said the patient said, ow, please stop when this occurred. The ALF medication aide M said once the patient refuses, she refuses. The ALF medication aide M said during the incident when the hospice nurse, the RN D, attempted to give the patient the morphine the patient reacted by reaching up and scratching her [the ALF medication aide M] neck. The ALF medication aide said she thought the patient was confused as to who had done that and thought it was her [the ALF medication aide M]. Record review of the client record for Patient #1 indicated the patient had a start of care date with the hospice of 10/19/17 and indicated the patient had a primary diagnosis of Alzheimer's disease. Record review of the clinical record for Patient #1 also included a skilled nurse's note, dated 12/04/21, signed by the RN D, which indicated a PRN skilled nurse visit was conducted on this date due to a report of low oxygen saturation levels. The note indicated the patient was demonstrating anxiety and agitation during the visit. The note indicated the patient said her hip hurt her. The note indicated the RN D asked the ALF medication aide to medicate the patient with liquid morphine, but the patient was resistant to the ALF medication aide. The note indicated the RN D attempted to administer the morphine and the patient refused and spit the medication out. The note indicated the ALF medication aide attempted to talk to the patient and the patient reached up grabbed her neck and dug her nails in. Record review of the clinical record for Patient #1 also included a hospice aide visit note, dated 12/06/21, signed by the hospice aide F which indicated on this date Patient #1 only allowed the hospice aide to provide peri-care, a brief change, application of lotion, and to brush the patient's hair. Record review of the clinical record for Patient #1 included a hospice aide visit note, dated 12/07/21, signed by the hospice aide F which indicated on this date the patient refused a bath and all other care. The note indicated the patient held onto her blanket and kept saying no. The note indicated the patient had a scared look on her face. During an interview conducted on 12/10/21 at 10:30 a.m., the hospice aide F said she couldn't recall the exact dates, but it was around 12/06/21 - 12/07/21, when the patient had refused care. The hospice aide F said the patient had held onto her blanket and wouldn't even let her check to see if she had been incontinent and needed to be changed. The hospice aide F said the patient had a scared look on her face. During an interview conducted on 12/10/21 at 1:30 p.m., the administrator/supervising nurse said if a patient refuses staff cannot force the patient to take medication and said touching the patient's face to give the medication was crossing the line. The administrator/supervising nurse said even if the nurse did not hold the patient's face it is still unacceptable to give a medication after the patient has said no or turned her head away indicating she is refusing the medication. Record review of a hospice policy titled, "Patient Bill of Rights," dated November 2020, indicated, "Patients have the right to ... be free from ... abuse." The administrator/supervising nurse was notified on 12/13/21 at 3:20 p.m. that an Immediate Jeopardy situation had been identified due to the above failure. On 12/10/21 at 9:51 p.m., the surveyor received the hospice's plan of removal. This plan of removal was first submitted for the IT which was identified on 12/10/21. The plan of removal was considered acceptable for the IJ as well as the IT as the issues involved were similar for the IT and the IJ. The plan of removal, dated 12/10/21, indicated the hospice would implement the following interventions to correct the immediate threat: The Administrator/Designee would provide mandatory in-service retraining and reeducation on 12/13/21 to nursing staff on policies regarding the Patient Bill of Rights, Assessment of Possible Abuse and Neglect, and Hospice Nursing Care. The Administrator/Designee would review 100% of current census beginning the week of 12/13/21 to ensure they are compliant with the regulatory standards, and the nurses involved are compliant in their respective practice acts. The Administrator/Designee would then review 5 charts each week beginning the week of 12/20/21 for the next 2 months for 90% compliance. On 12/13/21 the surveyor received in-service training records for the hospice's current staff indicating the hospice had provided in-service training on this date regarding the Patient Bill of Rights, Assessment of Possible Abuse and Neglect, and Hospice Nursing Care. On 12/13/21 the surveyor interviewed 3 current hospice employees (the administrator/supervising nurse, the hospice aide F, and the hospice aide J). (The administrator/supervising nurse is the only nurse currently employed at the hospice who is providing nursing visits.) The hospice aide F and the hospice aide J said they had received in-service training from the hospice on 12/13/21 regarding patient rights and abuse, neglect, and exploitation. The administrator/supervising nurse said she had received in-service training on 12/13/21 on patient rights, abuse, neglect and exploitation, and hospice nursing care policies and practices. The administrator/supervising nurse said the RN, D's, employment with the hospice had been terminated as of 12/11/21 and the hospice's investigation into this incident had now been concluded and indicated the allegations were substantiated. On 12/13/21 at 3:45 p.m., the administrator/supervising nurse was informed that the IJ was removed. However deficient practice was present at a condition level. The hospice was continuing to implement the plan of removal.

Based on interview and record review, the hospice failed to ensure the RN member of the interdisciplinary group provided coordination of care, ensured continuous assessment of each patient's and family's needs, and implemented the interdisciplinary plan of care for 1 of 3 (Patient #1) patient reviewed. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 12/13/21 after approval from CMS. While the IJ was removed on 12/13/21, the deficient practice continued at a condition level. This failure resulted in Patient #1 experiencing continuing pain and discomfort and could result in other patients experiencing pain which is not effectively managed. Refer to L540 Based on interview and record review, the hospice failed to ensure care and services were provided in accordance with the plan of care for 1 of 3 (Patient #1) patient reviewed. This failure could have contributed to Patient #1 experiencing continuing pain and discomfort and could result in other patients experiencing pain which is not effectively managed. Refer to L555 Based on interview and record review, the hospice failed to provide for and ensure the ongoing sharing of information between all disciplines providing care and services in all settings for 1 of 3 (Patient #1) patient reviewed. This failure resulted in Patient #1 experiencing continuing pain and discomfort and could result in other patients experiencing pain which is not effectively managed. Refer to L557

Based on interview and record review, the hospice failed to ensure the RN member of the interdisciplinary group provided coordination of care, ensured continuous assessment of each patient's and family's needs, and implemented the interdisciplinary plan of care for 1 of 3 (Patient #1) patient reviewed. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 12/13/21 after approval from CMS. While the IJ was removed on 12/13/21, the deficient practice continued at a condition level. This failure resulted in Patient #1 experiencing continuing pain and discomfort and could result in other patients experiencing pain which is not effectively managed. The findings included: Record review of the clinical record for Patient #1 indicated the patient had a start of care date with the hospice of 10/19/17 and indicated the patient had a primary diagnosis of Alzheimer's disease. Record review of the clinical record for Patient #1 included a Hospice POC Report, not dated, which indicated the patient had an identified problem of altered comfort. The Hospice POC Report indicated the patient had a skilled nursing need for observation and assessment of altered comfort. The Hospice POC Report indicated the skilled nurse would implement the following intervention: Monitor pain level using the appropriate pain scale. Record review of a physician's order, dated 09/17/21, indicated the client had the following medications ordered for pain: Gabapentin 300 mg three times a day by mouth; Hydrocodone 5mg/Acetaminophen 325 mg four times a day at 8:00 a.m., 12:00 p.m., 4:00 p.m., and 8:00 p.m. by mouth; Morphine Concentrate 100mg/5ml solution 1ml as needed [no other frequency is included] by mouth; and MS Contin 30 mg tablet, extended release, once a day at bedtime by mouth. Record review of a physician's order, dated 11/12/21, indicated the client had the following medications ordered for pain: Gabapentin 300 mg three times a day by mouth; Hydrocodone 5mg/Acetaminophen 325 mg four times a day at 8:00 a.m., 12:00 p.m., 4:00 p.m., and 8:00 p.m. by mouth; Morphine Concentrate 100mg/5ml solution 1ml as needed [no other frequency is included] by mouth; and MS Contin 30 mg tablet, extended release, once a day at bedtime by mouth. Record review of the clinical record for Client #1 indicated the client refused medications at times. Record review of the clinical record for Client #1 indicated the client did not have pain medication ordered via a route other than oral until 11/30/21. Record review of the clinical record for Patient #1 included skilled nurse's notes, for the dates of 09/20/21, 09/27/21, 10/04/21, 10/11/21, 10/18/21, 10/25/21, and 11/08/21, which indicated Patient #1's pain was rated at a 0 on these visits. Record review of the clinical record for Patient #1 included a skilled nurse's note, dated 11/03/21, signed by the RN D, which indicated the skilled nurse did not complete a comprehensive pain assessment, including use of a pain scale during this visit. There was no documentation to indicate if the patient was having pain during this visit. Record review of the clinical record for Patient #1 included a skilled nurse's note, dated 11/12/21, signed by the administrator/supervising nurse, which indicated the skilled nurse did not complete a comprehensive pain assessment, including use of a pain scale during this visit. The note indicated, "No acute distress at thisvtime (sic)." Record review of the clinical record for Patient #1 included a skilled nurse's note, dated 11/15/21, signed by the administrator/supervising nurse, which indicated the skilled nurse did not complete a comprehensive pain assessment, including use of a pain scale during this visit. The note indicated, "Patient denies pain or discomforts (sic)." Record review of the clinical record for Patient #1 included a skilled nurse's note, dated 11/18/21, signed by the administrator/supervising nurse, which indicated the skilled nurse did not complete a comprehensive pain assessment, including use of a pain scale during this visit. The note indicated, "No non-verbal S/S of pain noted." Record review of the clinical record for Patient #1 included an on-call nursing note, dated 11/21/21, signed by the RN H, which indicated the hospice's on-call nurse, the RN H, received a call from the ALF where Patient #1 resides reporting the patient fell out of bed to the floor with complaint of pain to her groin. The note indicated the call was received at 12:59 a.m. The note further indicated on 11/21/21 at 9:05 a.m. the hospice on-call nurse made a follow-up phone call with ALF staff. The note indicated the ALF staff reported the patient was still having pain but was refusing pain medication. The note indicated the patient reported she hurt from her head to her toes and was unable to be specific. The note indicated the patient's left groin/ left leg were in question and indicated no difference in size/length of legs and no internal or external rotation were noted. The note indicated no discoloration to the legs was noted. The note indicated the hospice on-call nurse advised the ALF to monitor the patient and notify the hospice of any changes. Record review of the clinical record for Patient #1 did not include documentation to indicate the hospice nurse conducted a visit with Patient #1 to assess the patient following the fall and complaint of pain on 11/21/21 or to indicate the physician was notified of the fall or complaints of pain on this date. Record review of the clinical record for Patient #1 included a skilled nurse's note, dated 11/22/21, signed by the administrator/supervising nurse, which indicated a comprehensive pain assessment, including use of the visual pain scale, was conducted during this visit. The note indicated the patient's pain during this visit was rated at a 4 - hurts a little more (the scale measures pain from no pain, hurts a little, hurts a little more, hurts even more, hurts a whole lot, hurts worst). The note further indicated, "Patient had falls over the weekend and some facial grimacing during assessment." Record review of the clinical record for Patient #1 did not include documentation to indicate the skilled nurse notified the physician of the falls over the weekend or the patient's complaint of pain during this visit. Record review of the clinical record for Patient #1 included a skilled nurse's note, dated 11/23/21, signed by the administrator/supervising nurse, which indicated a comprehensive pain assessment, including use of the pain scale for the cognitively impaired, was conducted during this visit. The note indicated the patient's pain during this visit was scored a 1 for displaying the following behaviors: occasional labored breathing, short period of hyperventilation, occasional moan or groan, low-level speech with negative or disapproving quality, sad and/or frightened facial expression or frown, tense body language with distressed pacing and/or fidgeting. The note further indicated, "Patient had a fall last night and has some facial grimacing during assessment." Record review of the clinical record for Patient #1 did not include documentation to indicate the skilled nurse notified the physician of the fall or the patient's signs of pain during this visit. Record review of the clinical record for Patient #1 included a hospice aide visit note, dated 11/24/21, signed by the hospice aide F which indicated, "Pt is harder to transfer due to her left hip & thigh hurts when she puts her weight on it. It is from