Every finding on record at Residential Hospice of Southern Illiniois, LLC

Based on policy review, clinical record review, and interview the hospice provider failed to ensure that patients received effective pain management and symptom control by the hospice staff for related terminal illness conditions in a timely fashion for nausea and a hurting stomach, in one of five full records reviewed (Record/Patient #5). This deficient practice has the potential to affect the pain and symptom management of all patients served by the provider. --- Findings included: Review of providers policy titled, ";On-Call/Weekend Services," Policy No. 4-036.1 and 4-036.2, revised May 2023, showed in part: - Purpose - To establish the process by which patients have access to hospice services 24 hours per day; - Clinical personnel are expected to perform visits on an as-needed basis, including weekends; - There will be on-call staff available after hours and on the weekends; - The triage nurse will provide follow-up appropriate to the call: * Send the on-call visit nurse to visit the patient, if necessary; * If the situation is determined a change in condition, the nurse will make a visit to the patients home. If the nurse feels or the family wants to call 911 (emergency services), the triage and/or on-call nurse will then call the emergency room (ER) with information regarding the patient and the current problem. A visit should then be made to the ER to see if the patient was seen and the outcome; - The triage nurse and/or visit nurse will document each patient/family interaction in a clinical note or coordination note; - The following list is meant to guide the on-call nurse. It is not an exhaustive list but includes many problems that may require a visit from the hospice nurse: * Nausea/vomiting not resolved with present medications; and * Patient/family/caregiver perceives a problem and requests a visit. RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to hospice services on 09/28/2023 with a terminal diagnosis of chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe) with acute exacerbation (sudden worsening in airway function and respiratory symptoms) and chronic respiratory failure with hypoxia (low blood oxygen levels.) The patient resided at home with his/her family member/primary caregiver. Review of the ";Client Coordination Notes Report," dated 10/09/2023, showed: - Note type - Hospice After Hours Triage; - Time - 7:19 AM; - Note - Received a call from the son, he would like to take the patient to the hospital. The patient complained of not feeling well, being nauseous and his/her stomach hurting. Asked the son if he would be willing to have a nurse come and assess the patient and he stated yes. Phone call to on-call licensed practical nurse (LPN), visit accepted. Review of the ";Visit Nurse Report," dated 10/09/2023, showed: - In-home time began at 10:32 AM and completed at 11:09 AM (three hours and 13 minutes after the family called the after-hours number); - Narrative – The patient placed a call to triage that morning reporting nausea and pain. The patients son reporting he/she wanted to go to the hospital. The nurse called the patient after triage called and stated he/she could come for a visit but he/she was scheduled for one that morning and he/she said that was fine with a visit a little later that morning. The patient was reporting pain ";all over his/her body" the nurse asked the patient to describe it and the patient stated ";its just so sore, all over. Im so tired and my body is so tired. I guess its more fatigue than pain". As needed pain medication was given that morning after the phone call. The patient was tearful during the conversation. The patient was fixated on medications, stating that the provider kept making changes and he/she thought that was what was wrong. Education given to the patient regarding when last medication changes were made. Once the nurse sat down and talked with the patient, he/she began to calm down. About 15 minutes into the assessment, the nurse asked the patient what his/her pain level was at and he/she stated four out of ten from the previous seven out of ten. Vitals and assessment were completed as documented. Refill for oxycodone was sent into the pharmacy. The physician was notified and made aware of the refill. No other concerns at that time. Compassionate listening offered and the patient appeared more comfortable and less anxious. 800 on call number reinforced upon departure. During an interview on 10/18/2023, at 3:18 PM, the administrator stated that the nurse should have made a visit and not waited until 10:30 AM.

Based on policy review, record review, observation, and interview, the hospice registered nurse (RN) failed to complete an adequate initial assessment to include the need for straight catheterization (also known as intermittent catheterization, is a soft, thin tube used to pass urine from the body) use for a patient with prostate cancer in one of five full records reviewed (Record/Patient #3). This deficient practice has the potential to affect all patients on service with the hospice provider. --- Findings included: Review of the providers policy titled, "Comprehensive Assessment," Policy No. 4-042.1, 4-042.2 and 4-042.3, revised date of May 2023, showed in part: - During the comprehensive patient assessment, all baseline data and other relevant information will be documented in the patients clinical record, including at least the following information, as relevant; * Review of current and related past medications, including prescription and over-the-counter medications, and other medication information; and * Specific, individualized patient needs/problems pertinent to the hospice care being provided. Review of the providers policy titled, "Ongoing Assessments," Policy No. 4-043.1, revised date of May 2023, showed in part: - To provide guidelines for assessments of patients during ongoing care; and The nurse will assess each patient on each visit, for: (See ";Comprehensive Assessment" Policy No. 4-042.) Review of the providers policy titled, "Comprehensive Assessment," Policy No. 4-042.1, revised date of May 2023, showed in part: - During the comprehensive patient assessment, all baseline data and other relevant information will be documented in the patients clinical record, including at least the following information, as relevant; * Review of current and related past medications, including prescription and over-the-counter medications, and other medication information; and * Specific, individualized patient needs/problems pertinent to the hospice care being provided. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to hospice services on 09/28/2023 with a terminal diagnosis of prostate cancer, bone cancer, type II diabetes (insulin resistance) with diabetic polyneuropathy (nerve damage from diabetes), depression and long-term (current) use of oral hypoglycemic (low blood sugars) drugs. The patient resided at home with his/her spouse and had a family member as the primary caregiver. Review of the start of care nursing visit dated 09/28/2023, showed in part: - Primary hospice diagnosis: Cancer; - Genitourinary: * Urinary/Renal status – Patient stated that he sometimes had difficulty starting the flow of urine related to his prostate cancer; * Urinary Incontinence or Urinary Catheter Presence: No incontinence or catheter; - Indicate Endocrine Findings: Diabetes; - Interventions provided: Instructed patient/caregiver regarding management of signs and symptoms of terminal diagnosis and comorbidities and to call hospice nurse if urinary symptoms/complications were unrelieved. Review of the nursing visit dated 10/04/2023, showed in part: - Patients current genitourinary status: Retention (no further assessment); and - Indicate other genitourinary issue: Patient required straight cathing now three to five times per day. During the home visit observation and interview in the patients home, on 10/17/2023 beginning at 10:00 AM: - The patient stated to the nurse that he/she only received 18-20 catheters the last delivery and the hospice staff said there were to be about 100 more delivered; and - The caregiver stated the patient had been using a Coude catheter (type of intermittent catheter with a curved tip used to empty urine from the bladder for those with an enlarged prostate or blockage) approximately four to five months and that was what led him/her to hospice because he/she couldnt go to the bathroom. During an interview on 10/18/2023, at 2:33 PM, the administrator stated that the catheter was not on the assessment because the patient did not tell him/her.

Based on policy review, record review, and interview, the hospice provider failed to ensure the chaplains comprehensive assessment was completed within five days of election of hospice care in one of five records reviewed (Record/Patient #5). This deficient practice has the potential to affect all patients served by the provider. --- Findings included: Review of the providers policy titled, "Comprehensive Assessment," Policy No. 4-042.1, revised date of May 2023, showed in part:- A comprehensive patient assessment will be performed by the registered nurse in collaboration with the interdisciplinary group no later than five calendar days after the election of hospice care in consultation with hospice medical director/physician and attending physician (if any); and- If patient and/or family/caregiver refuse social work and/or spiritual care services that refusal will be documented in the medical record. RECORD/PATIENT #5: Review of the hospice election statement showed the effective date of election was 09/28/2023. Review of the initial chaplain evaluation visit showed a date of 10/04/2023 (six days after election of hospice care). During an interview on 10/18/2023, at 3:35 PM, the administrator stated the chaplain assessment should be done within five days of hospice election.

