Every finding on record at The Elizabeth Hospice Inc.

Observed in Record Review. In 2 of 4 patient records reviewed, During review of RR# 1's patient record it was noted the organization had not ensured the clinician followed the organization policy Management of Pumps PC 34.2021 that included documentation of time remaining (days/hours/minutes) to determine when the bag needs to be changed and specific management of subcutaneous pumps to include E-Kit medications available on-site in the event infusion is disrupted. For example: review of RR# 1’s patient record revealed RR# 1 had a “Sapphire Pump” infusing morphine via subcutaneous for pain management and had a “crisis care” nurse present 24 hours a day for the pain pump management. Review of RR# 1’s patient record revealed no documentation that the family was trained on the use of the “Sapphire Pump”. Further review of RR# 1’s patient record revealed a RN visit note with documentation that RR# 1 was resting comfortably and the “crisis care” nurse was sent home. Further review of the RN visit note revealed no documentation of the time remaining (days/hours/minutes) to determine when the bag of morphine would need to be changed. Review of the on-call log revealed RR# 1’s Father called the organization approximately two hours after the RN left the home indicating the need for a “code” for the pump as the morphine bag had run out of medication and RR# 1’s Father was attempting to change the medication bag. Further review of the on call log revealed the Father called again approximately 20 minutes after the first call requesting a manager and there was a bottle of liquid morphine in the home and needed to know how much to give as RR# 1 was in severe pain and the triage nurse shared there was no liquid morphine ordered on the plan of care with no further documentation. The Father called a third time approximately 50 minutes after the first call with documentation the Father had concerns with no further documentation of what the Father’s concerns were. Review of RR# 1’s patient record revealed a RN arrived approximately 50 minutes after the Father’s first call to the triage and RR# 1 had pain of 7/10 upon arrival. This was reviewed, discussed, and validated with the Director of Clinical Practice and the Director of Compliance.

Observed in Record Review. During RR# 4’s patient record review it was noted the organization had not ensured staff followed organization policy “Wound Management” PC-121, that included a wound assessment to be completed at each visit that included: type of wound, length and width, depth/undermining, drainage, wound tissue, surrounding tissue, effectiveness of wound care, and wound care order. For example: review of RR# 4’s patient record revealed RR# 4 had a terminal diagnosis of cerebral vascular accident (CVA) and had a G-tube placed that RR# 4 pulled out and required surgical repair for re-insertion. RR# 4 had a mid-line abdominal incision with staples and a G-tube anchored with sutures at the time of admission. However, review of the start of care RN comprehensive assessment and the subsequent nursing visits notes revealed no documentation of an assessment of the mid-line abdominal incision, or the G-tube site with sutures. This was reviewed, discussed, and validated with the Director of Clinical Practice and Director of Compliance. Observed in Record Review. During review of RR# 1's patient record it was noted the organization had not ensured clinicians assessed and reassessed the patient per organization policy Subcutaneous Infusion, MM 02.021 that included: Date and time of insertion; the gauge, length, and type of catheter use; the anatomic site; number and location of attempts; the type of dressing applied to the site; and how the patient tolerated the procedure; subcutaneous sites/device will be assessed at each nursing visit and prior to medication administration for complications such as redness, tenderness, edema, bruising, bleeding, burning, leaking, blood in tubing, or cannula displacement. For example: review of RR# 1’s medication profile revealed RR# 1 was changed to subcutaneous morphine two days after the start of care. Review or RR# 1’s patient record revealed no documentation of the date and time of insertion; gauge, length, and type of catheter use, the anatomic site, type of dressing applied, or assessment of complications. In addition, review of RR# 1’s start of care RN comprehensive assessment revealed RR# 1 had a port on the left chest wall, a G-tube in the left quadrant, and a right chest Pleurx drain. However, further review of RR# 1’s nursing visit notes revealed no documentation of an assessment of the right Pleurx drain, the G-tube site, or the port on the left chest wall. This was reviewed, discussed, and validated with the Director of Clinical Practice and Director of Compliance.

