Every finding on record at Saint Luke's Health System Home Care and Hospice

Based on policy review, record review, and interview, the agency failed to reconcile medication discrepancies between the hospice medication profile and the skilled nursing facility profile in one (Record/Patient #5) of one applicable case. This deficient practice has the potential to affect all of the agencys patients. --- Findings included: Review of the agencys policy titled, ";HOSP Medications in Hospice ";, (Policy #: HOSP1029), dated effective date of 12/8/2016 showed medication profiles will be maintained for each patient and reviewed at least every 14 (fourteen) days. RECORD/PATIENT #5: Review of the current agency medication profile showed, in part: - Donepezil (Aricept) 5 mg (milligram) tablet. Take 2 (two) tablets every night (for memory); - Lorazepam (Ativan) 2mg/ml (milliliter) concentrated solution. Take 0.25-1ml (0.5-2mg total) by mouth every 4 (four hours as needed (anxiety); and - Morphine 20mg/ml concentrated solution. Take 0.25-1 ml (5-20mg total) by mouth every hour as needed for pain (air hunger). Max daily dose 480 mg; and - Mirtazapine failed to be listed. Observation on 03/14/2023 at 10:00 AM, during the patients home visit, a review of the facilitys March 2023 medication administration record showed the following discrepancies: - Donepezil failed to be listed; - Lorazepam intensol 2mg/ml 0.25ml by mouth every 4 (four) hours as need for anxiety; - Morphine Sulfate 100mg/5ml 0.25ml by mouth every 1 (one) hour as needed for air hunger/pain; and - Mirtazapine 7.5mg tablet 1 tablet PO (by mouth) at bedtime for appetite stimulant. Per interview conducted during observation, RN C stated that: - Mirtazapine was not listed on the agency medication profile; - Donepezil was listed on the agency profile; - Some facilities dont allow ranges for medication dosages; and - The medication profiles (agency/facility) should match. During an interview on 03/15/2023 at 10:06 AM the administrator designee stated that: - The medication profiles (agency/facility) should match; and - Medication reconciliation should be done every visit, especially in a facility.

Based on policy review, clinical record review, observation, and interview, the agency failed to ensure that each patient's written individualized plan of care (POC) included all required elements in, but not limited to, two (Records/Patients #1 and #2) of six full records reviewed. This deficient practice has the potential to affect all patients served by the agency. --- RECORD/PATIENT #2:Review of the clinical record, showed the patient was admitted to the hospice house on 03/06/2023 from the hospital with a terminal diagnosis of respiratory failure (a serious condition that makes it difficult to breathe on your own. It develops when the lungs cant get enough oxygen into the blood). The patient was admitted with a suprapubic catheter (a catheter surgically inserted through the wall of the abdomen into the bladder). Review of the plan of care, dated 03/06/2023, showed the following orders:-If IV (intravenous- in the vein) site is lost, route for administration can be changed to subcutaneous (SC) route; -May place and maintain SC line as indicated per protocol; and-Insert straight or indwelling catheter as needed with #16 or #18 french (size) foley (a sterile tube placed in the bladder to drain urine) 10 CC (cubic centimeter) balloon as needed (patient already had a suprapubic upon admission). Observations on 03/13/2023 at 5:30 PM, showed the patient had a SC line, a suprapubic catheter, a rash all over his/her torso, edema (swelling) of his/her hands and was suctioned (remove something using suction). The plan of care failed to be individualized with goals and interventions for the SC line, the suprapubic catheter, the rash, the edema, and the suctioning. Findings included: Review of the agency's policy titled, "Hospice Care Planning Process and Care Coordination," dated 01/20/2021, showed in part: - A plan of care (POC) is an individualized plan developed with the participation of the patient, family and/or caregivers and hospice interdisciplinary team in collaboration with the patients providers that support the patients goals; and - The POC must include all services, equipment, medical supplies, and pharmaceuticals necessary to meet the specific patient and family needs for palliation and management of the terminal illness and related conditions of the individual. RECORD/PATIENT #1 Review of the clinical record showed the patient admitted to the inpatient hospice for respite care on 03/09/2023 with an admitting diagnosis of malignant neoplasm of the right breast. Review of a nurse note dated 03/09/2023 at 11:21 PM, the patient had a wound covering the entire right breast, the peri-wound (tissue surrounding the wound) is bright red and lumpy, and the breast is red with white sloughing skin. The nurse educated on the proper dressing for this type of wound and the benefits of covering the wound as opposed to keeping a personal wipe over the wound area. The nurse dressed the wound with xeroform gauze (used to cover and protect low to non-exudating wounds) and ABD pads (used to absorb discharges from heavily draining wounds) and Medipore tape after cleansing the wound with wound cleanser. The patient reported pain at three out of ten (a pain scale used to rate the patients pain with zero representing no pain and ten representing the worst pain possible). During rounds, the patient was applying Aquaphor (petroleum-based to heal and protect dry or cracked skin, in addition to other irritants) lotion to the right breast, the patient reported pain and stated that the Aquaphor cooled the wound, and the nurse told the patient if he/she preferred that treatment that would be fine. Observation on 03/14/2023 at 10:50 AM, showed registered nurse (RN) D removed a large saturated dressing from the patients right breast. The entire right breast area showed an extensive, malodorous, and seeping wound. The patient asked the nurse to wash the wound with foam because that helped with the discomfort. The patient asked the nurse to put eucerin (used as a moisturizer to treat or prevent dry, rough, scaly, itchy skin and minor skin irritations). The nurse talked the patient into a dressing, he/she cleansed the area with a foam cleanser, applied a Vaseline gauze and ABD pad over the wound and secured with Medipore tape. The plan of care failed to include individualized problems, interventions and goals regarding the wound to the right breast and pain. During an interview on 03/14/2023 at 12:25 PM, the manager of clinical services (nursing coordinator) stated that the plan of care (POC) should have the most current treatment and be individualized to the patients needs. During an interview on 03/15/2023 at 10:30 AM, the director of home care and hospice (administrator designee) stated that the POC should be individualized and all treatments need to be included on the POC including education.

