Every finding on record at Three Rivers Hospice, Inc

Based on clinical record review, observation, and interview the hospice provider failed to ensure staff maintained an accurate updated medication profile in two of five full records reviewed (Records/Patients #1 and #2). This deficient practice has the potential to affect all patients served by the provider. --- Findings included: RECORD/PATIENT #1: Observation and interview on 02/20/2024, beginning at 2:45 PM, during the patients home visit, showed the following discrepancies between the providers medication profile and the patients home medications: - The providers medication profile showed an order dated 01/23/2024, for erythromycin (antibiotic) 250 milligrams (mg), give one tablet three times a day for gastroparesis. The patient stated that he/she was done with that; - The providers medication profile showed an order dated 01/23/2024, for cetirizine (allergy medication) 10 mg one tablet daily for allergies. The patient stated that he/she took this a couple of months ago but no longer took it; - The patient had a bottle dated 09/14/2023, of metoprolol (blood pressure/heart medication) 25 mg once daily. The patient stated that he/she had been on this a long time. The medication profile failed to include this medication; and - The patient had a bottle of meclizine (used for dizziness) 25 mg one tablet as needed for dizziness. The patient stated he/she had this prescription for a few months. The medication profile failed to include this medication. During an interview on 02/22/2024, at 2:20 PM, the regional registered nurse (RN) coordinator (Governing body designee-A) stated that they had talked to the patients family member about the medication discrepancies. The patient no longer took erythromycin or cetirizine. The patient did take the metoprolol and the meclizine was as needed. The medication profile should have been updated before 02/22/2024. RECORD/PATIENT #2: Review of the providers current medication profile and long-term care facility (LTCF) physician orders showed the following discrepancies: - The providers medication profile showed an order dated 12/20/2024, for timolol maleate (used to treat glaucoma) 0.5% eye drops, administer one drop in both eyes two times daily for optic edema. The LTCF physician orders showed an order dated 02/15/2024, for timolol maleate 0.5% eye drops, administer one drop between 6:00 AM and 12:00 PM and 5:00 PM and 12:00 AM in the left eye only; and - The LTCF orders showed an order dated 01/26/2024, for antacid-anti gas 400 milligrams (mg)-40 mg/5 milliliters (ml), give 30 ml every four hours as needed for gastrointestinal upset. The provider's medication profile failed to include this medication During an interview on 02/22/2024, beginning at 12:45 PM, the regional RN coordinator stated that at the visits staff look at the chart at the facilities or ask the caregivers in the home about medication changes. If the facilities have an electronic system they can ask for a print out of medications and get a copy of the signed physician orders sheets every month to review medications.

Based on policy review, clinical record review and interview, the hospice provider failed to obtain an initial bereavement assessment 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, ";Initial/Comprehensive Assessment," dated 2018, showed, in part, the following: - An initial bereavement assessment of the needs of the patients family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patients death; - The initial bereavement assessment is placed in the clients chart; and - Information gathered from the initial bereavement assessment must be incorporated into the plan of care and considered in the bereavement plan of care. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to hospice services on 09/13/2023 with a terminal diagnosis of chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe). The patient lived alone in an assisted living facility and had adult children who were involved in his/her care. Review of the document titled, ";Durable Power of Attorney (POA) for Health Care and Health Care Directive," dated/signed 12/17/2012, showed the patient appointed two adult children as powers of attorney (POA #1 and POA #2). Review of the hospice patient face sheet showed POA #1 lived out of state and was listed as the primary contact/caregiver. A third adult child was also listed as a patient contact. Review of the initial assessment, dated 09/13/2023, showed the registered nurse (RN) documented that communication with the patients children occurred and their questions were answered. On 02/22/2024, at approximately 9:30 AM, the initial bereavement assessment was requested from the provider. The regional registered nurse (RN) coordinator (Governing body designee-A) stated that a bereavement assessment was not done and provided this surveyor with three clinical notes that showed the following: - On 09/15/2023 the licensed master social worker (LMSW) attempted contact with POA#1 by phone without success with intention of completing a bereavement assessment. LMSW left a message requesting a return call; - A note from the visit date of 09/19/2023 stated that the BC (bereavement coordinator) had been unable to reach POA #1 to complete initial assessment. The note was electronically signed by the bereavement coordinator on 10/02/2023; and - A note, dated 09/20/2023, that showed the BC attempted to call POA#1 to complete initial assessment and a left voicemail requesting a return call. Review of the interdisciplinary group (IDG) meeting notes, dated 09/18/2023 and 09/19/2023, showed in part, the following: - The family was involved with the patients care but not with the physical care; - The patients children stated that they would get a copy of the POA document to the provider; - Social work, spiritual care, volunteer, bereavement, hospice aide, and homemaker services were explained and offered to the patient and family members; - The IDG notes failed to contain documentation that showed staff were having difficulty reaching POA #1 for the initial bereavement assessment; and - The IDG notes failed to show an attempt to perform a bereavement assessment with any of the other children/family members. During an interview immediately following a home visit on 02/20/2024 at 2:30 PM, the social worker (bachelor of social work, BSW) stated that he/she always called the patients children after the visits to let them know how the visit went. They may not always answer when he/she called but they were good about calling back. During an interview on 02/22/2024, the director of clinical services (Governing body designee-B), the regional RN coordinator, and the administrator from the Kansas City Region (Governing body designee-C) all stated that the LMSW should have kept trying to reach the family members and, if not successful, coordinated with the nurses (who were getting return calls from the family) so an initial bereavement assessment could be completed. Even completing it late would have been better than not doing one at all.

