Every finding on record at St Croix Hospice, LLC

It is required that the written Patient Bill of Rights includes the right to: choose his or her attending physician. This standard was not met as evidenced by clinical record review and interview. In 1 of 5 (20%) clinical records reviewed, the agency did not ensure that all patient rights were followed as the attending physician was not informed of changes in condition. Clinical Record 1: The patient chose his attending physician to follow him for care. As patient encountered changes in condition, there was no documentation that the attending physician was informed of the changes. The Skilled Nursing notes in the skilled facility record documented hypoglycemic and hyperglycemic episodes, medication discrepancies, physician ordered blood draws for INR orders not obtained, bleeding that was difficult to stop after falls, and reporting of falls and injuries. The Hospice Medical Director had provided physician orders for care. There was no documentation that the attending physician had declined to manage the patient's care. Hospice Care was delivered from 12/17/2022 until 02/02/2023, when the patient died. Interview with the Director of Clinical Services, and the Regional Director of Clinical Services stated that this record had been reviewed before 10/10/2023.

It is required that hospice aides are assigned to a specific patient by a Registered Nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 1 of 5 (20%) clinical records reviewed of patients receiving hospice aide services, the agency did not ensure the hospice aide received specific written patient care instructions for care delivery. Clinical Record 1: The patient elected hospice care on 12/21/2022. The skilled nursing visit note dated 01/03/2023 documented that the facility only used a Hoyer lift to transfer patient. Additionally, the patient had a Foley catheter. The care and maintenance of the Foley catheter and the use of a Hoyer Lift for transfers were not included in the hospice aide care plan. The Regional Clinical Specialist agreed that the hospice aide care plan was not complete and that this record had been reviewed prior to 10/10/2023.

It is required that the Interdisciplinary Group (IDG) member ensures that the IDG communicates with the SNF/NF or ICF/IDF medical director, the patient’s attending physician, and other physicians participating in the patient’s/resident’s care to coordinate the hospice care with the medical care provided by other physicians. This standard was not met as evidenced by clinical record review and interview. In 1 of 5 (20%) clinical records for patient's residing in skilled nursing facilities reviewed, the agency did not ensure that the attending physician was promptly notified of changes in condition by the IDG membership. Clinical Record 1: Patient was receiving hospice services in a skilled nursing facility. In reviewing the skilled nursing facility clinical record, on 12/26/2023, Insulin was not administrated timely or using the physician ordered dose, on 12/29/2023, an INR blood test was ordered but not obtained, the anticoagulant medication was discontinued by the anticoagulant clinic on 01/31/2023, several falls were documented, however, no specific detail about injury. The Hospice IDG notes and IDG members documentation at the initiation of care on 12/21/2023 and every two weeks thereafter did not document any coordination of care with the Attending Physician about changes in condition while patient was residing in the skilled nursing facility. Interview with the Regional Director of Clinical Service confirmed this record was had been previously reviewed by clinical leadership prior to 10/10/2023 and the agency ended the contract with this facility.

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. In 1 of 27 (4%) clinical records reviewed, the agency did not ensure that, when accepted, the chaplain completed the initial assessment within the required five days. Clinical Record 1: The initial plan of care included a chaplain visit frequency order, effective 10/19/22, for 1w1 (one visit in week one). The chaplain's initial visit was completed on 10/28/22. The record did not document why the visit was made outside the 5-day requirement. The record was reviewed by the Director of Accreditation, who confirmed that during an interview on 8/17/23, the visit was made beyond the 5-day requirement and could not locate any documentation to support why.

