Every finding on record at Silverado Hospice, Inc.

Observed in Record Review. In 1 of 14 patient records reviewed, During RR8 it was noted on the tertiary dx list, diabetes without complications was listed. The patient is prescribed Januvia. There was lack of documentation of the patient's diabetes status and ability of family to provide diabetic care. This was discussed with the organization leadership.

Observed in Record Review. In 2 of 14 patient records reviewed, During RR1 it was noted lack of documentation of progress toward goals at the IDG meetings and clinical SN notes. During RR4 it was noted the IDG comprehensive assessment, the middle of October 2025, was not updated to reflect the findings of the PT evaluation 12 days prior. This was discussed with the organization leadership.

Observed in Record Review. In 6 of 14 patient records reviewed, During RR1 it was noted the RN documented the patient had weight loss, dysphagia and poor appetite consuming 10-20% of small meals however the POC was not updated with interventions/education on the nutritional deficits and dysphagia. During RR4 it was noted the patient had a physical therapy eval with an MD order for 3 additional visits in October 2025 however interventions were not added to the POC. During RR5 it was noted the RN documented on the initial comprehensive assessment Patient meets hospice criteria for protein calorie malnutrition as evidence by pt. with significant decline in the last two months however there was lack of the nutritional deficit added to the POC. During RRHV1 RN initial assessment it was documented decreasing appetite, only a few bites at each meal and maybe one ensure a day, prior 3 ensures per day, 5 lb weight loss, dysphagia however a nutritional deficit was not added to the POC. During RR10 it was noted the patient had terminal dx of cancer of the pancreas with metastasis to lymph nodes and abdomen with a hx of diabetes and recent weight loss. The patient was receiving insulin and metformin. There was a lack of interventions on the POC related to the patient's diabetic status and care. During RRHV4 it was noted on the comprehensive assessment the beginning of September 2025 the patient sustained a skin tear with physician orders for wound care. Interventions related to instruction to the caregiver and assessment of healing not added to the POC. This was discussed with the organization leadership.

Observed in Record Review. In 7 of 14 patient records reviewed, During RRHV1,3, 4 and RR1,4,6, and 10 it was noted PRN visits were ordered for SN, MSW and Chaplain on the POCs without consistent documentation of the reason for the individual discipline PRN visits to be provided. This was discussed with the organization leadership.

Observed in Record Review. In 3 of 14 patient records reviewed, During RR7 it was noted a physician order for daily wound care to the right breast lacked who would perform the care on non-sn visit days with an SN frequency of two times per week. During RR5 it was noted a physician order the middle of September 2025 for wound care 3x weekly to prevent infection lacked the location of the wound, and the procedure. There were additional wound care orders written in October and November 2025 that lacked the frequency of the procedures to a wound on the left thigh. During RR10 it was noted on the POC wound care on the left shin and left foot however the order lacked the frequency of the dressing change. This was discussed with the organization leadership.

Observed in Record Review. In 1 of 14 patient records reviewed, During RR4 it as noted an order for a physical therapy eval with 3 additional visits. The PT, after the eval, documented to continue for transfer training, and home exercise program however there was lack of documentation of additional visits or the reason the visits were not performed. In addition it was noted an order for wound care 2x/week per physician order in October and November 2025 however the wound care was not documented as performed 2x/week. This was discussed with the organization leadership.

Observed in Record Review. In 1 of 14 patient records reviewed, During RR3 it was noted the second SN visit after the physician order to provide wound care 2x/week documented, Wound care provided per order without documenting the specific components of the procedure. During This was discussed with the organization leadership.

Observed in Record Review. In 1 of 14 patient records reviewed, During RR10 it was noted a medication order for Insulin Degludec 100 UNIT/ML 20 Unit SUBCUTANEOUS 2 times a day for Hyperglycemia (100 UNIT/ML Unit). The order lacked the hyperglycemic parameter to administer the medication. This was reviewed with the organization leadership.