Based on policy review, clinical record review, and interview the hospice provider failed to ensure the plan of care (POC) was revised to address the patients wounds in one of five full records reviewed (Record/Patient #2). This deficient practice has the potential to affect all patients served by the provider. --- Findings included: Review of the providers policy titled, ";Care Plans – Updates," updated 2018, showed in part: - An interdisciplinary group (IDG), in coordination with the client, his/her family, or representative, develops and maintains a comprehensive care plan for each client; - The POC shall be a direct link between the needs identified in the patient/family comprehensive assessment and POC; - Updates are to be initiated by any professional staff member that identifies necessary changes in the POC to ensure continued appropriateness of the care plan; and - Changes in care plans should be made under the guidance of the registered nurse care coordinator in conjunction with the care planning team. These changes should be documented within 24 hours of identification from the visit. RECORD/PATIENT #2: Review of the clinical record showed the patient elected hospice services on 12/20/2024. The patient had been transferred from the hospital back to a long-term care facility (LTCF) on 12/20/2024. Diagnoses included fractured ribs and infection due to ESBL (a bacteria found in the bowel). Review of the skilled nurse (SN) visit notes showed: - On 01/31/2024, licensed practical nurse (LPN) A documented the patient complained of discomfort to his/her bottom. The patient had two open Stage 2 (partial thickness loss of skin presenting as a shallow open ulcer with a red or pink wound bed) pressure ulcers. He/she cleaned the ulcers and applied an Allevyn (foam) dressing. He/she coordinated care with the registered nurse (RN) A. New order to apply Allevyn dressing to open sores on buttock, change every other day and as needed. - On 02/02/2024, LPN A documented the patient had two Stage 2 sores to the buttock and had a dressing intact (unsure if LPN A or LTCF applied the dressing). The nurse coordinated with RN A with no new orders; and -On 02/07/2024, RN B documented under the skin integrity section that the patient had Stage 1 (reddened skin that does not blanch when pressed and is not open) wounds to the buttocks with bright pink skin and no open areas. The skin assessment form showed that the patient had a Stage 2 decubitus ulcer to the coccyx (tailbone) without tunneling/undermining (openings underneath the surface of the skin) or odor (this contradicted what was documented under the skin integrity section). The treatment included turning every two hours and Allevyn every other day. Review of the combined IDG assessment dated 02/08/2024, showed the patient had Stage 1 wounds to the buttocks with bright pink skin and no open areas. Review of the IDG POC dated 02/08/2024, showed the patient was at risk to develop pressure wounds. Interventions included to turn the patient every two hours if unable to turn self in bed and use pillows to offset potential wounds. Staff failed to update the POC to address the patients current wound status with revised interventions and goals. During an interview on 02/22/2024, beginning at 12:45 PM, the regional RN coordinator (Governing body designee-A) stated that when a wound developed, the POC should be updated right away.