Based on policy review, record review, observation, and interview the hospice provider failed to ensure an accurate/updated medication profile was maintained in three of five full records reviewed (Record/Patient #3, #5, and #7). This deficient practice has the potential to affect all patients served by the provider. --- Findings included: Review of the providers policy titled, "Comprehensive Assessment," Policy No. 4-042.1, revised date of May 2023, showed in part: - During the comprehensive patient assessment, all baseline data and other relevant information will be documented in the patients clinical record, including at least the following information, as relevant; and * Review of current and related past medications, including prescription and over-the-counter medications, and other medication information. Review of the providers policy titled, "Ongoing Assessments," Policy No. 4-043.1, revised date of May 2023, showed in part: - To provide guidelines for assessments of patients during ongoing care; and - The nurse will assess each patient on each visit, for: (See ";Comprehensive Assessment" Policy No. 4-042.) RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to hospice services on 09/28/2023 with a terminal diagnosis of prostate cancer, bone cancer, type II diabetes (insulin resistance) with diabetic polyneuropathy (nerve damage from diabetes), depression and long-term (current) use of oral hypoglycemic (low blood sugars) drugs. The patient resided at home with his/her spouse and a family member was the primary caregiver. During the home visit observation and interview in the patients home, on 10/17/2023 beginning at 10:00 AM, review of the hospice providers medication profile/Client Medication Report and interview with the caregiver showed the following discrepancies: - The patient was taking Victoza (Anti-diabetic medication) 1.8 milligrams (mg)/3 milliliters (ml) injection every day (qd). The caregiver (adult child) stated he/she had been taking this prior to hospice admission. The hospice providers Client Medication Report printed on 10/16/2023 did not include Victoza; - The patient was taking Glipizide XL (extended release medication to treat high blood sugars) 4 mg tablet by mouth once a day. The caregiver stated he/she had been taking the dosage prior to hospice admission. The hospice provider's Client Medication Report printed on 10/16/2023 did not include Glipizide XL; - The patient was taking Lexapro (ant-depressant) 20 mg by mouth once a day. The caregiver stated he/she had been taking this prior to hospice admission. The hospice providers Client Medication Report printed on 10/16/2023 did not include Lexapro; - The patient was taking Trospium ER (extended release capsule for bladder spasms) capsule 60 mg by mouth every day in AM prior to breakfast. The caregiver stated he/she had been taking this prior to hospice admission. The hospice providers Client Medication Report printed on 10/16/2023 did not include Trospium ER; - The patient was not taking acetaminophen (analgesic) 650 mg suppository (supp) per the rectum every (q) six hours as needed (PRN). The caregiver stated he/she was not taking this and the patient didnt have the medication. The hospice providers Client Medication Report printed on 10/16/2023 showed one q six hours PRN; - The patient was not taking aspirin (nonsteroidal anti-inflammatory drug and blood thinner) extended release 81 mg by mouth qd. The caregiver stated he/she had not been taking for quite a while and that the patient has extremely thin blood. The hospice providers Client Medication Report printed on 10/16/2023 showed one qd; - The patient was not taking bisacodyl (stimulant laxative) 10 mg supp qd PRN. The caregiver stated he/she was not taking this medication at this time and hadnt taken for over a month (the patient admission date was 09/28/2023 (19 days ago).) The hospice providers Client Medication Report printed on 10/16/2023 showed one qd PRN; - The patient was not taking diazepam (sedative) 5 mg tablet by mouth twice a day. The caregiver stated he/she had not been taking for it was discontinued two to three weeks ago when he/she started Ativan (sedative). The hospice providers Client Medication Report printed on 10/16/2023 showed one tablet twice a day; - The patient was taking Flonase (steroid) Allergy Relief 50 micrograms (mcg) nasal spray one spray to each nostril PRN. The caregiver stated he/she was taking this medication PRN. The hospice providers Client Medication Report printed on 10/16/2023 showed one spray each nostril daily; - The patient was taking Gabapentin (anticonvulsant) 300 mg capsule three times a day (TID) PRN. The caregiver stated he/she was taking this medication PRN. The hospice providers Client Medication Report printed 10/16/2023 showed one capsule TID; - The patient was not taking hydrochlorothiazide (diuretic) 12.5 mg capsule one by mouth qd. The caregiver stated he/she was not taking this medication. The hospice providers Client Medication Report printed on 10/16/2023 showed one capsule qd; - The patient was not taking Levsin (anti-tremor and gut antispasmodic) 0.125 mg one tablet q four hours PRN. The caregiver stated he/she was not taking this medication and did not have this medication. The hospice providers Client Medication Report printed on 10/16/2023 showed one tablet q four hours PRN; - The patient was not taking magnesium citrate (laxative to treat occasional constipation) 15 ml qd. The caregiver stated he/she was not taking this medication. The hospice providers Client Medication Report printed on 10/16/2023 showed 15 ml qd; - The patient was not taking metformin (anti-diabetic medication) 500 mg tablet by mouth twice a day. The caregiver stated he/she was not taking this medication and that it was discontinued when he/she started the injection. The hospice providers Client Medication Report printed on 10/16/2023 showed 500 mg tablet by mouth twice a day; - The patient was not taking morphine (narcotic to treat moderate to severe pain) concentrate 100 mg/5 ml 0.25 mg q two hours PRN. The caregiver stated he/she was not taking this medication and that it was discontinued. He/she doesnt do well with morphine (feels awful) but it can be taken in an emergency situation. The hospice providers Client Medication Report printed on 10/16/2023 showed 0.25 mg q two hours PRN; - The patient was not taking ondansetron HCL (antiemetic) 4 mg tablet one tablet four times a day (QID) PRN. The caregiver stated he/she was not taking this medication and that he/she has no tablets. The hospice providers Client Medication Report printed on 10/16/2023 showed 4 mg tablet QID PRN; and - The patient was not taking Symbicort (bronchodilator) 160 mcg – 4.5 mcg / actuation inhaler two puffs twice a day (BID). The caregiver stated he/she did not take this medication. The hospice providers Client Medication Report printed on 10/16/2023 showed two puffs BID. RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to hospice services on 09/28/2023 with a terminal diagnosis of chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe) with acute exacerbation (sudden worsening in airway function and respiratory symptoms) and chronic respiratory failure with hypoxia (low blood oxygen levels.) The patient resided at home with his/her family member/primary caregiver. - The patient was taking Ipatropium (bronchodilator) 0.5 mg / Albuterol (prevent bronchospasm) 3 mg / 3 ml nebulizer (a machine used to deliver a medication to the lungs) BID. The caregiver stated he/she was taking this medication BID for over a year. The hospice providers Client Medication Report printed on 10/16/2023 showed QID; - The patient was not taking Lisinopril (treats high blood pressure) 10 mg tablets once a day. The caregiver stated he/she did not take this medication any longer and that it had been discontinued a week ago. The hospice providers Client Medication Report printed on 10/16/2023 showed 10 mg once a day; - The patient was on oxygen at 3 liters (L) continuous per nasal cannula (NC). The caregiver stated his/her oxygen setting was at 4 L continuous per NC since August. The hospice providers Client Medication Report printed on 10/16/2023 showed oxygen at 3 L continuous per NC; - The patient was taking probiotic (live microorganisms that are intended to have health benefits) 100 billion cell capsule one capsule daily. The caregiver stated he/she was taking this medication once a day. The hospice providers Client Medication Report printed on 10/16/2023 showed QID; - The patient was not taking Senna laxative 8.6 mg daily. The caregiver