Observed in Record Review. In 1 of 2 patient records reviewed, for a live discharge. During LiveD/CRR1 it was noted lack of a transfer/discharge summary was documented as sent to the admitting hospital. This was discussed with the organization leadership.

Observed in Record Review. In 1 of 2 patient records reviewed, where patient was discharged due to an extended prognosis. During LiveD/CRR2 it was noted lack of documentation of a discharge summary sent to other service providers who will provide the patient with care, treatment, or services. This was discussed with the organization leadership.

Observed in Document Review. In 2 of 5 contracts reviewed, During contract file review for therapy services it was noted lack of a stipulation that the outside agency will complete criminal background checks on contracted employees who provide direct patient care or have access to patient records. This was discussed with the organization leadership.

Based on interview and record review, the hospice failed to ensure the IDG had revised the patient's POC as frequently as the patients condition required for one of one sampled patient (Patient 1). This failure had the potential for not providing appropriate, consistent, and quality care to this patient. --- Findings: Review of the P&P titled Plan of Care-Revised dated 3/19/23, showed the IDG in consultation with the physician develops a plan of acre for each patient. The plan of care must specify the hospice care and services necessary to meet the patient and familys specific needs identified in the comprehensive assessment. Development of the plan of care is in collaboration with the patient and family. The IDG, in consultation with the attending physician must review, revise, and document updates to the plan of care as frequently as the condition requires but no less frequently than every 15 days. Revised plan of care must include information from the patients updated comprehensive assessment and must note the patients progress towards outcomes and goals as specified in the plan of care. Review of Patient 1's closed clinical record was initiated on 3/5/25. The closed clinical record showed the SOC was 1/19/25. The patient was certified for hospice during the certification period from 1/19/25 to 4/18/25. The patient was discharged from the hospice on 2/7/25. The IDG Comprehensive Assessment dated 1/28/25, showed the patient was alert and oriented ";x 3 -4." Documentation showed the patient lived in a senior living community; however, the family member lived in a different city. Documentation showed the patient had an unwitnessed fall on ";1/18" at home. Documentation showed the family member was able to visit daily to drop off food and provide assistance to the patient as needed. Documentation showed the patient was unable to cook and not able to use the microwave. The patients care plan problems included the following: -Initial plan of care prior to service provision effective date 1/19/25 -Pain related to terminal diagnosis effective date 1/19/25 -Deficit related to airway and breathing patterns effective date 1/19/25 -Morse fall score of 45 or higher indicating a high risk for falls effective date 1/19/25 -Deficit related to skin/membrane integrity effective date dated 1/20/25 -Patient/Family needing assistance with funeral/burial arrangements start date 1/20/25 -Need for skilled teaching regarding oral care start date 1/29/25 -Deficit related to bowel elimination start date1/29/25 -Patient is unsafe to live alone; high risk for injury to self, start date 2/7/25 Documentation showed each care plan problems had goals and interventions. The Triage-After hours Phone Call dated 1/31/25 at 1805 hours, showed the patients neighbor contacted 911 after the patient broke into the neighbors home. Documentation showed the patient was very confused and believed the neighbors home was the patients home. Documentation showed the patient attempted to light the gas stove and soiled herself. Documentation showed triage contacted the family member to inform of the event. Documentation showed the family member was in route to the patients home. The Triage-After hours Phone Call dated 1/31/25 at 1945 hours, showed a follow-up call was made to the family member. The family member stated the family member was currently with the patient at the patient's home. Documentation showed the patient was exhausted from todays event and the family member declined a follow up visit this evening. The SN Note dated 2/3/24, showed the patient had an episode of confusion on 1/31/25, where the patient went to the neighbors home and began to use the stove. Documentation showed the patient thought it was her home. Documentation showed the family member was educated on the safety concerns for the patient and neighbors. Documentation showed the family member was advised that someone needed to stay with the patient as her disease process was progressing and the patient had became more confused. Documentation also showed it was explained that patient would become increasingly confused and more likely to have repeated occurrences of leaving her home; and becoming lost and potentially injured. Documentation showed the family member verbalized understanding and stated the patient did not want to be placed in a facility. Documentation showed the family member had been waiting for IHSS to agree to send someone for care giving. Documentation showed the APS could potentially become involved if the patient had repeated instances like on 1/31/25. Documentation showed the family member will continue to monitor the need for a caregiver day by day. * However, there was no documented evidence the care plan problem was revised as frequently as the patients condition required when the patient was identified to have an episode of going to the neighbors home and attempted to light the gas stove. The care plan problem addressing the patient was unsafe to live alone; high risk for injury to self, had a start date of 2/7/25. On 3/13/25 at 1045 hours, an interview and concurrent clinical record review was conducted with the Administrator, DPCS, and Regional QAPI Manager. They were informed of the finding.