Based on policy review, clinical record review, and interview the hospice provider failed to obtain a discharge summary from the inpatient facility after discharge in one of one acute inpatient record reviewed (Record/Patient #7). This deficient practice has the potential to affect all patients that receive inpatient care. --- Findings included: Review of the provider's policy titled, "Inpatient Services," dated 2010, showed in part that a copy of the discharge summary shall be made available to the hospice. RECORD/PATIENT #7: Review of the clinical record showed the patient had been admitted to an inpatient facility after a fall on 08/25/2023 and discharged on 08/30/2023. The record did not include a discharge summary from the inpatient facility. During an interview on 02/22/2024, at 9:45 AM, the regional registered nurse (RN) coordinator (Governing body designee-A) provided a discharge summary. He/she stated that it had been obtained on 02/21/2024 (175 days after discharge). He/she stated that it should have been obtained at the patient's discharge.

Based on policy review, clinical record review, observation, and interview the hospice provider failed to ensure staff followed acceptable standards of practice for infection control in one of four home visit observations (Record/Patient #2). This deficient practice has the potential to affect all patients served by the provider. --- Findings included: Review of the providers policy titled, "Nursing Bag Technique," updated 2018, showed in part, to select a clean surface for the nursing bag, spread a clean barrier down on the selected surface, then place the bag on the suitable barrier. Review of the providers undated policy titled, ";Infection Control Program," showed in part, that gloves must be changed between different body sites of the same patient. RECORD/PATIENT #2: Review of the clinical record showed the patient elected hospice services on 12/20/2024. The patient had been transferred from the hospital back to a long-term care facility (LTCF) on 12/20/2024. Diagnoses included fractured ribs and infection due to ESBL (a bacteria found in the bowel). Observation and interview on 02/21/2024, beginning at 9:50 AM, during the patients home visit, the nurse placed a zippered pouch that contained his/her supplies on an overbed table without a barrier, then without cleaning the pouch when finished, the nurse left the room and placed the zippered pouch on the LTCF nursing desk. The nurse checked the patient's groin area with gloves on then removed the gloves, applied clean gloves but failed to sanitize his/her hands before applying the new gloves. The nurse then gathered several cleansing wipes in his/her hand and cleaned the patients groin folds. The nurse failed to change his/her gloves, sanitize his/her hands, and obtain a clean wipe before performing catheter care. The nurse stated that the patient was starting on intravenous antibiotics that day due to ESBL in the urine. He/she usually put a barrier under his/her supplies, and that he/she had a hand full of wipes and used one at a time then threw them away. During an interview on 02/22/2024, beginning at 12:45 PM, the regional registered nurse (RN) coordinator (Governing body designee-A) stated that he/she would expect a barrier to be placed under a supply bag, and would expect the nurse to change his/her gloves, wash hands, apply new gloves, and obtain a clean wipe before providing catheter care.