stated he/she was not taking the medication and it was discontinued about six months ago. The hospice providers Client Medication Report printed on 10/16/2023 showed 8.6 mg once a day; - The patient was not taking Singulair (anti-inflammatory) 10 mg daily. The caregiver stated he/she was not taking the medication and it was discontinued in May. The hospice providers Client Medication Report printed on 10/16/2023 showed 10 mg once a day; - The patient was taking Albuterol (prevent bronchospasm) inhaler (a device used to deliver medication into the lungs) (200 puffs) 8.5 gram (gm) one puff every four hours PRN. The caregiver stated he/she had been taking medication. The hospice providers Client Medication Report printed on 10/16/2023 did not include albuterol inhaler; - The patient was taking quetiapine (antipsychotic) 25 mg one tablet at bedtime (HS). The caregiver stated he/she had been taking the dosage prior to hospice admission. The hospice provider's Client Medication Report printed on 10/16/2023 did not include quetiapine; - The patient was taking mirtazapine (antidepressant) 15 mg one tablet at HS. The caregiver stated he/she had been taking the dosage prior to hospice admission. The hospice provider's Client Medication Report printed on 10/16/2023 did not include mirtazapine; and - The patient was taking tramadol (narcotic used to treat moderate to severe pain) 50 mg one by mouth BID. The caregiver stated he/she had been taking the dosage prior to hospice admission. The hospice provider's Client Medication Report printed on 10/16/2023 did not include tramadol. During an interview on 10/18/2023, at 11:26 AM, the administrator stated that medication profiles should be checked at every visit. RECORD/PATIENT #7:Review of the clinical record showed the patient resided in a skilled nursing facility. He/she was admitted to hospice services on 09/01/2023 with a terminal diagnosis of Parkinson's disease (a neurological disorder that causes unintended or uncontrollable movements or stiffness). The patient had a medical history of, but not limited to:- Peptic ulcer disease (open sores that develop on the inside lining of your stomach and the upper portion of your small intestine);- Pulmonary embolism (a blood clot in the arteries of the lungs) with long-term use of blood thinners; - Lumbar disc degeneration (a condition in which a damaged disc in the lower causes pain); and- Spinal stenosis (narrowing of the spaces in the spine causing pain in the back or neck, and tingling in the arms or legs). Comparison of the providers medication profile (PMP) to the facilitys medication administration record (FMAR) showed: - The FMAR showed the patient was taking Depakote 125mg two times per day (a medication used to treat seizure disorders). The PMP failed to contain orders for this medication;- The FMAR showed the patient was taking Effexor 150mg one time daily (a medication used to treat depression). The PMP showed the patient was taking 75mg of the medication one time daily; and- The FMAR showed the patient was taking Sertraline 100mg one time daily (a medication used to treat depression). The PMP showed the patient was taking 200mg one time daily. During an interview on 10/19/2023 at 4:10 PM, the administrator stated that the FMAR and the PMP failed to contain the same orders for some of the medications.

Based on policy review, record review, observation, and interview the hospice provider failed to ensure treatments were included on the plan of care (POC) to manage the patient's symptoms for prostate cancer and diabetes in one of five full records reviewed (Patient/Record #3). This deficient practice has the potential to affect all patients served by the provider. --- Findings included: Review of the providers policy titled, "The Plan of Care," Policy No. 4-027.1, revised date of March 2023, showed in part: - The POC will be based on the initial, comprehensive, and ongoing comprehensive assessments performed by members of the interdisciplinary group and will be reviewed on a regular basis; - The case manager or admitting registered nurse will complete the initial assessment and will initiate the development of the POC; - The POC will identify the patients needs and services to meet those needs; - Care decisions and services to be provided will be made as a result of the care planning process, analysis of initial and ongoing comprehensive assessments; - The written POC will contain, but will not be limited to, the following: * Medical supplies necessary to meet the patients needs; * Drugs and treatments; and * Patient or representatives level of understanding, involvement, and agreement with the POC. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to hospice services on 09/28/2023 with a terminal diagnosis of prostate cancer, bone cancer, type II diabetes (insulin resistance) with diabetic polyneuropathy (nerve damage from diabetes), depression and long-term (current) use of oral hypoglycemic (low blood sugars) drugs. The patient resided at home with his/her spouse and a family member was the primary caregiver. Review of the start of care nurses note, dated 09/28/2023, showed the following: - Primary hospice diagnosis: Cancer; - Neurologic: alert and oriented to person, place and time, forgetful; - Genitourinary: * Urinary/Renal status – Patient stated that he sometimes had difficulty starting the flow of urine related to his prostate cancer; * Urinary Incontinence or Urinary Catheter Presence: No incontinence or catheter; - Endocrine: diabetes; and - Interventions provided: Instructed patient/caregiver regarding management of signs and symptoms of terminal diagnosis and comorbidities and to call hospice nurse if urinary symptoms/complications are unrelieved. Review of the POC dated 09/28/2023 to 11/26/2023, showed the following: - Goals: Patient/caregiver verbalizes/demonstrates understanding of management of diabetes to prevent a diabetic event; and - The patient was taking metformin (anti-diabetic medication). Review of the nursing visit dated 10/04/2023, showed in part: - Patients current genitourinary status: Retention; and - Indicate other genitourinary issue: Patient required straight cathing now three to five times per day. Review of the ";Hospice POC Report", printed on 10/17/2023, showed the following: - NDP (nursing diagnosis problem): Need for skilled teaching related to diabetes; - I (interventions): Instructed regarding monitoring of blood glucose (there is no mention the patient is monitoring his own blood sugars two to three times a day or more if warranted, the surveyor was made aware during caregiver interview); - I: Instructed regarding insulin administration (the patient is not taking insulin); and - G (goals): Caregiver demonstrates appropriate knowledge of insulin administration (the patient is not taking insulin). Per interview conducted during observation, on 10/17/2023 beginning at 10:00 AM, the caregiver and patient stated the following: - The patient monitored his/her own blood sugar two or three times per a day and more if he/she felt off; - The patient was taking Victoza (Anti-diabetic medication) 1.8 milligrams (mg)/3 milliliters (ml) injection every day (qd) and he/she had been taking this prior to hospice admission; - The patient was taking Glipizide XL (extended release medication to treat high blood sugars) 4 mg tablet by mouth once a day and he/she had been taking the dosage prior to hospice admission; - The patient was taking Trospium ER (extended release capsule for bladder spasms) capsule 60 mg by mouth every day in AM prior to breakfast and he/she had been taking this prior to hospice admission; - The patient was not taking metformin and it was discontinued when he/she started the Victoza injection; - The patient stated to the nurse that he/she only received 18-20 catheters the last delivery and the hospice staff said there were to be about 100 more delivered; and - The caregiver stated the patient had been using a Coude catheter (type of intermittent catheter with a curved tip used to empty urine from the bladder for those with an enlarged prostate or blockage) approximately four to five months and that was what led him/her to hospice because he/she couldnt go to the bathroom. Review of the POC dated 09/28/2023 to 11/26/2023 failed to include the following: - Victoza; - Glipizide; - Trospium; and - Coude catheter (how often being used). During an interview on 10/18/2023, at 2:55 PM, the administrator stated that the POC should include all medications, treatments, supplies and be specific on documenting what education was provided.

