Every finding on record at St. Anthony's Medical Center

Based on policy review, record review, observation, and interview the hospice provider failed to ensure an accurate/updated medication profile was maintained in one of five full records reviewed (Record/Patient #1). This deficient practice has the potential to affect all patients served by the provider. --- Findings included: Review of the providers policy titled, "Medication – Monitoring," dated 12/29/2022, showed in part for patients residing in a SNF (skilled nursing facility) that administers medications to the patient, staff will check the facilitys patient medication list against the medication profile list in the hospice electronic medical record at least weekly. If the visit frequency is beyond weekly, then the staff will check the facilitys patients medication list at each visit. Review of the providers policy titled, ";Medication Reconciliation Medication Regime Review," dated 03/28/2023, showed in part that a medication profile is completed for each patient at the time of admission, updated as indicated, with review and reconciliation every two weeks as part of the comprehensive assessment. RECORD/PATIENT #1: Review of the current hospice medication profile showed the following discrepancies with the current SNF medication orders: - The hospice medication profile showed an order for acetaminophen (Tylenol) take 650 milligrams (mg) every six hours as needed for pain. The SNF medication orders did not include this order; - The hospice medication profile showed an order for aspirin 81 mg chewable tablet daily. The SNF medication orders showed an order dated 08/06/2023 for aspirin 81 mg delayed release once daily; - The hospice medication profile showed an order for loratadine (Claritin, for allergies) 10 mg every six hours as needed for allergies or rhinitis (inflammation of the nasal passages). The SNF medication orders showed an order dated 08/01/2023 for Claritin 10 mg daily as needed; and -The hospice medication profile showed an order for metoprolol succinate (heart medication) 25 mg, take 37.5 mg (1 ½ tablets) daily. The SNF orders showed an order dated 06/22/2022 for metoprolol 37.5 mg (1 ½ tabs) every 12 hours. Per interview conducted during observation, on 09/06/2023 at 10:10 AM, the RN stated that he/she gets a print out of the facility physician order sheet to compare orders. He/she reconciled the medications last night (09/05/2023) and brought a new medication list to the facility today (09/06/2023). During an interview on 09/07/2023, beginning at 11:00 AM, the community RN clinical supervisor stated that when they received a new medication order the nurse would add it to the medication profile. On the next visit, they would take a new medication sheet. He/she encouraged staff to ask the SNF staff to print out their orders weekly because sometimes they were not notified of changes.