the recent falls she has had. ---------------- (name of the administrator/supervising nurse) RN administrator notified." Record review of the clinical record for Patient #1 included a skilled nurse's note, dated 11/24/21, signed by the RN D, which indicated a comprehensive pain assessment, including use of a pain scale, was not conducted during this visit. The note indicated, "On call visit ... patient requesting to go to hospital due to pain in hip." The note indicated the nurse advised the ALF to medicate the patient for pain and upon the nurse's arrival the patient's pain was improved and she was assisted back into bed. Record review of the clinical record for Patient #1 did not include documentation to indicate the skilled nurse notified the physician of the patient's complaint of pain or request to be transferred to the hospital due to the pain in her hip on this date. Record review of the clinical record for Patient #1 included a patient coordination note, dated 11/26/21, which indicated, "Received a call from ------------- (name of the ALF where Patient #1 resides), Patient is in pain. Stated patient is in bed sleeping but wanted to let us know she has been in pain. I [hospice nurse] asked if she was currently comfortable stated yes, but she [ALF staff member] knows the client likes to be around in her wheelchair and she could not get up this evening because of pain." Record review of the clinical record for Patient #1 included a hospice aide visit note, dated 11/26/21, signed by the hospice aide F, which indicated, "I arrived & Pt was sitting on her sofa. She said she needed me to help her to the restroom, but she would not allow me to transfer her to the wheelchair because she has somuch (sic) pain in her left hip & side. I called for an aide to help me & she still would not allow us to get her up off of the sofa. She started yelling help & get away, leave me alone, so she refused bath & all care. ------------- (name of the administrator/supervising nurse) RN administrator notified." Record review of the clinical record for Patient #1 did not include documentation to indicate the skilled nurse notified the physician of the reports of pain from the ALF staff or the hospice aide during this visit. Record review of the clinical record for Patient #1 included a skilled nurse's note, dated 11/29/21 (9 days after the patient first began consistently complaining of pain to her left hip/leg/side area), signed by the administrator/supervising nurse, which indicated a comprehensive pain assessment, including use of a pain scale, was not conducted during this visit. The note indicated, "Spoke with ----------- (name of an ALF employee) about patients (sic) care, she states patient has not been consistent on taking her routine medication and will frequently c/o pain and then not open her mouth to take the pain medication. Spoke with ---------- (name of the physician for Patient #1, the medical director E) about patient status, discussed switching patient to Fentanyl patch for more effective pain control, call placed to patients (sic) --------- (family member) to ask if he approves of medication change with no answer to phone call. Message left." Record review of the clinical record for Patient #1 included a skilled nurse's note, dated 11/30/21, signed by the RN D, which indicated a comprehensive pain assessment, including use of a pain scale, was not conducted during this visit. The note indicated, "States she hurts all the time ... CM is changing her medication to Fentanyl patch for consistent pain control." Record review of the clinical record for Patient #1 included a patient coordination note, dated 12/08/21, as a late entry for 11/30/21, which indicated the patient's family member returned the hospice's phone call regarding medication changes. The note indicated the patient's family member was reluctant to change the patient's medications because the last time she was prescribed Fentanyl she became very drowsy. The note indicated the patient's family member agreed to the medication changes but requested the patient be started at the lowest dose. Record review of the clinical record for Patient #1 indicated Patient #1 was started on a Fentanyl patch at 25 MCG/HR one patch to be applied every 72 hours on 11/30/21. Record review of the clinical record for Patient #1 did not include documentation to indicate the hospice had attempted to contact Patient #1's family member prior to 11/29/21 to discuss changing her pain medications. Record review of the clinical record for Patient #1 included a hospice aide visit note, dated 12/01/21, signed by the hospice aide F, which indicated, "Pt is complaining of pain when she puts weight on her left leg. She says it hurts up in her left abdomen & left side of hip & the pain goes down her left leg ... ---------- (name of the administrator/supervising nurse) RN administrator notified." Record review of the clinical record for Patient #1 included a social worker visit note, dated 12/02/21, signed by the social worker G, which indicated the patient was "uncomfortable because of pain." The note indicated the social worker, G, notified the RN, D, regarding the patient's complaint of pain during this visit. The note further indicated, "Patient complained of pain in her left leg. Social worker talk (sic) to med aide [ALF medication aide] who said she has her Fentanyl patch and she gave her some morphine earlier, said it does not always cure for pain." Record review of the clinical record for Patient #1 included a skilled nurse's note, dated 12/02/21, signed by the RN D, which indicated a comprehensive pain assessment, including use of the verbal pain scale, was conducted during this visit. The note indicated the patient rated her pain during this visit as a 7-8, hurts a whole lot. The note indicated the patient reported her pain in the last 24 hours as severe pain. The note indicated the patient reported her acceptable pain level would be mild pain. The note indicated the patient reported the pain was to her left hip. The note further indicated, "Patient states she hurts on her left side ... she is unable to get out of bed without maximal lift assist to chair. Patient is aware of this change. She states she is in pain." Record review of the clinical record for Patient #1 did not include documentation to indicate the skilled nurse notified the physician of the patient's complaint of pain during this visit. Record review of the clinical record for Patient #1 included a skilled nurse's note, dated 12/04/21, signed by the RN, D, which indicated a comprehensive pain assessment, including use of a pain scale, was not conducted during this visit. The note indicated, "Patient reports that she has pain always and cannot walk or sit in chair because of pain." Record review of the clinical record for Patient #1 did not include documentation to indicate the skilled nurse notified the physician of the patient's complaint of pain during this visit. Record review of the clinical record for Patient #1 included a skilled nurse's note, dated 12/06/21 (16 days after the documentation shows the patient began consistently complaining of pain to the left hip/leg/side area), signed by the administrator/supervising nurse, which indicated, "Patient continues to be in pain dispite (sic) medication, pain medication adjustments to be made." The note indicated a comprehensive pain assessment, including use of the pain scale for the cognitively impaired, was completed during this visit. The note indicated the patient's pain during this visit was scored a 6 indicating moderate pain. The note indicated the patient demonstrated the following signs of pain: occasional labored breathing and/or short periods of hyperventilation, repeated trouble calling out, loud moaning or groaning, crying, sad and/or frightened facial expression and/or frown, and tense body language, distressed pacing and/or fidgeting. The note further indicated, "Staff from ------------ (name of the ALF where Patient #1 resides) had notified hospice this morning that patient was still having pain to the left leg. ------------- (name of the medical director, E) notified and xrays ordered ... During xrays ... patient moaning and showing facial grimacing ... Upon receiving final report, SN called results to ------------ (name of medical director E) and patient --------- (family member). Xrays showing fracture to left femoral neck into greater trochanter ... --------- (family member) agreed to increased (sic) medication for pain." Record review of the clinical record for Patient #1 included a physician's order, dated 12/06/21, which indicated the physician ordered to increase the Fentanyl patch from 25 to 50 MCG and increased the morphine to 1 ml every 2 hours as needed for pain. Record review of the clinical record for Patient #1 indicated the previous order for morphine indicated the patient was to receive morphine 1ml as needed but did not include a frequency, such as every two hours. Record review of the clinical record for Patient #1 included a skilled nurse's note, dated 12/08/21, signed by the administrator/supervising nurse, which indicated during this visit the patient rated her pain as a 2 - hurts a little bit. The note indicated, "Patient is more alert this visit ... Patient smiles at SN and appears relaxed. No s/s non-verbal or verbal during this visit." During an interview conducted on 12/09/21, from 10:48 a.m. - 11:54 a.m., the RN D said she was a case manager with the hospice. The RN D said the administrator/supervising nurse is Patient #1's case manager. The RN D said she [RN D] was on-call on 12/04/21. The RN D said she received a call from the on-call service on 12/04/21 regarding Patient #1. The RN D said when she arrived, she proceeded through the patient's apartment to her bedroom and found the patient on the floor. The RN D said she did not do an assessment or get the patient's vital signs until after the patient had been assisted back into bed. The RN D said the patient was complaining of pain while she was on the floor. The RN D said the patient has been complaining of pain to her left side and this was not a new complaint. The RN D said she was not sure when the patient had begun complaining of the pain to the left side and said the patient had multiple falls and while the complaint began after one of the falls she was not sure which fall. The RN D then said the patient had not complained of pain while on the floor but only complained of pain after she was in the bed. The RN D said she was speaking with the patient once she was in bed and the patient said she was hurting. The RN D said she could not recall if the patient stated verbally the location of her pain or indicated it with her hand, but the patient indicated she was having pain to her left hip. The RN D said the patient was not able to rate her pain using a 1-10 numerical scale. The RN D said the hospice did use a non-numerical scale for patients who were unable to use the numerical scale, but she did not ask the patient to rate her pain during the visit on 12/04/21. The RN D said the only indication she had regarding whether the patient's pain was improved, worsened, or the same by the end of the visit was that the patient appeared more comfortable and relaxed and was falling asleep. The RN D said she did not ask the patient if her pain was improved. The RN D said she did not get the patient's vital signs and didn't complete a full assessment. The RN D said the patient was breathing ok, and as far as she could tell the patient's leg was not rotated or shortened. The RN D said she did not manually move anything but just did a visual assessment and everything looked like it lined up ok. The RN D said she didn't try to move the leg to assess it. The RN D said she did not do a full skin assessment. The RN D said the patient had an abrasion on her knee, but it didn't look new. The RN D said the patient had experienced multiple previous falls. The RN D said she did not examine the patient's leg for injuries. The RN D said she did assist the ALF staff to change the patient's clothes and while they were doing this, she did look at the patient. The RN D said she did not go back and do an assessment after this. The RN D said she didn't do any physical manipulation of the patient's body to assess the patient but she did observe as the patient was changed which required pulling her up in bed and rolling her from side to side. The RN D said the patient's pain did not seem worse during this visit than previously to her. The RN D said it was difficult to tell with the patient. The RN D said the patient didn't cry out when they were changing her, but she kept grabbing things because she was afraid of falling. The RN D said the patient's only reaction was grabbing people or things due to her fear when they rolled her to the edge of the bed that she would fall. The RN D said she did contact the administrator/supervising nurse after the visit and sent a text to the medical director E reporting the patient had a fall with no apparent injuries. The RN D said no new orders were received. The RN D said she did not contact the patient's family as she assumed the ALF would do this. The RN D said she normally does not contact the families and usually would just notify the physician. The RN D said the medical director E, did respond and said, ok. The RN D said she called the administrator/supervising nurse as she was this patient's case manager and told her the patient had been found soaked in urine and had fallen. The RN D said the administrator/supervising nurse did not give her any additional tasks to do regarding the patient. The RN D said the patient routinely refuses her medications from the ALF and this is the reason she is on a Fentanyl patch. Record review of a written statement, dated 12/07/21, signed by RN D, indicated on 12/04/21 the RN D received a call from the ALF where Patient #1 resides reporting the patient's oxygen saturation level was low. The written statement indicated the RN D made a visit to the patient and indicated during the visit the patient was found on the floor and during the visit said her hip hurt. During an interview conducted on 12/09/21 at 2:26 p.m., with Patient #1, the patient was unable to answer questions about the hospice. During an interview conducted on 12/09/21 at 2:28 p.m., the ALF medication aide L said on 12/04/21 the ALF medication aide M got a call from the hospice nurse, the RN D, who said Patient #1 was on the floor. The ALF medication aide L said when she and the ALF medication aide M arrived at the patient's room the hospice nurse, the RN D, had put the patient back into