Based on policy review, record review, observation, and interview, the hospice provider failed to ensure physician orders were obtained to alleviate urine retention for a patient with prostate cancer, in, but not limited to, one of five full records reviewed (Record/Patient #3). This deficient practice has the potential to affect all patients served by the provider. --- Findings included: Review of the provider's policy titled, "Verification of Physician Orders," Policy No. 4-028.1, revised May 2023, showed in part, that accurate physician orders are obtained in accordance with applicable law and regulation and orders will be documented in the patients medical record, dated, and signed by the professional receiving the order and the signed order will be retained in the clinical record. Record/Patient #3: Review of the clinical record showed the patient was admitted to hospice services on 09/28/2023 with a terminal diagnosis of prostate cancer, bone cancer, and type II diabetes (insulin resistance) with diabetic polyneuropathy (nerve damage from diabetes). The patient resided at home with his/her spouse and a family member was the primary caregiver. Review of the start of care nurses note, dated 09/28/2023, showed the following: - Primary hospice diagnosis: Cancer; - Neurologic: alert and oriented to person, place and time, forgetful; - Genitourinary: * Urinary/Renal status – Patient stated that he sometimes had difficulty starting the flow of urine related to his prostate cancer; * Urinary Incontinence or Urinary Catheter Presence: No incontinence or catheter; - Endocrine: diabetes; and - Interventions provided: Instructed patient/caregiver regarding management of signs and symptoms of terminal diagnosis and comorbidities and to call hospice nurse if urinary symptoms/complications were unrelieved. Review of the nursing visit dated 10/04/2023, showed in part: - Patients current genitourinary status: Retention; and - Indicate other genitourinary issue: Patient required straight cathing (a sterile tube placed in the bladder to drain urine) now three to five times per day. Review of the POC dated 09/28/2023 to 11/26/2023, failed to show any catheter orders. Per interview conducted during observation, on 10/17/2023 beginning at 10:00 AM: - The caregiver stated the patient had been using a Coude catheter (type of intermittent catheter with a curved tip used to empty urine from the bladder for those with an enlarged prostate or blockage) approximately four to five months and that was what led him/her to hospice because he/she couldnt go to the bathroom. During an interview on 10/18/2023, at 2:40 PM, the administrator stated that the patient was admitted to hospice with the catheters.

Based on clinical record review and interview, the hospice provider failed to ensure a copy of the discharge summary was provided to the hospice at the time of respite discharge in one of one record reviewed (Record/Patient #11). This deficient practice has the potential to affect the coordination of respite care for all of the providers patients. Findings included: --- RECORD/PATIENT #11: Review of the clinical record showed, in part, that:- The patient began inpatient respite services on 12/01/2022 related to caregiver illness;- The patient completed five consecutive days of respite care;- The family privately paid for inpatient care on day six; - The provider resumed inpatient respite care on day seven; - The patient was discharged from inpatient respite on 12/09/2022; and- The clinical record failed to contain a discharge summary from the respite facility. During an interview on 10/18/2023 at 4:03 PM, the administrator stated that:- They did not have a copy of the discharge summary from the inpatient respite provider, and - They would expect to receive a discharge summary from the inpatient respite provider at the time of discharge.

Based on policy review, record review, and interview, the hospice provider failed to ensure that the hospice plan of care identified the care and services that were needed, and specifically identify which provider was responsible for performing the respective functions that were agreed upon in two of two applicable records (Records/Patients #6 and #7). This deficient practice has the potential to affect the coordination of care for all of the providers patients living in nursing facilities. Findings included: --- Review of the provider's policy titled, ";The Plan of Care," revised 03/2023, showed that:- The plan of care will identify the patients needs and services to meet those needs, including the management of pain and discomfort and symptom relief. It must state, in detail, the scope and frequency of services needed to meet the patients and family/ caregivers needs, goals and outcome achievement; - The written plan of care would contain the patients drugs and treatments (including wound care and allergies); and- The care provided to the patient will be in accordance with the plan of care. Review of the providers policy titled, ";Provision of Care to Residents of SNF/NF (Skilled Nursing Facility/Nursing Facility) or ICF/IID (Intermediate Care Facility/Individuals with Intellectual Disabilities), reviewed 04/2023, showed, in part, that:- A written plan of care must be established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided must be in accordance with this plan of care. The plan of care must: * Identify the care and services that are needed and specifically identify which provider is responsible for performing the respective functions; * Reflect the participation of the hospice, the SNF/NF or ICF/IID, and the patient and family to the extent possible; and * Document any hospice approved changes in the plan of care and that changes were discussed with the patient or representative, and SNF/NF or ICF/IID representatives; and- The provider would designate a member of each interdisciplinary group that is responsible for a patient who is a resident of the SNF/NF or ICF/IID. The designated member is responsible for: * Providing overall coordination of hospice care of the resident with the facility representatives; * Communicating with the facility representatives and other health care providers participating in the provision of care for the terminal illness and related conditions and other conditions to ensure quality of care for the patient and family; and * Ensuring that the hospice and the SNF/NF or ICG/IID maintain their own clinical records containing evidence of a coordinated plan of care, all forms, and other documentation. RECORD/PATIENT #6:Review of the clinical record showed the patient was admitted to hospice services on 11/09/2021 with a terminal diagnosis of hypertensive heart disease (structural and functional changes in the heart as a result of chronic high blood pressure) with heart failure (a decrease in the ability of the heart to pump blood). The patient weighed 79 pounds on 10/01/2023. The patient resided in a SNF. Review of the SNFs physician order sheet for October 2023 showed, in part, the following orders for the patient:- Regular diet (regular texture, thin liquid consistency, fortified foods with all meals); - House shake three times per day; - Ice cream twice per day with lunch and dinner; - Use plate guard at meals; and- Skin preparation wipes applied to redness of toes topically two times a day for skin care. Review of the document titled, ";Plan of Care Update," with an order date of 10/16/2023, showed the document, in part, contained:- Orders for the nurse to assess the patients nutrition and hydration status; - Nursing diagnosis/problem of altered nutrition/hydration;- A goal that the patient/caregiver will verbalize understanding of anorexia/dehydration in the terminal patient; and- The document failed to contain orders and/or interventions for the following items present on the facilitys plan of care:- Regular diet (regular texture, thin liquid consistency, fortified foods with all meals); - House shake three times per day; - Ice cream twice per day with lunch and dinner; - Use plate guard at meals; and- Skin preparation wipes applied to redness of toes topically two times a day for skin care. During an interview on 10/18/2023 at 2:19 PM, the administrator stated that:- The document titled, ";Plan of Care Update," with an order date of 10/16/2023 was the most current and updated plan of care for this patient; and- The provider would expect the orders on the SNFs plan of care to be reflected on the providers plan of care. RECORD/PATIENT #7:Review of the clinical record showed the patient resided in a SNF. He/she was admitted to hospice services on 09/01/2023 with a terminal diagnosis of Parkinson's disease (a neurological disorder that causes unintended or uncontrollable movements or stiffness). The patient had a medical history of, but not limited to:- Peptic ulcer disease (open sores that develop on the inside lining of your stomach and the upper portion of your small intestine);- Pulmonary embolism (a blood clot in the arteries of the lungs) with long-term use of blood thinners; - Lumbar disc degeneration (a condition in which a damaged disc in the lower causes pain); and- Spinal stenosis (narrowing of the spaces in the spine causing pain in the back or neck and tingling in the arms or legs). Review of the SNFs physician order sheet for October 2023 showed, in part, the patient was to receive:- Calazime applied to buttock and peri-area every shift for protection; - Skin preparation applied to right lateral thigh abrasion daily; and- Antifungal cream to right elbow crease and left cervical collar as needed three times per day. Review of the document titled, ";Hospice IDG (Interdisciplinary Group) and Plan of Care Update Report," dated 10/05/2023 showed the document failed to contain interventions and orders for: - Calazime applied to buttock and peri-area every shift for protection; - Skin preparation applied to right lateral thigh abrasion daily; and- Antifungal cream to right elbow crease and left cervical collar as needed three times per day. During an interview on 10/18/2023 at 4:10 PM, the administrator stated that:- The plan of care failed to contain the orders for Calazime, skin preparation, and antifungal cream; and- They would expect the plan of care to contain those orders.

