Every finding on record at Seasons Hospice & Palliative Care of Missouri, LLC

Observed in Patient Home. In 2 of 3 home visits conducted, with nurses it was noted that, the hospice nurse failed to conduct a medication assessment. For example during visits RRHV#3 and RRHV#4 the nurses asked the caregivers and patient questions about the medications and need for refills, but did not complete a medication assessment. This was confirmed with the manager present.

Observed in Record Review. In 10 of 14 patient records reviewed, it was noted that the written plan of care was not individualized. For example, in record RRHV#2, RRHV#3, RRNHV#2 and RRNHV#5 the spiritual goal was identical (name) and caregiver (name) will feel relief from spiritual concerns AEB calm demeanor during this month. For example in record RRHV#3 Patient will have safety needs met through certification period and (Patient name) and family will have decreased fear/anxiety regarding death and dying process. In records RRNHV#8, RRNHV# 10, and RRNHV#5 the Music Therapist goals were identical, (Patient name) will feel an enhanced quality of life and decreased sense of social isolation AEB making eye contact with MT and smiling at every visit In record RRNHV#7 the music therapy goal stated MT intern to visit in 2 wks. In record RRNHV#6 there were no current goals documented for social work, spiritual counselor and music therapy. In record RRNHV#1 the goals did not include time frames. In record RRNHV#3 there were no goals documented for social work. In records RRNHV#5 and RRNHV#10 the social work goals did not include time frames. This was confirmed with the Area Quality Director present.

Observed in Record Review. In 1 of 14 patient records reviewed, it was noted that care was not provided according to the plan of care. For example, in record RRHV#4 the plan of care stated volunteer was to visit the patient weekly beginning over a month ago, however there were no volunteer visits documented and no missed visit notes documented. This was confirmed with the Area Quality Director present.

Observed in Patient Home. In 2 of 3 home visits conducted, that included equipment cleaning it was noted that, the staff did not follow contact time (wet time) as specified by the disinfectant manufacturer’s IFUs. For example, during visits RRHV#1 and RRHV#3 the nurses used purple top Sani Wipes to clean the equipment however they did not observe the 2 minute contact/wet time required. This was confirmed with the managers present.

Observed in Tracer Activities. During the review of the volunteer program, the surveyor noted that the organization did not meet the 5% care requirement. Volunteer staff provided day to day administrative or direct patient care, but the amount was 4% of the total patient care hours paid to all hospice staff. This finding was discussed with the volunteer coordinator and the director of patient experience. The leaders had a identified this gap prior to the survey and had developed a quality improvement project plan in an attempt to increase the volunteer hours.

Observed in Record Review. In 2 of 2 patient records reviewed, for live discharge patients, it was noted that there was no documentation that the next health care provider was notified of the availability of a discharge summary or that the discharge summary and documents were faxed as the organization's process required. This was confirmed with the Area Quality Director present.

Observed in Patient Home. In 1 of 4 home visits conducted, it was noted that the education and training related to procedures to follow if care, treatment, or services were disrupted by a natural disaster or an emergency was incomplete. For example during the nurse visit RRHV#1 the patient's individualized emergency plan was incomplete with the oxygen equipment section left blank. The patient used oxygen continuously and with it was observed to be short of breath. This was confirmed with the DPCS who was present.

Based on policy review, record review, and interview, the hospice provider failed to document an ongoing comprehensive assessment that included all changes in the patient's condition and response to care and treatment provided in three of three records reviewed (L533). The cumulative effect of this deficient practice has the potential to affect all patients served by the provider.