Based on policy review, observation and interview, the agency failed to ensure that accepted standards of practice to prevent the transmission of infections was followed in one (Record/Patient #4) of two home visits conducted. This deficient practice has the potential for increased infection risk for all of the agencys patients. --- Findings included: Review of the agencys policy titled ";Management of Foley Catheters (a sterile tube placed in the bladder to drain urine), PC-082" dated last revised 01/2022, showed in part: - Purpose: To provide a guideline for the management of foley catheters at ";Named agency"; - Do not place the collection bag on the cart or in the bed with the patient, even during transport of the patient; and - Clean catheter-meatus (hole through which urine leaves the body) junction after every incontinent stool (policy failed to provide instructions on specifically how to clean this area). Review of the agencys policy titled ";Hand Hygiene, IPC-001", dated last revised 3/1/2022, showed in part: - Purpose: To provide a guideline to prevent the dissemination of disease through the contact means of transmission; - Hand hygiene is the single most important means of preventing the spread of disease; - All employees and licensed independent providers will comply with the hand hygiene guidelines and procedures set forth in this policy; - All employees will perform hand hygiene with either soap and water or alcohol-based hand rub for routine decontaminating of hands; - Routine indications for hand hygiene include after removing gloves; - Other aspects of hand hygiene: Gloves- Wear gloves when contact with blood or other potentially infectious materials, mucous membranes, and non-intact skin could occur; - Perform hand hygiene after glove removal; and - It failed to contain any information regarding double gloving. RECORD/PATIENT #4 Observation on 03/13/2023 at 3:50 PM, during the patients home visit, showed the hospice aide: - Removed their gloves and replaced with another pair of gloves without performing hand hygiene several times throughout the visit; - Applied 2 gloves to their right hand, utilized right gloved hand to apply a cream to the patients bilateral groin areas, then removed the outer glove on the right hand and continued providing cares; - After turning the patient to their side, picked up the catheter bag that had become unhooked from the bed frame and laid it on the foot of the bed while finishing the patients personal cares; - Only partially pulled back the patients foreskin when providing catheter care; and - Utilized the same disposable wipe to cleanse the urethral meatus down the foley catheter tube (from proximal to distal) three times without obtaining a clean wipe or folding the wipe used. Per interview conducted during the observation visit, the aide stated that: - He/she did not want to pull the foreskin back too far; - The patients child always provides the catheter care; and - The patients child asked that the foreskin not be pulled back very far. During an interview on 03/15/2023 at 10:20 AM the administrator designee stated that he/she: - Would expect the aide to sanitize their hands when changing gloves; - Did not recall their gloving policy including double gloving; - Believed it was standard procedure to pull the foreskin all the way back when providing catheter care; and - Did not believe it was appropriate to utilize the same disposable wash cloth to wipe from the urethral meatus down the catheter tubing three times, potentially introducing microorganisms (germs) from the distal portion of the catheter back up to the urethral meatus.