Based on policy review, record review, and interview, the hospice provider: - Failed to provide a hospice discharge/revocation when the patients family requested a different hospice provider; and failed to document concerns from the patient's family regarding the lack of care/services provided (L505); and - Failed to ensure the patient received effective pain management and symptom control (L512). The cumulative effect of these deficient practices has the potential to affect all patients served by the provider.

Based on policy review, record review, and interview, the hospice provider failed to protect and promote the patient's right to; exercise his or her rights, related to revoking hospice services, and failed to document concerns from the patient's family regarding the lack of services provided in one of three records reviewed (Record/Patient #1). These deficient practices have the potential to affect all patients served by the agency. --- Findings included: Review of the hospice provider's policy titled, "Patient Bill of Rights," revised November 2019, showed, in part: - The patient bill of rights statement defines the right of the patient to: * Exercise and understand his or her rights and responsibilities as a patient; * Receive an investigation by the organization of complaints made by the patient or patients family or guardian regarding treatment or care that is (or fails to be) furnished, the existence of the complaint and the resolution of the complaint must be documented; * Have his or her property and person treated with respect, consideration, and recognition of patient dignity and individuality; * Refuse care or treatment after the consequences of refusing care or treatment are fully presented; and * The patients family or guardian may exercise the patients rights when the patient is incompetent. Review of the hospice providers policy titled, ";Revocation of Hospice Benefit," revised May 2022, showed, in part: - To ensure the patients right to revoke the Medicare or Medicaid hospice benefit is understood and properly applied; - A patient and family/caregiver may revoke the election of hospice care at any time; - The patient will choose to revoke his/her election of hospice benefit when he/she; chooses to withdraw from the program with or without cause; - The case manager or designee will facilitate the patients revocation and assist with a smooth transition to another setting or independent care; and - Relevant information will be documented in the clinical record by the case manager and/or clinical supervisor. Review of the hospice providers policy titled, ";Complaint/Grievance Process," revised December 2020, showed, in part: - To set forth guidelines for the resolution of patient concerns, dissatisfaction, or companies and to protect patient and family rights; - Any difference of opinion, dispute, or controversy between a patient or family/caregiver or patient representative and the organization concerning any aspect of services or the application of policies and procedures will be considered a grievance until proven otherwise; - The organization staff member receiving the complaint will immediately discuss, verbally and in writing, the grievance with a supervisor. The supervisor will investigate the grievance within five (5) days after receipt of such grievance and will make every effort to resolve the grievance to the patients satisfaction. Response to the patient regarding the complaint will occur within ten (10) days of receipt; and - Complaints and any action taken will be documented in the organizations complaint reporting system. Review of the hospice providers admission folder, provided by the hospice on 08/14/2023, showed in part, the following: - Problem-solving procedure; - We are committed to ensuring that your rights are protected; - You or your family have the right to voice a complaint about any condition, event, or procedure because of the care and services you receive from our hospice without citing a specific violation or code; - You may submit a complaint orally or in writing by notifying the agency Administrator or in writing; - We will investigate your complaint within five business days of its receipt and will provide you with a response of the results of our investigation within 10 business days; and - Most complaints are solved at this level. RECORD/PATIENT #1: Review of the clinical record showed the patient admitted to hospice services on 05/10/2023, with a primary diagnosis of severe protein-calorie malnutrition. The patient resided in a long-term care facility (LTCF). Review of the coordination notes, dated 07/09/2023, showed: - At 9:07 AM, the after-hours triage registered nurse (RN) received a call from the LTCF that the patient was transferred to the hospital; - The patient had fallen and had blood coming from his/her head. He/she had been more anxious and weaker overnight. The nurse was unable to assess and clean the wound due to the patient being combative; - The wound appeared to be on the right side of his/her head and the emergency medical system (EMS) staff said it looked like he/she injured his/her mouth as well; - At 8:34 PM, the after-hours triage RN received a call from the LTCF that the patient returned from the emergency room (ER) and the family was requesting a nurse visit to review the plan of care and medications; - The LTCF nurse states the patient is not swallowing, and an as needed ";tuck in visit" was assigned to the after-hours RN (the documentation failed to show that a visit was made by a nurse); - At 11:44 PM, the after-hours RN called the patients family regarding concerns about medications after the discharge from the hospital; and - The family discussed dissatisfaction with the patients medications and in the morning, they would be changing the patient to a different hospice (The documentation failed to show if the hospice provider offered the option to transfer the patient and/or revoke hospice service). Review of the coordination note, dated 07/10/2023 at 8:56 AM, showed licensed practical nurse (LPN) A called the patients family and they were not happy with the hospice care. The patient was in pain, they did not receive phone calls each visit, the patient was not tolerating pills, and a nurse did not visit the patient after he/she returned from the hospital (07/09/2023). They will be switching hospice companies in the morning (the hospice provider failed to offer the option to transfer the patient and/or revoke hospice service). Review of the coordination note, dated 07/11/202 at 2:38 PM, showed the LTCF director of nursing (DON) called the hospice again, and was very upset, their next phone call is going to be to the department of human services to file a formal complaint. The patients family has the right to revoke and they have been waiting for two days for this form. Review of the hospice Medicare benefit revocation form, dated 07/11/2023, untimed, showed: - The date of revocation was 07/11/2023; - Revoking hospice Medicare benefit for the remainder of the current benefit period for the following reason: Does not wish to work with the hospice provider; and - Signed by the legal representative. Review of the hospice complaint reporting system failed to show a written investigation of the patient/family (Patient #1) grievances regarding the patients pain, medications, not receiving phone calls during each visit, the nurse failed to make a visit when the patient returned from the hospital, and the late discharge/revocation. During an interview on 08/14/2023 at 2:36 PM, the assistant vice president of sales stated that on 07/09/2023 the patients family called regarding discharge. The LPN called the family on 07/10/2023 and they wanted to revoke, on 07/11/2023 the patient revoked. During an interview on 08/14/2023 at 2:40 PM, the clinical director stated that the patients family wanted to possibly discharge and was upset because the care was not adequate. The following day he/she called the patients family and they wanted to revoke, later the clinical director stated that the family wanted to transfer the patient to another hospice. He/she did not document this information in the clinical record. During an interview on 08/14/2023 at 5:15 PM, LPN A stated that: - He/she spoke to the patients family on 07/10/2023; - The family was very upset because the patient fell, was in pain, and the hospice nurse did not make a visit; - The family asked about the discharge paperwork, and the LPN called the clinical administration and they stated they would let intake know and call the family; - On 07/10/2023 around 4:00 PM, the LPN called the family back and they were very upset and stated that nobody reached out about the discharge; - He/she spoke to the assistant vice president of sales and they could send the family the paperwork by e-mail but needed to know if it was a revocation or transfer; - The LPN called the family and they were so mad they wanted to revoke; - The LPN called the administrator and clinical director to ask about the paperwork and they did not know why intake had not handled it; - The family had been ";stewing" all day