Every finding on record at The Caring Coalition of Central New York

Based on a review of clinical records and interviews with the Chief Executive Officer (CEO) and Director of Patient and Family Services (DPFS), it was determined in 6 of 16 records (patients # 1, 2, 3, 8, 11 and 12), the comprehensive assessments were incomplete and failed to identify all of the patient's needs. Evidence as follows: --- HV Patient #2 was admitted to the hospice on 12/02/21 with a terminal diagnosis of lung cancer. The hospice nurse (HN) failed to perform a comprehensive assessment of all of the patient's needs. The physician's plan of care (PPOC) dated 08/30/22-1028/22 included the following medication order: Keppra (anti-seizure) 500 mg tablet by mouth (PO) every 12 hours or by rectal suppository if patient unable to take PO. On 10/13/22 the surveyor completed an observational home visit with the HN. During the visit, the HN asked the caregiver if there were any changes in medications. The caregiver stated there were no changes. The surveyor asked the caregiver how medications were administered to the patient. The caregiver stated all medications were crushed and added to food. The HN failed to perform a comprehensive medication assessment to ensure the caregiver was administering medications as ordered and was educated on why some medications such as Keppra were not to be crushed for administration. On 10/19/22 at 1:30 p.m. the record was reviewed with the CEO and the DPFS. They acknowledged the findings, and no additional information was provided. HV Patient #3 was admitted to the hospice on 09/15/22 with a terminal diagnosis of pancreatic cancer. The HN failed to perform a comprehensive assessment of all of the patient's needs. On 09/15/22 the HN documented in the admission assessment the patient had a urinary catheter # 16 French with 5 ml balloon. The catheter was draining a moderate amount of clear dark amber urine in leg bag and the patient/caregiver demonstrated competency on admission. The HN failed to include an assessment of what education was provided to the patient and caregiver and what skills were demonstrated, such as emptying and changing the leg bag over to the gravity bag, routine catheter cleansing, signs and symptoms of infection, obstruction and leaking to report to the HN. On 10/19/22 at 1:30 p.m. the record was reviewed with the CEO and DPFS. They acknowledged the findings, and no additional information was provided. Patient #11 was admitted to the hospice on 08/23/22 with a terminal diagnosis of heart failure. The HN failed to perform a comprehensive assessment of all of the patient's needs. On 08/23/22 the HN documented in the admission assessment the patient used respiratory inhalers and nebulizer treatments routinely and as needed (PRN) for wheezing and shortness of breath. The caregiver was instructed on use of inhalers/nebulizer and verbalized understanding. The HN failed to assess that nebulizer machine was available in the home and in good operating condition. There was no HN assessment of the caregiver ability to set-up the machine and administer the medication correctly. On 10/19/22 at 1:30 p.m. the record was reviewed with the CEO and DPFS. They acknowledged the findings, and no additional information was provided. Patient #12 was admitted to the agency on 05/20/22 with a terminal diagnosis of amyotrophic lateral sclerosis (ALS) and additional diagnoses of weight loss, dysphagia and depression. The 05/12/22 referral information included a 05/04/22 neurology which noted the patient was tolerating a dysphagia diet with swallowing significantly impaired. Patient had significant impairment of chest wall and diaphragmatic movement that resulted in an inability to produce an effective cough and therefore clear secretions. The recommendations included a cough assist device to reduce the risk of infections and promote good bronchopulmonary hygiene and a suction machine due to difficulty swallowing and secretions pooling in the mouth. The 05/18/22 a registered nurse (RN) performed an Evaluation of Terminal Status which included a review of medical records and documented the patient was still able to eat but had lost a significant amount of weight on a dysphagia diet and needed a cough assist device and suction machine. On 05/20/22 the hospice nurse (HN) visited for the admission assessment and documented the patient weighed 88 pounds and was shortness of breath with minimal exertion with use of accessory muscles for breathing, the patient had 2 pillow orthopnea, and aspiration precautions were in place and the head of the bed up 45 degrees. The HN failed to assess the presence of a cough assist device or suctioning machine and assess the caregiver's ability to operate and maintain the equipment. On 10/19/22 at 11:30 a.m. the surveyor interviewed the primary nurse (PN) who stated the patient was not using any respiratory treatments and she didnt know anything about a cough assist device. The PN stated the patient ate soft foods and small bites of solids and had used suctioning 2-3 times since admission. On 10/19/22 at 1:30 p.m. the surveyor reviewed the record with the CEO and DPFS. They acknowledged the findings, and no additional information was provided. On 10/20/22 the PN visited the patient an addressed respiratory status clarifying that Oral suction was in the home, and the patient had cough assist previously while in another hospice which she felt did not work well and did not like it so did not continue when transferred to current hospice. HV Patient #1 was admitted to the hospice on 09/14/22 with a terminal diagnosis of mesothelioma of