Based on policy review, record review, and interview, the hospice provider failed to ensure the comprehensive assessment was updated to include all changes in the patient's condition and the reassessment of the patient's response to care in three of three records reviewed (Records/Patients #1, #2, and #3). This deficient practice has the potential to affect all patients served by the provider. --- Findings included: Review of the providers policy, titled ";Ongoing Nursing Assessment," revised 02/15/2022, showed the following: - Nursing care and services are provided by or under the supervision of a registered nurse in compliance with the patient plan of care and ensure that the nursing needs are met as identified in the patients initial assessment, comprehensive assessment, and any updated assessments; - Ongoing assessments shall focus on patients response to care and changes in patient condition level of deterioration; - Based on the assessments, the care plan-including, needs, goals, and outcomes shall be reviewed and updated by interdisciplinary group (IDG) members responsible for the case; - Based upon findings of the assessment, change/verbal orders shall be generated and forwarded to the physician as needed; and - The physician shall be notified to verify any changes in medications and treatment/interventions that require physician approval and signature. RECORD/PATIENT #1: Review of the start of care assessment, dated 07/18/2023, showed the following: - The patient resided in a long-term care facility (LTCF); - Admitting diagnosis was malignant neoplasm of the prostate (prostate cancer); and - Past medical history included seizures (a sudden, uncontrolled burst of electrical activity in the brain. It can cause changes in behavior, movements, feelings and level of consciousness). Review of a coordination note, dated 09/14/2023 at 11:01 PM, showed that the LTCF called the hospice call center to report the patient exhibited potential seizure like activity for approximately 40 seconds to include ";shaking and staring off into space." The patient appeared less verbal and was ";staring into space." The LTCF caller reported the patient did not have any Ativan (lorazepam; used to treat seizure activity). The plan of care failed to include interventions for seizures. The provider failed to ensure the comprehensive assessment was updated when the patients condition changed (the patient had seizure like activity, and he/she did not have any Ativan). During an interview on 10/30/2023 at 9:26 AM, the administrator stated that the hospice on-call nurse attempted to contact the LTCF several times and was unsuccessful. The next call was received from the hospital on 09/15/2023 at 1:16 PM (13 hours later) to verify the patient was receiving hospice care. The patient had been admitted to the neuro intensive care unit. During an interview on 10/31/2023 at 9:46 AM, registered nurse (RN) A stated that he/she was unable to get a hold of the staff at the LTCF. He/she did not make a visit to assess the patient. The next shift would follow up with the patient. During an interview on 10/31/2023 at 9:54 AM, the case manager stated that the patient was in the hospital currently with seizures, this was the patient's first seizure while on hospice services. Staff are expected to assess a patient that has a change in condition. During an interview on 11/01/2023 beginning at 1:17 PM, the administrator stated that the on-call hospice nurse did not make a visit to patient #1 after the call was received from the LTCF. He/she would expect the on-call hospice nurse to contact the LTCF or family to get more information and then decide if a visit is needed. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice care on 08/23/2023. The admitting diagnosis was sequelae of cerebral infarction (stroke). Review of the coordination note, dated 10/21/2023 at 8:25 PM, showed that the LTCF called the hospice call center to report the patient had dyspnea (shortness of breath). The patients oxygen saturation (blood oxygen level) was 89 percent (a value lower than 90 percent is considered low oxygen saturation) on room air and 96 percent on three liters of oxygen, respiratory rate was 24 (normal respirations range is 12 to 20), heart rate 144 (normal rate is 60 to 100 beats per minute). The patient did not have an order for oxygen. The patient needed an order for lorazepam and they needed the medication, the LTCF pharmacy would not deliver the medication until Monday or Tuesday. The hospice call center RN contacted the hospice on-call nurse to follow up, the hospice on-call nurse had access to the chart, and a visit was assigned in case the visit was needed. Review of the coordination note, dated 10/21/2023 at 9:00 PM, showed the following: - The patient had a change in condition; - New orders were received from the physician: * Duoneb (a combination of medication used to treat chronic obstructive pulmonary disease) one vial per nebulizer every four hours as needed for wheezing and dyspnea; * Oxygen three liters via nasal cannula as needed for comfort and dyspnea (shortness of breath); * Lorazepam Intensol 2 milligram (mg)/milliliter (ml) give 0.25 ml sublingual every three hours as needed for anxiety/restlessness; * Morphine (opioid narcotic) 20 mg/ml give 0.25 ml sublingual every three hours as needed for pain/dyspnea; and * The physician orders were relayed to the LTCF nurse and verified the LTCF had morphine on hand but needed the Ativan; - At 10:00 PM, the prescriptions were ordered from the pharmacy and the prescriptions would be ready at 11:00 PM, the medication was not ready (at 11:00 PM) and the hospice nurse had to wait over an hour to pick up the prescriptions; and - On 10/22/2023 at 12:38 AM (4 (four) hours and 13 minutes after on-call received the call from the LTCF), upon the delivery of the medications and the start of the hospice nurse visit the patient was found to be non-responsive. As the hospice nurse was counting breaths, the patient's last breath was taken at 12:44 PM. The hospice visit was restarted as a death visit. The provider failed to ensure the comprehensive assessment was updated after the LTCF had called and reported a change in condition that required medication changes. During interview on 11/01/2023 at 2:35 PM, RN B stated that the patient was short of breath, he/she called the LTCF nurse and let the nurse know he/she would do a visit after he/she picked up the medication. The patient was minimally responsive after the hospice nurse arrived to the LTCF. The LTCF nurse wanted the Ativan because the patient was transitioning (dying) and short of breath. The on-call nurse gathers the information when they receive a call regarding a hospice patient and then triage the call. The on-call nurse can decide if the patient requires a visit. If a patient was short of breath, they automatically assigned a visit, and the nurse has one hour to make a visit to the patients home. If the patient required orders or clarification of medications, he/she provided a visit. RECORD/PATIENT #3: Review of the start of care assessment, date 10/09/2023, showed the following: - The patient was admitted to hospice on 10/09/2023; - The patient resided at home; and - Admitting diagnosis was peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). Review of the coordination note report, dated 10/16/2023 at 8:23 AM, showed the patients caregiver called and reported the patient had a different breathing pattern and involuntary movements during sleep, the caregiver was very concerned and requested a nurse visit for that day (10/16/2023). The provider failed to ensure the comprehensive assessment was updated after the patient had a change in his/her breathing pattern, involuntary movements, and the caregiver requested a nurse visit. Review of the visit note, dated 10/19/2023 at 10:42 AM, (3 (three) days after the caregiver requested a visit) showed the patient had irregular ";drum like" heart sound rhythm and experienced a significant decrease in appetite. The hospice nurse encouraged the patient's family to offer smooth and soft foods. The patient's skin tone to both lower extremities was bluish/purple. The patient required continuous assist from the caregiver and was unsafe to bear weight. The patient had some sun downing (state of confusion occurring in the late afternoon and lasting into the night) over the past week. The haloperidol (antipsychotic) was not working, and the RN suggested lorazepam (anti-anxiety) as an alternate as needed. Review of the coordination note report, dated 10/20/2023, showed the following: - At 6:02 PM, the patients family member reported the patient kept trying to get out of bed when he/she was awake; - He/she would not leave his/her brief on; - He/she was having some breathing pattern changes when he/she was sleeping, breathing out of his/her mouth and the patient was not short of breath, and his/her fingers were whiter and cooler; - The family had given the patient Ativan (lorazepam; sedative) 0.25 milligrams (mg) four to five hours prior and that was not effective; - They had tried giving liquid acetaminophen (Tylenol; used to treat minor aches, pains, and fever), and was only able to give about a quarter of the dose when the patient had refused to take the rest of the acetaminophen dose; - Outcome of the call showed the medications were reviewed, the caller was educated on the Ativan and Haldol order, and the caller stated that the Haldol made the patient more anxious when he/she took it for the first time; - The on-call nurse was contacted for follow up at 6:19 PM; - At 7:53 PM (1 (one) hour and 51 minutes after the first call), the patients family member called again to report that the patient was restless despite having the lorazepam one hour prior, his/her hands were pale in color, and the patient was getting up every 30 minutes to go to the bathroom; - The family stated that the patient appeared to be agitated; - The patient was given Remeron (used to treat depression) as well as Haldol in the past, the Tylenol and Ativan would help with restlessness and agitation; - The patient would not allow the caregiver to administer a Tylenol suppository (a dosage form used to deliver medications by insertion into a body orifice); - The family would like a nurse visit; - The triage on-call nurse reviewed the patient profile and notified the on-call nurse, and an as needed visit was scheduled; and - The on-call nurse was contacted at 8:26 PM for the visit. Review of the nurse visit note, dated 10/20/2023 at 9:13 PM (3 (three) hours and 11 minutes after receiving the family's call reporting a change in condition), showed that the patient had increased restlessness