and the discharge did not happen until 07/11/2023; - He/she said the family had every right to be mad because no one addressed their complaints over the weekend or provided the discharge paperwork when it was requested; and - He/she did not document the complaint to investigate and he/she should have because the administrator is strict about documenting complaints. During an interview on 08/15/2023 at 12:44 PM, the LTCF director of nursing (DON) stated that: - The patients family was upset with the hospice over medications, care, and communication; - He/she recommended a different hospice provider if they were not satisfied with the current provider; - The family requested to revocate; - The DON stepped in to help and contacted the hospice provider the family was wanting and they needed the current provider to discharge the patient; - The DON called the current hospice provider again and pleaded for them to discharge the patient because the patient was dying, and no hospice was caring for him/her (the current provider had not made a visit since the patients fall on 07/09/2023); - He/she told the current hospice provider he/she encouraged the family to call the department of health and senior services since they would not send the paperwork and requested to talk to the staff in line and fifteen minutes he/she got the discharge paperwork; - The hospice provider discharged the patient on 07/11/2023. The other hospice provider could not admit the patient the same day, and had to wait until the next day, 07/12/2023; and - The patient died on 07/12/2023 without hospice services in place. During an interview, on 08/15/2023 at 3:44 PM, the patients family stated that: - The patient fell out of bed, went to the emergency room, and declined drastically; - The patient had difficulty swallowing and pain; - The family requested a visit from the hospice nurse when he/she returned from the hospital and the nurse did not show up; - The LTCF suggested changing hospices; - The family asked the hospice to discharge the patient, and the hospice kept saying they needed to hear from the new hospice to discharge the patient; - No hospice staff followed up with the complaints made regarding the poor care provided by the hospice; - The hospice did not offer to send a nurse after the patients fall on 07/09/2023; -The hospice finally discharged the patient on 07/11/2023, two days after the family requested to revoke services, because the nurse from the LTCF threatened to ";hotline" them; and - The patient passed away without hospice care. During an interview on 08/16/2023 at 9:18 AM, the clinical director stated that: - When the LTCF DON threatened the triage nurse he/she would call the hotline if the agency did not discharge the patient, he/she would have expected the triage nurse to write a grievance; and - There was no documentation of the complaints over the weekend or follow-up, which may have contributed to the state hotline call. During an interview, on 08/16/2023 at 10:45 AM, the admi nistrator stated that: - The patients family stated that he/she had talked to another hospice provider and would not tell him/her who the hospice provider was; - He/she stated that the other hospice provider would assess the patient and contact the current provider for information; - The nurse that received the complaint is supposed to document the complaint; and - There was no documentation of the patient/family (Patient #1) complaints over the weekend.

Based on policy review, record review, and interview the hospice provider failed to provide pain management and symptom control in, one of three records reviewed (Record/Patient #1). This deficient practice has the potential to affect all patients served by the agency. --- Findings included: Review of the provider's policy titled, "Patient Bill of Rights," revised November 2019, showed that the patient has the right to receive effective pain and symptom management for conditions related to the terminal illness(es). RECORD/PATIENT #1: Review of the skilled visit note, dated 07/05/2023 at 11:26 AM, showed: - Haldol (antipsychotic) injection recently reinitiated due to patients behaviors (The plan of care failed to include nursing orders/interventions for behaviors); - The patient continued to show non-verbal cues of pain and the morphine (narcotic used to treat moderate to severe pain) 0.25-milliliter (ml) order was for every four hours as needed; - Hospice staff observation showed a pain intensity of four on a scale of zero to ten (zero representing no pain and ten representing unbearable pain); and - The long-term care facility (LTCF) nurse asked for a routine order for Ativan (antianxiety) and morphine, they did not think the patient's symptoms were managed. An e-mail was sent to the physician for approval. The note failed to show documentation of orders received and/or follow-up. Review of the hospice aide visit note, dated 07/06/2023 at 6:24 AM, showed the patient was on the floor upon arrival, this was not from a fall, and the patient had skin breakdown on his/her tailbone. The LTCF nurse was documenting as a blister (a painful skin condition where fluid fills a space between layers of skin) and placed a dressing on it to prevent opening. An e-mail was sent out to the hospice nursing team. The clinical record failed to show documentation of orders received and/or follow-up. Review of the skilled nurse visit note, dated 07/07/2023 at 10:29 AM, showed: - The patient was lying on the floor in common area upon arrival and the patient was assisted off the floor by the hospice nurse and walked to recliner (the documentation failed to show how the patient ended up on the floor, assessment of possible injury, and physician notification); - The patients pain score was five; - No open wound; - The patient showed signs of "pain on bottom", allevyn dressing (foam dressing, designed to support a range of wound management and prevention) was applied to bottom as patient had begun to have breakdown. With patient being so skinny and not eating, some breakdown has begun (the documentation failed to include measurements, description, location, and physician notification of the breakdown on the patients bottom); and - The LTCF medication technician stated that the patients nurse was still wanting to give morphine and Ativan routinely every four hours (Two days since the LTCF requested this from the hospice provider). Review of the coordination note, dated 07/09/2023 at 9:07 AM, showed: - The LTCF notified hospice the patient had transferred to the hospital; - The patient had fallen and had blood coming from his/her head; - The patient had been more anxious and weaker overnight; - The LTCF nurse was unable to assess and clean the wound due to the patient being more combative; - The wound appeared to be on the right side of the head and the emergency medical system stated that it looked like he/she injured his/her mouth as well; and - The hospice providers documentation failed to show physician notification. The LTCF staff requested scheduled Ativan for anxiety 4 days prior and no documentation of orders received and/or follow-up. Review of the coordination note, dated 07/09/2023 at 10:34 PM, showed the LTCF called to report patient returned from emergency room (ER). The family was present and requesting a nurse (hospice) visit to review the plan of care and medications. The patient was not swallowing. A ";tuck in" visit was assigned to the hospice care coordinator. The documentation failed to show if a hospice nurse provided a visit at the familys request to assess the patient for medication management and the patient not swallowing. Review of the coordination note, dated 07/10/2023 at 8:56 AM, showed: - The licensed practical nurse (LPN) called the family and they were not happy with the hospice care; - The family concerns were that the patient was in pain and should be getting a higher dose of morphine, the patient was not tolerating pills, and Ativan was not changed to liquid and nurse (hospice) did not come to see the patient after he/she returned from the hospital (on 07/09/2023); and - The documentation failed to show a hospice nurse made a visit on 07/10/2023 to assess the patients change in condition, review medications for effectiveness, and evaluate the current plan of care. Review of a physicians order, dated 07/09/2023 at 8:47 AM, showed morphine concentrate 0.5 ml every four hours for pain and shortness of breath. The documentation failed to show the LTCF was notified of the new order. During an interview on 08/14/2023 at 2:40 PM, the clinical director stated that the patients family wanted to possibly discharge and was upset because the care was not adequate. During an interview on 08/14/2023 at 5:15 PM, LPN A stated that: - He/she did a visit with the patient on 07/05/2023 and the patient was drowsier and had a gradual decline; - He/she displayed non-verbal cues and looked like he/she had pain on his/her bottom and he/she would lean back to get off of his/her butt; - He/she reached out for routine orders for morphine and Ativan and received an order (there was no order for routine morphine in