Every finding on record at Palos Community Hospital

Observed in Patient Home. In 1 of 4 patient records reviewed, the hospice plan of care failed to include all medications and treatments necessary to meet the patient’s needs. For example, during the home visit for HOS 1 who resided in a skilled nursing facility, it was noted that the medication list on the hospice plan of care was not accurate and included conflicting orders for Lorazepam 0.5 mg tablets. One order was for the Skilled Nursing Facility to give the patient 0.5 mg by mouth every four hours as needed for mild to moderate anxiety/agitation/restlessness and another order was to give the patient 1 mg by mouth every four hours as needed for mild to moderate anxiety/agitation/restlessness. The visiting RN and Hospice Manager verified that the order should have stated Lorazepam 0.5 mg tablets 1 mg by mouth every four hours as needed for moderate to severe anxiety/agitation/restlessness. Additionally, there were several medications where the route was listed by mouth however the patient was receiving medications per g-tube including acetaminophen, diphenhydramine, and haloperidol. Additionally, although the medication list on the hospice care plan included nystatin cream for wound care it did not include zinc oxide or antifungal powder. This was verified with the Hospice Manager.

Observed in Tracer Activities. Pain assessment was not documented prior to giving pain medication to the IPU hospice patient as evidenced by: the lack of pain scale documentation for one out of last three doses of hydromorphone administered (5/9 @4:28am). This observation was confirmed with the oncology unit nurse manager. Observed in Tracer Activities. For three of last three doses of prn hydromorphone administered, the IPU hospice patient’s pain was not reassessed within 30 minutes after the dose as required by policy. This observation was confirmed with the oncology unit nurse manager. Observed in Tracer Activities. The pain screening tool used during a med pass to an IPU hospice patient was not appropriate for the patient's condition as evidenced by: the nurse documented a patient reported pain score of 6 in an unresponsive patient, instead of using the clinical observation pain scale. This observation was confirmed with the oncology unit nurse manager.

Observed in Individual Tracer. In 2 of 16 patient records reviewed, the Hospice interdisciplinary group did not update the patient assessment based on changes to the plan of treatment. Hospice RR#4 was placed on prednisone and the interdisciplinary team conference immediately following the change in treatment did not reflect the change of medication and or its effectiveness. RR#6 had a Foley inserted during the certification period. The update to the comprehensive assessment following the insertion did not reflect the Foley or describe the effectiveness of the new intervention. These observations were discussed with the RN.

Observed in Individual Tracer. In 1 of 16 patient records reviewed, Hospice care plan goals were not measurable and did not have target dates to achieve. HV#4 had issues with pain, and the goal documented on the care plan was as follows- pain will remain at acceptable levels and there was no date to achieve this goal. This observation was discussed with the RN.

Observed in Individual Tracer. In 1 of 16 patient records reviewed, the Hospice comprehensive care plan (or updates to the care plan) did not include required orders. RR#11 was on continuous care and based on a review of the record, there was no order for continuous care. This observation was discussed with the RN.

Observed in Patient Home. In 2 of 16 patient records reviewed, the Hospice care plan/medication record did not reflect what patients were taking. RR#1 and RR#2 both resided in a nursing home and the SNF medication administration record (MAR) reflected that these patients were given medications that were not on the Hospice plan of care. The MAR for RR#1 reflected that the patient was on aspirin and a antihistamine. These medications were not on the Hospice medication profile. The MAR for RR#2 did not reflect that the patient was given an antipsychotic and a stool softener however these medications were included on the Hospice plan of care/medication record. These observations were discussed with the RN. Observed in Individual Tracer. In 1 of 16 patient records reviewed, the Hospice comprehensive care plan did not reflect all of the treatments required based on the patient assessment. RR#6 had a gastrostomy tube in place for nutrition and hydration. The care plan did not reflect orders for the feeding. This observation was discussed with the RN.

Observed in Data Tracer. The Hospice QAPI program did not address the bereavement program, the volunteer program or contracted services such as DME, pharmacy and SNFs. This observation was confirmed with the acting administrator.

Observed in Individual Tracer. In 4 of 4 patient records reviewed, with hospice aides, the hospice aide care plan did not reflect all of the interventions required based on the patient assessment. RR#1 was on daily aspirin therapy and had a wound, precautions for these issues were not included on the Hospice aide care plan. RR#2 had a wound and the hospice aide care plan did not include precautions related to wounds. RR#3 was also on a blood thinner and bleeding precautions were not listed on the hospice aide care plan. RR#6 had a gastrostomy tube and Foley. The Hospice aide care plan did not reflect aspiration precautions or that the patient had a GT tube or Foley. RR#7 had a suprapubic tube and the hospice aide care plan did not reflect precautions related to the catheter. These observations were discussed with the RN. Observed in Individual Tracer. the Hospice record did not reflect accurate information related to the patient. The Hospice aide care plan for Hospice RR#1 reflected that the patient had a urinary catheter. Based on a review of the nursing assessment, the patient did not have an urinary catheter. This observation was discussed with the RN.

Observed in Leadership Session. The governing body/leadership did not ensure that the following Conditions of Participation were met as determined through observations, documentation. There was a pattern of staff not following policies for a number of Hospice conditions of participation that included 418.56, 418.58, 418.112, 418.116, 418.100, 418.104.