Based on interview and record review, the hospice failed to ensure the IDG maintained the responsibility for supervising the care and services related to the indication for the use of pain medication and consistency of pain assessment for one of one sampled patient (Patient 1). This failure had the potential for not addressing the care needs for this patient. --- Findings: The hospice's P&P titled Interdisciplinary Group revised 6/19/23, showed the hospice designates an IDG or groups composed of individual who worked together to meet the physical, medical, psychosocial, emotional, and spiritual needs of the hospice patients and families facing terminal illness and bereavement. The IDG members provide the care, and services provide by the hospice, and the IDG supervises the care and services. The hospice designates a Registered Nurse to coordinate care and implementation of the POC for each patient. Scheduled and unscheduled IDG meetings are held. The IDG is responsible to: - Participate in the establishment of the written POC - Provide or supervise hospice care and services - Enforcing policies governing the day-to-day provision of hospice care and services. The IDG: a. Establishes the POC in consultation with the patients attending physician b. Reviews and updates the POC in collaboration with the patients attending physician, as frequently as the condition requires but no less frequently than Q 15 days c. Is notified of significant changes to the POC d. Reviews services provided/available to patients and families. Review of Patient 1's closed clinical record was initiated on 3/5/25. The closed clinical record showed the SOC was 1/19/25. The patient was certified for hospice during the certification period from 1/19/25 to 4/18/25. The patient was discharged from the hospice on 2/7/25. The IDG Comprehensive Assessment dated 1/28/25, showed the patients pain medications included acetaminophen 650 mg one suppository rectal every six hours PRN for mild pain (pain level of 1-3) (on a 0-10 pain scale, 0=no pain and 10=worst pain) or fever above 100.4 degrees Fahrenheit and morphine sulfate (opioid analgesic) 20 mg/ml 0.25 ml SL Q four hours PRN for severe pain (pain level of 7-10). The physicians order dated 2/4/24, showed Fentanyl (opioid analgesic) 12 mcg/hour one patch Q 72 hours PRN for pain/SOB. The care plan problem addressing pain related to terminal diagnosis dated 1/19/25, showed the goal included the patient will report a tolerable pain score of 1/10 in 14 days. The interventions included to administer pain medications as ordered and evaluate effectiveness, assess current pain score, assess pain score since last nursing visit and effectiveness of any pain interventions, collaborate with the physician as indicated for ineffective pain management, and evaluate the effectiveness of current medications. a. The SN note dated 2/3/25, showed the type of pain scale used was PAINAD. Documentation showed the patients pain level was 3. Documentation under the narrative section of the note showed the patient denied pain but had facial grimacing and posturing/guarding observed. Documentation showed a dose of morphine for pain was given. * However, the indication for the use of morphine as per the physicians order was not consistent with the assessed patients pain level. b. The SN Note dated 2/6/25 at 2100 to 2200 hours, showed the SN conducted a PRN visit for pain management. Documentation showed the type of pain scale used was FLACC. Documentation showed the patients pain level was 0. Documentation under the narrative section of the note showed the family member reported the patient had been resting but noted grimacing of the face and at times moving around the bed. Documentation showed when touched, the patient got agitated. Documentation showed the patient was in the bedroom sleeping, eyes closed, and non-responsive. Documentation showed upon touched, the patient was combative and refused to be touched. Documentation showed morphine (opioid analgesic) and phenobarbital (anticonvulsant/sedative) were administered. Documentation showed the medications were effective after 30 minutes and the patient was calm, comfortable, and the grimacing subsided. * However, the indication for the use of morphine as per the physicians order was not consistent with what the patients pain level was. In addition, the pain level was not consistent with the patients behavior in the SN note. c. There was no documented evidence of the specific information when to administer the Fentanyl PRN for pain in the physicians order. On 3/6/25 at 1316 hours, an interview was conducted with RN 1. She stated the family member asked via text message about an alternative option for pain management relief. RN 1 stated the family member messaged RN 1 that the patient refused to take oral medication for pain and the physician ordered Fentanyl. On 3/13/25 at 1045 hours, an interview and concurrent clinical record review was conducted with the Administrator, DPCS, and Regional QAPI Manager. They were informed of the findings.