and increased attempts to toilet independently and his/her ambulation was unsteady. Each time the patient went to the bathroom he/she was unable to void but felt like he/she had to. The patient denied burning or pain on urination, he/she just had the feeling of having to go. The patient was having increased difficulty swallowing medications per the caregiver but did not have difficulty swallowing medications for the nurse. The patient appeared more restless, had slight edema to both hands, and respirations were shallow. The patient took a ½ tablet of lorazepam at 11:00 AM, a whole tablet at 4:00 PM, and the patient was still restless. The physician ordered lorazepam 0.5 mg every four hours as needed, the medication was ordered from the pharmacy and the family would pick up the medication. (The note failed to say if the nurse had administered a new dose prior to him/her leaving and if the patient had enough lorazepam on hand) Review of a coordination note report, dated 10/20/2023 at 11:51 PM, showed the patients family member called and the patient was getting up to go to the bathroom every 6.5 minutes despite the on-call nurse administering the Tylenol, lorazepam, and Cymbalta (anti-depressant and nerve pain medication, there was no physician order for Cymbalta) at 10:00 PM. The hospice on-call center reviewed the patient profile and notified the on-call nurse to follow up at 11:58 PM. The clinical record failed to show if the lorazepam 0.5 mg was picked up from the pharmacy. The provider failed to ensure the comprehensive assessment was updated to include the patient's response to his/her medications being ineffective, after the caregiver called on 10/20/2023 at 11:51 PM. Review of an e-mail provided by the administrator, dated 10/21/2023 at 3:33 AM, showed subject Colors (internal communication), the patient had increased agitation and educated the family on medication administration and frequency (review of the clinical record failed to show any documentation in regard to this communication). Review of the coordination note report, dated 10/21/2023 at 11:23 PM, showed the patients family member called and stated that the patient had been very anxious and the lorazepam 0.75 mg (order was for 0.5 mg) ";has been wearing off prior to four (4) hours." He/she would like a follow up from the on-call nurse to give advice as to whether or not the lorazepam orders could be adjusted to promote the patients comfort. The provider failed to ensure a reassessment was completed in regard to the patient's response to lorazepam and the patient's increased anxiety. Review of the coordination note report, dated 10/22/2023 at 12:00 AM, showed the patients family member called and stated that the patient had begun taking morphine and he/she was now bedbound. He/she did not have supplies and needed mouth moisturizer, bed pads and size medium briefs with tape (incontinent briefs, under pad, and personal care was ordered 10/23/2023 at 10:27 AM). Review of the coordination note report, dated 10/22/2023 at 12:04 AM, showed the hospice on-call nurse contacted the caregiver who stated that the patient was still somewhat restless. The patients family attempted to increase the Ativan and gave 1.5 tablets equal to 0.75 mg at 8:00 PM and that did not help much, the hospice nurse clarified that the family was giving the Ativan 0.75 mg without a physicians order. The nurse advised the caregiver to give Ativan 0.5 mg per the physicians order (0.25 mg less than what the caregiver gave and was not effective) and to give Morphine 0.25 milliliters (ml) at the same time to help with the Ativan's effectiveness. The provider failed to ensure the comprehensive assessment was updated to include the patient being bedbound, needing supplies, and the patient's response to his/her care. Review of the coordination note report, dated 10/22/2023 at 8:00 PM, showed the hospice on-call nurse called the caregiver. The caregiver reported the patient had no oral intake over the weekend other than water which he/she took with his/her medications. The patient was taking Ativan 0.5 mg and Morphine 5 mg every four hours routinely. The patient had less agitation and was sleeping better. The patient's breathing was deeper and louder with short periods of apnea (temporary cessation of breathing) and shallow breathing. The patient's hands were slightly swollen. The patients family declined a visit. Reinforced 24 hour availability for changes or if visit needed/wanted overnight. The provider failed to ensure the comprehensive assessment was updated to include the change in the patient's condition. Review of the visit note report, dated 10/23/2023 at 10:09 AM, (the first assessment conducted since the family member called the provider on 10/20/2023 at 11:51 PM, (approximately 2 (two) days and 11 hours), showed the reason for the visit was "patient care due to unexpected status change". Review of a coordination note report, dated 10/24/2023 at 6:55 PM, showed the patients family member called and stated that the patient passed away about 20 minutes prior. During an interview on 11/01/2023 at 3:20 PM, the administrator stated that there was no follow up from the call received on 10/20/2023 at 11:51 PM. He/she would expect the on-call hospice nurse to contact the LTCF or family to get more information and then decide if a visit was needed.