the bed. The ALF medication aide L said the ALF's policy is that they are supposed to get the patient's vital signs before picking the patient up off the floor. The ALF medication aide L said the patient was complaining of pain to her left side and she appeared to be in pain. The ALF medication aide L said she and the ALF medication aide M went to get pain medication for the patient. The ALF medication aide L said the ALF medication aide M attempted to give the patient the medication, but the patient moved her head away. The ALF medication aide L said the hospice nurse, the RN D, tried to hold the patient's head still and tried to force it in the patient's mouth. The ALF medication aide L said the medication they attempted to administer to Patient #1 was morphine and it was in a syringe. The ALF medication aide L said the ALF medication aide M put the syringe near the patient's mouth and the patient pulled her head away. The ALF medication aide L said because of this the ALF medication aide M gave up on trying to administer the medication. The ALF medication aide L said the hospice nurse, the RN D, then tried to administer the medication. The ALF medication aide L said the hospice nurse, the RN D, held the patient by her jaw and tried to put the medication in her mouth. The ALF medication aide L said the syringe was a couple of inches from the patient's mouth and the hospice nurse, the RN D, was trying to put the medication in the patient's mouth. The ALF medication aide L demonstrated this by holding her own jaw with one hand and putting her finger to the corner of her mouth to indicate the placement of the syringe. The ALF medication aide L said the patient turned her head away or tried to but was unable because the hospice nurse, the RN D, was holding her head. The ALF medication aide L said when the patient tried to turn her head away the medication went half-way into her mouth and the rest got on the side of her mouth. The ALF medication aide L said the hospice nurse, the RN D, did not say anything to the patient about the medication to tell her what she was doing or ask her if she wanted it. The ALF medication aide L said the patient was in pain and she could see that the patient was in pain. The ALF medication aide L said the ALF staff asked the hospice nurse, the RN D, about getting an x-ray for the patient and the hospice nurse, the RN D, said she thought the patient only needed rest and pain medication. The ALF medication aide said, however, the patient had refused the pain medication. The ALF medication aide L said it didn't seem like the hospice nurse cared. The ALF medication aide L said this was the first time she had seen the patient complain of pain like that. The ALF medication aide L said she thought the patient was in a lot of pain and said the patient usually doesn't complain of pain. During an interview conducted on 12/09/21 at 2:36 p.m., the ALF caregiver N said on 12/04/21 she was in the dining room at the ALF when Patient #1's light went off. The ALF caregiver N said when she got to the patient's room the patient was in bed. The ALF caregiver N said the ALF medication aides were trying to get the patient's vital signs but were unable to do so. The ALF caregiver N said the patient said her hip hurt, her hip hurt, and was complaining about it and yelling. The ALF caregiver N said it seemed like the hospice nurse wanted to leave. The ALF caregiver N said the patient doesn't complain of pain a lot and said the patient had never complained to her of pain. The ALF caregiver N said the whole time the patient was complaining and said usually when the patient says something is hurt something is hurt. During an interview conducted on 12/09/21 at 2:44 p.m., the ALF medication aide M said on Saturday 12/04/21 at around 12:45 to 12:50 p.m., she got a call from the hospice nurse, the RN D, saying Patient #1 had fallen. The ALF medication aide M said she asked the RN D if she had gotten the patient's vital signs and asked her not to move the patient because the ALF's policy is for the staff to make sure the patient is in a somewhat comfortable position, get the patient's vital signs, ask the patient if they have any injuries or are hurt anywhere, and then notify the ALF's on-call medical staff before getting the patient up. The ALF medication aide M said she was just down the hall and was there in minutes, quickly, and as soon as she walked into the patient's room the RN D said she had put the patient in the bed. The ALF medication aide M said the patient was crying and she had never seen her cry before. The ALF medication aide M said the patient was begging to go to the hospital. The ALF medication aide M said the patient said her side hurt and was touching her hip indicating her hip was hurting. The ALF medication aide M said the patient refused vital signs when she tried to take them and asked her if she could send her to the hospital. The ALF medication aide M said she told the patient she did not have that authority, but the hospice nurse could make that decision. The ALF medication aide M said the hospice nurse, the RN D, said nothing could be done. The ALF medication aide M said it was not like the patient to even be crying. The ALF medication aide M said the patient will sometimes complain of pain or make a crying sound, but she doesn't cry tears and, on this date, (12/04/21) the patient was crying tears. The ALF medication aide M said she could tell this was different from the patient's usual behavior. The ALF medication aide M said the patient specifically said she wanted to go to the hospital. The ALF medication aide M said she did not see the RN D assess the patient's leg or hip and said the RN D said nothing could be done. The ALF medication aide M said she told the RN D there was something wrong and said the patient was crying and crying which was unusual for her. During an interview conducted on 12/10/21 at 10:02 a.m., the RN H said the weekend of 11/21/21 was her first-time taking call for the hospice. The RN H said she was assisting the hospice that weekend by taking call as the hospice had a nursing staff shortage. The RN H said Patient #1 had two falls on 11/21/21. The RN H said after the first fall on 11/21/21 there were no injuries. The RN H said after the second fall the patient was complaining of pain to the left groin/leg but no signs or symptoms of injuries were noted and the patient was able to move and just had some discomfort which was to be expected after the number of falls that weekend. The RN H said she did not notify the patient's physician regarding the falls or complaints of pain on this date because she didn't know who the physician was. The RN H said this was her first time working at this hospice and said there was a hiccup as she was not assigned to any patients and could not review their records in the electronic medical record system at first. The RN H said she let the administrator/supervising nurse and her bosses at her primary agency know and the issue was corrected. The RN H said she believed she was able to access the patient records by 11/21/21 from her laptop but said she still couldn't get to all the information from her tablet which is where she knew how to do things. The RN H said she did notify the administrator/supervising nurse of the falls and she was sure of this because she was unable to do an occurrence report regarding the falls and usually she would do one so she contacted the administrator/supervising nurse who said she would do this. During an interview conducted on 12/10/21 at 10:14 a.m., the social worker G said on 12/02/21 she called the RN D to report the patient's complaints of pain and that the ALF staff said the pain medications were not always effective. The social worker G said the patient's family member can be very difficult to get a hold of and said she knew they had been trying to reach him regarding this, but it was several days before he called back. During an interview conducted on 12/10/21 at 10:30 a.m., with the hospice aide F when presented with the findings regarding Patient #1 which indicated the patient had a change in the amount of pain she experienced and in her functional status beginning on or around 11/21/21, the hospice aide F said this was correct. The hospice aide F said the patient became harder to transfer around this time and said previously the patient had been able to help more but she could tell it was a lot harder for the patient. The hospice aide F said around this time the patient had experienced several falls. The hospice aide F said the patient was consistently complaining of pain to the left hip/leg/side area. The hospice aide F said on 11/26/21 the patient was sitting on the sofa in living room and said she needed to go to the bathroom but when she went to assist her up the patient began crying and holding her side like she was in pain. The hospice aide F said she pulled the call light for assistance but when the ALF aide came to assist her the patient would not allow them to assist her. The hospice aide F said she had notified the RN of the patient's complaints of pain. The hospice aide F said she couldn't recall the exact dates but around 12/06/21 - 12/07/21 the patient had refused care. The hospice aide F said on one visit the patient held onto her blanket and wouldn't even let her check to see if she had been incontinent and needed to be changed. The hospice aide F said the patient had a scared look on her face during this visit. During an interview conducted on 12/10/21 at 10:43 a.m., the RN D, said she could not recall if she notified the physicia n of Patient #1's complaint of pain and request to go to the hospital on 11/24/21. The RN D said she could not recall if she notified the administrator/supervising nurse, Patient #1's case manager, of the patient's complaint of pain and request to go to the hospital on 11/24/21. The RN D said she could not recall if she notified the physician or the administrator/supervising nurse regarding the ALF's report that Patient #1 was unable to get up in her wheelchair due to pain on 11/26/21. The RN D said she could not recall if she notified the physician or the administrator/supervising nurse of Patient #1's complaint of pain on 12/02/21. The RN D said the patient had multiple falls and had an increase in pain around that time. The RN D said the patient often refused medications from the ALF staff. The RN D said they changed the patient's pain medications from oral medications to a Fentanyl patch around this time. The RN D said she texted the physician that the patient had a fall with no injuries regarding the visit on 12/04/21. The RN D said her process for completing pain assessments depends on how well the patient can vocalize. The RN D said if the patient was able to use the numerical scale she would use this and said if the patient was not able to do this, for example Patient #1, she would use the scale that says it hurts a little, hurts a lot, hurts a whole lot. The RN D said if she documented that no comprehensive pain assessment was completed during a visit it was because the patient wasn't complaining of pain. Record review of the personnel record for the RN D indicated this individual had a date of employment with the hospice of 05/24/21. The record did not include any documentation of disciplinary action for this employee. During an interview conducted on 12/10/21 at 1:30 p.m., the administrator/supervising nurse said she couldn't be 100% sure that the physician was notified of the patient's falls and complaint of pain on 11/21/21. The administrator/supervising nurse said it was the responsibility of the on-call nurse to notify the physician. When presented with the findings indicating the on-call nurse had reported she did not contact the physician but had notified the administrator/supervising nurse, the administrator/supervising nurse said she (the administrator/supervising nurse) did not notify the physician of the falls or the patient's complaint of pain on this date. The administrator/supervising nurse said the physician was probably not notified of the patient's complaint of pain on 11/22/21 because the pain on that date was generalized soreness and the patient was not super specific about the location of the pain. The administrator/supervising nurse said she was not sure if the physician was notified of the patient's fall and complaint of pain on 11/23/21. The administrator/supervising nurse said she was not sure if the physician was notified of the patient's request to go to the hospital due to her pain on 11/24/21. The administrator/supervising nurse said she had read the nurse's note for this visit and it doesn't say. The administrator/supervising nurse said she was not sure if the physician was notified that the patient was unable to get up to her wheelchair or that the patient had refused hospice aide services on 11/26/21 due to complaints of pain. The administrator/supervising nurse said Patient #1's family member was called regarding the patient's pain prior to 11/29/21. The administrator/supervising nurse said the family member was called several times and several messages were left. The administrator/supervising nurse said the patient's family is very particular with what he will allow for the patient's care. The administrator/supervising nurse said she would have to ask to determine if the physician was informed of the patient's complaint of pain on 12/01/21. The administrator/supervising nurse said she did not know if the patient's complaint of pain, her pain medications not always being effective, and her need for additional assistance and decreased functional status were reported to the physician on 12/02/21. The administrator/supervising nurse said she would look to see if the physician was notified of the patient's complaint of pain on 12/04/21. The administrator/supervising nurse said there is always room to improve and she thought the hospice could do a better job of ensuring documentation of coordination of care with family members and the physician was included in the clinical record. The administrator/supervising nurse said Patient #1's family member usually does not want aggressive treatment or surgery for the patient and said it is difficult to get him to agree to allow the patient to go to the ER. The administrator/supervising nurse said Patient #1's plan of care didn't change that much after the x-rays were obtained and the fracture was identified. The administrator/supervising nurse said the hospice did increase the dosage of the patient's pain medications following identification of the fracture. The administrator/supervising nurse said