It is required that each patient’s individualized written plan of care identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and observation. In 4 of 27 (15%) clinical records reviewed, the agency did not ensure that the plans of care included individualized interventions to meet the patient's needs; especially related to safety and aspiration precautions. Clinical Record 3: Initial nursing assessment (4/4/23) documented, "Patient is on a regular diet with pureed textures and thin liquids. Medications are crushed as the patient has difficulty swallowing due to an esophageal stricture." On 5/28/23, a triage note reported, "patient had a choking episode at lunch and required Heimlich maneuver." The plan of care, effective from 4/4/23 to the present, listed a pureed diet but did not include any problems, goals, or interventions related to aspiration precautions, dysphagia, or crushed medications. Clinical Record 6: Initial nursing assessment (6/22/23) documented "according to the MAHC 10 Fall Risk Assessment, this patient's score is: 8. Based on the score, the patient is: at risk for falling." Narrative note (6/22/23) stated, "patient and family report that patient had three falls in 1 day earlier in May 2023...he has increasing falls related to back pain and chest pain and occasional complaints of dizziness." The plan of care, effective 6/22/23 to the present, did not include any problems, goals, or interventions related to safety or fall precautions. Clinical Record 10: Initial nursing assessment (7/27/23) documented "according to the MAHC 10 Fall Risk Assessment, this patient's score is: 9. Based on the score, the patient is: at risk for falling." On 8/10/23, nursing documentation revealed the patient had two falls. The plan of care, effective 7/27/23 to the present, did not include any problems, goals, or interventions related to safety or fall precautions. Clinical Record 20: Initial nursing assessment (2/28/23) documented "according to the MAHC 10 Fall Risk Assessment, this patient's score is: 8. Based on the score, the patient is: at risk for falling." Narrative note (8/8/23) documented the patient fell and obtained a bruise on their head. The plan of care, effective 2/28/23 to the present, did not include any problems, goals, or interventions related to safety or fall precautions. The Director of Accreditation and Administrator reviewed the records and confirmed, during an interview on 8/17/23, that the plans of care were not individualized to meet the patient's needs.

It is required that hospice aides are assigned to a specific patient by a Registered Nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 3 of 23 (13%) clinical records reviewed, in which aide services were accepted, the agency did not ensure the aide care plans included specific instructions for patient care, thus leaving the aide to make decisions outside the scope of practice. Clinical Record 3: Initial nursing assessment (4/4/23) documented that the patient was on a puree texture diet due to difficulty swallowing. The aide care plan, effective 4/5/23 to current, listed the following relevant tasks: "socialization, every visit, patient loves company, drinking coffee and eating little snacks." The care plan did not alert the aide of the pureed diet requirements or include aspiration precautions. Clinical Record 12: Initial nursing assessment (8/9/23) documented that the patient had a G-tube (gastrostomy tube) in place with continuous tube feeding being administered. Aide care plan, effective 8/9/23 to current, listed the following relevant tasks: bed bath and dressing. The care plan did not alert the aide of the gastrostomy tube or what, if any, care should be performed around the site. Clinical Record 13: On 8/3/23, the nurse documented a heel wound, with orders for daily wound care and "wrap heel with gauze." On 8/15/23, wound care was changed to twice daily, and the wound was covered with a foam dressing. The aide care plan, effective 6/30/23 to present, listed the following relevant task: shower the first visit of the week. The care plan did not alert the aide that the patient had wound dressings and what precautions the aide needed to take during the shower. During an interview with the agency Director of Accreditation and the Administrator on 8/17/23, it was confirmed that the aide care plans "should have" been more specific to include the above information.

Based on record review and interview the agency staff failed to investigate a serious injury for 1 of 10 patients (Patient #1) when the source of the injury was not observed and was unknown. --- Findings include: Agency staff failed to ensure injuries of unknown origin were investigated. See L509.