the medical record); - He/she did not assess the patients bottom during that visit because they were out in the common area; - The hospice aide made a visit on 07/06/2023 and noted the patient was still having a general decline and reported skin issues; - There was no further communication other than asking the LTCF to make sure they had pain medication orders in the computer; - He/she had received a message on 07/10/2023 that the patient fell over the weekend (on 07/09/2023), the family wanted a visit, and did not receive one and wanted to discharge; - The nurse should have provided a visit when the family requested and discussed with the family the changes in pain medications prior to the weekend; - He/she stated that since the patient got medications before the weekend (07/05/2023), had a fall, and declined he/she would imagine the pain was not controlled; - He/she offered the family a visit on 07/10/2023 (no documentation of offered visit) and the family said no; and - The family was very upset because the patient fell and was in pain and there was no visit, if a nurse would have made a visit when the family requested, they could have explained medications increased on 07/05/2023 (review of the clinical record showed no medication changes on 07/05/2023). During an interview on 08/15/2023 at 11:44 AM, the clinical manager was unable to find an order for morphine scheduled every four hours on 07/05/2023, there was an order on 07/09/2023 for morphine 0.5 ml every four hours and there was no documentation to show if staff notified the LTCF. During an interview on 08/15/2023 at 12:44 PM, the LTCF director of nursing (DON) stated that the family was upset with the hospice over medications, care, and communication and wanted to transfer to another hospice. The hospice staff did not provide a visit after the patient fell on 07/09/2023 and did not communicate with the LTCF about symptom management. The family revoked hospice services on 07/11/2023. The LTCF started initiating medications and kept the patient comfortable. The patient died on 07/12/2023. During an interview, on 08/15/2023 at 3:44 PM, the patients family stated that: - The family received a phone call the patient fell out of bed, went to the emergency room and declined drastically; - Hospice did not visit the patient after he/she fell; - The patient was having difficulty swallowing and was in pain; - He/she could tell the patient was in pain, he/she was moaning, fidgety, restless and could not get comfortable; - Hospice asked what they could do better and he/she told them manage pain; - The hospice nurse told them when medications are started they go ";low and slow" and what does that even mean, each patient is different; - The patient started declining and the LTCF took over and managed the patients pain; and - Hospice did not offer to send a nurse after the patients fall on 07/09/2023, the family revoked hospice services on 07/11/2023, and the patient passed away on 07/12/2023 (review of the patients record showed no hospice staff visit from 07/09/2023 through discharge on 07/11/2023). During an interview, on 08/15/2023 at 10:45 AM, the administrator stated that he/she would have expected the on-call RN to provide a visit when the family requested a visit to assess the patient for any changes that required hospice interventions to manage the patient.

Based on policy review, record review, and interview, the provider failed to ensure that: - Hospice ensured professional management responsibility, oversight and coordination of care/services to a patient that resided in a long-term care facility (762). The cumulative effect of this deficient practice has the potential to affect all patients served by the agency.

Based on policy review, record review and interview, the hospice provider failed to ensure professional management responsibility, oversight and coordination of care/services for a patient that resided in a long-term care facility (LTCF), in one of two applicable records (Record/Patient #1). This deficient practice has the potential to negatively affect all patients on service with the hospice provider, who reside in a nursing facility. --- Findings included: Review of the provider's policy titled, "Provision of Care to Residents of Skilled Nursing Facility (SNF) or Nursing Facility (NF) or Intermediate Care Facilities with Individuals with intellectual Disabilities (ICF/IID)" reviewed April 2023, showed: - To ensure the coordination of care provided to residents of SNF/NF or ICF/IID; - Core services including physician, nursing, social work, counselors, medical supplies, durable medical supplies, and drugs will be directly provided by hospice; - A designated interdisciplinary group member is responsible for the coordination of services; - Hospice will assume responsibility for professional management of the SNF/NF residents hospice services provided, in accordance with the hospice plan of care in a participating Medicare/Medicaid facility; - An agreement that it is the hospices responsibility to provide services at the same level and the same extent as those services would be provided in the residents own home; - A delineation of the hospices responsibilities, which include, but are not limed to: * Providing medical direction and management; and * Provide nursing including ongoing assessments. - A written plan of care must be established and maintained in consultation with SNF/NF. All hospice care provided must be in accordance with this plan of care. The plan of care must: * Identify the care and services needed and specifically identify which provider is responsible for performing the respective functions. - The organization will designate a team member of each interdisciplinary group that is responsible for a patient who is a resident of the SNF/NF. The designated member: * Providing overall coordination of hospice care of the resident with the facility representatives; * Ensuring that the hospice and SNF/NF maintain their own clinical records containing evidence of a coordinated plan of care, all forms and other documentation; and - The organization will provide the SNF/NF the following information specific to each patient: * Hospice medication information. RECORD/PATIENT #1: The initial assessment showed: - The patient admitted to hospice services on 05/10/2023, with a primary diagnosis of severe protein-calorie malnutrition; - The patient resided in a LTCF on the memory care unit; - He/she had struggled with anxiety, difficulty sleeping, and behaviors for years. The behaviors were increasing, he/she went to a psychiatric facility, and was started on haloperidol (antipsychotic) injections as the patient refuses to take medications, but has agitation and reports pain at times; - On admission, the patient had agitation and anxiety treatments of Ativan (Brand name for lorazepam, an antianxiety medication) and haloperidol. There were no abnormal psychiatric symptoms identified; - Total pain score of three (one to three is considered to be mild pain, four to six is considered moderate pain, and seven to ten severe pain) and distraction relieves pain; - The patient had a 12-pound weight loss in the past month and was not eating at time of admission to hospice; and - The hospice plan of care failed to include skilled nursing interventions and/or orders for weight loss, behavior problems, haloperidol (the documentation failed to show why hospice did not continue the haloperidol injections), and pain. Review of the Hospice interdisciplinary group (IDG) comprehensive assessment and plan of care (POC) update, dated 06/15/2023, showed, an order for Haldol (haloperidol) deaconate 50 milligram (mg)/milliliter (ml) intramuscular (IM) 1 ml monthly that was received on 06/02/2023. (The clinical record failed to show documentation of the patient receiving the injection as ordered). Review of the skilled nurse visit note, dated 06/23/2023 at 10:01 AM, showed: - The patient was crawling on the floor upon arrival, he/she had a skin tear to forearm and an abrasion on his/her back, and the LTCF staff believe these are a result of lying/kneeling/rolling on the floor; - The hospice staff observations showed a total pain score of seven indicating severe pain and the patients Fentanyl patch dosage was increased on 06/23/2023 (the documentation failed to show that the skilled nurse assessed/monitored the patients use of the fentanyl patch); - The patient continued to not eat, had become more difficult to get the patient to take oral medication, and the skilled nurse would consult registered nurse (RN) to get his/her opinion on the patients status; and - The documentation failed to show follow-up from a RN, assessment/evaluation of the skin tear to forearm and the abrasion on the patients back and adequate pain management interventions. Review of the coordination note, dated 06/24/2023, showed: - The LTCF called the after-hours triage nurse to report the patient has been restless; - The patient sat on the floor thinking it was a Hoyer lift (mechanical lift) (there was no documentation to show the patient used a Hoyer lift) and hit his/her head, the patient