the staff absolutely should have notified the physician of the issues identified during the investigation and documented above. The administrator/supervising nurse said the timeframe for staff to report to the physician would depend on the issue but should be reported quickly. The administrator/supervising nurse said most reports should be made the same day. The administrator/supervising nurse said the hospice's policy regarding documentation of coordination of care should indicate the hospice would document this in the patient's clinical record but she would have to review the written policy to determine if this was included in the policy or not. The administrator/supervising nurse said she didn't think RN D's, statement that if she documented that she had not conducted a comprehensive pain assessment during a visit that this meant the patient did not have any pain on this visit was accurate based on her review of the records. The administrator/supervising nurse said in the hospice's electronic medical record system if you select, yes, to indicate the clinician is conducting a comprehensive pain assessment, the clinician can select the type of pain scale being used to conduct the assessment. The administrator/supervising nurse said she would expect the nurse to utilize a pain scale of some type to assess the patient's pain during each skilled nurse visit when the patient experienced pain. The administrator/supervising nurse said she would expect the clinician to assess a patient for injuries after a fall prior to getting the patient up to the bed from the floor. During an interview conducted on 12/10/21 at 9:31 a.m., the medical director E said she did not receive a call from the nurse regarding Patient #1` on 11/21/21. The medical director E said she did receive a call on 11/22/21 and they discussed pain medications and looked at changing her to a pain patch. The medical director E they were unable to get ahold of the patient's family member to get approval. The medical director E said she also had text messages on 11/29/21 and 11/30/21 where they were still discussing changing her medications and getting her pain under better control. The medical director E said she was never informed of the patient's request to go to the hospital due to pain on 11/24/21. The medical director E said on 12/04/21 she was notified of the fall, but she was just told the patient scraped her knee. The medical director E said on 12/06/21 they decided to do the x-rays. The medical director E said she was not notified that the ALF staff had reported the patient's pain medications were not always effective at controlling her pain. The medical director E said if she had known the patient was consistently complaining of pain to the same area and had a change in her functional status this could have affected her decisions to order additional interventions and said she might have ordered x-rays sooner if she had been notified of this information. Record review of a hospice policy titled, "Hospice Nursing Care," dated November 2020, indicated, "--------------- (name of hospice) ... nursing services will be provided in accordance with physician's order, the patient plan of care, and accepted standards of practice by or under the supervision of a registered nurse ... The hospice nurse will play a key role in easing physical and psychosocial symptoms and initiating communication with the interdisciplinary group to establish the plan of care ... Duties will include the responsibility for coordination of care, fostering communication between the patient and the interdisciplinary group ... The hospice nurse will ... report the condition of patient and family/caregiver to the attending physician, Medical Director, and interdisciplinary group on a regular basis, as well as changes in the plan of care ... The hospice nurse will ... Manage discomfort and provide symptom relief according to physician orders ... Provide an ongoing evaluation of the patient and family/caregiver response to care ..." The administrator/supervising nurse was notified on 12/13/21 at 3:20 p.m. that an Immediate Jeopardy situation had been identified due to the above failure. On 12/10/21 at 9:51 p.m., the surveyor received the hospice's plan of removal. This plan of removal was first submitted for the IT which was identified on 12/10/21. The plan of removal was considered acceptable for the IJ as well as the IT as the issues involved were similar for the IT and the IJ. The plan of removal, dated 12/10/21, indicated the hospice would implement the following interventions to correct the immediate threat: The Administrator/Designee would provide mandatory in-service retraining and reeducation on 12/13/21 to nursing staff on policies regarding the Patient Bill of Rights, Assessment of Possible Abuse and Neglect, and Hospice Nursing Care. The Administrator/Designee would review 100% of current census beginning the week of 12/13/21 to ensure they are compliant with the regulatory standards, and the nurses involved are compliant in their respective practice acts. The Administrator/Designee would then review 5 charts each week beginning the week of 12/20/21 for the next 2 months for 90% compliance. On 12/13/21 the surveyor received in-service training records for the hospice's current staff indicating the hospice had provided in-service training on this date regarding the Patient Bill of Rights, Assessment of Possible Abuse and Neglect, and Hospice Nursing Care, including access to emergency room, radiology, and laboratory, on-call/weekend services, provision of care to clients who reside in nursing or assisted living facilities, on-going assessment, and pain assessments. On 12/13/21 the surveyor interviewed 3 current hospice employees (the administrator/supervising nurse, the hospice aide F, and the hospice aide J). (The administrator/supervising nurse is the only nurse currently employed at the hospice who is providing nursing visits.) The hospice aide F and the hospice aide J said they had received in-service training from the hospice on 12/13/21 regarding client rights and abuse, neglect, and exploitation. The administrator/supervising nurse said she had received in-service training on 12/13/21 on client rights, abuse, neglect and exploitation, and hospice nursing care policies and practices. On 12/13/21 at 3:45 p.m., the administrator/supervising nurse was informed that the IJ was removed. However deficient practice was present at a condition level. The hospice was continuing to implement the plan of removal.

Based on interview and record review, the hospice failed to ensure care and services were provided in accordance with the plan of care for 1 of 3 (Patient #1) patient reviewed. This failure could have contributed to Patient #1 experiencing continuing pain and discomfort and could result in other patients experiencing pain which is not effectively managed. The findings included: Record review of the clinical record for Patient #1 indicated the patient had a start of care date with the hospice of 10/19/17 and indicated the patient had a primary diagnosis of Alzheimer's disease. Record review of the clinical record for Patient #1 included a Hospice POC Report, not dated, which indicated the patient had an identified problem of altered comfort. The Hospice POC Report indicated the patient had a skilled nursing need for observation and assessment of altered comfort. The Hospice POC Report indicated the skilled nurse would implement the following intervention: Monitor pain level using the appropriate pain scale. Record review of a physician's order, dated 09/17/21, indicated the client had the following medications ordered for pain: Gabapentin 300 mg three times a day by mouth; Hydrocodone 5mg/Acetaminophen 325 mg four times a day at 8:00 a.m., 12:00 p.m., 4:00 p.m., and 8:00 p.m. by mouth; Morphine Concentrate 100mg/5ml solution 1ml as needed [no other frequency is included] by mouth; and MS Contin 30 mg tablet, extended release, once a day at bedtime by mouth. Record review of a physician's order, dated 11/12/21, indicated the client had the following medications ordered for pain: Gabapentin 300 mg three times a day by mouth; Hydrocodone 5mg/Acetaminophen 325 mg four times a day at 8:00 a.m., 12:00 p.m., 4:00 p.m., and 8:00 p.m. by mouth; Morphine Concentrate 100mg/5ml solution 1ml as needed [no other frequency is included] by mouth; and MS Contin 30 mg tablet, extended release, once a day at bedtime by mouth. Record review of the clinical record for Client #1 indicated the client refused medications at times. Record review of the clinical record for Client #1 indicated the client did not have pain medication ordered via a route other than oral until 11/30/21. Record review of the clinical record for Patient #1 included skilled nurse's notes, for the dates of 09/20/21, 09/27/21, 10/04/21, 10/11/21, 10/18/21, 10/25/21, and 11/08/21, which indicated Patient #1's pain was rated at a 0 on these visits. Record review of the clinical record for Patient #1 included a skilled nurse's note, dated 11/03/21, signed by the RN D, which indicated the skilled nurse did not complete a comprehensive pain assessment, including use of a pain scale during this visit. There was no documentation to indicate if the patient was having pain during this visit. Record review of the clinical record for Patient #1 included a skilled nurse's note, dated 11/12/21, signed by the administrator/supervising nurse, which indicated the skilled nurse did not complete a comprehensive pain assessment, including use of a pain scale during this visit. The note indicated, "No acute distress at thisvtime (sic)." Record review of the clinical record for Patient #1 included a skilled nurse's note, dated 11/15/21, signed by the administrator/supervising nurse, which indicated the skilled nurse did not complete a comprehensive pain assessment, including use of a pain scale during this visit. The note indicated, "Patient denies pain or discomforts (sic)." Record review of the clinical record for Patient #1 included a skilled nurse's note, dated 11/18/21, signed by the administrator/supervising nurse, which indicated the skilled nurse did not complete a comprehensive pain assessment, including use of a pain scale during this visit. The note indicated, "No non-verbal S/S of pain noted." Record review of the clinical record for Patient #1 included an on-call nursing note, dated 11/21/21, signed by the RN H, which indicated the hospice's on-call nurse, the RN H, received a call from the ALF where Patient #1 resides reporting the patient fell out of bed to the floor with complaint of pain to her groin. The note indicated the call was received at 12:59 a.m. The note further indicated on 11/21/21 at 9:05 a.m. the hospice on-call nurse made a follow-up phone call with ALF staff. The note indicated the ALF staff reported the patient was still having pain but was refusing pain medication. The note indicated the patient reported she hurt from her head to her toes and was unable to be specific. The note indicated the patient's left groin/ left leg were in question and indicated no difference in size/length of legs and no internal or external rotation were noted. The note indicated no discoloration to the legs was noted. The note indicated the hospice on-call nurse advised the ALF to monitor the patient and notify the hospice of any changes. Record review of the clinical record for Patient #1 did not include documentation to indicate the hospice nurse conducted a visit with Patient #1 to assess the patient's pain following the fall and complaint of pain on 11/21/21. Record review of the clinical record for Patient #1 included a skilled nurse's note, dated 11/22/21, signed by the administrator/supervising nurse, which indicated a comprehensive pain assessment, including use of the visual pain scale, was conducted during this visit. The note indicated the patient's pain during this visit was rated at a 4 - hurts a little more (the scale measures pain from no pain, hurts a little, hurts a little more, hurts even more, hurts a whole lot, hurts worst). The note further indicated, "Patient had falls over the weekend and some facial grimacing during assessment." Record review of the clinical record for Patient #1 included a skilled nurse's note, dated 11/23/21, signed by the administrator/supervising nurse, which indicated a comprehensive pain assessment, including use of the pain scale for the cognitively impaired, was conducted during this visit. The note indicated the patient's pain during this visit was scored a 1 for displaying the following behaviors: occasional labored breathing, short period of hyperventilation, occasional moan or groan, low-level speech with negative or disapproving quality, sad and/or frightened facial expression or frown, tense body language with distressed pacing and/or fidgeting. The note further indicated, "Patient had a fall last night and has some facial grimacing during assessment." Record review of the clinical record for Patient #1 included a hospice aide visit note, dated 11/24/21, signed by the hospice aide F, which indicated, "Pt is harder to transfer due to her left hip & thigh hurts when she puts her weight on it. It is from the recent falls she has had. ---------------- (name of the administrator/supervising nurse) RN administrator notified." Record review of the clinical record for Patient #1 included a skilled nurse's note, dated 11/24/21, signed by the RN D, which indicated a comprehensive pain assessment, including use of a pain scale, was not conducted during this visit. The note indicated, "On call visit ... patient requesting to go to hospital due to pain in hip." The note indicated the nurse advised the ALF to medicate the patient for pain and upon the nurse's arrival the patient's pain was improved and she was assisted back into bed. Record review of the clinical record for Patient #1 included a patient coordination note, dated 11/26/21, which indicated, "Received a call from ------------- (name of the ALF where Patient #1 resides), Patient is in pain. Stated patient is in bed sleeping but wanted to let us know she has been in pain. I asked if she was currently comfortable stated yes, but she knows the client likes to be around in her wheelchair and she could not get up this evening because of pain." Record review of the clinical record for Patient #1 included a hospice aide visit note, dated 11/26/21, signed by the hospice aide F, which indicated, "I arrived & Pt was sitting on her sofa. She said she needed me to help her to the restroom, but she would not allow me to transfer her to the wheelchair because she has