Based on policy review, clinical record review and interview, the hospice provider failed to ensure staff documented complete wound assessments and failed to follow physician orders for changing the patients urinary catheter in one patient (Record/Patient #2) and failed to notify the physician of missed nursing visits in one patient (Record/Patient #5) of five full records reviewed. This deficient practice has the potential to affect all patients served by the provider. --- RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to hospice services with a terminal diagnosis of hypertensive heart disease with heart failure (changes in function of the heart muscle due to high blood pressure causing a decrease in the ability of the heart to pump blood). The patient had additional diagnoses of atrial fibrillation (abnormal heart rhythm characterized by rapid and irregular heartbeat) and hepatitis C with cirrhosis from a history of alcohol abuse. He/she lived at home with his/her adult child and continued to smoke and drink daily whiskey shots. Review of the physician orders, dated 12/21/2023, showed skilled nursing (SN) visits twice weekly. Review of the SN notes, with dates ranging from 12/22/2023 to 02/13/2024, showed in part: - A SN visit occurred on 01/10/2024; - A missed SN visit note due to patient refusal on 01/12/2024; - The SN failed to notify the physician of the missed visit (01/12/2024); - A SN visit occurred on 02/13/2024; - A missed SN visit note due to patient refusal on 02/16/2024; and - The SN failed to notify the physician of the missed visit (02/16/2024). During an interview on 02/22/2024, at 12:50 PM, the director of clinical services and the regional registered nurse coordinator stated that they agreed the SN should have notified the physician when they could not complete the physicians order for twice weekly visits. Findings included: Review of the hospice providers policy titled, ";Physician Orders," dated 2018, showed in part: - All client medications, treatments, diets and overall plan of treatment are approved by the hospice interdisciplinary group (IDG) in consultation with the attending physician; - The plan of treatment services shall include the specific procedures and modalities to be used and the amount, frequency, and duration of the treatments; - The total plan of treatment shall be reviewed by the attending physician and the hospice personnel as often as the severity of the clients condition requires, but at least weekly during case conferencing; and - Hospice professional nursing staff shall promptly alert the attending physician to any changes that suggest a need to alter the plan. Review of the hospice providers policy titled, ";Comprehensive Assessment/Care Plan Development," dated 2018, showed in part: - The written plan of care (POC) will be developed by the interdisciplinary group (IDG) with the attending physician involvement; and - All care provided to the individual will be in accordance with the POC. RECORD/PATIENT #2: Review of the record showed the patient elected hospice services on 12/20/2024. The patient had been transferred from the hospital back to a long-term care facility (LTCF) on 12/20/2024. Diagnoses included fractured ribs and infection due to ESBL (a bacteria found in the bowel). The patients primary hospice diagnosis was hypertensive heart disease without heart failure. Other diagnoses included benign prostatic hyperplasia (enlarged prostate) and spinal stenosis (a narrowing of the space around the spinal cord). Review of the physician orders showed an order dated 12/26/2023, to change the urinary catheter every month and as needed using a 16 french (diameter size of the catheter) coude catheter (a catheter designed to maneuver around obstructions in the urethra (the tube through which urine leaves the body). The order failed to include the balloon/bulb size (a balloon is inflated with sterile water to hold it in place) of the catheter. Review of the skilled nurse (SN) visit notes showed: - On 01/31/2024, licensed practical nurse (LPN) A documented the patient complained of discomfort to his/her bottom. The patient had two open Stage 2 (partial thickness loss of skin presenting as a shallow open ulcer with a red or pink wound bed) pressure ulcers. The nurse failed to document further assessment of the wound to include wound bed, drainage, odor, surrounding skin or measurements. He/she cleaned the ulcers and applied an Allevyn (foam) dressing. He/she coordinated care with the hospice registered nurse (RN) B. New order to apply Allevyn dressing to open sores on buttock, change every other day and as needed. - On 02/02/2024, LPN A documented the patient had two Stage 2 sores to the buttock and had a dressing intact (unsure if LPN A or LTCF applied the dressing). The nurse failed to document further assessment and measurements of the Stage 2 sores. The nurse coordinated with RN B with no new orders; - On 02/07/2024, RN B documented under the skin integrity section that the patient had Stage 1 (reddened skin that does not blanch when pressed and is not open) wounds to the buttocks with bright pink skin and no open areas. The skin assessment form showed that the patient had a Stage 2 decubitus ulcer to the coccyx (tailbone) without tunneling/undermining or odor. The drainage was was thin yellow, and wound bed was pink and open (this contradicted the documentation in the skin integrity section). The bottom of the assessment showed that hospice was responsible for wound care on Wednesdays and Fridays. The treatment included turning every two hours and Allevyn every other day; - On 02/09/2024, LPN A documented the sore to the bottom was healed and just red; - On 02/14/2024, LPN A documented no skin concerns; - On 02/16/2024, RN B documented no new issues or concerns. The skin assessment showed the patient had redness to the groin that was fading; and - On 02/19/2024, RN C documented the patient had Stage 2 pressure areas to both buttocks. The coccyx area was dark red with fragile skin. RN C failed to document measurements, description of the wound bed, odor, or drainage. During an interview on 02/22/2024, at 9:00 AM, LPN A stated that he/she used a 16 french 30 cc bulb. He/she did not use a coude catheter. During an interview on 02/22/2024, at 9:10 AM, RN B stated that he/she could not remember but thought he/she used an 18 french catheter with a 30 cc balloon. He/she used a regular catheter not a coude catheter. He/she did not think it was necessary to include the balloon size with the order. During an interview on 02/22/2024, beginning at 12:45 PM, the regional RN coordinator stated that when a wound developed, he/she would expect the nurse to do a full assessment and measure the area. Staff should follow the physician order for a coude catheter and document that was what they used. The order should include a bulb size.