Based on policy review, record review, and interview, the hospice provider failed to ensure an individualized plan of care was developed for each patient in, but not limited to, two of five full records reviewed (Records/Patients #3 and #4). This deficient practice has the potential to affect all patients served by the provider. --- RECORD/PATIENT #4: Review of the document titled, ";Hospice Plan of Care," dated 09/05/2023, showed the patient to take medications from pill bottle set up by Skilled Nurse. The patient resided in the hospice house and medications are brought to the patients room in cups on a set schedule by a skilled nurse. During an interview on 09/07/2023 at 11:30 AM, the hospice clinical manager stated that he/she would expect the plan of care to be specific to patient situations. Findings included: Review of the providers policy titled, ";SOUTH HOSPICE Coordination of Services - Hospice Care Policy," dated 09/14/2022, showed the providers registered nurse staff were to: - Develop and implement, with physician, IDG and the patient, an individualized Plan of Care based on patients physical, medical psychosocial and environmental needs; - Make appropriate revisions to the Plan of Care as the patients condition changes; - Establish and achieve appropriate realistic measureable goals, then evaluate progress; - Prepare patient care instructions for a Hospice Aide; and * Documentation of these instructions will be on the hospice aide care plan in the electronic medical record. RECORD/PATIENT #3: Review of the RN (registered nurse) initial assessment dated 09/01/2023, showed the following: - Diagnosis of squamous cell carcinoma to anorectum with metastases (cancer of the anus and rectum area), protein calorie malnutrition and Alzheimers disease (dementia); - Pain assessment: patient has pain, unable to communicate; * Pain reported by direct observation; - Pain Assessment in Advanced Dementia (PAINAD): eight out of 10; - Patient arrived via ambulance and speech nonsensical; - Neurological: * Orientation: times one (person); * Cognition: difficulty sequencing, impaired learning capacity, impaired safety awareness, poor problem solving, and unable to follow commands; - Judgement: inappropriate judgement; - Memory loss: immediate; - Speech: incomprehensible; - Genitourinary: * Urine color – amber; and * Urine odor – none. Review of the POC dated 09/01/2023 and updated 09/05/2023, showed the following: - Diagnoses that included malignant neoplasm of anorectum, rectal mass and Alzheimers dementia with agitation; - Durable medical equipment – Foley catheter supplies; - Problem – Genitourinary function: patient, family, caregivers, facility staff will verbalize understanding of catheter care; - Home Health Aide Plan of Care: * Aide vitals: and * Ask patient to provide a pain rating using 1-10 pain scale. Report to licensed clinician a pain rating that is unacceptable to patient. Observation on 09/06/2023 showed the following: - At 9:57 AM, no Foley draining urine from the patient; - At 10:20 AM, no Foley draining urine during the patients bed bath; - At 1:30 PM, no Foley draining urine from the patient; and - At 3:55 PM, no Foley draining urine from the patient. During an interview on 09/07/2023, beginning at 11:40 AM, the RN Coordinator and Inpatient RN Clinical Supervisor stated the POC should be individualized and a Foley catheter should not be on the POC if the patient does not have a Foley, and when a dementia patient has pain and its noted by a certified nurses aide (CNA) he/she should notify the nurse. The pain rating scale should not be on the POC if the patient is unable to verbalize the pain using the pain scale.

Based on clinical record review and interview, the provider failed to ensure the clinical record contained and the SNF provided, a discharge summary at the end of a respite stay in a skilled nursing facility (SNF) in two of two respite (short term inpatient care for caregiver relief) records reviewed, (Records/Patients #6 and #7). This deficient practice has the potential to affect patients receiving respite services in a SNF. --- Findings included: RECORD/PATIENT #6 Review of the clinical record showed:- The patient was admitted to hospice services on 09/20/2022, with a diagnosis of Cerebral Degeneration (a condition causing a decline in mental ability including memory, balance and other activities of daily living);- The patient was admitted to a SNF for Respite care on 05/29/2023;- The patient was discharged from the SNF back to the provider on 06/02/2023; and- The clinical record failed to contain a discharge summary from the SNF. RECORD/PATIENT #7: Review of the clinical record showed:- The patient was admitted to hospice services on 09/20/2022, with a diagnosis of Cerebral Degeneration (a condition causing a decline in mental ability including memory, balance and other activities of daily living);- The patient was admitted to a SNF for Respite care on 08/21/2023;- The patient was discharged from the SNF back to the provider on 08/26/2023; and - The clinical record failed to contain a discharge summary from the SNF. During an interview on 09/06/2023 at 3:38 PM, the community RN clinical supervisor stated that there was no discharge summary in the patients record. During an interview on 09/07/2023 at 11:18 AM, the community coordinator stated that he/she would expect a discharge summary to be provided from the SNF to the provider. The Registered Nurse Coordinator also stated that he/she would expect the hospice staff to document that they received report from the SNF at time of discharge.