somuch (sic) pain in her left hip & side. I called for an aide to help me & she still would not allow us to get her up off of the sofa. She started yelling help & get away, leave me alone, so she refused bath & all care. ------------- (name of the administrator/supervising nurse) RN administrator notified." Record review of the clinical record for Patient #1 did not include documentation to indicate the hospice nurse conducted a visit with Patient #1 to assess the patient's pain following the report from the ALF or the hospice aide on 11/26/21. Record review of the clinical record for Patient #1 included a skilled nurse's note, dated 11/29/21 (9 days after the patient first began consistently complaining of pain to her left hip/leg/side area), signed by the administrator/supervising nurse, which indicated a comprehensive pain assessment, including use of a pain scale, was not conducted during this visit. The note indicated, "Spoke with ----------- (name of an ALF employee) about patients (sic) care, she states patient has not been consistent on taking her routine medication and will frequently c/o pain and then not open her mouth to take the pain medication. Spoke with ---------- (name of the physician for Patient #1, the medical director E) about patient status, discussed switching patient to Fentanyl patch for more effective pain control, call placed to patients (sic) --------- (family member) to ask if he approves of medication change with no answer to phone call. Message left." Record review of the clinical record for Patient #1 included a skilled nurse's note, dated 11/30/21, signed by the RN, D, which indicated a comprehensive pain assessment, including use of a pain scale, was not conducted during this visit. The note indicated, "States she hurts all the time ... CM is changing her medication to Fentanyl patch for consistent pain control." Record review of the clinical record for Patient #1 included a patient coordination note, dated 12/08/21, as a late entry for 11/30/21, which indicated the patient's family member returned the hospice's phone call regarding medication changes. The note indicated the patient's family member was reluctant to change the patient's medications because the last time she was prescribed Fentanyl she became very drowsy. The note indicated the patient's family member agreed to the medication changes but requested the patient be started at the lowest dose. Record review of the clinical record for Patient #1 indicated Patient #1 was started on a Fentanyl patch at 25 MCG/HR one patch to be applied every 72 hours on 11/30/21. Record review of the clinical record for Patient #1 did not include documentation to indicate the hospice had attempted to contact Patient #1's family member prior to 11/29/21 to discuss changing her pain medications. Record review of the clinical record for Patient #1 included a hospice aide visit note, dated 12/01/21, signed by the hospice aide F, which indicated, "Pt is complaining of pain when she puts weight on her left leg. She says it hurts up in her left abdomen & left side of hip & the pain goes down her left leg ... ---------- (name of the administrator/supervising nurse) RN administrator notified." Record review of the clinical record for Patient #1 included a social worker visit note, dated 12/02/21, signed by the social worker G, which indicated the patient was "uncomfortable because of pain." The note indicated the social worker G notified the RN D regarding the patient's complaint of pain during this visit. The note further indicated, "Patient complained of pain in her left leg. Social worker talk (sic) to med aide who said she has her Fentanyl patch and she gave her some morphine earlier, said it does not always cure for pain." Record review of the clinical record for Patient #1 included a skilled nurse's note, dated 12/02/21, signed by the RN D, which indicated a comprehensive pain assessment, including use of the verbal pain scale, was conducted during this visit. The note indicated the patient rated her pain during this visit as a 7-8, hurts a whole lot. The note indicated the patient reported her pain in the last 24 hours as severe pain. The note indicated the patient reported her acceptable pain level would be mild pain. The note indicated the patient reported the pain was to her left hip. The note further indicated, "Patient states she hurts on her left side ... she is unable to get out of bed without maximal lift assist to chair. Patient is aware of this change. She states she is in pain." Record review of the clinical record for Patient #1 included a skilled nurse's note, dated 12/04/21, signed by the RN, D, which indicated a comprehensive pain assessment, including use of a pain scale, was not conducted during this visit. The note indicated, "Patient reports that she has pain always and cannot walk or sit in chair because of pain." Record review of the clinical record for Patient #1 included a skilled nurse's note, dated 12/06/21 (16 days after the documentation shows the patient began consistently complaining of pain to the left hip/leg/side area), signed by the administrator/supervising nurse, which indicated, "Patient continues to be in pain dispite (sic) medication, pain medication adjustments to be made." The note indicated a comprehensive pain assessment, including use of the pain scale for the cognitively impaired, was completed during this visit. The note indicated the patient's pain during this visit was scored a 6 indicating moderate pain. The note indicated the patient demonstrated the following signs of pain: occasional labored breathing and/or short periods of hyperventilation, repeated trouble calling out, loud moaning or groaning, crying, sad and/or frightened facial expression and/or frown, and tense body language, distressed pacing and/or fidgeting. The note further indicated, "Staff from ------------ (name of the ALF where Patient #1 resides) had notified hospice this morning that patient was still having pain to the left leg. ------------- (name of the medical director, E) notified and xrays ordered ... During xrays ... patient moaning and showing facial grimacing ... Upon receiving final report, SN called results to ------------ (name of medical director E) and patient --------- (family member). Xrays showing fracture to left femoral neck into greater trochanter ... ----------- (family member) agreed to increased (sic) medication for pain." Record review of the clinical record for Patient #1 included a physician's order, dated 12/06/21, which indicated the physician ordered to increase the Fentanyl patch from 25 to 50 MCG and increased the morphine to 1 ml every 2 hours as needed for pain. Record review of the clinical record for Patient #1 indicated the previous order for morphine indicated the patient was to receive morphine 1ml as needed but did not include a frequency, such as every two hours. Record review of the clinical record for Patient #1 included a skilled nurse's note, dated 12/08/21, signed by the administrator/supervising nurse, which indicated during this visit the patient rated her pain as a 2 - hurts a little bit. The note indicated, "Patient is more alert this visit ... Patient smiles at SN and appears relaxed. No s/s non-verbal or verbal during this visit." During an interview conducted on 12/09/21, from 10:48 a.m. - 11:54 a.m., the RN D, said she was a case manager with the hospice. The RN D said the administrator/supervising nurse is Patient #1's case manager. The RN, D, said she [RN D] was on-call on 12/04/21. The RN D said she received a call from the on-call service on 12/04/21 regarding Patient #1. The RN D said when she arrived, she proceeded through the patient's apartment to her bedroom and found the patient on the floor. The RN D said she did not do an assessment or get the patient's vital signs until after the patient had been assisted back into bed. The RN D said the patient was complaining of pain while she was on the floor. The RN D said the patient has been complaining of pain to her left side and this was not a new complaint. The RN D said she was not sure when the patient had begun complaining of the pain to the left side and said the patient had multiple falls and while the complaint began after one of the falls she was not sure which fall. The RN D then said the patient had not complained of pain while on the floor but only complained of pain after she was in the bed. The RN D said she was speaking with the patient once she was in bed and the patient said she was hurting. The RN D said she could not recall if the patient stated verbally the location of her pain or indicated it with her hand, but the patient indicated she was having pain to her left hip. The RN D said the patient was not able to rate her pain using a 1-10 numerical scale. The RN D said the hospice did use a non-numerical scale for patients who were unable to use the numerical scale, but she did not ask the patient to rate her pain during the visit on 12/04/21. The RN D said the only indication she had regarding whether the patient's pain was improved, worsened, or the same by the end of the visit was that the patient appeared more comfortable and relaxed and was falling asleep. The RN D said she did not ask the patient if her pain was improved. The RN D said the patient's pain did not seem worse during this visit than previously to her. The RN D said it was difficult to tell with the patient. The RN D said the patient didn't cry out when they were changing her, but she kept grabbing things because she was afraid of falling. The RN D said the patient's only reaction was grabbing people or things due to her fear when they rolled her to the edge of the bed that she would fall. During an interview conducted on 12/09/21 at 2:26 p.m., with Patient #1, the patient was unable to answer questions about the hospice. The patient was observed to be calm. During an interview conducted on 12/10/21 at 10:02 a.m., the RN H said the weekend of 11/21/21 was her first-time taking call for the hospice. The RN H said she was assisting the hospice that weekend by taking call as the hospice had a nursing staff shortage. The RN H said Patient #1 had two falls on 11/21/21. The RN H said after the first fall on 11/21/21 there were no injuries. The RN H said after the second fall the patient was complaining of pain to the left groin/leg but no signs or symptoms of injuries were noted and the patient was able to move and just had some discomfort which was to be expected after the number of falls that weekend. During an interview conducted on 12/10/21 at 10:14 a.m., the social worker G said on 12/02/21 she called the RN D to report the patient's complaints of pain and that the ALF staff said the pain medications were not always effective. The social worker G said the patient's family member can be very difficult to get a hold of and said she knew they had been trying to reach him regarding this, but it was several days before he called back. During an interview conducted on 12/10/21 at 10:30 a.m., with the hospice aide F when presented with the findings regarding Patient #1 which indicated the patient had a change in the amount of pain she experienced and in her functional status beginning on or around 11/21/21, the hospice aide F said this was correct. The hospice aide F said the patient became harder to transfer around this time and said previously the patient had been able to help more but she could tell it was a lot harder for the patient. The hospice aide F said around this time the patient had experienced several falls. The hospice aide F said the patient was consistently complaining of pain to the left hip/leg/side area. The hospice aide F said on 11/26/21 the patient was sitting on the sofa in living room and said she needed to go to the bathroom but when she went to assist her up the patient began crying and holding her side like she was in pain. The hospice aide F said she pulled the call light for assistance but when the ALF aide came to assist her the patient would not allow them to assist her. The hospice aide F said she had notified the RN of the patient's complaints of pain. The hospice aide F said she couldn't recall the exact dates but around 12/06/21 - 12/07/21 the patient had refused care. The hospice aide F said on one visit the patient held onto her blanket and wouldn't even let her check to see if she had been incontinent and needed to be changed. The hospice aide F said the patient had a scared look on her face during this visit. During an interview conducted on 12/10/21 at 10:43 a.m., the RN D said around 11/21/21 - 12/04/21, the patient had multiple falls and had an increase in pain around that time. The RN D said the patient often refused medications from the ALF staff. The RN D said they changed the patient's pain medications from oral medications to a Fentanyl patch around this time. The RN D said her process for completing pain assessments depends on how well the patient can vocalize. The RN D said if the patient was able to use the numerical scale she would use this and said if the patient was not able to do this, for example Patient #1, she would use the scale that says it hurts a little, hurts a lot, hurts a whole lot. The RN D said if she documented that no comprehensive pain assessment was completed during a visit it was because the patient wasn't complaining of pain. During an interview conducted on 12/10/21 at 1:30 p.m., the administrator/supervising nurse said Patient #1's plan of care didn't change that much after the x-rays were obtained and the fracture was identified. The administrator/supervising nurse said the hospice did increase the dosage of the patient's pain medications following identification of the fracture. The administrator/supervising nurse said she didn't think RN D's, statement that if she documented that she had not conducted a comprehensive pain assessment during a visit that this meant the patient did not have any pain on this visit was accurate based on her review of the records. The administrator/supervising nurse said in the hospice's electronic medical record system if you select, yes, to indicate the clinician is conducting a comprehensive pain assessment, the clinician can select the type of pain scale being used to conduct the assessment. The administrator/supervising nurse said she would expect the nurse to utilize a pain scale of some type to assess the patient's pain during each skilled nurse visit when the patient experienced pain. Record review of a hospice policy titled, "The Plan of Care," dated August 2021, indicated, "The care provided to the patient must be in accordance with the plan of care."