Based on review of 19 CSR 30-35.010 hospice program operations manual, policy review, record review, and interview, the hospice provider failed to ensure the nursing needs of the patients were met when an on-call hospice nurse failed to follow the hospice provider's policy and procedure and go assess a patient with a significant change in condition for over five hours, for one patient (Record/Patient #3), and nursing staff failed to document notification of changes to physician when the patient had changes in condition for three patients of three records reviewed (Records/Patients #1, #2, and #3). This deficient practice has the potential to adversely affect the provision of care to all patients served by the provider. --- FINDINGS INCLUDED: Review of 19 CSR 30-35.010 Hospice Program Operations, showed that: - (H) twenty four (24) hour response: * 1. The hospice shall have written policies and procedures defining access to all services, medications, equipment, and supplies during regular business hours, after hours, and in emergency situations, including a plan for prompt telephone response; * 2. Unscheduled non-emergent nursing visits when indicated should normally occur within three (3) hours from the time the need is identified or as agreed upon by the hospice and patient; and * 3. When clinically indicated, emergent visits shall be made within ninety (90) minutes from the time the need is identified. Review of the providers policy, titled ";Ongoing Nursing Assessment," revised 02/15/2022, showed the following: - Nursing care and services are provided by or under the supervision of a registered nurse in compliance with the patient plan of care and ensure that the nursing needs are met as identified in the patients initial assessment, comprehensive assessment, and any updated assessments; - Ongoing assessments shall focus on patients response to care and changes in patient condition level of deterioration; - Based on the assessments, the care plan-including, needs, goals, and outcomes shall be reviewed and updated by interdisciplinary group (IDG) members responsible for the case; and - Based upon findings of the assessment, change/verbal orders shall be generated and forwarded to the physician as needed. Review of the providers policy, titled ";Triage", revised 04/24/2023, showed the following: - Purpose: To create a consistent process for triaging the needs of our patients, families, and communities that we service; - Urgent/Immediate Changes/Needs: * The call center receives call from patient, family, or facility/residence caregiver regarding situations such as unmanaged symptoms, uncontrolled pain, actively dying and in need of additional support, family coping issues, patient/family psychosocial issues, etcetera; - If unresolved symptoms/problem or additional interventions or orders needed, call center will contact site on-call nurse or patient experience (PE) staff to visit the patient; - On-call nurse will be contacted for a visit if: * The caregiver is unable, reluctant, or unwilling to provide interventions based on existing orders for symptomatic patient; * If patients/caregivers have called two or more times with symptom management questions/needs within an eight to 12-hour period; * If a caregiver in unlicensed facilities is unable to administer ";as needed" medications for symptomatic patients; * If the patient/family/caregiver request a visit; and - The triage registered nurse (RN) will inform family that the on-call nurse/PE staff, or themselves, will call back with an estimated time of arrival: * All patients with reported urgent/immediate change in condition will receive a visit ideally within one or two hours (Missouri state regulations show emergent visits are to be made within one and half hours from call); * The on-call nurse should not contact the family/caregiver/facility/patient to make another assessment of the need for a visit; - Local on-call nurse assesses patient and coordinates necessary changes to his/her plan of care immediately: * Reference Enclara (pharmacy) resource for respective symptom management recommendations/suggestions; * Obtain/documents new physician orders, if necessary; and * Arranges medication delivery/pick up from local pharmacy if necessary; - Less Urgent Changes/Needs: * The call center receives call from patient, family, or facility/residence caregiver regarding concerns such as durable medical equipment (DME)/supply requests, skin changes not related to a fall, increased weakness, diet changes, medication refills, and etcetera; - If unresolved symptoms/problem/or updated orders needed, call center will contact site on-call nurse or PE staff to visit and contact local physician as appropriate; - Patients reporting less urgent changes in condition/situation whose needs were unable to be addressed by current orders will receive a local on-call nurse or PE staff member visit ideally by the end of the same business day; - The on-call nurse should not contact the family/caregiver/facility/patient to make another assessment of the need for a visit; - If