Every finding on record at Solaris Hospice Inc

Based on record reviews and interviews, a Patient had the right to be free from abuse (physical) for 1 (Patient #2) of 6 patient charts reviewed who received hospice aide services.  The hospice aide A failed to protect Patient #2 from harm when turning the patient, allowing the patients face to hit the side rails and administering medication without an order. Hospice Aide A placed Patient #2 at risk of pain and injury due to face hitting side rail while turning and adverse affects from administering medication. --- Findings Included: Review of the Consumer Rights and Services Investigation Worksheet included a self-report received date 8/22/2024.  The report included the following allegations:  Resident/Patient/Patient Abuse. Review of TULIP (a database utilized by the State of Texas to maintain licensing, demographic information, complaints and self-reported incidents on home health and hospice agencies) included an email received from the HHA that included form 3613-provider investigation report and the agency background search, statement by Office Manager and employability checks for the alleged perpetrator, hospice aide A. The provider investigation report dated 8/22/24, emailed to CII on 8/30/24, signed and dated by Compliance Director on 08.30.2024,  read in part,…”Incident category Abuse…When 8/21/2024…Location Patient’s private residence, Description of the Allegation Private paid caregiver reported that hospice aide A was rushy, rude, administered Morphine/Diazepam SR Suppository, and rolled the Patient in the bed causing his face to be pushed up against the side rails of bed. Alleged Perpetrator hospice aide A, How was the alleged perpetrator identified? By Name, The alleged perpetrator denied, Did investigation reveal the presence of a witness? Yes, Witness Name: Private caregiver, Injury or adverse effect? No, Assessment Date 8/21/24, Description of Injury and Assessment No injuries observed and no adverse effects from medication administered by hospice aide A. Agency Immediate Response investigation immediately initiated when report was received. RN visit was made to assess for injuries and any adverse effects from medication that was administered by hospice aide A. Hospice aide A’s schedule was cleared for the remainder of the week while investigation ongoing. Interviews were conducted with office manager who heard hospice aide A state she gave the Patient a suppository and with paid private caregiver. Private caregiver who witnessed the events. Hospice aide A was interviewed by the clinical supervisory and denied administering the suppository. Investigation Summary There were no injuries observed or adverse affects from the medication administered (sic) upon RN assessment on 08.21.2024. After interview was completed with private caregiver of the Patient. It was confirmed that hospice aide A did administer the Morphine/Diazepam SR Suppository and roll the Patient where his face was pushed against the bedrails even after it was requested a pillow be placed to protect the Patient’s face. Investigation Findings Confirmed Agency Action Post-Investigation Hospice aide A was termed on the morning of 08.22.2024. Inservice completed with staff timely reporting any complaints or concerns for Patients, families, caregivers or facilities.”…  Patient #2 chart review revealed a plan of care for episode of 7/30/24 through 8/23/2024 with a start of care of 7/30/24. The plan of care included a primary diagnosis of senile degeneration of brain (a progressive decline in cognitive abilities like memory, thinking, and problem-solving, primarily associated with aging). The plan of care included orders for skilled nursing 2 times a week for 2 weeks and 1 time a week for 2 weeks, medical social worker 1 time a month for 1 month, chaplain 1 time a month for 1 month and hospice aide 3 times a week for 1 week and 5 times a week for 3 weeks. The chart included a form titled “Aide Care Plan Report” The care plan included the following ADL Services to be completed every visit: Turn and position in bed, bathing (bed bath), skin care, perineal (area between the genitals and the anus) care, oral care and check pressure areas. The care plan did not include the hospice aide to administer medications and/or suppositories.  Surveyor called private caregiver for Patient #2 on 3/28/25 at 10:23 am. No answer, left message requesting return call.  Surveyor called hospice aide A on 3/28/25 at 10:23 am. No answer, left message requesting return call.  An interview was conducted on 3/28/25 at 10:24 pm with Office Manager. Surveyor asked Office Manager to recall the incident related to Patient #2 and hospice aide A on 8/20/24. The Office Manager stated, “Hospice aide A directly told me she administered a suppository to Patient #2. Hospice aide A said, “the lady had it out and I administered it.” The Office Manager said I told her, “Oh no, we shouldn’t do that.” and hospice aide A said, “I was just being helpful, the lady had it out, so I put it in” An interview was conducted on 4/1/25 at 3:54 pm with the hospice aide A. The surveyor asked had she provided care to Patient #2. Hospice aide A said, “Yes.” Surveyor asked Hospice Aide A to explain to surveyor how she bathed Patient #2. Hospice aide A said, “I gave him a bed bath. I would use 2 towels and 2 pails of water. Patient #2’s FM 1 wanted his hair washed first, though he didn’t have much. Then I would wash his lower body and then the middle. The paid caregiver would help me roll him over so I could wash his back.” The surveyor asked hospice aide A had Patient #2’s FM 1 request she use a pillow on bedrails to avoid injuring Patient #2’s face. Hospice aide A said, “Yes.” The Surveyor asked hospice aide A if she was using a pillow to avoid mashing Patient 2’s face into the side railing as Patient #2’s FM 1 requested. Hospice aide A said, “No.” The surveyor asked hospice aide A if she had administered a suppository to Patient #2. Hospice aide A said, “Yes, the private caregiver had laid it out and was about to do it but she was holding Patient #2, so I just did it to help out.” Surveyor asked hospice aide A how not following the care plan by administering medications or suppositories could affect the patient. Hospice aid A said, “Something could go wrong, and the patient could die.” Surveyor asked hospice aide A how not using the pillow when turning Patient #2 could affect the patient. Hospice aide A said, “Patient #2 could have been hurt." Agency policy: Rights of Elderly TX 2-093.1 revised 09.12.18 read in part…”Policy: To encourage awareness rights of the elderly, in accordance with the Texas Human Resources Code chapter 102…Rights of the Elderly…4) Has the right to be free from abuse, neglect, and exploitation”…