Observed in HR File Review. In 2 of 11 HR records reviewed, orientation about the hospice philosophy had not been provided to the Medical Director or the backup Medical Director. This observation was confirmed with the hospice administrator.

Observed in Individual Tracer. In 2 of 2 patient records reviewed, that were discharged to another facility did not have documentation that the hospice discharge summary was sent to the next provider. RR#8 was transferred to another hospice and RR#13 was transferred to palliative care and there was no documentation in the record that the discharge summaries were sent to the next providers. These observations were discussed with the RN.

Observed in Individual Tracer. In 1 of 2 home visits conducted, with oxygen, the Hospice did not educate and or re-education patient/caregivers in the proper maintenance of oxygen concentrator. The oxygen concentrator external filter for Hospice RR#1 was occluded with dust and there was no documentation in the record of education provided to caregivers. This observation was discussed with the RN.

Observed in Tracer Activities. For two of the last four prn hydromorphone doses given to an IPU hospice patient, the plan of care was not followed as evidenced by administration of hydromorphone ordered for severe pain (scale 7-10) when the pain scale documented was =5 on 5/7 and =6 on 5/9. This observation was confirmed with the oncology unit nurse manager.

Observed in Individual Tracer. In 1 of 16 patient records reviewed, the Hospice Care Plan did not reflect who would be providing required services. Hospice RR#1 resided in a nursing home and had a wound. The care plan of RR#1 did not include which staff would be providing the wound care. Per the RN, the nursing home staff provides the care when the hospice does not visit. This observation was discussed with the RN.

Observed in Individual Tracer. In 2 of 2 patient records reviewed, of patients that resided in a nursing home, the Hospice did not have a process in place to ensure that the SNF maintains required Hospice documents. Except for the plan of care, the Hospice did not routinely send to the SNF other hospice documents such as hospice election of benefits, physician certification, 24 hour contact information etc. These documents were not observed in RR#1 and RR#2 who both resided in a nursing home. This observation was discussed with the RN manager.

Observed in Individual Tracer. In 1 of 2 patient records reviewed, that no longer required hospice, did not have the appropriate consent form completed upon discharge. RR #13 was a Medicare patient that was determined to be no longer appropriate for hospice. Based on a review of the record, the Notice of Hospice Noncoverage Form was not obtained. This observation was discussed with the RN.

A. Based on Clinical Records Review and Staff interviews, it was determined the hospice failed to ensure consent was obtained for all people administering medications and providing wound care for the patient in the home. Thereby the interdisciplinary group failed to ascertain drugs and biologicals were administered to the patient safely. This was found in 1 of 5 records (Pt. #2) reviewed. Findings include: 1. Pt. # 2 SOC 10/06/2021 Primary Diagnosis: Alzheimer's Disease The clinical record was reviewed on 03/23/2022 between 11:00 AM and 11:45 AM. The Record included a consent titled, "Notice of Hospice Election Statement." The consent documented, " ...I designate ..." Pt's daughter, " ...as my primary caregiver. This role will name the person mainly responsible for overseeing my care in my place of residence ... I hereby authorize PH to release verbal medical information to my designated caregiver and to my family and friends as follows: ..." Pt's significant other and daughter are listed. The consent form does not include any additional caregivers as authorized persons. The clinical record contained an SN note dated, 10/08/2021. The SN note documented, " ...Clinical Note ... pt ... accompanied by ..." name of caregiver agency, " ...CG and girlfriend ... (Dulcolax suppository given earlier by CG) ... Who manages medications? Other (specify): CG and girlfriend ..." SN note dated 10/09/2021 documented, " ...Clinical Note ...SO ... and caregiver present ... coccyx dressing changed educated ... CG on dressing changes ..." SN note dated 10/13/2021 documented, "Clinical Note ... visit conducted with pt hired CG and wife ... present ... educated CG on dressing changes ... Who Manages Medication? Other (specify) ..." SN note dated 11/01/2021 documented, " ...weekly hospice visit conducted with pt ... SO ... and CG ... present ... reviewed wound care with ... CG ..." SN note dated 01/21/22 documented, " ... RN provided instruction to CGs to increase morphine dose to 10 mg, and every 2 hours ..." While reviewing clinical records with the Hospice Charge Nurse, she confirmed there is no documentation in Pt. #2's clinical record that includes the caregiver as an authorized person to receive medical information from the hospice. 2. During an interview with E #1 at 12:50 PM, she stated that she becomes aware of who is designated to care for patients during, "our elections, our MSW or chaplain usually completes the election consent, it's [the authorized person(s)] listed on the election consent form." She also stated, "In the event there is a hired caregiver, it is on the form as well." She stated that detailed instruction is given to the person who primarily cares for the patient, however other family members may be there during instruction as well. 3. During an interview with E #2 at 1:00 PM, she stated, "If the patient has a 24-hour caregiver, they are educated along with the POA." She also stated the caregiver is "not usually," on the list of people authorized, "it's stated by the family they want the caregiver to provide care." 4. During an interview with the Clinical Nurse Leader at 4:25 PM, she stated, "If we are notified the live-in caregiver will be providing care for the patient, they would be listed on the notice of election consent." She also stated, "Education should be provided to the authorized people listed on the consent. Sometimes others are present during that time, but we are primarily educating the appointed person." 5. During interviews with the Administrator and Clinical Nurse Lead between 12:00 PM and 4:30 PM. The above findings were confirmed.