the patient has an inadequate supply of medications (not enough until next delivery): * On-call will be contacted for follow up coordination with Enclara (pharmacy) and/or local pharmacy; * Triage nurse will notify the regional after hour administrator (RAHA) that a quality indicator/event (QI) is needed to be documented in the electronic medical record to indicate the emergent refill needed; and - Non-urgent needs: CSR will notify team via call enter coordination note report for ";24-hour follow-up request," and those requiring IDG approval. RECORD/PATIENT #1 Review of the start of care assessment, date 07/18/2023, showed the following: - The patient resided in a long-term care facility (LTCF); - Admitting diagnosis malignant neoplasm of the prostate (prostate cancer); and - Past medical history included seizures (a sudden, uncontrolled burst of electrical activity in the brain. It can cause changes in behavior, movements, feelings and level of consciousness). Review of a coordination note, dated 09/14/2023 at 11:01 PM, showed that the LTCF called the hospice call center to report the patient exhibited potential seizure like activity for approximately 40 seconds to include ";shaking and staring off into space." The patient appeared less verbal and was ";staring into space." The LTCF caller reported the patient did not have Ativan as needed or a comfort kit available. Review of the clinical record failed to show a visit occurred after the call on 09/14/2023 regarding a change in the patient's condition. During an interview on 10/30/2023 at 9:26 AM, the administrator stated that the on call nurse attempted to contact the LTCF several times and was unsuccessful. The next call was received from the hospital on 09/15/2023 at 1:16 PM (13 hours later after the LTCF staff reported the patients change in condition) to verify the patient was receiving hospice care. The patient was admitted to the neuro intensive care unit. The patient was discharged from hospice. During an interview on 10/31/2023 at 9:46 AM, registered nurse (RN) A stated that he/she was the on-call nurse and was unable to get a hold of the staff at the LTCF. He/she did not make a visit to assess the patient. The next shift would follow up with the patient. During an interview on 10/31/2023 at 9:54 AM, the case manager stated that the patient was in the hospital currently with seizures, this was the patient's first seizure while on hospice services. Staff are expected to assess a patient that has a change in condition. During an interview on 11/01/2023 beginning at 1:17 PM, the administrator stated that the on-call hospice nurse did not make a visit to the patient after the call was received from the LTCF. He/she would expect the on-call hospice nurse to contact the LTCF or family to get more information and then decide if a visit was needed. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice care on 08/23/2023. The admitting diagnosis was sequelae of cerebral infarction (stroke). Review of the coordination note, dated 10/21/2023 at 8:25 PM, showed that the LTCF called the hospice call center to report the patient had dyspnea (shortness of breath). The patients oxygen saturation (blood oxygen level) was 89 percent (a value lower than 90 percent is considered low oxygen saturation) on room air and 96 percent on three liters of oxygen, respiratory rate was 24 (normal respirations range is 12 to 20), heart rate 144 (normal rate is 60 to 100 beats per minute). The patient did not have an order for oxygen. The patient needed an order for lorazepam (sedative), and they needed the medication, the LTCF pharmacy would not deliver the medication until Monday or Tuesday. The hospice call center RN contacted the hospice on-call nurse to follow up, the hospice on-call nurse had access to the chart, and a visit was assigned in case it was needed. Review of the coordination note, dated 10/21/2023 at 9:00 PM, showed the following: - The patient had a change in condition; - New orders were received from the physician: * Duoneb (a combination of medication used to treat chronic obstructive pulmonary disease) one vial per nebulizer every four hours as needed for wheezing and dyspnea; * Oxygen three liters via nasal cannula as needed for comfort and dyspnea (shortness of breath); * Lorazepam Intensol (sedative) 2 milligrams (mg)/milliliters (ml) give 0.25 ml sublingual every three hours as needed for anxiety/restlessness; * Morphine (opioid narcotic) 20 mg/ml give 0.25 ml sublingual every three hours as needed for pain/dyspnea;and * Relayed orders to LTCF nurse and he/she verified that morphine was on hand but needed Ativan (lorazepam); - At 10:00 PM, the prescriptions were ordered from the pharmacy and the prescriptions would be ready at 11:00 PM, the medication was not ready (at 11:00 PM) and the hospice nurse had to wait over an hour to pick up the prescriptions; and - At 12:38 AM, (4 (four) hours and 13 minutes after the LTCF had reported the patients change in condition) upon the delivery of medications and start of visit the patient was found non-responsive. As