Based on interview and record review, the hospice failed to ensure ongoing sharing of information between the SN and MSW occurred related to the patients psychosocial circumstances for one of one sampled patient (Patient 1). This failure had the potential for not addressing the care needs for this patient. --- Findings: The hospice's P&P titled Coordination of Services revised 6/19/23, showed the interdisciplinary group maintains the responsibility for directing, coordinating, and supervising the care and services provided according to the plan of care whether provided directly of under arrangement. The hospice uses a case management system to direct an IDG to provide comprehensive coordinated hospice services. The RN Case Manager has a primary responsibility for the coordination of services with the IDG form referral to discharge. Care and services provided are based on all assessments of the patient and family needs and are in accordance with the plan of care. The RN has oversight of the coordination of the aspects of the plan of care across changing status or locations. Any observed or communicated significant changes in the patients condition are communicated to the patients care team in a timey manner to ensure the patients care and safety needs are addressed. If the hospice employee or volunteer observes that the patients primary caregiver cannot provide the continuing support and care the patient requires, it is communicated to the patients care team in a timely manner to ensure the patients care and safety needs are addressed. The RN is responsible to facilitate communication about changes in the patients status between IDG members and the patients attending physician. IDG members facilitate the coordination of care by frequent written and oral communication among each other and other non-hospice care providers and care provided under arrangement. Documentation of any communications is included in the clinical record. Review of Patient 1's closed clinical record was initiated on 3/5/25. The closed clinical record showed the SOC was 1/19/25. The patient was certified for hospice during the certification period from 1/19/25 to 4/18/25. The patient was discharged from the hospice on 2/7/25. The start of care note dated 1/19/25, showed the patient was alert and oriented ";x 3-4." Documentation showed the patient lives in a senior living community in one city the family member lives in another city. Documentation showed the patient had an unwitnessed fall on ";1/18" at home. The MSW note dated 1/20/25, showed the MSW called the family member. Documentation showed the MSW provided the family member with caregiver resources and end of life education. Documentation showed the family member declined a MSW visit for the patient at this time. Documentation showed the MSW agreed to assist the daughter with contacting IHSS for and expedited processing time due to the patients deteriorating condition. The Triage-After hours Phone Call dated 1/31/25 at 1805 hours, showed the "Reason For Visit wandering from home/confusion." Documentation showed the patients neighbor contacted 911 after the patient broke into the neighbor's home. Documentation showed the patient was very confused and believed the neighbors home was the patients home. Documentation showed the patient attempted to light the gas stove and soiled herself. Documentation showed the triage staff contacted the family member to inform of the event. Documentation showed the family member was in route to the patients home. The Triage-After hours Phone Call dated1/31/25 at 1945 hours, showed a follow-up call was made to the family member. The family member stated the family member was currently with the patient at the patient's home. Documentation showed the patient was exhausted from today's event and the family member declined follow up visit this evening. The SN Note dated 2/3/24, showed the patient had an episode of confusion on 1/31/25, where the patient went to the neighbors home and began to use the stove. Documentation showed the patient thought it was her home. Documentation showed the family member was educated on the safety concerns for the patient and the neighbors. Documentation showed the family member was advised that someone needed to stay with the patient as her disease process was progressing and the patient was more confused. Documentation also showed it was explained the patient would become increasingly confused and more likely to have repeated occurrences of leaving her home; and becoming lost and potentially injured. Documentation showed the family member verbalized understanding and stated the patient did not want to be placed on a facility. Documentation showed the family member had been waiting for IHSS to agree to send someone for care giving. Documentation showed the APS could potentially become involved if the patient had repeated instances like on 1/31/25. Documentation showed the family member would continue to monitor the need for a caregiver day by day. * However, there was no documented evidence of the communication between the SN and MSW regarding the information related to the episode of the patient going to the neighbors house, the status of the IHSS, and the discussion with the family member to monitor the need for a caregiver day by day during the SN visit on 2/3/24. On 3/6/25 at 1100 hours, an interview was conducted with the DPCS. She stated on 2/7/25, the patient was declining rapidly and had asked MSW to follow up. On 3/12/24 at 1233 hours, a telephone interview was conducted with the MSW. The MSW stated a telephone call was conducted to the family member on 1/20/25, and declined the MSW visit. When asked if the MSW was aware of the patients episode of going to the neighbors house/wandering and the possibility of APS being involved. The MSW stated the MSW was not involved with the case after the MSW service was declined on the initial call (1/20/25) with the family member. On 3/12/24 at 1422 hours, a follow-up telephone interview was conducted with the MSW. The MSW stated a text message was received from the family member that there was an IHSS case number and had a social worker assigned to the patient from IHSS. The MSW stated the MSW did not know where they were in the process. On 3/13/25 at 1045 hours, an interview and concurrent clinical record review was conducted with the Administrator, DPCS, and Regional QAPI Manager. They were informed of the findings. On 3/13/25 at 1438 hours, an electronic message was received from the Regional QAPI Coordinator and showed the text message was sent on 1/20/25, from the family member to the MSW about the IHSS case number.