Based on record review and interview the agency failed to provide all hospice care in accordance with the hospice plan of care in 1 (Patient #2) of 6 charts reviewed. Hospice aide A placed Patient #2 at risk of adverse effects, pain and injury due to face hitting side rail while turning and administering medication without an order. --- Findings Included: Patient #2 chart review revealed a plan of care for episode of 7/30/24 through 8/23/2024 with a start of care of 7/30/24. The plan of care included a primary diagnosis of senile degeneration of brain (a progressive decline in cognitive abilities like memory, thinking, and problem-solving, primarily associated with aging). The plan of care included orders for skilled nursing 2 times a week for 2 weeks and 1 time a week for 2 weeks, medical social worker 1 time a month for 1 month, chaplain 1 time a month for 1 month and hospice aide 3 times a week for 1 week and 5 times a week for 3 weeks. The chart included a form titled “Aide Care Plan Report” The care plan included the following ADL Services to be completed every visit: Turn and position in bed, bathing (bed bath), skin care, perineal (area between genitals and anus) care, oral care and check pressure areas. The care plan did not include the hospice aide to administer medications and/or suppositories. Surveyor called private caregiver for Patient #2 on 3/28/25 at 10:23 am. No answer, left message requesting return call.  Surveyor called hospice aide A on 3/28/25 at 10:23 am. No answer, left message requesting return call.  An interview was conducted on 3/28/25 at 10:24 pm with Office Manager. Surveyor asked Office Manager to recall the incident related to Patient #2 and hospice aide A on 8/20/24. The Office Manager stated, “Hospice aide A directly told me she administered a suppository to Patient #2. Hospice aide A said to me, “the lady had it out and I administered it.” The Office Manager said I told her, “Oh no, we shouldn’t do that.” and hospice aide A said, “I was just being helpful, the lady had it out, so I put it in (sic) ”  An interview was conducted on 4/1/25 at 3:54 pm with the hospice aid A. The surveyor asked had she provided care to Patient #2. Hospice aide A said, “Yes.” Surveyor asked Hospice Aide A to explain to surveyor how she bathed Patient #2. Hospice aide A said, “I gave him a bed bath. I would use 2 towels and 2 pails of water. Patient #2’s FM 1 wanted his hair washed first, though he didn’t have much. Then I would wash his lower body and then the middle. The paid caregiver would help me roll him over so I could wash his back.” The surveyor asked hospice aide A had Patient #2’s FM 1 requested she use a pillow on bedrails to avoid injuring Patient #2’s face. Hospice aide A said, “Yes.” The Surveyor asked hospice aide A if she was using a pillow to avoid mashing Patient 2’s face into the side railing as Patient #2’s spouse requested. Hospice aide A said, “No.” The surveyor asked hospice aide A if she had administered a suppository to Patient #2. Hospice aide A said, “Yes, the private caregiver had laid it out and was about to do it but she was holding Patient #2, so I just did it to help out. Surveyor asked hospice aide A how a hospice aide administering medications or suppositories could affect the patient. Hospice aid A said, “Something could go wrong, and the patient could die.” Surveyor asked hospice aide A how not using the pillow when turning Patient #2 could affect the patient. Hospice aide A said, “Patient #2 could have been hurt.” An interview was conducted on 4/4/25 at 11:15 am with the Supervising Nurse. Surveyor reviewed findings of hospice aide A abusing patient by turning Patient #2’s face into side rails and administering a suppository with the Supervising Nurse. The Supervising Nurse said, “ We suspended hospice aide A immediately until we finished our investigation, she was then termed (terminated) because there was a witness to hospice aide A not protecting Patient #2’s face and administering the suppository. The surveyor asked how a hospice aide not protecting the patient when turning and not following the care plan by administering a suppository could affect the patient. The Supervising Nurse said, “It could affect them in a negative way if they don’t know what they are giving them and not following the aide care plan.” Agency policy: Hospice Aide Services TX 2-005.1 revised 12.06.18 read in part…” Policy: To specify the role of the hospice aide and/or homemaker in hospice care…Services provided by an aide could include: bathing, shampoo, range of motion activities, assisting the patient to the bathroom, use of commode or bed pan, assisting with meal preparation, feeding the patient, light housekeeping and/or linen changes. These activities in accordance with the interdisciplinary plan of care and the physician’s (or other authorized independent practitioner’s) orders will be assigned and supervised by a registered nurse and will be included in the patient’s plan of care.”…