the hospice nurse was counting breaths the last breath was taken at 12:44 AM, the visit was restarted as a death visit. During an interview on 11/01/2023 at 2:35 PM, RN B stated that the patient was short of breath, he/she called the LTCF nurse and let the nurse know he/she would do a visit after he/she picked up the medication. The patient was minimally responsive after he/she arrived to the LTCF. The LTCF nurse wanted the Ativan because the patient was transitioning (dying) and short of breath. Typically, the medication is on hand. RN B stated that "the patient was stable during the previous visit and was not sure if the patient had aspirated". The on-call nurse gathers the information when they receive a call regarding a hospice patient and then triage the call. The on-call nurse can decide if the patient requires a visit. If a patient was short of breath, they automatically assign a visit and the nurse has one hour to make a visit to the patients home. If the patient required orders or clarification of medications, he/she provided a visit. Record/Patient #3: Review of the coordination note report, dated 10/16/2023 at 8:23 AM, showed the patients family called and reported the patient had a different breathing pattern and was making involuntary movements during sleep, the family member was very concerned and requested a nurse visit that day (10/16/2023). Review of the clinical record failed to show a nurse visit on 10/16/2023 as requested by the caregiver, to assess the patients respiratory status. Review of the visit note, dated 10/19/2023 at 10:42 AM, (3 (three) days after the caregiver requested a visit) showed the patient had irregular ";drum like" heart sound rhythm, and experienced a significant decrease in appetite. The hospice nurse encouraged the patient's family to offer smooth and soft foods. The patient's skin tone to both lower extremities was bluish/purple. The patient required continuous assist from the caregiver and was unsafe to bear weight. The patient had some sun downing (state of confusion occurring in the late afternoon and lasting into the night) over the past week. The haloperidol (antipsychotic) was not working and the RN suggested lorazepam as an alternate as needed. Review of the coordination note report, dated 10/20/2023, showed the following: -At 6:02 PM, the patients family member reported the patient kept trying to get out of bed when he/she was awake; - He/she would not leave the brief on; - He/she was having some breathing pattern changes when he/she was sleeping, breathing out of his/her mouth and the patient was not short of breath, and his/her fingers were whiter and cooler; - The family had given the patient Ativan (lorazepam, sedative) 0.25 milligrams (mg) four to five hours prior and that was not effective. They had tried giving liquid acetaminophen (Tylenol; used to treat minor aches, pains, and fever), they was only able to give about a quarter of the dose when the patient had refused to take the rest of the acetaminophen dose; - Outcome of the call showed the medications were reviewed, the caller was educated on the Ativan and Haldol order, and the caller stated that the Haldol made the patient more anxious when he/she took it for the first time; - The on-call nurse was contacted for follow up at 6:19 PM; - At 7:53 PM (1 (one) hour and 51 minutes after family called), the patients family member called again and stated that the patient was restless despite having the lorazepam one hour prior, his/her hands were pale in color, and the patient was getting up every 30 minutes to go to the bathroom; - The family stated that the patient appeared to be agitated; - The patient was given Remeron (used to treat depression) as well as Haldol in the past, the Tylenol and Ativan would help with restlessness and agitation ; - The patient would not allow the caregiver to administer a Tylenol suppository (a dosage form used to deliver medications by insertion into a body orifice); - The family would like a nurse visit; - The on-call nurse reviewed the patient profile and notified the on-call nurse, and an as needed visit was scheduled; and - The on-call nurse was contacted at 8:26 PM for the visit. Review of the nurse visit note, dated 10/20/2023 at 9:13 PM (3 hours and 11 minutes after receiving the family's call reporting a change in condition), showed that the patient had increased restlessness and increased attempts to toilet independently and his/her ambulation was unsteady. Each time the patient went to the bathroom he/she was unable to void but felt like he/she had to. The patient denied burning or pain on urination, he/she just had the feeling of having to go. The patient was having increased difficulty swallowing medications per the caregiver but did not have difficulty swallowing medications for the nurse. The patient appeared more restless, had slight edema to both hands, and respirations were shallow. The patient took a ½ tablet of lorazepam at 11:00 AM, a whole tablet at 4:00 PM, and the patient was still restless. The physician ordered Ativan 0.5 mg every