Based on policy review, record review, observation, and interview, the agency failed to ensure the licensed professional (registered nurse-RN) followed the agency policy when administering medication via hypodermoclysis (method for infusing fluid into subcutaneous tissue that requires only minimal equipment) for one (Record/Patient #2) of one applicable case. This deficient practice has the potential to affect all patients that receive medications via hypodermoclysis. --- Findings included: Review of the agency's policy titled, ";Subcutaneous (SC-just below the skin) Medication Administration for Patients at the End of Life," dated revised 11/2021, showed in part the following:-Indications: Common indications for use of the subcutaneous route for the administration of comfort medications include:• Circumstances that can compromise oral administration in the hospice house setting- decreased level of consciousness and persistent nausea and vomiting; and• Loss of intravenous access during end of life care only measures in which symptom control is required;-Administer medication (page 5 of 7): The maximum amount of medication to be administered at one time (without including a normal saline flush) is 2 milliliter (ml); -Flush the subcutaneous line with 0.5 ml to 1 ml normal saline flush; and-Ensure that the total volume of medication does not exceed 2.5 ml to the subcutaneous site (this amount does not include normal saline flushes-from page 6 of 7). RECORD/PATIENT #2:Review of the clinical record, showed the patient was admitted to the hospice house on 03/06/2023 from the hospital with a terminal diagnosis of respiratory failure (a serious condition that makes it difficult to breathe on your own. It develops when the lungs cant get enough oxygen into the blood). Review of the plan of care, dated 03/06/2023, showed the following orders:-If IV (intravenous- in the vein) site is lost, route for administration can be changed to SC route; -May place and maintain subcutaneous line as indicated per protocol;-Diphenhydramine (Benadryl - antihistamine) injection 50 to 100 mg give intravenous (IV; through the vein) every four hours; and-Hydromorphone (narcotic- used for moderate to severe pain) injection 2 to 4 mg give IV every 30 minutes as needed for pain or dyspnea (shortness of breath). Administration instructions: Please give 0.5 mg for mild pain or dyspnea, 1 mg for moderate pain or dyspnea, or 2 mg for severe pain or dyspnea. Observation on 03/14/2023 at 4:58 PM, showed RN A administer the following:-Benadryl 50 mg per milliliter (ml)-1 ml via SC port;-Hydromorphone 2 mg per ml-2 ml via SC port for a total medication volume of 3 ml (which is 0.5 ml to 1 ml more than their policy allotted); and-Normal saline flush 1 ml via SC port. During an interview on 03/14/2023 at 3:25 PM the director of home care and hospice stated that he/she expected the policy to be followed.

Based on clinical record review, policy review, observation and interview, the agency failed to ensure that care was provided as ordered on the aide care plan in one (Record/Patient #4) of two home visit observations. This deficient practice has the potential to adversely affect all patients receiving aide services. --- Findings included: RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to hospice services on 04/28/2022. Review of the current plan of care showed: - It failed to list miconazole cream; and - It failed to contain an intervention of application of miconazole cream by the aide. Further review of the clinical record showed a physician order (order #396397648) dated 03/14/2023 entered by RN E for miconazole 2% cream apply topically daily as needed (reddened yeast area). Observation on 03/13/2023 at 3:50 PM, during the patients home visit, the hospice aide was noted applying miconazole 2% cream to bilateral groin areas (area between the abdomen and the thigh) of the patient. During an interview on 03/15/2023 at 10:20 AM, the administrator designee stated that: - He/she would expect the miconazole cream to be on the aide plan of care; - He/she would expect the aide to follow the aide plan of care; and - He/she would expect a current order in the clinical record.