Based on interview and record review, the hospice failed to ensure the care and services were provided in accordance with the plan of care for one of one sampled patient (Patient 1), creating the risk of not providing appropriate, consistent, and quality care to this patient. --- Findings: The hospices P&P titled Coordination of Services revised 6/2023 showed the care and services provided are based on all assessments of the patient and family needs and are in accordance with the plan of care. The hospice's P&P titled Nursing Services revised dated 7/2024, showed the nursing staff administer the medications and other treatments in accordance with the physicians' orders, generally accepted standards of practice, and any federal and state laws pertaining to medication administration. Review of Patient 1's closed clinical record was initiated on 9/23/24, and showed the SOC was 8/31/24. The patient was certified for hospice services during the certification period from 8/31/24 to 10/29/24. The patient resided in an ALF (assisted living facility). The patient expired on 9/7/24. The physicians order dated 8/31/24, showed lorazepam (antianxiety) 0.5 mg one tablet oral every four hours as needed for anxiety/agitation. Instructions included to give one tablet by mouth or sublingually every four hours as needed for anxiety or agitation; may crush medication; educated on use, purpose, and side effects. The SN note dated 9/6/24, showed on arrival, RN 1 was informed by the MSW as the MSW was speaking with the family member on the telephone that the family member stated it was okay the patient receive ";2.5." Documentation showed RN 1 repeated ";2.5 mg" and the MSW repeated while the family member was on the telephone line, "2.5." Documentation showed RN 1 assessed the patient. Documentation showed the patient was raising her voice out loud sounding in distress. Documentation showed RN 1 immediately went into the medication room and informed an ";LVN" that the family member was on the telephone with the MSW, and the family member was requesting 2.5 mg. Documentation showed another nurse was in the room and informed RN 1 that RN 1 needed to prepare the medication from the bubble pack. RN 1 ";removed 5 tablets of 0.5 mg." Documentation included RN 1 showed it to an LVN and the LVN had RN 1 signed the medication log book. Documentation showed RN 1 administered the Ativan sublingually at approximately 0830 hours. Documentation showed RN 1 attended a meeting. Documentation showed approximately 30-45 minutes later, RN 1 reassessed the patient with the family member present; the patient was calm; and informed ";her" 2.5 mg was given and nodded the head okay as ";she" was with the hospice chaplain. Documentation showed roughly 45 minutes later, a ";LVN" came to ask RN 1 ";how what" was the dosage administered since the family member came to ask. Documentation showed RN 1 went to the patients room; the patient was calm; and informed ";her" that the patient was transitioning near death. Documentation showed ";she" recalled and stated that RN 1 had given 2.5 mg which RN 1 acknowledged, and RN 1 stated that was what ";she" said to the MSW. Documentation showed RN 1 called the Supervisor and was instructed to notify the physician. Documentation showed the physician was notified of the situation. * However, the Ativan dose administered to the patient was not consistent with the physicians order dated 8/31/24. There was no physician's order to administer Ativan 2.5 mg on 9/6/24. On 9/23/24 at 1545 hours, an interview was conducted with the DPCS. The DPCS stated RN 1 administered Ativan 2.5 mg to the patient. On 9/24/24 at 1430 hours, an interview and concurrent closed clinical record review was conducted with the SVP of Operations, VP of Clinical Operations, Administrator, and DPCS. They were informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the IDG maintained the responsibility for directing, coordinating, and supervising the care and services related to medication and recording of telephone order for one of one sampled patient (Patient 1), creating the risk of not