Every finding on record at Tidewell Hospice Inc

Based on clinical record review, review of policies and procedures and staff interview, the hospice failed to show coordination to ensure effective pain management for 1(Patient #900) of 3 sampled residents reviewed for symptom management. --- The findings included: On 1/6/23 Resident #900 was admitted to the hospice with a diagnosis of unspecified protein calorie malnutrition, anorexia, and disorientation. On 1/7/23 the hospice RN assessment documented pain was an active problem for patient #900. "A nonverbal pain scale was used with a score of 2, subsides in 5 minutes, frequency was intermittent, rest relieves pain, morphine starting today." On 1/7/23 the physician ordered Morphine Sulfate 20 milligram(mg)/milliliter(ml) give 5 mg every 6 hours around the clock by mouth or sub-lingual for pain or shortness of breath. On 1/8/23 the facility nurse contacted the hospice triage to ask if the script for the morphine was sent to the pharmacy as it was not delivered. On 1/9/23 the pharmacy delivered a total of 60 syringes of single dose Morphine sulfate 5 mg to the facility. Review of the facility medication observation record, documented on 1/10/23 at 10:00 p.m., patient #900 received the first scheduled dose of morphine. On 1/30/23 at 2:00 p.m. in an interview, the hospice physician said she was not notified patient #900 did not receive the scheduled morphine 5 mg every 6 hours as ordered from 1/7/23 until 1/10/23 at 10:00 p.m. The physician said if a pharmacy cant deliver the day a medication is ordered, then we make other arrangements. I was not notified patient #900 did not receive the medication; we could have arranged to obtain it elsewhere.

Based on record review and staff interview the hospice failed to engage effective interventions and coordination of care between the hospice interdisciplinary group and the assisted living facility to address the lack of licensed staff to administer ordered medications according to the physicians order and plan of care for 1(Patient #900) of 3 residents reviewed for coordination of care. --- On 1/6/23 Resident #900 was admitted to the hospice with a diagnosis of unspecified protein calorie malnutrition, anorexia, and disorientation. On 1/7/23 the hospice RN assessment documented pain was an active problem for patient #900. "A nonverbal pain scale was used with a score of 2, subsides in 5 minutes, frequency was intermittent, rest relieves pain, morphine starting today." On 1/7/23 the physician ordered Morphine Sulfate 20 milligram(mg)/milliliter(ml) give 5 mg every 6 hours around the clock by mouth or sub-lingual for pain or shortness of breath. On 1/10/23 the hospice physician ordered Morphine Sulfate 20 milligram(mg)/milliliter(ml) give 5 mg every 4 hours as needed (PRN) for pain or dyspnea (shortness of breath). The order specified the hospice nurse to administer the medication. On 1/10/23 the controlled medication record showed the facility licensed practical nurse (LPN) Resident Care Manager administered one dose of the morphine sulfate 5 mg at 9:30 a.m. On 1/10/23 a med tech signed for one dose of morphine sulfate 5mg at 9:30 a.m. There was no documentation of coordination with the hospice to administer the PRN morphine sulfate per the physicians order. On 1/30/23 at 12:00 p.m. in a phone interview, the Hospice Director of the South Assisted Living Facility Team Staff B said if the physician ordered a PRN medication, the patients care plan would instruct staff to contact the hospice nurse to administer the medication. The current care plan for patient #900 did not specify the assisted living facility staff were to call the hospice nurse to administer the morphine. Hospice Director Staff B said the morphine order on 1/10/23 for Resident #900 should have said for the facility is to call us and we will come to administer the medication. Staff B confirmed Patient #900's care plan was not updated with the specified physicians instructions for the morphine administration.