Upon patient record review, 30 of 30 (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30) did not have evidence that the hospice had informed and provided written information to these patient concerning the availability of various Advance Directives, nor a description of applicable state law. There was no evidence of Advance Directive information having been provided to these patients' families, regarding the option of a Do Not Resuscitate order, and its definition. In addition, the hospice had included in their patient admission booklet only a website, wherein the patient could go to find state specific law applicable to Advance Directives.

Upon patient record review 4 of 30 (Patients # 17, 24, 25, 26) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training: Patient 17: Aide POC effective 02/05/2025 assigned the task of skin care to include applying lotion, wrapping ace bandages and elevating BLE. This intervention was not performed on 2/6, 2/7/ 2/10, 2/11, 2/13 2/17, 2/19, 2/21, and 2/25/2025. The aide documented 'skin care' was performed with yes, and did not include details of what skin care was provided. Patient 24: Aide POC effective 10/19/2024. Shower was ordered for Tuesdays and Thursdays. Shower performed on Monday 01/20, Wednesday 01/21 and Friday 01/22/2025. Patient 25: Aide POC effective 11/08/2024. Bed baths were ordered for Tuesdays and Thursdays. Bed bath performed Monday 02/10/2025. Patient 26: Aide POC effective 12/19/2024 ordered aide visits with a frequency of 5x per week. An aide visit was not made on 12/25/2024.

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. The 2024 calendar year volunteer usage equals 0.58%.