Observed in Record Review. During RR# 4's patient record review it was noted that the organization had not ensured a written plan of care was prepared according to organization policy Plan of Care No 02.016 that included the plan of care must be initiated at start of care. For example: review of RR# 4’s patient record revealed a written plan of care created approximately 22 days after the start of care. Review of RR# 4’s start of care RN comprehensive assessment revealed RR# 4 had a mid-line abdominal incision with staples, a G-tube in place with sutures, was NPO and receiving all nutrition via G-tube feedings with Fiber Source at 100 ml over 12 hours. However, review of the start of care plan of care and subsequent updates to the plan of care revealed no documentation of a mid-line abdominal incision or staples, G-tube, sutures, G-tube feeding, or diet. Further review of RR# 4’s patient record revealed care, treatment, and services were provided by the nurse, MSW, and Chaplain for the first 21 days without physician orders/plan of care. This was reviewed, discussed, and validated with the Director of Clinical Practice and Director of Compliance.

Observed in Record Review. In 2 of 4 patient records reviewed, During RR# 1 and RR# 1's patient records review it was noted the organization had not ensured the written plan of care was based on the patient’s goals and the services needed to meet those goals. For example: review of RR# 1’s start of care RN comprehensive assessment revealed documentation that RR# 1 had a port on the left chest wall, with a single lumen and dressing intact, a G-tube in the left quadrant, and a right chest Pleurx drain. Further review of the start of care RN comprehensive assessment revealed documentation of G-tube feeding nourishment Peptide formula and ate 25% of meals. Review of RR# 1’s plan of care and subsequent updated plans of care revealed no documentation of goals for the right chest Pleurx drain, the port to the left chest wall, the G-tube, and the G-tube feeding. In addition, review of RR# 1's medication profile revealed RR# 1 was changed from IV morphine to subcutaneous morphine two days after the start of care. Further review of the plan of care and subsequent update to plan of care revealed no documentation of a goal for the subcutaneous site/infusion. Review of RR# 4’s patient record revealed a written plan of care created approximately 22 days after the start of care. Review of RR# 4’s start of care RN comprehensive assessment revealed RR# 4 had a mid-line abdominal incision with staples, a G-tube in place with sutures, was NPO and receiving all nutrition via G-tube feedings with Fiber Source at 100 ml over 12 hours. However, review of the start of care plan of care and subsequent updates to the plan of care revealed no documentation of a goal for the mid-line abdominal incision or staples, G-tube, sutures, or G-tube feeding. This was reviewed, discussed, and validated with the Director of Clinical Practice and Director of Compliance.

Observed in Record Review. In 2 of 4 patient records reviewed, During RR# 1's patient record review it was noted the organization had not ensured the plan of care included all services needed for the palliation and management of the terminal illness and related conditions. For example: review of RR# 1’s start of care RN comprehensive assessment revealed documentation that RR# 1 had a port on the left chest wall, with a single lumen and dressing intact, a G-tube in the left quadrant,and a right chest Pleurx drain. Further review of the start of care RN comprehensive assessment revealed documentation of G-tube feeding nourishment Peptide formula and ate 25% of meals. Review of RR# 1’s plan of care and subsequent updated plans of care revealed no documentation of a right chest Pleurx drain, a port to the left chest wall, a G-tube, G-tube feeding, or diet, and no interventions. In addition, review of RR# 1's medication profile revealed RR# 1 was changed from IV morphine to subcutaneous morphine two days after the start of care. Further review of the plan of care and subsequent update to plan of care revealed no documentation of the subcutaneous site or interventions. This was reviewed, discussed, and validated with the Director of Clinical Practice and the Director of Compliance.

Observed in Record Review. In 1 of 4 patient records reviewed, During review of RR# 4's patient record it was noted the organization had not ensured the Interdisciplinary Group (IDG) reviewed and revised the plan of care no less frequently than every 15 calendar days. For example: review of RR# 4's patient record revealed the written plan of care was created 22 days after the start of care and reviewed by the IDG approximately 23 days after the start of care. This was reviewed, discussed, and validated with the Director of Clinical Practice and Director of Compliance.

Observed in Leadership Session. No evidence that the governing body and leadership had established processes to support patient care treatment and services through sustained compliance as evidenced by repeat findings from previous survey completed in March 2024, in the areas of Provision of Care, and Leadership. In addition to repeat condition level deficiencies in 418.54, 418.56, and 418.00. Observed in Record Review. There was no evidence the governing body and leadership had consistently implemented policies and procedures to support the patient care, treatment, and services as evidenced by condition level deficiencies at 418.54, 418.56, 418.104, and 418.100.