Based on interview and record review, the hospice failed to provide for and ensure the ongoing sharing of information between all disciplines providing care and services in all settings for 1 of 3 (Patient #1) patient reviewed. This failure resulted in Patient #1 experiencing continuing pain and discomfort and could result in other patients experiencing pain which is not effectively managed. The findings included: Record review of the clinical record for Patient #1 indicated the patient had a start of care date with the hospice of 10/19/17 and indicated the patient had a primary diagnosis of Alzheimer's disease. Record review of the clinical record for Patient #1 included a Hospice POC Report, not dated, which indicated the patient had an identified problem of altered comfort. The Hospice POC Report indicated the patient had a skilled nursing need for observation and assessment of altered comfort. The Hospice POC Report indicated the skilled nurse would implement the following intervention: Monitor pain level using the appropriate pain scale. Record review of a physician's order, dated 09/17/21, indicated the client had the following medications ordered for pain: Gabapentin 300 mg three times a day by mouth; Hydrocodone 5mg/Acetaminophen 325 mg four times a day at 8:00 a.m., 12:00 p.m., 4:00 p.m., and 8:00 p.m. by mouth; Morphine Concentrate 100mg/5ml solution 1ml as needed [no other frequency is included] by mouth; and MS Contin 30 mg tablet, extended release, once a day at bedtime by mouth. Record review of a physician's order, dated 11/12/21, indicated the client had the following medications ordered for pain: Gabapentin 300 mg three times a day by mouth; Hydrocodone 5mg/Acetaminophen 325 mg four times a day at 8:00 a.m., 12:00 p.m., 4:00 p.m., and 8:00 p.m. by mouth; Morphine Concentrate 100mg/5ml solution 1ml as needed [no other frequency is included] by mouth; and MS Contin 30 mg tablet, extended release, once a day at bedtime by mouth. Record review of the clinical record for Client #1 indicated the client refused medications at times. Record review of the clinical record for Client #1 indicated the client did not have pain medication ordered via a route other than oral until 11/30/21. Record review of the clinical record for Patient #1 included skilled nurse's notes, for the dates of 09/20/21, 09/27/21, 10/04/21, 10/11/21, 10/18/21, 10/25/21, and 11/08/21, which indicated Patient #1's pain was rated at a 0 on these visits. Record review of the clinical record for Patient #1 included a skilled nurse's note, dated 11/03/21, signed by the RN D, which indicated the skilled nurse did not complete a comprehensive pain assessment, including use of a pain scale during this visit. There was no documentation to indicate if the patient was having pain during this visit. Record review of the clinical record for Patient #1 included a skilled nurse's note, dated 11/12/21, signed by the administrator/supervising nurse, which indicated the skilled nurse did not complete a comprehensive pain assessment, including use of a pain scale during this visit. The note indicated, "No acute distress at thisvtime (sic)." Record review of the clinical record for Patient #1 included a skilled nurse's note, dated 11/15/21, signed by the administrator/supervising nurse, which indicated the skilled nurse did not complete a comprehensive pain assessment, including use of a pain scale during this visit. The note indicated, "Patient denies pain or discomforts (sic)." Record review of the clinical record for Patient #1 included a skilled nurse's note, dated 11/18/21, signed by the administrator/supervising nurse, which indicated the skilled nurse did not complete a comprehensive pain assessment, including use of a pain scale during this visit. The note indicated, "No non-verbal S/S of pain noted." Record review of the clinical record for Patient #1 included an on-call nursing note, dated 11/21/21, signed by the RN H, which indicated the hospice's on-call nurse, the RN H, received a call from the ALF where Patient #1 resides reporting the patient fell out of bed to the floor with complaint of pain to her groin. The note indicated the call was received at 12:59 a.m. The note further indicated on 11/21/21 at 9:05 a.m. the hospice on-call nurse made a follow-up phone call with ALF staff. The note indicated the ALF staff reported the patient was still having pain but was refusing pain medication. The note indicated the patient reported she hurt from her head to her toes and was unable to be specific. The note indicated the patient's left groin/ left leg were in question and indicated no difference in size/length of legs and no internal or external rotation were noted. The note indicated no discoloration to the legs was noted. The note indicated the hospice on-call nurse advised the ALF to monitor the patient and notify the hospice of any changes. Record review of the clinical record for Patient #1 did not include documentation to indicate the hospice nurse conducted a visit with Patient #1 to assess the patient following the fall and complaint of pain on 11/21/21 or to indicate the physician was notified of the fall or complaints of pain on this date. Record review of the clinical record for Patient #1 included a skilled nurse's note, dated 11/22/21, signed by the administrator/supervising nurse, which indicated a comprehensive pain assessment, including use of the visual pain scale, was conducted during this visit. The note indicated the patient's pain during this visit was rated at a 4 - hurts a little more (the scale measures pain from no pain, hurts a little, hurts a little more, hurts even more, hurts a whole lot, hurts worst). The note further indicated, "Patient had falls over the weekend and some facial grimacing during assessment." Record review of the clinical record for Patient #1 did not include documentation to indicate the skilled nurse notified the physician of the falls over the weekend or the patient's complaint of pain during this visit. Record review of the clinical record for Patient #1 included a skilled nurse's note, dated 11/23/21, signed by the administrator/supervising nurse, which indicated a comprehensive pain assessment, including use of the pain scale for the cognitively impaired, was conducted during this visit. The note indicated the patient's pain during this visit was scored a 1 for displaying the following behaviors: occasional labored breathing, short period of hyperventilation, occasional moan or groan, low-level speech with negative or disapproving quality, sad and/or frightened facial expression or frown, tense body language with distressed pacing and/or fidgeting. The note further indicated, "Patient had a fall last night and has some facial grimacing during assessment." Record review of the clinical record for Patient #1 did not include documentation to indicate the skilled nurse notified the physician of the fall or the patient's signs of pain during this visit. Record review of the clinical record for Patient #1 included a hospice aide visit note, dated 11/24/21, signed by the hospice aide F which indicated, "Pt is harder to transfer due to her left hip & thigh hurts when she puts her weight on it. It is from the recent falls she has had. ---------------- (name of the administrator/supervising nurse) RN administrator notified." Record review of the clinical record for Patient #1 included a skilled nurse's note, dated 11/24/21, signed by the RN D, which indicated a comprehensive pain assessment, including use of a pain scale, was not conducted during this visit. The note indicated, "On call visit ... patient requesting to go to hospital due to pain in hip." The note indicated the nurse advised the ALF to medicate the patient for pain and upon the nurse's arrival the patient's pain was improved and she was assisted back into bed. Record review of the clinical record for Patient #1 did not include documentation to indicate the skilled nurse notified the physician of the patient's complaint of pain or request to be transferred to the hospital due to the pain in her hip on this date. Record review of the clinical record for Patient #1 included a patient coordination note, dated 11/26/21, which indicated, "Received a call from ------------- (name of the ALF where Patient #1 resides), Patient is in pain. Stated patient is in bed sleeping but wanted to let us know she has been in pain. I [hospice nurse] asked if she was currently comfortable stated yes, but she [ALF staff member] knows the client likes to be around in her wheelchair and she could not get up this evening because of pain." Record review of the clinical record for Patient #1 included a hospice aide visit note, dated 11/26/21, signed by the hospice aide F which indicated, "I arrived & Pt was sitting on her sofa. She said she needed me to help her to the restroom, but she would not allow me to transfer her to the wheelchair because she has somuch (sic) pain in her left hip & side. I called for an aide to help me & she still would not allow us to get her up off of the sofa. She started yelling help & get away, leave me alone, so she refused bath & all care. ------------- (name of the administrator/supervising nurse) RN administrator notified." Record review of the clinical record for Patient #1 did not include documentation to indicate the skilled nurse notified the physician of the reports of pain from the ALF staff or the hospice aide during this visit. Record review of the clinical record for Patient #1 included a skilled nurse's note, dated 11/29/21 (9 days after the patient first began consistently complaining of pain to her left hip/leg/side area), signed by the administrator/supervising nurse, which indicated a comprehensive pain assessment, including use of a pain scale, was not conducted during this visit. The note indicated, "Spoke with ----------- (name of an ALF employee) about patients (sic) care, she states patient has not been consistent on taking her routine medication and will frequently c/o pain and then not open her mouth to take the pain medication. Spoke with ---------- (name of the physician for Patient #1, the medical director E) about patient status, discussed switching patient to Fentanyl patch for more effective pain control, call placed to patients (sic) --------- (family member) to ask if he approves of medication change with no answer to phone call. Message left." Record review of the clinical record for Patient #1 included a skilled nurse's note, dated 11/30/21, signed by the RN D, which indicated a comprehensive pain assessment, including use of a pain scale, was not conducted during this visit. The note indicated, "States she hurts all the time ... CM is changing her medication to Fentanyl patch for consistent pain control." Record review of the clinical record for Patient #1 included a patient coordination note, dated 12/08/21, as a late entry for 11/30/21, which indicated the patient's family member returned the hospice's phone call regarding medication changes. The note indicated the patient's family member was reluctant to change the patient's medications because the last time she was prescribed Fentanyl she became very drowsy. The note indicated the patient's family member agreed to the medication changes but requested the patient be started at the lowest dose. Record review of the clinical record for Patient #1 indicated Patient #1 was started on a Fentanyl patch at 25 MCG/HR one patch to be applied every 72 hours on 11/30/21. Record review of the clinical record for Patient #1 did not include documentation to indicate the hospice had attempted to contact Patient #1's family member prior to 11/29/21 to discuss changing her pain medications. Record review of the clinical record for Patient #1 included a hospice aide visit note, dated 12/01/21, signed by the hospice aide F, which indicated, "Pt is complaining of pain when she puts weight on her left leg. She says it hurts up in her left abdomen & left side of hip & the pain goes down her left leg ... ---------- (name of the administrator/supervising nurse) RN administrator notified." Record review of the clinical record for Patient #1 included a social worker visit note, dated 12/02/21, signed by the social worker G, which indicated the patient was "uncomfortable because of pain." The note indicated the social worker G notified the RN D regarding the patient's complaint of pain during this visit. The note further indicated, "Patient complained of pain in her left leg. Social worker talk (sic) to med aide who said she has her Fentanyl patch and she gave her some morphine earlier, said it does not always cure for pain." Record review of the clinical record for Patient #1 included a skilled nurse's note, dated 12/02/21, signed by the RN D, which indicated a comprehensive pain assessment, including use of the verbal pain scale, was conducted during this visit. The note indicated the patient rated her pain during this visit as a 7-8, hurts a whole lot. The note indicated the patient reported her pain in the last 24 hours as severe pain. The note indicated the patient reported her acceptable pain level would be mild pain. The note indicated the patient reported the pain was to her left hip. The note further indicated, "Patient states she hurts on her left side ... she is unable to get out of bed without maximal lift assist to chair. Patient is aware of this change. She states she is in