pleura and bone. On 09/14/22 the hospice nurse (HN) visited the patient for the admission assessment and documented the patient had an implanted port "functional no ongoing flushes". The HN failed to assess location of the port and appearance of the site. On 09/25/22 the HN visited and documented yes to vascular access device (VAD) with no further information. On 10/04/22 hospice MD made phone visit while HN and infusion nurse present. Discussed IV Dilaudid with order for 1 mg/hr and 0.5 mg every 15 minutes as needed via Patient-Controlled Analgesia (PCA). On 10/04/22 the HN documented a joint visit with the infusion nurse who accessed the implanted port (no location) no documentation of any dressing to site. On 10/13/22 the surveyor conducted an observational home visit with the HN. During the visit the HN assessed pain level and the IV pump readings and wrote down numbers of what the patient was taking, however, the HN failed to assess the port site. The 10/13/22 HN nursing assessment failed to include the port location, status of the site and presence of a dressing. On 10/19/22 at 1:30 p.m. the surveyor reviewed the record with the CEO and DPFS. They acknowledged the findings, and no additional information was provided. Patient #8 was admitted to the agency on 01/18/22 with a terminal diagnosis of pulmonary fibrosis, and additional diagnoses of rheumatoid arthritis (RA), anxiety and depression. On 01/18/22 the hospice nurse (HN) visited the patient for the admission assessment and failed to assess the following: The medication list included an injectable medication, Orencia subcutaneous every week for RA. The HN failed to assess who was responsible to administer the injection and observe to determine competency. The HN documented the patient had difficulty swallowing ";certain pills" with no further details. The 01/25/22 IDG report did not mention crushing of medications or who administered the injection. There was no assess of how medications were being given in the initial or ongoing assessments, however, on 02/08/22 the IDG meeting note revealed "pills crushed as patient has difficulty swallowing pills" and on 03/08/22 "crushes pills due to Barretts esophagus". Care plan interventions did not include crushing of pills. It was noted Orencia was no longer available, so the rheumatologist had increased the dosage of methotrexate to 12.5 mg weekly. There was no evidence specific medications were reviewed to determine appropriateness of crushing. On 05/26/22 the methotrexate dosage was increased to 17.5 mg per week with order to increase prn up to 8 tablets per week. On 09/22/22 and 09/30/22 the HN visited the patient and documented ";pills crushed or placed into something in order to be able to swallow". The medication list included methotrexate 2.5 mg 4 tablets weekly. PDR.net advises ";Do not administer to patients who are unable to swallow" ";cutting, crushing or manipulating tablets/capsules will increase exposure". On 10/19/22 at 1:30 p.m. the surveyor reviewed the record with the CEO and DPFS. They acknowledged the findings, and no additional information was provided. Failure to conduct a comprehensive assessment of the patient has the potential for the development of an incomplete plan of care and unmet patient needs.

Based on a review of clinical records and interviews with the Chief Executive Officer (CEO) and Director of Patient and Family Services (DPFS), it was determined in 2 of 16 records (patients # 12 and 13), the plan of care failed to address all problems identified during the initial, comprehensive and updated comprehensive assessments. Evidence as follows: --- 1. Patient #12 was admitted to the agency on 05/20/22 with a terminal diagnosis of amyotrophic lateral sclerosis (ALS) and additional diagnoses of weight loss, dysphagia and depression. The 05/12/22 referral information included a 05/04/22 office visit with a neurologist who noted the patient was tolerating a dysphagia diet with swallowing significantly impaired. The patient had significant impairment of chest wall and diaphragmatic movement that resulted in an inability to produce an effective cough and therefore clear secretions. The recommendations included a cough assist device to reduce the risk of infections and promote good bronchopulmonary hygiene and a suction machine due to difficulty swallowing and secretions pooling in the mouth. The 05/18/22 a registered nurse (RN) performed an Evaluation of Terminal Status which included a review of medical records and documented the patient was still able to eat but had lost a significant amount of weight, was on a dysphagia diet, needed a cough assist device and a suction machine. On 05/20/22 the hospice nurse (HN) visited for the admission assessment and documented the patient weighed 88 pounds and was shortness of breath with minimal exertion and used accessory muscles for breathing, the patient had 2 pillow orthopnea, and aspiration precautions were in place and the head of the bed up 45 degrees. The 05/20/22 plan of care listed under durable medical equipment ";suction machine", however, the plan of care lacked specifics related to frequency and type of suctioning needed. The 05/25/22 IDG meeting note referenced the patient was eating small meals with dysphagia. Respiratory status not addressed. The 06/08/22 IDG meeting note included dysphagia managed by soft diet. The IDG plan of care failed to include respiratory difficulties as a potential problem and included no respiratory interventions. On 09/15/22 the primary nurse (PN) visited and documented the patient was unable to take a deep breath. On 10/19/22 at 11:30 a.m. the