Based on record review and interview, the agency failed to include physician orders in the clinical record for 1 (#2) of 3 clinical records reviewed. The failure placed the agency's patients at risk for omission of care/inappropriate care that could result in a negative patient outcome. --- Patient #2: Record review of Patient #2's clinical record revealed a Plan of Care dated 10/3/2022 to 12/31/2022. The Plan of Care indicated that Patient #2 started on the hospice's services on 10/3/2022. The Plan of Care listed Heart Disease as the primary diagnosis. The Plan of Care contained orders for nursing services. The clinical record contained documentation of skilled nurse visits on documents titled, "Visit Note Report." Registered Nurse E conducted a skilled nurse visit on 12/26/2022. Registered Nurse E documented that Diazepam SR (medication used to treat anxiety) 5 milligrams frequency of administration was decreased to morning only to prevent the patient being lethargic. The clinical record contained an order, dated 12/21/2023, for Patient #2 to received Diazepam SR 5 milligrams twice a day for anxiety. Patient #2's clinical record contained a "Client Medication Report" that listed Diazepam SR 5 milligrams twice a day for anxiety. Patient #2's clinical record did not contain an order for Diazepam SR 5 milligrams to be taken daily. Registered Nurse D conducted a skilled nurse visit on 12/31/2023. Registered Nurse D documented that Patient #2 was having constipation. Registered Nurse D documented that Patient #2 had Dulcolax tablets (used to treat constipation) ordered as needed and instructed the caregiver to give two doses at this time. Patient #2's "Client Medication Report" indicated that Patient #2 could have Bisacodyl (brand name Dulcolax) 5 milligrams, 1 tablet, twice a day. Registered Nurse D documented that Patient #2 had redness and maceration to the bottom area. Registered Nurse D applied a dressing to Patient #2's bottom. Patient #2's clinical record did not contain an order for Patient #2 to take two doses of laxative at one time and did not contain an order for a dressing to Patient #2's bottom. The client record contained a Plan of Care dated 1/1/2023 to 3/31/2023. The Plan of Care listed Heart Disease as the primary diagnosis. The Plan of Care included orders for nursing services. The Plan of Care did not contain an order for laboratory testing of urine. Registered Nurse E conducted a skilled nurse visit on 1/2/2023. Registered Nurse E documented obtaining a urine specimen. Patient #2's clinical record did not contain an order to obtain a urine specimen on 1/2/2023. During an interview on 5/18/2023 at 2:37 p.m. with the Alternate Administrator, the surveyor discussed the skilled nurse visits conducted on 12/26/2023, 12/31/2022. and 1/2/2023. The surveyor discussed that Patient #2's record did not contain orders for the medication changes, application of a dressing, and urine laboratory testing. The Alternate Administrator was asked the timeframe to have orders recorded in the clinical records. The Alternate Administrator stated, "I will have to look." The Alternate Administrator assisted with arranging interviews with Registered Nurses D, and E. During a telephone interview on 5/18/2023 at 4:23 p.m. with Registered Nurse D, the surveyor discussed the visit that was conducted on 12/31/2023 and asked questions regarding giving Patient #2 two doses of laxative at the same time and the application of a dressing to Patient #2's bottom. Registered Nurse D informed the surveyor that the dressing was a preventative dressing. Registered Nurse D stated, "I don't remember that far back." Registered Nurse D informed the surveyor that the physician ordered the dressing and to give two doses of Dulcolax. Registered Nurse D informed the surveyor the orders should have been there and did not know why unless it was due to trying to get charting done for the day. "I usually write them the same day, it probably was a busy day." During a telephone interview on 5/19/2023 at 12:15 p.m. with Registered Nurse E, the surveyor discussed the visit conducted on 12/26/2022 with Patient #2. Registered Nurse E was asked if the physician had ordered the change in Diazepam SR 5 milligrams to be taken only once a day in the morning, and no longer to be taken twice a day. The surveyor discussed with Registered Nurse E that there was no order in Patient #2's clinical record to decrease Diazepam SR 5 milligrams to daily. Registered Nurse E informed the surveyor that Registered Nurse E could not view Patient #2's record and stated, "If I decreased the dose, I would have spoken with the physician." The surveyor discussed the visit conducted on 1/2/2023 when a urine specimen was obtained for laboratory testing. The clinical record did not contain an order for laboratory testing of Patient #2's urine. Registered Nurse E was asked if there had been an order to obtain a urine specimen. Registered Nurse E stated, "Yes." Registered Nurse E stated that it was "not charted correctly." The agency had a policy titled "Verification of Physician Orders" that was labeled TX 2-032.1. The policy read in part: "Policy To ensure that accurate physician (or other authorized independent practitioner) orders are obtained in accordance with applicable law and regulation...A copy of the physician's or licensed independent practitioner's order will be kept in the clinical record..."