four hours as needed, the medication was ordered from the pharmacy and the family would pick up the medication. Review of a coordination note report, dated 10/20/2023 at 11:51 PM, showed the patients family member called and the patient was getting up to go to the bathroom every 6.5 minutes despite the on-call nurse administering the Tylenol, lorazepam, and Cymbalta (anti-depressant and nerve pain medication, there was no physician order for Cymbalta) at 10:00 PM. The on-call nurse reviewed the patient profile and notified the nurse for a follow up at 11:58 PM. The documentation failed to show if the Ativan 0.5 mg was picked up by the family from the pharmacy. Review of the clinical record failed to show any follow-up/assessment by the on-call nurse after the family called on 10/20/2023 at 11:51 PM. Review of the coordination note, dated 10/21/2023, showed: - At 11:23 PM, the patients family member called and stated that the patient had been very anxious and the lorazepam 0.75 mg ";has been wearing off prior to four hours. He/she would like a follow up from the on-call nurse to advise as to whether or not the lorazepam orders could be adjusted to promote the patients comfort; and - At 11:39 PM, the on-call nurse was notified and stated that he/she would follow up. Review of the coordination note report, dated 10/22/2023, showed the following: - At 12:00 AM, the patients family member called and stated that the patient had begun taking morphine and was now bedbound; - He/she did not have supplies and needed mouth moisturizer, bed pads and size medium briefs with tape; - At 12:04 AM, the hospice nurse contacted the caregiver who stated that the patient was still somewhat restless; - The patients family had attempted to increase the Ativan and had gave 1.5 tablets equal to 0.75 mg at 8:00 PM and that did not help much. The hospice nurse clarified that the family was giving the Ativan 0.75 mg without a physicians order; - The nurse advised the caregiver to give Ativan 0.5 mg per the physicians order (0.25 mg less than what the caregiver gave that was not effective) and to give Morphine 0.25 milliliters (ml) at the same time to help make the Ativan more effective; - At 8:00 PM, the nurse called the caregiver, the patient had no oral intake over the weekend other than the water taken with his/her medications; - The patient was taking Ativan 0.5 mg and Morphine 5 mg every four hours routinely and was less agitated and sleeping better; - The patient had deeper louder breathing with short periods of apnea (temporary cessation of breathing) and shallow breathing; - His/her hands were slightly swollen; - The patients family declined a visit; - Reinforced 24 hour availability for changes or if visit needed/wanted overnight; and - Follow-up actions/plan: Make a visit in the morning based on last night's call, may need daily visits. Review of the nurse visit note dated 10/23/2023 at 10:09 AM (10 hours and 46 minutes after the hospice received a call from the caregiver), showed that the patient was non-responsive and unable to swallow safely. Review of a coordination note report, dated 10/24/2023 at 4:11 AM, showed the patients family member called in regards to the patient ";choking". The call center nurse asked the patients family member if it sounded like gurgling or a rattle and the caller agreed. The call center nurse provided education about terminal secretions (the sound caused when air moves over pooled secretions in the back of the throat). The call center nurse encouraged the caller to elevate the head of the bed. The caller was instructed to place the hyoscyamine (used to reduce or help prevent throat congestion) one tablet under the tongue and repeat in four hours, educated the caregiver that the hyoscyamine would not completely dry out all secretions. The family member had given the patient morphine and Ativan at 2:30 AM. The family member was instructed to give a dose of morphine right then and if no relief in 30-45 minutes call back for further assistance. The call was resolved over the phone by the triage (call center) nurse. Review of the nurse visit note dated 10/24/2023 at 9:31 AM (5 (five) hours and 30 minutes after the caregiver called the hospice), showed the patient was having periods of apnea, abnormal breath sounds, and Cheyne-Stokes respirations (abnormal breathing pattern). Mild pain, terminal secretions, erythema (superficial reddening of the skin) of the buttocks, swelling, mottling (blotchy, red-purplish marbling of the skin) to both heels, orthopnea (discomfort breathing while lying flat), and pallor (pale). The patient was actively dying. The visit ended at 10:18 AM (47 minutes after arrival). Review of a coordination note report, dated 10/24/2023 at 6:55 PM, showed the patients family member called and stated that the patient had passed away about 20 minutes prior. During an interview on 11/01/2023 beginning at 1:17 PM, the administrator stated that he/she would expect the on-call hospice nurse to contact the LTCF or family to get more information and then decide if a visit was needed.