Every finding on record at Traditions Hospice of Glen Allen LLC

Based on clinical record review, document review and an interview the hospice agency failed to provide adequate pain management and symptom control for one (1) of six (6) clinical records reviewed. (Patient #1) --- The clinical record for Patient #1 was reviewed for the following certification periods: January 03, 2023, through March 03, 2023 March 04, 2023, through May 02, 2023 May 03, 2023, through July 01, 2023 July 02, 2023, through August 30, 2023 August 31, 2023, through October 29, 2023 The Plan of Care for Patient #1 for certification period January 03, 2023, through March 03, 2023, included the following orders: Morphine Concentrate Solution 100mg/5ml (20mg/ml) 0.25ml every three (3) hours as needed for pain and shortness of breath Tramadol 50mg tablet daily for pain Tramadol 50mg tablet every six (6) hours as needed for pain The Plan of Care for Patient #1 for certification period March 04, 2023, through May 02, 2023, included the following orders: Morphine Concentrate Solution 100mg/5ml (20mg/ml) 0.25ml hourly for pain and shortness of breath Tramadol 50mg tablet daily for pain; 0.5 tablet daily for pain Tramadol 50mg tablet every six (6) hours as needed for pain The Plan of Care for Patient #1 for certification period May 03, 2023, through July 01, 2023, included the following orders: Morphine Concentrate Solution 100mg/5ml (20mg/ml) 0.25ml hourly for pain and shortness of breath Tramadol 50mg tablet daily for pain; 0.5 tablet daily for pain Tramadol 50mg tablet every six (6) hours as needed for pain The Plan of Care for Patient #1 for certification period July 02, 2023, through August 30, 2023, included the following orders: Morphine Concentrate Solution 100mg/5ml (20mg/ml) 0.25ml hourly for pain and shortness of breath Tramadol 50mg tablet daily for pain; 0.5 tablet daily for pain Tramadol 50mg tablet every six (6) hours as needed for pain The Plan of Care for Patient #1 for certification period August 31, 2023, through October 29, 2023, included the following orders: Morphine Concentrate Solution 100mg/5ml (20mg/ml) 0.25ml hourly for pain and shortness of breath Tramadol 50mg tablet daily for pain; 0.5 tablet daily for pain Tramadol 50mg tablet every six (6) hours as needed for pain The MFI reviewed the agencys Pain and Symptom Management Procedure (PC135 effective April 2022) on October 21, 2024. Page one (1) section II indicated the Hospice will respect the patients right to receive effective pain management and symptom control for conditions related to the terminal illness. The MFI reviewed the agencys policy Medication List and Monitoring (PC85 effective April 2022) on October 22, 2024. Page three (3) XI.A indicated the patients most current reconciled medication list is communicated to the next provider of service. All communication will be documented. The MFI reviewed the on-call log on October 22, 2024. The on-call log indicated Power of Attorney called on September 26, 2023, at 5:57 PM and September 27, 2024, at 8:10 AM revealing #1 was out of medication. The IDG (Interdisciplinary Group) Plan of Care Update Report dated September 26, 2023, indicated an order for Fentanyl Dermal Patch 50mcg to be applied topically in hairless area and to be changed every 72 hours for pain on September 21, 2023. The IDG Plan of Care Update Report revealed scheduled and as needed Tramadol was discontinued on September 23, 2023. Patient #1 did not receive the Fentanyl Dermal Patch ordered on September 21, 2023 until September 27, 2023 (6 days). The interview with Staff Member #1 on October 23, 2024, indicated Patient #1 was prescribed Morphine for pain since start of care on January 03, 2023, however, the POA did not want Morphine used for Patient #1 and wanted to utilize Tramadol. The interview revealed Tramadol was discontinued and replaced with a Fentanyl patch and the medication was late arriving to facility where Patient #1 resides due to being ordered from the wrong pharmacy. Additional Clinical Records: The clinical record for Patient #2 was reviewed for the period of October 08, 2024 through December 06, 2024 and revealed no issues relating to pain management. The clinical record for Patient #3 was reviewed for the period of September 09, 2024 through December 07, 2024. The clinical record revealed no issues relating to pain management. . The clinical record for Patient #4 was reviewed for the period of December 05, 2023 through January 02, 2024. The clinical record revealed no issues relating to pain management. The clinical record for Patient #5 was reviewed for the period of October 18, 2024 through December 16, 2024. The clinical record revealed no issues relating to pain management. The clinical record for Patient #6 was reviewed for the period of September 18, 2024 through December 16, 2024. The clinical record revealed no issues relating to pain management. The clinical record review, document review and an interview, revealed the hospice agency failed to provide adequate pain management and symptom control for Patient #1.