addressing the care needs for this patient. --- Findings: The hospice's P&P titled Interdisciplinary Group revised 7/2024 showed the hospice designates an Interdisciplinary Group (IDG) or groups composed of individuals who work together to meet the physical, medical, psychosocial, emotional, and spiritual needs of the hospice patients and families facing terminal illness and bereavement. The IDG members provide the care and services offered by the hospice, and the IDG supervises the care and services. The hospice nurse designates a registered nurse to coordinate care and the implementation of the POC for each patient. The IDG is responsible to participate in the establishment of the written plan of care (POC), provide or supervise hospice care and services, and enforcing the policies governing the day-to-day provision of care and services. The hospice's P&P titled Coordination of Services revised 6/2023 showed the interdisciplinary group maintains responsibility for directing, coordinating, and supervising the care and services are provided according to the plan of care whether provided directly or under arrangement. The hospice uses a case management system to direct an interdisciplinary group to provide comprehensive, coordinated hospice services. The RN Case Manager has primary responsibility for the coordination of services with the IDG from referral to discharge. The type and scope of services is based on the initial and comprehensive assessment(s) determining the needs of the patient and caregiver and the Plan of Care that identifies the patient and caregiver problems, goals, and interventions. The combination of services is unique to each patient/caregiver and change as the needs of the patient/caregiver progress over the course of care while in hospice. Care and services provided are based on all assessments of the patient and family needs and are in accordance with the plan of care. The RN has oversight of the coordination of the aspects of the plan of care across changing status or locations. Any observed or communicated significant changes in the patient's conditions are communicated to the patient's care team in a timely manner to ensure the patient's care and safety needs are addressed. The RN is responsible to facilitate communication about changes in the patients status between IDG members and the patients attending physician. IDG members facilitate the coordination of care by frequent written and oral communication among each other and other non-hospice care providers and care provided under arrangement. Documentation of any communications is included in the clinical record. The hospice's P&P titled Physician Orders revised 9/2024 showed if the drug order is verbal or given by or through electronic transmission: the individual receiving the order records and signs it immediately and has the prescribing person sign it in accordance to State and Federal regulations. Verbal orders for medications and controlled substances are given to appropriately licensed staff members, acting with the scope of their licenses, and are immediately recorded, signed, and dated by the licensed staff member receiving the order. Review of Patient 1's closed clinical record was initiated on 9/23/24. The clinical record showed the SOC was 8/31/24. The patient was certified for hospice services during the certification period from 8/31/24 to 10/29/24. The patient resided in an ALF and had expired on 9/7/24. a. The physicians order dated 8/31/24, showed lorazepam (antianxiety) 0.5 mg one tablet oral every four hours as needed for anxiety/agitation. Instructions included to give one tablet by mouth or sublingually every four hours as needed for anxiety or agitation; may crush medication; educated on use, purpose, and side effects. The SN note dated 9/4/24, showed the patient was sitting in a wheelchair to be transferred to the dining area for breakfast. Documentation showed the facility staff was able to feed oral liquids less than ¼ cup to the patient. The patient was able to swallow without coughing, then got anxious, and making audible noises. Documentation