Based on record review and staff interview, the facility failed to develop and update a care plan that accurately reflects the residents condition, and addresses the specific care needs to self-administer medications for 1(Resident #900) of 3 resident care plans reviewed. The hospice failed to coordinate care to ensure facility staff understood the need to contact the hospice when patient #900 required an as-needed medication for management of end-of-life symptoms. The Findings included: --- On 1/6/23 Resident #900 was admitted to the hospice with a diagnosis of unspecified protein calorie malnutrition, anorexia, and disorientation. The initial admission assessment completed by the registered nurse dated 1/7/23 documented Patient #900 was minimally responsive. The Coordination of Services among Resident, Hospice, and Assisted Living Facility (ALF) dated 1/10/13 documented services provided by facility and patient/family/caregiver: Medication Management, documented Assist with self administration medication administration. On 1/10/23 the hospice physician ordered Morphine Sulfate 20 milligram(mg)/milliliter (ml) give 5 mg every 4 hours as needed (PRN) for pain or dyspnea (shortness of breath). The order specified the hospice nurse to administer the medication. On 1/10/23 the controlled medication record showed the facility licensed practical nurse (LPN) Resident Care Manager administered one dose of the morphine sulfate 5 mg at 9:30 a.m. On 1/10/23 a med tech signed for one dose of morphine sulfate 5mg at 9:30 a.m. There was no documentation of coordination with the hospice to administer the PRN morphine sulfate per the physicians order when patient #900 was not able to be assisted to self-administer medications. On 1/12/23 the RN assessment documented the reason for the visit was end of life stage. Pain assessment documented patient unable to provide details and no barriers to pain control. The assessment documented Patient #900 was unresponsive to voice and touch. On 1/30/23 at 12:00 p.m., in a phone interview the Hospice Director of the South Team for assisted living facility Staff B said if the physician ordered a PRN medication, the patients care plan would instruct staff to contact the hospice nurse to administer. The current care plan for patient #900 did not specify the assisted living facility staff were to call the hospice nurse to administer the morphine. The morphine order on 1/10/23 for Resident #900 should have said for the facility is to call us and we will come to administer the medication. Hospice Director Staff B confirmed Patient #900's care plan should have specified the physicians instructions for the morphine administration. On 1/30/23 at 2:00 p.m. in an interview, the hospice physician said if a patient is in an assisted living facility and there is no licensed person to administer the PRN medication, then I write on the order hospice nurse to administer. The hospice nurse assigned is responsible to let the facility know to contact the extended hours/triage line to have a hospice nurse come and administer the medication when a patient is unable to assist with self-administration.

Based on record review and staff interview, the facility failed to ensure effective communication and collaboration with the facility staff to ensure medications were administered as ordered by the physician. The findings included: --- On 1/6/23 patient #900 was admitted to the hospice with a diagnosis of unspecified protein calorie malnutrition, anorexia, and disorientation. The hospice care plan documented, ";facility staff to administer medications. . . Collaborate with ALF staff and document the facilities access to nursing staff. . . Educate patient, family, and staff on safe medication management". On 1/7/23 the physician ordered Morphine Sulfate 20 milligram(mg)/milliliter(ml) give 5 mg every 6 hours around the clock by mouth or sub-lingual for pain or shortness of breath. On 1/10/23 the hospice physician ordered Morphine Sulfate 20 milligram(mg)/milliliter (ml) give 5 mg every 4 hours as needed for pain or dyspnea (shortness of breath). The order specified the hospice nurse to administer the medication. Review of the facility medication observation record (MOR) for the month of January 2023 documented morphine sulfate take 5 mg by mouth/under the tongue every 6 hours around the clock. The medication was scheduled at 8:00 a.m., 2:00 p.m., and 10:00 p.m. The facility MOR was not updated with the physician order for the change in morphine frequency on 1/10/23 as ordered by the hospice physician. On 1/30/23 at 10:10 a.m., in a phone interview, hospice registered nurse (RN) Staff A said she was the nurse assigned to patient #900. The RN said she would check the medications at every visit, this involves looking at the facility MOR to see if the resident was using the prn medication. The RN said we have IDT meetings weekly, and the care plan and patients' symptoms are reviewed. Hospice RN Staff A said she reviews the care plan with the facility Health Wellness Director and med techs. The RN said she was not aware the facility had not updated the MOR with the new physician order on 1/10/23. RN Staff A said, "I dont know, I look at the MOR at every visit, I did not see it."