Based on clinical record review, document review and interviews, the agency failed to provide a confidential clinical record without specific consent of the patient or legal representative for one (1) of six (6) patients. (Patient #1) --- The clinical record for Patient #1 was reviewed for the following certification periods: January 03, 2023, through March 03, 2023 March 04, 2023, through May 02, 2023 May 03, 2023, through July 01, 2023 July 02, 2023, through August 30, 2023 August 31, 2023, through October 29, 2023 The Patient Information Sheet revealed the POA and another family member as the contacts for Patient #1. The Visit Note Report dated October 03, 2024, ending at 10:53 PM written by Staff Member #4 revealed Patient #1 was observed with facial grimace and Patient #1 was medicated with scheduled Morphine with effective results; family at bedside and support provided and contact information given to notify on-call service; Lorazepam and Morphine will be re-ordered and POA will be updated. The MFI reviewed the mutual contract between the agency and the facility effective October 27, 2022, in which Patient #1 resides on October 22, 2024. Page two (2) #9 of the contract indicates the Hospice will support and adhere to Communitys principles of choice, privacy, dignity, independence, and individuality while providing are to the resident in the Community. The MFI reviewed the Respect for Privacy, Security and Property Policy (LCL/RI.50Mcr reviewed September 01, 2024) on October 22, 2024. Page 1 (one) Section IV indicated the Hospice and any agent acting on behalf of the Hospice in accordance with a written contract must ensure the confidentiality of all patient identifiable information contained in the clinical record and may not release patient identifiable information to the public. The MFI reviewed the Patient Information Handbook on October 22, 2024. On Page 13 section titled Right to Receive Confidential Communications, this reads in part as follows: You have the right to request that we communicate with you in a certain way. For example, you may ask that we only conduct communications pertaining to your health information with you privately with no other family members present. If you wish to receive confidential communications, please contact the Privacy Officer (contact information listed). We will not request reasons for your request and will attempt to honor your reasonable requests for confidential communications. There was no documentation indicating this request had been made by the POA to the Privacy Officer. The Employee Counseling Form dated November 14, 2023, for Staff #4 was reviewed by the MFI on October 23, 2024. Documentation indicated Staff #4 shared medical information regarding Patient #1 with members of the family who were not authorized to receive it by the POA and occurred in the room of Patient #1 and in a public area of the facility. The POA of Patient #1 contacted Staff Member #1 to report on October 04, 2024, at the same time, Staff #4 also self-reported the HIPAA (Health Insurance Portability and Accountability Act, a federal law that protects the privacy and security of sensitive health information) violation. Staff Member #4 acknowledged in a written statement the medical condition of Patient #1 was discussed with a person not authorized to receive the information and had additional discussion with non-authorized family members in a public area of the facility in which Patient #1 resides and is a violation of HIPAA and the (agency name redacted) Health Code of Business Conduct. Corrective Action indicated Staff Member #1 will review the HIPAA Policy and Agency Health Code of Conduct with Staff Member #4. Interview with Staff Member #1 on October 21, 2024, indicated Power of Attorney (POA) had made a complaint to the agency regarding Staff #4 sharing information with other family members who were visiting Patient #1 at the facility in which patient #1 residents. Staff Member #1 indicated the agency policy is to speak to family members who are listed on the contact list for each patient. Staff Member #1 indicated the conversation with the family members occurred within a common area of the facility. The interview with Staff Member #1 revealed the POA contacted Staff Member #4 regarding sharing information with family members and that Staff Member #4 self-reported the incident, had been given verbal counseling and provided additional training as it relates to Patient Confidentiality. Interview with Staff Member #4 on October 22, 2024, indicated a visit was made to Patient #1 at the facility where patient resides and Staff Member #4 administered Morphine due to to Patient #1 being in distress and family members were present. Staff Member #4 indicated when the family member inquired about medication administered, Staff Member #4 explained to the family members present, that Patient #1 was transitioning and this was done outside of room of Patient #1.Staff Member #4 indicated this was not done intentionally as she had been a nurse for over 30 years and initially did not realize she had done anything wrong as family members were in an out visiting the patient and were aware Patient #1 was receiving hospice services. Staff Member #4 indicated she was called by the POA and accused of violating HIPAA (Health Insurance Portability and Accountability Act, a federal law that protects the privacy and security of sensitive health information) and that POA indicated ";you knew you couldnt talk to anyone in my family, and you set me up." Staff Member #4 indicated when POA made her aware of this, Staff Member #4 told the POA she would self-report this incident to the agency and apologized to the POA. Staff Member #4 indicated she received a write-up for this incident. The interview with Staff Member #4 revealed when a family member inquired about the type of medication being administered, Staff Member #4 disclosed medication name, provided education on transitioning (the stage when a patient is approaching the end of their life) of Patient #1, offered support to the family members in the room, a common area and the POA was not present at the time of the visit. The clinical record review, document review and interviews, revealed the agency failed to provide a confidential clinical record without specific consent of the patient or legal representative for Patient #1.