surveyor interviewed the PN who stated the patient was not using any respiratory treatments and she didnt know anything about a cough assist device. The PN stated the patient ate soft foods and small bites of solids and had used suctioning 2-3 times since admission. On 10/19/22 at 1:30 p.m. the surveyor reviewed the record with the CEO and DPFS. They acknowledged the findings, and no additional information was provided. On 10/19/22 the PN added Breath Patterns-Respiratory Status Altered due to Disease Progression to the IDG plan. Suctioning was not added to plan. On 10/20/22 the PN visited the patient and addressed respiratory status clarifying that oral suction was in the home and the patient had a cough assist previously while in another hospice which she felt did not work well and did not wish to continue when transferred to the current hospice. 2. Patient #13 was admitted to the hospice on 05/17/22 with a terminal diagnosis of Alzheimers disease, and additional diagnoses of weight loss and history of COVID-19 infection. On 05/17/22 the HN visited the patient for the admission visit and documented denies dysphagia (difficulty swallowing). On 05/19/22 the HN visited with no documentation of dysphagia. On 05/20/22 the on-call manager documented receiving a telephone call from a pharmacist to report that Thick-it should not be used with MiraLAX (laxative) as is has the opposite effect. The manager informed the primary nurse and patient caregiver. The 05/20/22 order for Thick-it powder, "Take 1 of starch (thickener) (starch (thickening) powder) by oral daily as needed for dysphagia" was unclear and did not specify what the desired consistency of fluids was and how to mix the powder into the fluid to obtain that consistency. Th 05/24/22 IDG meeting note documented the patient was eating 3 meals and Thick-It will be started. The IDG plan failed to specify the consistency of thickening of fluids. On 05/24/22 the HN visited and documented aspiration precautions, PCG stated patient was having difficulty with pills and fluids. They just received Thick it today. She demonstrated competency in using. On 10/19/22 at 1:30 p.m. the surveyor reviewed the record with the CEO and DPFS. They acknowledged the findings, and no additional information was provided. Failure of the agency to develop a complete plan of care that is individualized and addresses the patient's needs has the potential for unmet patient needs and negative outcomes.

Based on a review of clinical records for patients receiving home health aide (HHA) services, observation, and interviews with the Chief Executive Officer (CEO) and Director of Patient and Family Services (DPFS), it was determined in 3 of 9 records (patients # 4, 7, and 15) the aide written instructions were incomplete and/or inaccurate. Evidence as follows: --- Patient #7 was admitted to the hospice on 04/13/22 with a terminal diagnosis of bladder cancer. The home health aide patient care plan dated 09/13/22 was incomplete as follows: The aide care plan instructed the aide to provide the patient with a bath at every visit. The HN failed to specify the method of bathing with instructions to provide either a bed bath, sponge bath at the sink or tub bath/shower to ensure the method used was safe and appropriate for the patient. On 10/19/22 at 1:30 p.m. the record was reviewed with the CEO and DPFS. They acknowledged the findings, and no additional information was provided. HV Patient # 4 was admitted to the agency on 05/18/22 with a terminal diagnosis of chronic obstructive pulmonary disease (COPD) and additional diagnoses of rheumatoid arthritis, atrial fibrillation and obstructive sleep apnea. The 04/27/22 hospital discharge summary revealed the patient had atrial fibrillation and was on Eliquis (blood thinner). On 05/18/22 the hospice nurse visited the patient for the initial assessment and documented the hospice would cover 2 hours per week of aide service. The 10/13/22 Active Medications included Eliquis 5 mg twice daily. On 10/14/22 the surveyor conducted an observational home visit with the HN. During the visit the HN reviewed the aide plan with the aide who was present in the home. The aide plan was present in the patients folder, previously updated 09/14/22 and directed the aide to shave the patient weekly and failed to include bleeding precautions. On 10/19/22 at 1:30 p.m. the surveyor reviewed the record with the CEO and DPFS. They acknowledged the findings, and no additional information was provided. Patient #15 was admitted to the hospice on 07/14/22 with a terminal diagnosis of chronic myelomonocytic leukemia and additional diagnoses of congestive heart failure, pancytopenia, type 2 diabetes and hypothyroidism. On 07/14/22 the hospice nurse (HN) visited the patient for the initial assessment and documented the patient needed assistance with bathing, dressing, toileting and feeding. The patient was able to stand with assist and ambulate with a walker and required a wheelchair for locomotion. The HN developed a plan for twice weekly hospice aide (HHA) service. The 07/14/22 HHA care plan was incomplete as follows: -The HHA care plan was not specific regarding the method of bathing assistance to provide and included instructions to provide a bed bath, sponge bath a sink and a tub bath/shower. On 10/20/22 at 2:20 p.m. the surveyor reviewed the record with the CEO and DPFS. They acknowledged the findings, and no additional information was provided. Failure of the hospice to ensure aide plans of care include complete instructions necessary to provide care has the potential for unmet patient needs and possible negative patient outcomes.