Based on policy review, record review, and interview the hospice provider failed to ensure the hospice aide followed the plan of care (POC) in one of five full records reviewed (Record/Patient #1). This deficient practice has the potential to affect all patients that received aide services from the provider. --- Findings included: Review of the providers policy titled, ";Coordination of Services – Hospice Care Policy," dated 09/14/2022, showed in part that the hospice aide will take assignments to specific patients, receive care instructions via electronic medical record, be supervised by a registered nurse (RN), and give personal care in accordance with the POC established by the nurse, including bathing, mouth, hair and nail care, and special skin care. RECORD/PATIENT #1: Review of the aide POC dated 07/17/2023, 07/26/2023, 08/09/2023, and 08/23/2023 showed the aide was to visit twice a week for eight weeks. The aide was to perform a complete bed bath. Review of the aide visit notes showed on 07/21/2023, 07/25/2023, and 08/01/2023 under the section of the aide POC, an intervention for the aide to perform a complete bed bath. The aide documented he/she assisted with showering. The aide visit notes failed to contain documentation that showed the aide discussed assisting the patient with a shower instead of a bed bath with the hospice nurse . During an interview on 09/07/2023, beginning at 11:00 AM, the community RN clinical supervisor stated that the aide should note if a shower was per the patient request and should notify the RN case manager of any requests or if changes needed to be made to the POC.

Based on policy review, record review, and interview, the provider failed to ensure the registered nurse (RN) made a hospice aide on-site supervisory visit every 14 days in two of five full records reviewed (Records/Patients #2 and #5). This deficient practice has the potential to affect patients with aide services through the provider. --- Findings included: Review of the provider's policy titled, ";Coordination of Services," dated 09/14/2022, showed in part the RN would:- Supervise and assess the hospice aide to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the interdisciplinary group meet the patients needs; - Make an on-site visit to the patients home no less frequently than every 14 days; - Document the supervisory visit in the electronic medical record; and- Update the hospice aide services as necessary. RECORD/PATIENT #2:Review of the clinical record showed:- The patient was admitted on 05/24/2022 with a primary diagnosis of Pulmonary Fibrosis (a condition that causes the scarring or thickening of the lungs that impedes normal gas exchange);- The patient resided at home alone;- RN A made routine visits to the patients home on 08/15/2023, 08/18/2023, 08/22/2023 and 08/25/2023 with no documentation of the supervision of the aide; - RN A documented an aide supervisory visit on 08/24/2023 without being on-site in the patients home; and- RN A failed to perform a hospice aide supervisory on-site visit within the 14 days. RECORD/PATIENT #5:Review of the clinical record showed:- The patient was admitted on 08/30/2022 with a primary diagnosis of Prostate Cancer;- The patient resided at home with family; - RN B made routine visits to the patients home on 08/01/2023, 08/04/2023, 08/08/2023, 08/11/2023, and 08/15/2023 with no documentation of the supervision of the aide; - RN B documented an aide supervisory visit on 08/07/2023 without being on-site in the patients home; and- RN B failed to perform a hospice aide supervisory on-site visit within the 14 days. During an interview on 09/07/2023 at 11:18 AM, the community RN clinical supervisor stated that it is expected of the RNs to make hospice aide supervisory visits at least every 14 days and to ask the patient or caregiver if the aide staff is providing appropriate care, following the assigned tasks on the plan of care, demonstrates competency, respects the patients rights, and if the documentation occurs after the on-site visit the nurse should document that the discussion of the aide abilities happened in person at the last visit.

Based on policy review, record review, and interview the hospice provider failed to ensure the registered nurse (RN) performed adequate aide supervision in one of five full records reviewed (Record/Patient #1). This deficient practice has the potential to affect all patients that receive aide services from the provider. --- Findings included: Review of the providers policy titled, ";Coordination of Services – Hospice Care Policy," dated 09/14/2022, showed in part that the RN will: - Prepare patient care instructions for a hospice aide and be responsible for the supervision of that hospice aide. Documentation of these instructions will be on the hospice aide care plan in the electronic medical record; and - Supervise and assess the hospice aides ability to demonstrate initial and continued satisfactory performance in meeting outcome criteria that includes following the patients plan of care (POC) for completion of tasks assigned by the RN. Review of the aide visit notes showed on 07/21/2023, 07/25/2023, and 08/01/2023, the aide POC showed an intervention for the aide to perform a complete bed bath. The aide documented he/she assisted with showering. The aide visit notes failed to contain documentation that showed the aide discussed assisting the patient with a shower instead of a bed bath with the hospice nurse . Review of the RN aide supervisory visits dated 07/25/2023, 08/08/2023, and 08/22/2023 showed the aide provided services in accordance with the POC. The supervisory visits failed to address the aide assisting with showering instead of a bed bath. During an interview on 09/07/2023, beginning at 11:00 AM, the community RN clinical supervisor stated that he/she would expect the nurse to look at the aide notes and address whether the POC needed to be updated.