pain." Record review of the clinical record for Patient #1 did not include documentation to indicate the skilled nurse notified the physician of the patient's complaint of pain during this visit. Record review of the clinical record for Patient #1 included a skilled nurse's note, dated 12/04/21, signed by the RN D, which indicated a comprehensive pain assessment, including use of a pain scale, was not conducted during this visit. The note indicated, "Patient reports that she has pain always and cannot walk or sit in chair because of pain." Record review of the clinical record for Patient #1 did not include documentation to indicate the skilled nurse notified the physician of the patient's complaint of pain during this visit. Record review of the clinical record for Patient #1 included a skilled nurse's note, dated 12/06/21 (16 days after the documentation shows the patient began consistently complaining of pain to the left hip/leg/side area), signed by the administrator/supervising nurse, which indicated, "Patient continues to be in pain dispite (sic) medication, pain medication adjustments to be made." The note indicated a comprehensive pain assessment, including use of the pain scale for the cognitively impaired, was completed during this visit. The note indicated the patient's pain during this visit was scored a 6 indicating moderate pain. The note indicated the patient demonstrated the following signs of pain: occasional labored breathing and/or short periods of hyperventilation, repeated trouble calling out, loud moaning or groaning, crying, sad and/or frightened facial expression and/or frown, and tense body language, distressed pacing and/or fidgeting. The note further indicated, "Staff from ------------ (name of the ALF where Patient #1 resides) had notified hospice this morning that patient was still having pain to the left leg. ------------- (name of the medical director, E) notified and xrays ordered ... During xrays ... patient moaning and showing facial grimacing ... Upon receiving final report, SN called results to ------------ (name of medical director E) and patient --------- (family member). Xrays showing fracture to left femoral neck into greater trochanter ... ------------- (family member) agreed to increased (sic) medication for pain." Record review of the clinical record for Patient #1 included a physician's order, dated 12/06/21, which indicated the physician ordered to increase the Fentanyl patch from 25 to 50 MCG and increased the morphine to 1 ml every 2 hours as needed for pain. Record review of the clinical record for Patient #1 indicated the previous order for morphine indicated the patient was to receive morphine 1ml as needed but did not include a frequency, such as every two hours. Record review of the clinical record for Patient #1 included a skilled nurse's note, dated 12/08/21, signed by the administrator/supervising nurse, which indicated during this visit the patient rated her pain as a 2 - hurts a little bit. The note indicated, "Patient is more alert this visit ... Patient smiles at SN and appears relaxed. No s/s non-verbal or verbal during this visit." During an interview conducted on 12/09/21, from 10:48 a.m. - 11:54 a.m., the RN D, said she was a case manager with the hospice. The RN D said the administrator/supervising nurse is Patient #1's case manager. The RN, D, said she [RN D] was on-call on 12/04/21. The RN D said she received a call from the on-call service on 12/04/21 regarding Patient #1. The RN D said when she arrived, she proceeded through the patient's apartment to her bedroom and found the patient on the floor. The RN D said she did not do an assessment or get the patient's vital signs until after the patient had been assisted back into bed. The RN D said the patient was complaining of pain while she was on the floor. The RN D said the patient has been complaining of pain to her left side and this was not a new complaint. The RN D said she was not sure when the patient had begun complaining of the pain to the left side and said the patient had multiple falls and while the complaint began after one of the falls she was not sure which fall. The RN D then said the patient had not complained of pain while on the floor but only complained of pain after she was in the bed. The RN D said she was speaking with the patient once she was in bed and the patient said she was hurting. The RN D said she could not recall if the patient stated verbally the location of her pain or indicated it with her hand, but the patient indicated she was having pain to her left hip. The RN D said the patient was not able to rate her pain using a 1-10 numerical scale. The RN D said the hospice did use a non-numerical scale for patients who were unable to use the numerical scale, but she did not ask the patient to rate her pain during the visit on 12/04/21. The RN D said the only indication she had regarding whether the patient's pain was improved, worsened, or the same by the end of the visit was that the patient appeared more comfortable and relaxed and was falling asleep. The RN D said she did not ask the patient if her pain was improved. The RN D said she did not get the patient's vital signs and didn't complete a full assessment. The RN D said the patient was breathing ok, and as far as she could tell the patient's leg was not rotated or shortened. The RN D said she did not manually move anything but just did a visual assessment and everything looked like it lined up ok. The RN D said she didn't try to move the leg to assess it. The RN D said she did not do a full skin assessment. The RN D said the patient had an abrasion on her knee, but it didn't look new. The RN D said the patient had experienced multiple previous falls. The RN D said she did not examine the patient's leg for injuries. The RN D said she did assist the ALF staff to change the patient's clothes and while they were doing this, she did look at the patient. The RN D said she did not go back and do an assessment after this. The RN D said she didn't do any physical manipulation of the patient's body to assess the patient but she did observe as the patient was changed which required pulling her up in bed and rolling her from side to side. The RN D said the patient's pain did not seem worse during this visit than previously to her. The RN D said it was difficult to tell with the patient. The RN D said the patient didn't cry out when they were changing her, but she kept grabbing things because she was afraid of falling. The RN D said the patient's only reaction was grabbing people or things due to her fear when they rolled her to the edge of the bed that she would fall. The RN D said she did contact the administrator/supervising nurse after the visit and sent a text to the medical director E reporting the patient had a fall with no apparent injuries. The RN D said no new orders were received. The RN D said she did not contact the patient's family as she assumed the ALF would do this. The RN D said she normally does not contact the families and usually would just notify the physician. The RN D said the medical director E did respond and said, ok. The RN D said she called the administrator/supervising nurse as she was this patient's case manager and told her the patient had been found soaked in urine and had fallen. The RN D said the administrator/supervising nurse did not give her any additional tasks to do regarding the patient. The RN D said the patient routinely refuses her medications from the ALF and this is the reason she is on a Fentanyl patch. Record review of a written statement, dated 12/07/21, signed by RN D indicated on 12/04/21 the RN D received a call from the ALF where Patient #1 resides reporting the patient's oxygen saturation level was low. The written statement indicated the RN D made a visit to the patient and indicated during the visit the patient was found on the floor and during the visit said her hip hurt. During an interview conducted on 12/09/21 at 2:26 p.m., with Patient #1, the patient was unable to answer questions about the hospice. During an interview conducted on 12/09/21 at 2:28 p.m., the ALF medication aide L said on 12/04/21 the ALF medication aide M got a call from the hospice nurse, the RN D, who said Patient #1 was on the floor. The ALF medication aide L said when she and the ALF medication aide M arrived at the patient's room the hospice nurse, the RN D, had put the patient back into the bed. The ALF medication aide L said the ALF's policy is that they are supposed to get the patient's vital signs before picking the patient up off the floor. The ALF medication aide L said the patient was complaining of pain to her left side and she appeared to be in pain. The ALF medication aide L said she and the ALF medication aide M went to get pain medication for the patient. The ALF medication aide L said the ALF medication aide M attempted to give the patient the medication, but the patient moved her head away. The ALF medication aide L said the hospice nurse, the RN D, tried to hold the patient's head still and tried to force it in the patient's mouth. The ALF medication aide L said the medication they attempted to administer to Patient #1 was morphine and it was in a syringe. The ALF medication aide L said the ALF medication aide M put the syringe near the patient's mouth and the patient pulled her head away. The ALF medication aide L said because of this the ALF medication aide M gave up on trying to administer the medication. The ALF medication aide L said the hospice nurse, the RN D, then tried to administer the medication. The ALF medication aide L said the hospice nurse, the RN D, held the patient by her jaw and tried to put the medication in her mouth. The ALF medication aide L said the syringe was a couple of inches from the patient's mouth and the hospice nurse, the RN D, was trying to put the medication in the patient's mouth. The ALF medication aide L demonstrated this by holding her own jaw with one hand and putting her finger to the corner of her mouth to indicate the placement of the syringe. The ALF medication aide L said the patient turned her head away or tried to but was unable because the hospice nurse, the RN D, was holding her head. The ALF medication aide L said when the patient tried to turn her head away the medication went half-way into her mouth and the rest got on the side of her mouth. The ALF medication aide L said the hospice nurse, the RN D, did not say anything to the patient about the medication to tell her what she was doing or ask her if she wanted it. The ALF medication aide L said the patient was in pain and she could see that the patient was in pain. The ALF medication aide L said the ALF staff asked the hospice nurse, the RN D, about getting an x-ray for the patient and the hospice nurse, the RN D, said she thought the patient only needed rest and pain medication. The ALF medication aide said, however, the patient had refused the pain medication. The ALF medication aide L said it didn't seem like the hospice nurse cared. The ALF medication aide L said this was the first time she had seen the patient complain of pain like that. The ALF medication aide L said she thought the patient was in a lot of pain and said the patient usually doesn't complain of pain. During an interview conducted on 12/09/21 at 2:36 p.m., the ALF caregiver N said on 12/04/21 she was in the dining room at the ALF when Patient #1's light went off. The ALF caregiver N said when she got to the patient's room the patient was in bed. The ALF caregiver N said the ALF medication aides were trying to get the patient's vital signs but were unable to do so. The ALF caregiver N said the patient said her hip hurt, her hip hurt, and was complaining about it and yelling. The ALF caregiver N said it seemed like the hospice nurse wanted to leave. The ALF caregiver N said the patient doesn't complain of pain a lot and said the patient had never complained to her of pain. The ALF caregiver N said the whole time the patient was complaining and said usually when the patient says something is hurt something is hurt. During an interview conducted on 12/09/21 at 2:44 p.m., the ALF medication aide M said on Saturday 12/04/21 at around 12:45 to 12:50 p.m., she got a call from the hospice nurse, the RN D, saying Patient #1 had fallen. The ALF medication aide M said she asked the RN D, if she had gotten the patient's vital signs and asked her not to move the patient because the ALF's policy is for the staff to make sure the patient is in a somewhat comfortable position, get the patient's vital signs, ask the patient if they have any injuries or are hurt anywhere, and then notify the ALF's on-call medical staff before getting the patient up. The ALF medication aide M said she was just down the hall and was there in minutes, quickly, and as soon as she walked into the patient's room the RN D said she had put the patient in the bed. The ALF medication aide M said the patient was crying and she had never seen her cry before. The ALF medication aide M said the patient was begging to go to the hospital. The ALF medication aide M said the patient said her side hurt and was touching her hip indicating her hip was hurting. The ALF medication aide M said the patient refused vital signs when she tried to take them and asked her if she could send her to the hospital. The ALF medication aide M said she told the patient she did not have that