Observed in Record Review. In 2 of 4 resident records reviewed, During review of RR# 1 and RR# 4’s patient records it was noted the organization had not ensured the it maintained a complete and accurate patient record. For example: review of RR# 1’s SN visit notes revealed no documentation of the time remaining (days/hours/minutes) to determine when the morphine bag needed to be changed. Further review of RR3 1’s patient record revealed no documentation of date and time subcutaneous infusion began, the gauge, length, and type of catheter used, anatomic insertion site, or type of dressing. In addition, review of RR# 1’s start of care RN comprehensive assessment revealed RR# 1 had a port on the left chest wall, a G-tube in the left quadrant, and a right chest Pleurx drain. However, further review of RR# 1’s nursing visit notes revealed no documentation of an assessment of the right Pleurx drain, the G-tube site, or the port on the left chest wall. Review of RR# 4’s patient record revealed RR# 4 had a terminal diagnosis of cerebral vascular accident (CVA) and had a G-tube placed that RR# 4 pulled out and required surgical repair for re-insertion. RR# 4 had a mid-line abdominal incision with staples and a G-tube anchored with sutures at the time of admission. However, review of the start of care RN comprehensive assessment and the subsequent nursing visits notes revealed no documentation of an assessment of the mid-line abdominal incision, or the G-tube site with sutures. This was reviewed, discussed, and validated with the Director of Clinical Practice and Director of Compliance.

Observed in Record Review. In 2 of 4 patient records reviewed, the plan of care did not include complete orders for medications and treatments necessary to meet the patient's needs. In the chart for RRNHV#3, the order for prn Ondansetron had no indication for when the medication was to be used. Also, the patient was noted to have arterial ulcers on his bilateral feet with the nurse noting the patient's refusal for the RN to assess the wounds. There were no orders for care to the feet on the hospice plan of care. In the chart for RRNHV#2, Morphine was ordered prn for pain/shortness of breath, Tylenol was ordered prn pain/fever with no further direction as to when to give Tylenol vs Morphine for pain. Additionally, Oxygen was ordered 0.25-2lpm for SOB/comfort and Morphine was ordered prn for pain/shortness of breath with no further direction as to when to give Morphine for SOB vs the oxygen. This was discussed with the Clinical Director.

Observed in Individual Tracer. The organization did not provide ongoing education and training to volunteer staff consistent to their roles and responsibilities in an emergency. This was evidenced by the lack of emergency management education and documented in 3 of 3 volunteer records reviewed. This finding was discussed with the manager of the volunteer program.

Observed in Tracer Activities. In 4 of 4 patient records reviewed, The hospice nurse surveyor noted that the organization failed to defined criteria to screen, assess, and reassess pain that was consistent with the patient’s age, condition, and ability to understand. The surveyor noted that in 4 of 4 pediatric patient records ranging from newborn to ten years old, there was no defined criteria or tools for assessing pain according the age specific needs of the patients. The standard FLACC and numerical scale, were the only tools utilized and were no appropriate for children. Also, it was noted that a PAIN-AD was not available to evaluate the pain of patient's with dementia.

Observed in Individual Tracer. In 8 of 23 patient records reviewed, The hospice nurse surveyor noted (HVRR#4) that the organization failed to use an age appropriate assessment tool to assess the severity of the patient needs. In discussion with leadership team they did not have a newborn assessment tool that evaluated the patient's pain, agitation and respiratory effort. In (ARR#13) there was an incomplete pain assessment that did not include how severe the patient's pain got. , it was scaled at zero with symptoms of pain described. Also, in (ARR#14), there was no assessment of the severity of the patient's distension, N/V, and constipation. In (ARR#15) there was no pain scale documented. In (ARR#17) the severity of chronic diarrhea and seizures was not assessed. In (ARR#20) there was no assessment of the severity of the patient's agitation. In (ARR#22) there was no assessment of the patient GI system, for this patient prescribed opioids. In (ARR#23-Pedi), the assessment did not address the age-specific needs of the patient or the severity of the child's symptoms such as growth and development needs (autism), eye pain including the worst it gets and how he tolerated the prosthesis care, age specific falls risk, the environmental safety needs of a child and the symptoms related to his chemotherapy palliation. Also, there was no assessment of the implanted port. In (ARR#24-Pedi), the assessment of the severity of symptoms was not age specific to a toddler including the assessment of pain, severity of seizures, and oxygen safety. This was confirmed with the utilization nurse.