Based on record review, observation and interview, the agency failed to ensure physician orders were obtained for one (Record/Patient #2) of six full records reviewed. This deficient practice has the potential to affect all patients served by the agency. --- Findings included: RECORD/PATIENT #2:Review of the clinical record, showed the patient was admitted to the hospice house on 03/06/2023 from the hospital with a terminal diagnosis of respiratory failure (a serious condition that makes it difficult to breathe on your own. It develops when the lungs cant get enough oxygen into the blood). The patient was admitted with a suprapubic catheter (a catheter surgically inserted through the wall of the abdomen into the bladder). Observations on 03/13/2023, showed the following:-At 4:58 PM, Registered Nurse (RN) A administered a normal saline flush of 1 milliliter (ml) after administering two other medications into the patients subcutaneous (just below the skin) port; and-At 5:30 PM, RN B suctioned (remove something using suction) the patient. Further review of the plan of care, showed the agency failed to get physicians orders for:-The suprapubic catheter to include care and frequency of change;-The normal saline flush; and-The suctioning. During an interview on 03/14/2023 at 3:25 PM, the director of home care and hospice stated he/she would have expected to have physicians orders for those items listed above.

Based on record review, observation and interview, the agency failed to ensure the coordinated task plan of care (POC) with the long term care facility (LTCF) included the days of the week the skilled nurse (SN) and aide were to visit, in one (Record/Patient #5) of one applicable case. This deficient practice has the potential to adversely affect all hospice patients residing in a LTCF. --- Findings included: RECORD/PATIENT #5: Review of the clinical record showed the patient began receiving hospice care 12/23/2022 and on 01/23/2023 began residing in a LTCF. Observation on 03/14/2023 at 10:00AM, during the patients home visit, a review of the coordinated task POC, most recently dated 1/24/23, maintained in the LTCF hospice binder showed the SN and Aide were to visit one time weekly, but failed to show what day of the week they would be visiting. The days of the week on the coordinated task POC failed to be circled. Per interview conducted during observation, RN C, stated that he/she doesnt usually circle the expected days of the week of the disciplines visits because they could change. During an interview on 03/15/2023 at 10:06 AM the administrator designee stated that he/she would expect the coordinated task POC to be completed with the anticipated day of the week for SN and aide visits.

Based on record review, observation and interview, the hospice failed to ensure the long term care facility (LTCF) record contained a copy of all required hospice documents in one (Record/Patient #5) of one applicable case. This deficient practice has the potential to adversely affect all patients residing in nursing facilities served by the hospice. --- Findings included: RECORD/PATIENT #5: Review of the clinical record showed the patient began receiving hospice care 12/23/2022 and on 01/23/2023 began residing in a LTCF. Observation on 03/14/2023 at 10:00AM, during the patients home visit, a review of the hospice binder showed: - It failed to contain the hospice election form; and - It failed to contain the patients advance directives. Per interview conducted during observation, RN C, stated that he/she: - Did not see the hospice election form in the hospice binder; and - Did not see the advance directive in the hospice binder. During an interview on 03/15/2023 at 10:06 AM the administrator designee stated that he/she would expect the hospice binder to contain the required documents including the hospice election form and the advance directives.

Based on observation and interview the facility failed to ensure a remote generator stop button was installed. --- Findings included: 1 Observation on 03/12/23, showed the generator location and mechanical rooms did not show that a remote stop button for the generator was present in those locations. 2During an interview on 03/12/23 at 12:20 PM, maintenance A and maintenance B stated that if the generator stop button had been installed it would be in the locations observed and that the generator did not have a remote stop button.

Based on agency policy review, observation and interview, the dietary department of the inpatient hospice house failed to preserve and not compromise nutritive food value due to prolonged food storage of food items located in the kitchen refrigerator. This had the potential to affect all patients, visitors, and staff in the inpatient hospice house. --- Findings included: Review of the agency's policy titled, "Nutrition Services Standard Operating procedure," dated 06/07/12, showed all food labeled with the date the item was prepared, opened, or thawed and the date of expiration or use by date. Observation on 03/13/2023 at 9:00 AM, the hospice house dietary kitchen showed a ¾ full pan of taco salad (identified by the kitchen staff) labeled ";made 03/03/2023" (ten days after observation) in the walk in refrigerator. The pan of taco salad showed no expiration date or use by date. During an interview on 03/15/2023 at 10:30 AM, the administrator designee stated that he/she would expect food discarded within seven days of being prepared.