Based on clinical record review, document review and an interview, the agency failed to provide supervision of the delivery of services by a Licensed Practical Nurse (LPN) to three (3) of (6) Patients. (Patients #1, #5, #6) --- The clinical record for Patient #1 was reviewed for the following certification periods: January 03, 2023, through March 03, 2023 March 04, 2023, through May 02, 2023 May 03, 2023, through July 01, 2023 July 02, 2023, through August 30, 2023 August 31, 2023, through October 29, 2023 The clinical record for Patient #1 revealed only two supervisory visits of the LPN providing care had been conducted on April 16, 2023 and October 01, 2023 by a Registered Nurse. The clinical record for Patient #5 was reviewed for the period of October 18, 2024 through December 16, 2024. The clinical record revealed no supervisory visits were conducted by the RN for LPN/LVN providing care to Patient #5. The clinical record for Patient #6 was reviewed for the period of September 18, 2024 through December 16, 2024. The clinical record revealed no supervisory visits were conducted by the RN for LPN/LVN providing care to Patient #5. Page 156 of the agencys Administrative Policy Manual (HCL/HR.60 Mcr reviewed September 01, 2021) for Employee Supervision E.2 Nursing Services indicates a RN will make an onsite visit, with or without the licensed practical/vocational nurse (LPN/LVN) present, to supervise the LPN/LVN as indicated by the appropriate state practice act. The interview with Staff Member #1 on October 24, 2024, and October 25, 2024, indicated supervisory visits for LPNs and LVNs had not been conducted consistently. The interview with Staff Member #1 confirmed two (2) supervisory visits by the RN for the LPN/LVN had been made for Patient #1 on April 16, 2023 and October 01, 2023 and no supervisory visits had been conducted for Patient #5 and Patient #6.

Based on an interview and a review of clinical records it was determined the agency failed to ensure all supplies and appliances were included in the plan of care to meet the needs of the patient. Specifically, a suprapubic catheter was left off the plan of care for one (1) of thirteen (13) clinical records reviewed in the survey sample (clinical record # 12). --- The findings were: The electronic clinical records were reviewed in read only mode from 12/27/2022 through 12/29/2022. A review of clinical record #12 revealed the patient had a suprapubic catheter (a hollow flexible tube that is used to drain urine from the bladder and is inserted into the bladder through a cut in the abdomen). The suprapubic catheter was not listed on the plan of care and no orders were in the clinical record for the care of the catheter. On 11/11/2022 the skilled nurse visit note contained a narrative note which states in part: patient 16 f sp (size of catheter 16 French suprapubic) tube changed under sterile conditions, noted for minimal cloudy return. On 12/15/2022 the skilled nurse note contained a narrative note which states in part: prn (as needed) visit concern was that patient had blood in catheter bag and tubing. Flushed catheter, pale yellow urine was returned. Writer believes catheter was pulled by patient during peri care. An interview was conducted with the administrator on 12/29/2022 at 1 PM. The administrator had researched the findings and spoke with the primary nurse. The administrator stated several verbal orders were obtained during IDG meetings and not documented. Late entries were done after the missing orders were discovered by this surveyor. The administrator apologized and acknowledged this was a deficient practice. Copies of the late entries were provided to the surveyor.