authority, but the hospice nurse could make that decision. The ALF medication aide M said the hospice nurse, the RN D, said nothing could be done. The ALF medication aide M said it was not like the patient to even be crying. The ALF medication aide M said the patient will sometimes complain of pain or make a crying sound, but she doesn't cry tears and, on this date, (12/04/21) the patient was crying tears. The ALF medication aide M said she could tell this was different from the patient's usual behavior. The ALF medication aide M said the patient specifically said she wanted to go to the hospital. The ALF medication aide M said she did not see the RN D, assess the patient's leg or hip, and said the RN D, said nothing could be done. The ALF medication aide M said she told the RN D, there was something wrong and said the patient was crying and crying which was unusual for her. During an interview conducted on 12/10/21 at 10:02 a.m., the RN H said the weekend of 11/21/21 was her first-time taking call for the hospice. The RN H said she was assisting the hospice that weekend by taking call as the hospice had a nursing staff shortage. The RN H said Patient #1 had two falls on 11/21/21. The RN H said after the first fall on 11/21/21 there were no injuries. The RN H said after the second fall the patient was complaining of pain to the left groin/leg but no signs or symptoms of injuries were noted and the patient was able to move and just had some discomfort which was to be expected after the number of falls that weekend. The RN H said she did not notify the patient's physician regarding the falls or complaints of pain on this date because she didn't know who the physician was. The RN H said this was her first time working at this hospice and said there was a hiccup as she was not assigned to any patients and could not review their records in the EMR at first. The RN H said she let the administrator/supervising nurse and her bosses at her primary agency know and the issue was corrected. The RN H said she believed she was able to access the patient records by 11/21/21 from her laptop but said she still couldn't get to all the information from her tablet which is where she knew how to do things. The RN H said she did notify the administrator/supervising nurse of the falls and she was sure of this because she was unable to do an occurrence report regarding the falls and usually she would do one so she contacted the administrator/supervising nurse who said she would do this. During an interview conducted on 12/10/21 at 10:14 a.m., the social worker G said on 12/02/21 she called the RN D to report the patient's complaints of pain and that the ALF staff said the pain medications were not always effective. The social worker G said the patient's family member can be very difficult to get a hold of and said she knew they had been trying to reach him regarding this, but it was several days before he called back. During an interview conducted on 12/10/21 at 10:30 a.m., with the hospice aide F when presented with the findings regarding Patient #1 which indicated the patient had a change in the amount of pain she experienced and in her functional status beginning on or around 11/21/21, the hospice aide F said this was correct. The hospice aide F said the patient became harder to transfer around this time and said previously the patient had been able to help more but she could tell it was a lot harder for the patient. The hospice aide F said around this time the patient had experienced several falls. The hospice aide F said the patient was consistently complaining of pain to the left hip/leg/side area. The hospice aide F said on 11/26/21 the patient was sitting on the sofa in living room and said she needed to go to the bathroom but when she went to assist her up the patient began crying and holding her side like she was in pain. The hospice aide F said she pulled the call light for assistance but when the ALF aide came to assist her the patient would not allow them to assist her. The hospice aide F said she had notified the RN of the patient's complaints of pain. The hospice aide F said she couldn't recall the exact dates but around 12/06/21 - 12/07/21 the patient had refused care. The hospice aide F said on one visit the patient held onto her blanket and wouldn't even let her check to see if she had been incontinent and needed to be changed. The hospice aide F said the patient had a scared look on her face during this visit. During an interview conducted on 12/10/21 at 10:43 a.m., the RN D said she could not recall if she notified the physician of Patient #1's complaint of pain and request to go to the hospital on 11/24/21. The RN D said she could not recall if she notified the administrator/supervising nurse, Patient #1's case manager, of the patient's complaint of pain and request to go to the hospital on 11/24/21. The RN D said she could not recall if she notified the physician or the administrator/supervising nurse regarding the ALF's report that Patient #1 was unable to get up in her wheelchair due to pain on 11/26/21. The RN D said she could not recall if she notified the physician or the administrator/supervising nurse of Patient #1's complaint of pain on 12/02/21. The RN D said the patient had multiple falls and had an increase in pain around that time. The RN D said the patient often refused medications from the ALF staff. The RN D said they changed the patient's pain medications from oral medications to a Fentanyl patch around this time. The RN D said she texted the physician that the patient had a fall with no injuries regarding the visit on 12/04/21. The RN D said her process for completing pain assessments depends on how well the patient can vocalize. The RN D said if the patient was able to use the numerical scale she would use this and said if the patient was not able to do this, for example Patient #1, she would use the scale that says it hurts a little, hurts a lot, hurts a whole lot. The RN D said if she documented that no comprehensive pain assessment was completed during a visit it was because the patient wasn't complaining of pain. During an interview conducted on 12/10/21 at 1:30 p.m., the administrator/supervising nurse said she couldn't be 100% sure that the physician was notified of the patient's falls and complaint of pain on 11/21/21. The administrator/supervising nurse said it was the responsibility of the on-call nurse to notify the physician. When presented with the findings indicating the on-call nurse had reported she did not contact the physician but had notified the administrator/supervising nurse, the administrator/supervising nurse said she (the administrator/supervising nurse) did not notify the physician of the falls or the patient's complaint of pain on this date. The administrator/supervising nurse said the physician was probably not notified of the patient's complaint of pain on 11/22/21 because the pain on that date was generalized soreness and the patient was not super specific about the location of the pain. The administrator/supervising nurse said she was not sure if the physician was notified of the patient's fall and complaint of pain on 11/23/21. The administrator/supervising nurse said she was not sure if the physician was notified of the patient's request to go to the hospital due to her pain on 11/24/21. The administrator/supervising nurse said she had read the nurse's note for this visit and it doesn't say. The administrator/supervising nurse said she was not sure if the physician was notified that the patient was unable to get up to her wheelchair or that the patient had refused hospice aide services on 11/26/21 due to complaints of pain. The administrator/supervising nurse said Patient #1's family member was called regarding the patient's pain prior to 11/29/21. The administrator/supervising nurse said the family member was called several times and several messages were left. The administrator/supervising nurse said the patient's family is very particular with what he will allow for the patient's care. The administrator/supervising nurse said she would have to ask to determine if the physician was informed of the patient's complaint of pain on 12/01/21. The administrator/supervising nurse said she did not know if the patient's complaint of pain, her pain medications not always being effective, and her need for additional assistance and decreased functional status were reported to the physician on 12/02/21. The administrator/supervising nurse said she would look to see if the physician was notified of the patient's complaint of pain on 12/04/21. The administrator/supervising nurse said there is always room to improve and she thought the hospice could do a better job of ensuring documentation of coordination of care with family members and the physician was included in the clinical record. The administrator/supervising nurse said Patient #1's family member usually does not want aggressive treatment or surgery for the patient and said it is difficult to get him to agree to allow the patient to go to the ER. The administrator/supervising nurse said Patient #1's plan of care didn't change that much after the x-rays were obtained and the fracture was identified. The administrator/supervising nurse said the hospice did increase the dosage of the patient's pain medications following identification of the fracture. The administrator/supervising nurse said the staff absolutely should have notified the physician of the issues identified during the investigation and documented above. The administrator/supervising nurse said the timeframe for staff to report to the physician would depend on the issue but should be reported quickly. The administrator/supervising nurse said most reports should be made the same day. The administrator/supervising nurse said the hospice's policy regarding documentation of coordination of care should indicate the hospice would document this in the patient's clinical record but she would have to review the written policy to determine if this was included in the policy or not. The administrator/supervising nurse said she didn't think RN D's, statement that if she documented that she had not conducted a comprehensive pain assessment during a visit that this meant the patient did not have any pain on this visit was accurate based on her review of the records. The administrator/supervising nurse said in the hospice's electronic medical record system if you select, yes, to indicate the clinician is conducting a comprehensive pain assessment, the clinician can select the type of pain scale being used to conduct the assessment. The administrator/supervising nurse said she would expect the nurse to utilize a pain scale of some type to assess the patient's pain during each skilled nurse visit when the patient experienced pain. The administrator/supervising nurse said she would expect the clinician to assess a patient for injuries after a fall prior to getting the patient up to the bed from the floor. During an interview conducted on 12/10/21 at 9:31 a.m., the medical director E said she did not receive a call from the nurse regarding Patient #1` on 11/21/21. The medical director E said she did receive a call on 11/22/21 and they discussed pain medications and looked at changing her to a pain patch. The medical director E they were unable to get ahold of the patient's family member to get approval. The medical director E said she also had text messages on 11/29/21 and 11/30/21 where they were still discussing changing her medications and getting her pain under better control. The medical director E said she was never informed of the patient's request to go to the hospital due to pain on 11/24/21. The medical director E said on 12/04/21 she was notified of the fall, but she was just told the patient scraped her knee. The medical director E said on 12/06/21 they decided to do the x-rays. The medical director E said she was not notified that the ALF staff had reported the patient's pain medications were not always effective at controlling her pain. The medical director E said if she had known the patient was consistently complaining of pain to the same area and had a change in her functional status this could have affected her decisions to order additional interventions and said she might have ordered x-rays sooner if she had been notified of this information. Record review of a hospice policy titled, "Hospice Nursing Care," dated November 2020, indicated, "--------------- (name of hospice) ... nursing services will be provided in accordance with physician's order, the patient plan of care, and accepted standards of practice by or under the supervision of a registered nurse ... The hospice nurse will play a key role in easing physical and psychosocial symptoms and initiating communication with the interdisciplinary group to establish the plan of care ... Duties will include the responsibility for coordination of care, fostering communication between the patient and the interdisciplinary group ... The hospice nurse will ... report the condition of patient and family/caregiver to the attending physician, Medical Director, and interdisciplinary group on a regular basis, as well as changes in the plan of care ... The hospice nurse will ... Manage discomfort and provide symptom relief according to physician orders ... Provide an ongoing evaluation of the patient and family/caregiver response to care ..."