Based on policy review, record review, and interview, the hospice provider failed to ensure an order was obtained for all treatments provided to a patient in one of five full records reviewed (Record/Patient #4). This deficient practice has the potential to affect all patients served by the provider. --- Findings included: Review of the providers policy titled, ";Physician Orders Policy Plan of Care," dated 02/15/2023, showed drugs, services, and treatments are administered only as ordered by a physician. RECORD/PATIENT #4: Review of the document titled, ";Skilled Nurse (SN) - Hospice House Care Note," dated 08/20/2023, showed "patient agreed to a digital examination of rectal vault and patient has soft stool to vault at inspection". Review of the clinical record failed to include a physician order for a digital examination. During an interview on 09/07/2023 at 11:30 AM, the hospice clinical manager stated that he/she would expect there to be an order for any invasive procedure performed on a patient and that he/she failed to produce the order.

Based on clinical record review, observation, and interview, the hospice house staff failed to ensure the nursing needs of the patients were met in, but not limited to, one of ten inpatient facility patients when the staff failed to prepare a liquid medication without air bubbles to ensure the patient received the correct medication dose (Record/Patient #12). This deficient practice has the potential to affect all patients in the hospice house. --- Findings included: The provider failed to provide a medication administration policy as requested prior to the survey exit. RECORD/PATIENT #12: During the hospice house tour on 09/05/2023 at 2:30 PM, MSW (Masters of Social Work) stated that patient #12 had a diagnosis of megacolon (abnormal dilation of the colon that is not caused by mechanical obstruction) and that he/she was super confused, agitated, and on a lot of medications. Review of the electronic medical record (EMR) on 09/06/2023 at 10:10 AM showed Haldol 2 milligrams (mg) / milliliter (ml), administer 2 mg by mouth every hour as needed. Observation on 09/06/2023 at 10:10 AM, during a medication pass, showed the following: - The registered nurse (RN C) inserted a one ml syringe into the bottle of Haldol 2 mg per ml and pulled back on the syringe plunger passing the 1ml mark; - RN C laid the syringe on top of the medication cart and turned away to get the patient's Ativan tablets; - The surveyor asked RN C to look at the syringe and RN C just looked and didnt state anything was wrong; - Surveyor asked why the syringe plunger was past the 1 ml mark; - RN C stated there was an air bubble and that is why he/she pulled the plunger past the 1 ml mark to make up for the air bubble; - The surveyor asked RN C where he/she learned to do that; - RN C stated he/she just knew that; and - RN C then picked the syringe up and shook it and then he/she held it in one hand and flicked it with the other hand to remove the air bubble and stop the plunger at the 1 ml mark. During an interview on 09/07/2023 at 11:40 AM, The inpatient RN clinical manager stated that staff are to flick out the air bubble or squeeze it out and start over.

Based on observation and interview, the hospice provider failed to ensure the reliability of all equipment in the facility. This deficient practice has the potential to affect all patients served by the provider. --- Findings included: Observation on 09/06/2023 at 4:00 PM, during a walkthrough of the facility, showed the call lights in the public area restrooms were not functioning. The surveyor activated the call light in the public restroom to check the alert system. The alert failed to activate the handheld devices that are carried by staff. When the call light was deactivated, the handheld devices were alerted that the call light had been answered. During an interview on 09/07/2023 at 11:30 AM, the hospice clinical manager stated that he/she would expect all call lights in the facility to function properly and there was a maintenance request placed to get them assessed and fixed.