Based on record review and interview, agency staff failed to investigate injuries of an unknown origin in 1 out 10 patient records reviewed (Patient #1). --- Findings include: Review of Patient #1s hospice medical record revealed Patient #1 was admitted to service on 12/21/2022 with a primary diagnosis of CHF (Congestive Heart Failure) with secondary diagnoses that included chronic pulmonary edema, chronic obstructive pulmonary disease, and Type 2 diabetes. Patient #1 resided in an Assisted Living Facility (ALF.) Review of Patient #1s ";On Call RN (Registered Nurse) Visit" dated 1/30/2023 at 11:59 p.m. through 1/31/2023 at 2:30 a.m. revealed ";Fall Follow Up." Further review revealed ";Coordination of care with facility director. Director states that patient fall occurred at 11:30 p.m. on 1/30/2023 and that patient may have been trying to reach for his/her water on the nightstand as the water was spilled when they found him/her. He/she was found on the floor next to the bed. They got patient off the floor using the Hoyer (mechanical lift) and by the time they got him/her into his/her recliner, patient was sound asleep." Further review revealed, ";RN finds patient asleep in the recliner. He/she sleeps so soundly that he/she doesnt awaken to noise or touch for first 5-10 minutes of visit. Patient denies pain. Allowed RN to wash face. Patient has a rug burn above and below left eye as well as a hematoma (bruise) along the top of the orbital (eye) bone. The abrasions have some sanguineous (bloody) exudate. Bacitracin applied to both abrasions. Pulse WNL (within normal limits). Breathing is even and unlabored. O2 sats (measure of oxygen in the blood) are 98% on 3LPM (3 liters of oxygen per minute.) Appears comfortable with no visible signs or symptoms of pain. RN requested that facility staff check on patient every half hour to an hour throughout the night. RN reviews what s/s (signs/symptoms) to watch for indicating head trauma and to call with any questions/concerns." There was no documentation of any other injuries observed or reported. Review of Patient #1s ";PRN On Call Visit" dated 2/1/2023 at 3:51 a.m. revealed ";Facility states patient has been very restless W/C/O [sic] (with complaints of) arm and leg pain. Morphine and lorazepam given at 3:15 a.m. but neither appear to have had a positive effect. RN finds patient in recliner with legs elevated, a blackened left eye. He/she is yelling out in pain. RN can feel a large bump on left bicep; cuts the sleeve of his/her shirt to find a large protrusion on left bicep. It is not bruised but it appears to be a fractured humerus (upper arm bone). RN attempts to determine where leg pain is coming from, but it is too difficult to discern exact location. Call placed to [family member] for family to decide if they want patient to go to the hospital or not. During this time, RN requested facility give 1 ml (milliliter) of morphine at 4 a.m. and at 4:18 a.m. plus an additional dose of 0.25 mg (milligram) lorazepam. It takes patient close to half an hour before falling asleep and resting comfortably. Patients [family member] calls back and states that he/she is coming to facility. He/she wants to give patient the opportunity to decide if he/she wants to go to the ER (emergency room). RN did state that patient had requested to do that initially. Once [family member] arrived, a discussion was had as to how it would impact the patient to be taken to the ER. [Family member] understands and does not want him/her to go to ER. Further discussion about comfort. [Family members] agree with comfort only going forward." Review of Patient #1's "PRN On Call Visit" dated 2/2/2023 at 1:10 a.m. revealed "Patient's facial wounds had completely soaked through all dressings. We then cut patient's clothing off due to pain. RN got patient cleaned up. Given the way patient's left hip was externally rotated he/she most likely sustained a hip fracture in his/her fall. After cutting socks off, patient's right great toe also appeared to be broken. He/she also had extensive bruising to right hand." Further review of Patient #1's medical record revealed the patient passed away on 2/2/2023 at 6:06 a.m. A telephone interview was conducted with Manager of Clinical Services C on 7/27/2023 at 1:50 p.m. Manager of Clinical Services C was asked if an investigation into Patient #1's injuries was completed. Manager of Clinical Services C stated "I'm not sure about that. I'll touch base with Statewide Clinical Director A and see if we have it or not. I'll get back to you." An email was received from Statewide Clinical Director A on 7/27/2023 at 1:58 p.m. It read "After the patients fall, (on 1/30/2023) Xrays or further work-up had been declined by the POA. Therefore we have no confirmed fracture due to the lack of work-up. This patient had a known history of falls and had a known fall (on 1/30/2023) that we had recently followed up on. Due to this, we had no reason to believe that this was an ";unknown origin injury". There was no documentation of an investigation of the injuries discovered from the RN visit dated 2/1/2023 at 3:51 a.m. when the RN visit dated 1/30/2023 at 11:59 p.m. revealed no injuries after the 1/30/2023 fall other than abrasions and a hematoma over the left eye.