Upon patient record review, 1 of 25 (Patient #11) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #11: Orders for Saline Flush 5 ml IV present on the Plan of care dated 1/27/22 however, no evidence of 5 ml Saline Flush on the medication profile.

Upon client record review, 10 of 25 (Patient #2,3,4,6,7,9,12,13,16,25) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #2: MSW orders on POC dated 3/2/22 1W1. No evidence of visit performed first week nor missed visit. Visit performed 3/7/22. Patient #3: MSW orders on POC dated 3/19/20 1W1, no evidence of visit performed first week nor missed visit. Visit performed 3/23/20. Chaplain orders on POC dated 3/19/20 1W1, no evidence of visit performed first week nor missed visit. Visit performed on 3/23/20. Patient #4: MSW orders effective 12/8/21 1xmo. No evidence of visit or missed visit for March 2022 (episode 12/3/21-3/2/22). Chaplain orders effective 12/6/21 1xmo by phone. No evidence of visit or missed visit for March 2022 (episode 12/3/21-3/2/22). SN frequency on POC 12/3/21-3/2/22 2w1, 1w9, 2w1, 1w3, 3 prn no evidence of second visit for week 11 of the episode (week of 1/23/22). Patient #6: POC dated 1/24/22-3/24/22 Chaplain ordered 1 mo2 by phone effective 1/24/22. No evidence of visit nor missed visit for January. SN order effective 1/24/22 1w5, 2w1, 1w3, 2 prn. No evidence of 2nd visit for week of 2/27/22. Patient #7: POC dated 1/30/22-3/30/22 SN ordered 1w6, 2w1, 1w2 2 prn. No evidence of second visit or missed visit for week of 3/6/22. Visit made 3/7/22. MSW orders effective 1/30/22 1xmo2, 2 prn, No evidence of visit or missed visit for January. Chaplain orders effective 1/30/22 1xmo2, 2 prn, No evidence of visit or missed visit for January. Patient #9: SN orders on POC dated 5/10/21. Freq 2w1, 1w8, 2w1, 1w3. No evidence of second visit or missed visit during week of 7/5/21. Visit performed 7/9/21. Patient #12: POC orders starting 11/23/21: SN 2w1, 1w8, 2w1, 1w3, No evidence of second visit or missed visit during week 10. One visit performed on 1/25/22. MSW ordered 1xmo effective 11/24/21. No evidence of visit or missed visit for month of November. Chaplain ordered 1xmo effective 11/24/21. No evidence of visit or missed visit for month of November. Patient #13:MSW orders effective 4/15/21 1xmo. No evidence of visit or missed visit for April. Chaplain orders effective 4/19/21 1xmo, No evidence of visit or missed visit for April. Patient #16: Orders for Chaplain effective 3/24/21 1mo2. No evidence of visit or missed visit for March. Orders for MSW effective 3/24/21 1mo2. No evidence of visit or missed visit for March. Patient #25: POC dated 1/21/22 orders SW 1w1, No evidence of visit or missed visit for week #1. Visit performed 1/24/22.

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #5: Chaplain did not show evidence of placing an effective barrier between personal book and patient's table.