had abrasions to the left side of the face, it took three staff members to move him/her, and his/her gait was unsteady; - The patient had on a Fentanyl patch for pain, received lorazepam 1 mg for anxiety that morning. The patient used to receive Ativan 0.5 mg injection every four hours as needed, that controlled the anxiety but no longer had orders for the injections (no documentation of why the hospice agency did not continue the orders); - The LTCF nurse requested that hospice reorder the Ativan injections; - The LTCF nurse was informed that a hospice nurse could do a visit to assess the patient, would follow up with the physician after assessing the patient, and see if he/she will reorder the lorazepam as needed (the clinical record failed to show any documentation and/or history of Ativan injections); and - The LTCF is agreeable to a visit to assess the fall. The after-hours RN was assigned the as needed nurse visit. Review of the physician order, dated 06/24/2023, showed an as needed nursing visit to assess the patient due to fall and review as needed medications (The clinical record failed to show documentation that this visit was made). Review of the coordination note, entered by the after-hour RN, dated 06/24/2023, showed: - The LTCF nurse reported the patient was resting and does not need a nursing visit, just a lorazepam script sent in; - The LTCF had the medication but needed a written order from the physician before they could give the medication to the patient; - The RN called the physician for the prescription order; - The clinical record failed to show documentation of any orders received by the physician for the lorazepam, there was no physician notification that the patient did not receive the skilled nurse visit to assess the fall as ordered, and there was no follow-up with the LTCF regarding the lorazepam requested. Review of the hospice aide visit note, dated 06/29/2023 at 6:25 AM, showed the patient was very combative while giving care. The hospice nursing staff stated that he/she is difficult to handle and that it takes three to four staff members to get him/her dressed and cleaned up. E-mail sent to the hospice nursing team. The plan of care failed to show documentation related to the patients behavior problems and/or combativeness. Review of the skilled nurse note, dated 06/29/2023 at 8:40 AM, showed the patient was combative and hitting, the LTCF asked to reinstate the patients monthly Haldol injection. The skilled nurse note failed to show that the hospice nurse failed to assess when the monthly Haldol injection was last given and/or due next. The clinical record failed to show any Haldol discussions and/or changes in the Haldol order since the IDG update on 06/15/2023. Review of the skilled visit note, dated 07/05/2023 at 11:26 AM, showed: - The patient had non-verbal cues of pain and morphine (narcotic used to treat moderate to severe pain) 0.25 ml every four hours as needed was the order for pain management; - Hospice nurse observation showed a pain intensity of four on a scale of zero to ten (zero representing no pain and ten representing unbearable pain) and a total score (pain) of five which indicates moderate pain; - The LTCF nurse requested a routine order for Ativan and morphine to control symptoms; - An e-mail was sent to the physician for approval; - The clinical record failed to show documentation and/or email of physician being notified about the routine Ativan and morphine orders requested by the LTCF. The clinical record failed to show any new orders and failed to show documentation of follow up with the LTCF regarding the routine order request. Review of the hospice aide visit note, dated 07/06/2023 at 6:24 AM, showed the patient was on the floor upon arrival, this was not from a fall, and the patient has skin breakdown on his/her tailbone. The LTCF nurse was documenting as a blister (a painful skin condition where fluid fills a space between layers of skin) and placed a dressing on it to prevent opening. An e-mail was sent out to the hospice nursing team (No documentation of orders received and/or follow-up). Review of the skilled nurse visit note, dated 07/07/2023 at 10:29 AM, showed: - The patients pain score was a five; - The patient was lying on the floor and the hospice nurse assisted the patient off the floor and walked to the recliner (no documentation to show if the patient fell); - The LTCF medication technician stated that the patients nurse was still wanting an order to give morphine and Ativan routinely every four hours (the LTCF requested orders 2 days prior and the hospice provider failed to follow-up on the request); and - The patient showed signs of pain on bottom, allevyn dressing (foam dressing, designed to support a range of wound management and prevention) applied to bottom for skin breakdown, and due to the patient being so skinny and not eating, some breakdown had begun (No documentation the physician being notified and/or any new orders received). Review of the coordination note, dated 07/09/2023 at 9:07 AM, showed: - The LTCF nurse notified hospice that the patient was transferred to the hospital; - The patient was sitting in the middle of the floor with blood coming from his/her head and had fallen; - The patient had been more anxious and weaker overnight and the LTCF staff had been doing 15-minute checks on the patient; - The LTCF nurse was unable to assess and clean the wound due to the patient being more combative, and the wound appeared to be on the right side of the head; - The emergency medical system staff stated that it looked like he/she injured his/her mouth as well; and - The documentation failed to show that the hospice physician was notified of the patient having a fall with injury and was sent to the hospital. Review of the coordination note, dated 07/09/2023, at 9:42 PM, showed the LTCF called the hospice agency at 8:34 PM to report that the patient returned from the emergency room (ER). The family was present and requested a nurse (hospice) visit to review the plan of care and medications. The patient was not swallowing. A ";tuck in" visit was assigned to the hospice care coordinator (The record failed to contain documentation of any nurse from hospice making a patient visit as requested). Review of the physicians order, dated 07/09/2023 at 8:44 PM, showed an order description for "lorazepam to be given in liquid not applesauce and morphine increase to 0.5 ml every four hours alternating with lorazepam". The clinical record failed to show a dosage and frequency for lorazepam and the hospi ce failed to coordinate orders with the LTCF. The patient did not receive a visit from the hospice nurse. Review of the coordination note, dated 07/10/2023 at 8:56 AM, showed: - The licensed practical nurse (LPN) called the patients family, they were upset the nurse did not make a visit and was not happy with the hospice care; - The concerns were that the patient was in pain and should have been getting a higher dose of morphine; and - The patient was not tolerating pills and the Ativan was not changed to liquid. During an interview on 08/15/2023 beginning at 10:15 AM, the clinical manager stated that: - The staff did not document an assessment of the patients buttocks when the hospice aide reported a blister and the plan of care failed to include skin issues; - The interdisciplinary group is every two weeks; - Review of the hospice IDG meetings, dated 06/01/2023, 06/15/2023, and 06/29/2023 showed the nursing section was blank, he/she was unsure why the nursing section was blank and at the least, he/she should have documented ";no new concerns"; - The clinical manager and LPN do all nursing cases and both attend IDG and discuss any changes since the last IDG meeting; - A tuck in visit means a hospice staff member does a visit and makes sure all medications and supplies are available, when an as needed nurse visit is ordered he/she expects staff to make the visit; and - He/she is the nurse manager (clinical manager) that is responsible for follow-up and coordination of care/orders with the LTCF. During an interview on 08/15/2023 at 10:45 AM, the administrator stated that: - He/she expected the nurse to make a visit per the physician order on 07/09/2023; - Staff should notify the physician of any changes in condition and the plan of care updated and if it is not, it is unacceptable; - The plan of care should include falls, pain, behaviors, and skin integrity problems and individualized interventions; - The "original order for Ativan on 06/24/2023 shows the script and dispense report is not matching" and he/she had an order on 07/09/2023 for lorazepam 2 mg/ml (the order failed to show dosage) to be given in liquid and not applesauce every four hours as needed (the order failed to show frequency) and to increase morphine to 0.5 ml every four hours routinely; - There was no documentation of communication regarding this order with the LTCF; and - On 07/11/2023, the pharmacy report showed "Ativan 2mg/ml liquid IM every four hours as needed" dispensed (review of the clinical record failed to show Ativan 2mg/ml liquid IM every four hours as needed).