Observed in Record Review. The hospice nurse surveyor noted (ARR#20) that the order for Metronidazole 250 mg crush into wound bed 3 x weekly was unclear and did not specify which wound; the patient has three wounds. Also, there was no plan for managing the care of bilateral nephrostomy tubes for displacement or obstruction. This was confirmed with the director. Observed in Record Review. The hospice nurse surveyor noted (CRR#10) that the plan of care did not include any nutrition orders or oxygen orders. The surveyor noted that the assessment and visit noted indicated that the pediatric patient was NPO and receiving enteral feedings, but they were not included on the plan of care or physician orders. Also, the patient was on BiPAP at night and was weaning her oxygen during the day; however, there were no orders. The notes indicated that her flow rate varied from1-4 LPM when in use. This was confirmed with the utilization nurse. Observed in Individual Tracer. The hospice nurse surveyor noted that (HVRR#4) the plan of care order for oxygen 0.25-2 lpm as needed NC for SOB/comfort did not include parameters for dosing for this newborn. This was confirmed with the director. Observed in Individual Tracer. In 10 of 23 patient records reviewed, The hospice nurse surveyor noted (HVRR#2) that the patient was ordered continuous oxygen in December; however, the patient was not using oxygen during the visit. Every nursing visit note reviewed after the admission assessment indicated that the patient was not on oxygen. The plan of care did not reflect the patients intermittent use of oxygen at night. Also, in (HVRR#1) the medication orders were unclear. The patient was prescribed Carbidopa every six hours; however the instructions stated give 5 x per day and the order for Pramipexole was ordered every four hour and the instructions stated give 5 times per day. Also, there was no care plan no care plan to address intermittent seizure activity. On (HVRR#6), the surveyor noted that the current oxygen order was incorrect. The order was Oxygen 2LPM as needed NC; however, the visit notes indicated that the patient's dosing ranged between 2-3 LPM. This was corrected on site. Also, there were no measurable outcomes for managing dysphagia and agitation as noted in the IDT physician summary. In (ARR#12)there were no Foley catheter change orders or instructions for what to do if the catheter is obstructed or dislodged. In (ARR#13) there were no oxygen orders for oxygen present in the home and the plan of care did not indicate that the patient was NPO or any orders for the enteral feeding. In (ARR#16) the care plan did not indicate that all medications were to be crushed meds and the oxygen order was unclear and written as O2 2-4 LPM continuous. In (ARR#19) the oxygen order was unclear and did not include any parameters for dosing O2 1-5 lpm. In (ARR#20) there were no orders for managing bilateral nephrostomy tubes if they were dislodged or became obstructed. In (ARR#22) there was no plan for managing the patient's port access, or prosthetic eye. Also, the caregiver bereavement risk assessment indicated that the patient's mother was at moderate to high risk; however there were no outcome measures or interventions for managing the pre-bereavement risk. In (ARR#23) the plan of care did not indicate that the patient was NPO and there were no orders for G-tube site care, trach care or oxygen. This was confirmed with the director.

Observed in Record Review. In 3 of 23 patient records reviewed, The hospice nurse surveyor noted (CRR#7) that the patient SN visit frequency was ordered 1-2 x week; however, the patient did not receive any nursing visits the last two weeks of services and the was discharged without any evidence of discharge planning. In (ARR#16) the plan of care included respiratory therapy orders for RT 1xwx2 weeks; however, a respiratory assessment and visit was never completed and there was no evidence that the physician was notified. In (ARR#19) the surveyor noted that the plan of care orders for monitored weights each week was not completed as there was no evidence in the record that a weight was obtained or reported. This was confirmed with the director.

Observed in Tracer Activities. The hospice nurse surveyor noted that leadership had not not developed, implemented, maintained compliance with established Policies & Procedures. The surveyor noted that there were no established policies for age-specific assessments and care plans for there pediatric hospice program. Also, the leaders had not maintained compliance with Medicare COP's 418.52, 418.54, 418.56 and 418.100.