showed the patient was brought back to the room and drifted to sleep in an upright position. Documentation showed approximately 30 minutes later, when tried to administer Ativan and other medication but the patient was too lethargic to open the mouth. Documentation showed the family member came in the afternoon and was updated of the patients status. Documentation showed, ";Does not want to discontinue any medication at this time but agreed to hold" if the patient was too lethargic. Documentation showed, ";Ativan is ok sublingually but to only give half dose 0.25 mg." Documentation showed the family member stated if full dose was given it will have an opposite effect on the patient and the patient would get more anxious. * However, there was no documented evidence RN 1 coordinated with the physician regarding the discussion conducted with the family member on 9/4/24, concerning of Ativan dosage. Further review of the closed clinical record showed the IDG Comprehensive Assessment was conducted on 9/12/24, after the patient had expired, which included the discussion of the SN visit dated 9/4/24. b. The SN note completed by LVN 1 dated 9/6/24 from 1130 to 1230 hours, showed the family member stated the patient had been very sensitive to all medications ";previos" and would like to see if comfort medications can be adjusted to the patients sensitivity. Documentation showed the physician was notified and gave the new orders for acetaminophen (analgesic) suppository 650 mg to be given for mild-severe pain only and Ativan (antianxiety) to give 0.25 mg if ineffective provide additional 0.25 mg, total "5" mg every four hours. Documentation showed the family member was provided new ";newdications" instructions and dosages. Documentation showed the new orders were sent to the pharmacy. The physicians order dated 9/6/24 at 1553 hours, received by LVN 1, showed the following information: - discontinue lorazepam ";1 tablet ORAL every 4 hours As Needed for Anxiety/Agitation (0.5 MG tablet) on 9/6/24." - lorazepam ";0.25 tablet oral every four hours as needed for agitation (0.5 MG tablet)." Instructions included give half tablet 0.25 mg by mouth or sublingually every four hours as needed for anxiety or agitation, if ineffective may provide additional 0.25 mg, total= 0.5 mg. The SN note dated 9/6/24 from 2228 hours to 0056 hours, showed the patients breathing was labored with moments of apnea. Documentation showed the family member was at bedside. Documentation showed the family member was uncomfortable giving Ativan. Documentation showed the SN educated on the patient who was actively dying, Ativan was advised. Documentation showed the family member was more comfortable getting an okay from a hospice physician before medication was given. Documentation showed the SN contacted the physician to update on the patients condition. Documentation showed the SN received an order for Haldol (antipsychotic) 0.5 mg SL twice daily as needed for terminal agitation. Documentation showed the new order was sent to the pharmacy for delivery tonight. Documentation showed the SN gave Ativan 0.5 mg at 2320 hours. The physicians order dated 9/6/24 at 2326 hours, received by LVN 2, showed Haldol ";0.5 Tablet ORAL (0.5 MG tablet)." Instructions included take one tablet by mouth SL twice daily as needed for terminal delirium and severe agitation. On 9/24/24 at 1110 hours, an interview was conducted with LVN 2. LVN 2 stated the SN visit was conducted and the patient was ";already transitioning." LVN 2 stated the patients breathing was labored. LVN 2 stated she notified the physician and the physician told LVN 2 to give Ativan 0.5 mg at that time. LVN 2 stated the facility nurse gave the Ativan. LVN 2 stated the family member was okay with the Ativan dose. * However, further review of the clinical record showed no documented evidence of a physicians order to administer Ativan 0.5 mg. On 9/24/24 at 1430 hours, an interview and concurrent clinical record review was conducted with the SVP of Operations, VP of Clinical Operations, Administrator, and DPCS. They were informed of the findings.