Based on policy review, clinical record review and interview, the hospice provider failed to obtain physician orders for interventions and treatments provided in two of five full records reviewed (Records/Patients #1 and #5). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the hospice providers policy titled, ";Physician Orders," dated 2018, showed in part: - All client medications, treatments, diets and overall plan of treatment are approved by the hospice interdisciplinary group (IDG) in consultation with the attending physician; - The plan of treatment services shall include the specific procedures and modalities to be used and the amount, frequency, and duration of the treatments; - The total plan of treatment shall be reviewed by the attending physician and the hospice personnel as often as the severity of the clients condition requires, but at least weekly during case conferencing; and - Hospice professional nursing staff shall promptly alert the attending physician to any changes that suggest a need to alter the plan. --- RECORD/PATIENT #5: Review of the skilled nurse (SN) notes, dated 02/06/2024 and 02/09/2024, showed the patient had a skin tear to the left elbow and the SN cleaned with wound cleanser, applied triple antibiotic ointment and a foam bordered dressing. The SN failed to obtain orders for this dressing change. During an interview on 2/22/2024 at 12:50 PM, the regional registered nurse coordinator stated that he/she could not find an order in the clinical record for the intervention to the skin tear. The director of clinical services stated that the SN should have obtained an order for the dressing change. RECORD/PATIENT #1: Review of a nursing visit report dated 02/09/2024, showed that the nurse administered an enema to the patient. Review of the record failed to show a physician order for the enema. During an interview on 02/22/2024, beginning at 12:45 PM, the regional registered nurse (RN) coordinator showed where the nurse had communicated with the physician and obtained an order for an enema via their secure system. When they receive the order they print it out and scan it into the medical record. The nurse should have written the order and scanned it in.

Based on review of the respite contract and interview, the hospice provider failed to include the requirement that a copy of the facilitys discharge summary be supplied to the hospice provider at the time of discharge. This deficient practice has the potential to affect all patients served by the hospice provider. --- Findings included: Review of the provider's policy titled, "Hospice Service Agreements," dated 2018, showed in part, hospice agreements with contracted providers will include the following: - Identification of the services to be provided; - A stipulation that the services may be provided only with the express authorization of the hospice; - The manner in which the contracted services are coordinated, supervised, and evaluated by the hospice; - The delineation of the role(s) of the hospice, and the contractor in the admission process, patient/family assessment, and the interdisciplinary group care conferences; - Requirements for documenting that the services are furnished in accordance with the agreement; and - The qualifications of the personnel providing the services. Review of the providers respite contract showed the document failed to include the requirement that the contracted facility provide the hospice with a copy of the discharge summary and/or clinical record at the time of discharge. During an interview on 02/22/2024, at 10:30 AM, the administrator for the Kansas City region (Governing body designee-C) stated that the provision regarding the discharge summary was not in the respite contract but they would make sure they got it added and they had already started working on it.

Based on review of the respite contract and interview, the hospice provider failed to include the requirement that the facility identified a staff person responsible for implementations of the provisions of the agreement. This deficient practice has the potential to affect all patients served by the hospice provider. --- Findings included: Review of the provider's policy titled, "Hospice Service Agreements," dated 2018, showed in part, hospice agreements with contracted providers will include the following: - Identification of the services to be provided; - A stipulation that the services may be provided only with the express authorization of the hospice; - The manner in which the contracted services are coordinated, supervised, and evaluated by the hospice; - The delineation of the role(s) of the hospice, and the contractor in the admission process, patient/family assessment, and the interdisciplinary group care conferences; - Requirements for documenting that the services are furnished in accordance with the agreement; and - The qualifications of the personnel providing the services. Review of the providers respite contract showed the document failed to include the requirement that the contracted facility identify a staff person responsible for implementations of the provisions of the agreement. During an interview on 02/22/2024, at 10:30 AM, the administrator for the Kansas City region (Governing body designee-C) stated that the provision regarding the identification of a staff person was not in the respite contract but they would make sure they got it added and they had already started working on it.