Based on interview and record review, the agency failed to ensure the Skilled Nurse (SN) followed the infection control practices when an expired indwelling catheter (a soft rubber tube inserted into the urethra to collect or remove urine) was used for 1 of 2 sampled patients (1). As a result, there was a potential for the sterility (free from germs) of the indwelling catheters to be compromised. --- Findings:Patient 1 was admitted to the agency on 3/31/22 with diagnoses that included spastic cerebral palsy (the muscles stiffen, which can make movement difficult or even impossible), per the agency's Patient Information.A review of Patient 1's clinical record was conducted. Per the Clinical Notes dated 7/29/22, SN 1 documented Patient 1's Responsible Party (PRP) request for a visit to collect a urine sample to check for infection. SN 1 further documented she could not place the catheter in the urethral, and on the second attempt, blood was seen at the end of the catheter.On 9/12/22 at 10 A.M., an interview with the Director of Quality and Compliance (DQC). The DQC stated they were informed that SN 1 could not collect a urine sample and that the catheter kit had expired. The DQC further stated the expectation was for the SNs to read the kit and not use the expired catheter kit.On 11/20/22 at 3 P.M., an interview was conducted with SN 1. SN 1 stated she went to Patient 1's house to collect a sample, and the first attempt was unsuccessful because the catheter went to the vaginal area. SN 1 stated she did not have an extra catheter kit, and the PRP offered their catheter kit.SN 1 stated she attempted to collect a sample and was unsuccessful again. SN 1 further stated she inserted the catheter into the vagina area, and bleeding occurred. SN 1 said she did not inspect or read the second catheter kit to see if it was expired or if she had the correct size. SN 1 stated she should have checked the catheter kit and not used it when it expired.On 1/23/23 at 3 P.M., an interview was conducted with the Primary Pediatrics Doctor (PPD). The PPD stated that the sterility could have been questioned when using an expired kit.Per the agency's Standard of Practice, dated 11/14/19, titled Indwelling Urinary Catheter (Foley) Urine Specimen Collection Pediatric, "...Inspect all equipment and supplies. If a product is expired or defective or has compromised integrity, remove it from patient use..."

Observed in Record Review. In 1 of 3 active patient records reviewed, the comprehensive assessment was not completed by the interdisciplinary group within 5 calendar days as required. Upon review of HV#2, it was noted the spiritual assessment was completed a month after start of care and there was no documentation to validate the patient/family had requested the spiritual counselor visit to be completed after the 5-day window. This was reviewed and validated with the Quality and Compliance Manager.

Observed in Record Review. In 1 of 3 active patient records reviewed, an initial bereavement risk assessment was not completed as required. Upon review of HV#3, it was noted there was no documentation to validate an initial bereavement risk assessment had been completed. This was reviewed and validated with the Quality and Compliance Manager.

Observed in Record Review. In 2 of 6 patient records reviewed, the plan of care did not include all interventions/orders to meet the patient's needs. Upon review of HV#1, it was noted the patient was taking medication for Parkinson’s disease, and medications for agitation and anxiety; however, on review of the plan of care, there were no interventions established related to this disease process and/or symptoms. Upon review of RR#4, it was noted the patient had a foley catheter in place; however, on review of the plan of care and physician orders, there was no documentation to validate an order for a foley catheter was obtained nor interventions established related to catheter care. This was reviewed and validated with the Director of Clinical Services.

Observed in Record Review. In 1 of 6 patient records reviewed, the plan of care was not revised based on changes to the patient's condition. Upon review of HV#3, it was noted the patient developed a urinary tract infection with antibiotics ordered; however, on review of the plan of care, there were no interventions established related to the patient's newly developed infection and change in condition. This was reviewed and validated with the Quality and Compliance Manager.

Observed in Record Review. In 1 of 2 patient records reviewed with aide services, complete written patient care instructions were not prepared by the RN. Upon review of HV#1, it was noted the patient had oxygen therapy ordered; however, on review of the aide plan of care, there were no specific instructions provided to the aide regarding oxygen precautions. This was reviewed and validated with the Director of Clinical Services.

Observed in Record Review. In 1 of 2 patient records reviewed with aide services, the aide provided care that was not ordered on the plan of care. During HV#2, the aide was observed assisting the patient in transferring and ambulating with her walker to the restroom; however, on review of the aide plan of care, these tasks were not assigned. This was reviewed and validated with the Quality and Compliance Manager.

Observed in Record Review. In 1 of 2 patient records reviewed with aide services, the hospice aide did not report complaints of pain to the RN. Upon review of aide visit documentation for HV#1, it was noted on a routine aide note the aide documented the patient was complaining of pain when turning and facial grimacing was observed; however, there was no documentation to validate the aide had informed the RN of the patient's pain. This was reviewed and validated with the Director of Clinical Services.

Observed in Patient Home. In 2 of 2 home visits in which medication reconciliation was conducted, the medication profile in the record was inaccurate. During HV#1 and upon interview with the patient's spouse, the patient takes Pepto Bismol and Milk of Magnesia as needed; however, on review of the medication profile in the record, these medications were not included. During HV#3 and upon interview with the patient's caregiver, the patient takes Colace daily for bowel management; however, on review of the medication profile in the record, this medication was not included. This was discussed with the Director of Clinical Services and Quality and Compliance Manager following the visits.