Observed in Record Review. In 1 of 9 patient records reviewed, for active patients, it was noted by the surveyor that for HOSRR#4 the bereavement risk assessment was not completed as part of the comprehensive assessment. This was confirmed with the Regional QAPI Manager.

Observed in Record Review. In 6 of 9 patient records reviewed, it was noted by the nurse surveyor that for HOSHV#1/RR#1, HOSHV#2/RR#2, HOSHV#3/RR#3, HOS/RR#5, HOS/RR#8, and HOS/RR#9, the goals were not measurable. Examples were “patient’s pain will be at an acceptable level” or “patient will have adequate bowel movements”. Findings were validated by the Director of Patient Care Services and the Regional QAPI Manager.

Observed in Record Review. In 1 of 9 patient records reviewed, of active patients, it was noted by the surveyor that for HV#1/RR#1 the patient was ordered to have oxygen PRN for shortness of breath and the plan of care was not updated to reflect the change for over a month. Finding was validated by the Director of Patient Care Services and the Regional QAPI Manager.

Observed in Patient Home. In 1 of 1 home visits conducted, with the hospice aide, it was noted by the surveyor that during HV#2/RR#2, care was not provided according to the hospice aide plan of care. The hospice aide plan of care specified that the hospice aide was not to remove the patient’s oxygen. During the visit, the hospice aide removed the patient’s oxygen to get his shirt off. Additionally, the hospice aide plan of care stated to shave the patient every visit. When the hospice aide was questioned about this she said she did not shave the patient as he did not want to be shaved. Findings were validated by the Director of Patient Care Services who was present during the home visit.

Observed in Patient Home. In 2 of 3 home visits conducted, it was observed by the Nurse Surveyor that the organization did not implement the infection prevention and control activities it had planned. For example, during HOSHV#1/RR#1 the skilled nurse did not follow agency policy during the patient visit as to when to perform hand hygiene. There were two opportunities to hand sanitize after removing gloves and donning clean ones. During HOSHV#2/RR#2, the CHHA washed her hands, donned gloves and set up the supplies needed to perform the bath to include the wash basin. She then began to provide patient care without changing her gloves and performing hand hygiene per agency policy. Finding was validated by the Director of Patient Care Services who was present on the visit.

Observed in Record Review. In 6 of 9 patient records reviewed, for active patients, it was noted by the surveyor that for HOSHV#1/RR#1, HOS/RR#5, HOS/RR#8, and HOS/RR#9, the patient was on oxygen and the hospice aide care plan did not mention that the patient had oxygen in the home nor what to do with the oxygen should the patient be using it at the time of the bath. For HOSHV#2/RR#2, the patient had a trach with an oxygen cuff, a gastrostomy tube, and was not actively able to talk. The hospice aide careplan did not address any of these special issues nor what the hospice aide’s responsibility was regarding them. For HOS/RR#4, the patient had a jaw wound dressing, a central line dressing, and a pain pump. The hospice aide careplan did not address any of these special issues nor what the hospice aide’s responsibility was regarding them. Findings were validated by the Director of Patient Care Services and the Regional QAPI Manager.