Every finding on record at Tranquility Hospice and Palliative Care Inc

Based on observation, record review and interview, the hospice agency failed to ensure patients rights to be free from mistreatment, neglect, or verbal, mental and physical abuse, including injuries of unknown source (see tag L517); and failed to ensure the patients rights for effective pain management for the conditions related to the terminal illness (see tag L512). The Immediate Jeopardy has the potential to affect all agency patients. The cumulative effect of these systemic problems resulted in the hospice agency's inability to ensure the provision of quality health care in a safe environment for the Condition of Participation 42 CFR §418.52: Patient's Rights. Findings include: --- Based on observation, record review, and interview the hospice agency failed to ensure patient's rights to be free from mistreatment, neglect, verbal, mental and physical abuse and injuries of unknown source and failed to ensure patient's rights for effective pain management for conditions related to the terminal illness in 3 of 10 active clinical records reviewed of patient's living in a home (Patient #1, #9, #10). An Immediate Jeopardy was announced on 04/12/2023 at 12:00 PM, at Tranquility Hospice. The Immediate Jeopardy was as follows: 1. Record review evidenced an agency policy dated 10/02/2021, titled, ";Patients Rights and Responsibilities," which stated, ";... The hospice staff will be responsible for knowing, observing, and implementing the patients rights and patient responsibilities on an ongoing basis. The staff also be responsible for protecting and promoting these rights ... Regarding patients rights, the patient has a right to the following: To receive effective pain management and symptom control from the Hospice for conditions related to the terminal illness ... To be free from mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriate of patient property ...." 2. Record review evidenced an agency policy dated 12/01/2020, titled, ";Rights and Responsibilities," which stated, ";The law provides certain rights to all hospice patients. Each patient has a right to be informed of his or her rights. These include the right to: ... Receive quality end of life care with effective pain management and symptom control for the terminal illness and related conditions ... Hospice Responsibilities: To protect and promote the exercise of patients rights ... To provide a safe home environment in which care can be given ... To notify the physician of changes in the patients status ...." 3. Record review evidenced an agency policy dated 10/01/2021, titled, ";Abuse, Neglect and Exploitation," which stated, ";Purpose to identify suspected or alleged victims of abuse, neglect, or exploitation of a patient, or misappropriation of patient property and establish protocols for reporting and/or referring abuse, neglect, or exploitation of a patient or misappropriate of patients property immediately to the Hospice and other appropriate authorities in accordance with state law. The Centers for Medicare and Medicaid Services (CMS) provides the following definitions: ";Abuse" means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This includes mental, physical, sexual, or verbal abuse. ";Mental Abuse" includes, but is not limited to, humiliation, harassment, and threats of punishment or deprivation, sexual coercion, and intimidation [e.g., living in fears in ones own home] ... ";Physical abuse" refers to any action intended to cause physical harm or pain, trauma, or bodily harm [e.g., hitting, slapping, punching, kicking, pinching, etc.,] ... ";Verbal abuse" refers to any use of insulting, demeaning, disrespectful, oral, written, or gestured language directed toward and in the presence of the patient. ";Immediately" means reporting without delay ... ";Injury of unknown source" means an injury that was not witnessed by any person and the source of the injury could not be explained by the patient ... ";Neglect" means a failure to provide goods and/or services necessary to avoid physical harm, mental anguish, or mental illness ... Any Hospice staff ... who identifies, notices, or recognizes incidences or circumstances of mistreatment, neglect, verbal, mental, sexual, and/or physical abuse, including injuries of unknown source, or misappropriation of property, must report these findings immediately to the Hospice and other appropriate authorities ... Any hospice staff member ... will ... Immediately report an assessment of a patients condition which might include abuse, or neglect of a patient ... to the Hospice supervisor ... acquire input from other disciplines providing patient care regarding concerns ... The Hospice management will ... Address any allegations of or evidence of abuse to determine if immediate care is needed, a change in the plan is indicated, or if a referral to an appropriate agency is warranted ... Incidents of family violence will be reported to law enforcement per federal, state, and local law ... ";Neglect" means the endangered adult [incapable by reason of ... dementia ... or other physical or mental incapacity of managing or directing the management of the ... self-care] or the person who takes care of the endangered adult is unable to or fails to provide adequate food, clothing, shelter or medical care ... Each endangered adult report will be communicated immediately to at least one of the following: The adult protective services unit ...." 4. Record review evidenced an agency policy dated 10/20/2022, titled, ";Pain and Symptom Management," which stated, ";... The hospice staff are committed to pain and symptom prevention and management will respond quickly to provide effective management. The hospice will respect the patients right to receive effective pain management and symptom control related to the terminal illness. The hospice will direct patient care staff and the patient regarding pain assessment, reassessment, prevention, and management. The Interdisciplinary Group/Team (IDG/IDT) will screen, assess, and reassess pain ... Pain intensity ratings will be recorded utilizing a pain scale as determined by the Hospice ... Pain will be assessed as part of every patient contact if patient reports pain or is at risk for pain. Pain assessed to be greater than the patients goal will include an appropriate intervention be performed by nursing staff. Interventions may include but are not limited to contacting the physician for additions and/or changes in the current pain medication regimen ... When medication changes occur in relation to pain and symptom management, timely follow up by the nurse will be made to determine the effectiveness of those changes. When the IDG/IDT determines that the patients pain and symptoms cannot be adequately managed in the home, appropriate referrals will be made ...." 5. During an observation of a home visit on 04/05/2023, from 8:30 AM to 9:40 AM, patient #1 indicated to RN (registered nurse) 1 that he/she was pushed down by caregiver/significant other 1. Patient #1 showed bruising to right hand and right leg/calf area. Patient #1 indicated to RN 1 that he/she felt unsafe in the home. Clinical record review indicated patient #1 resided with caregiver/significant other 1 and had a primary diagnosis of malignant neoplasm of the brain. Patient #1 indicated his/her pain level was 9 (pain scale where 0 is no pain and 10 is worst pain). During an observation of the interdisciplinary group meeting on 04/05/2023, from 6:00 PM-6:51 PM, the patients pain level failed to be addressed. Clinical record review for patient #1 evidenced nursing visit notes dated 03/01/2023, 03/08/2023, 03/14/2023, 03/31/2023, and 04/07/2023, which indicated the patient was alert and oriented to person, place, and time. Review of nursing visit notes dated 03/15/2023, 03/16/2023, and 03/17/2023, indicated the patient was disoriented. Review of social worker 1s notes dated 03/21/2023, indicated the patient revealed caregiver/significant other 1 was controlling, paternalistic, the patients needs were not being addressed, and that caregiver/significant other 1 did not want the patient to share this information with the hospice staff. Review of a nursing visit note dated 04/07/2023, evidenced patient #1 indicated his/her pain level was 10 (on a pain scale), the Fentanyl patch (pain patch) was not helping, the patient was in constant pain. Review of a nursing visit note dated 03/14/2023, indicated the patient was reluctant to take the morphine (pain medication). Review of an agency document titled, ";Patient Medication Record," for certification period 02/25/2023-05/25/2023, evidenced the patient was taking hydrocodone and tramadol as needed for pain. Review of the interdisciplinary group meeting notes conducted on 04/05/2023, evidenced documentation the patients average pain level was 2. Review and observation of the interdisciplinary group meeting failed to evidence RN 1 notified the Clinical Supervisor, physician, or interdisciplinary group of the patients increased pain level during the previously conducted skilled nursing visit on 04/05/2023. Review of the RN initial assessment dated 02/25/2023, indicated a pain level greater than 5 (on a pain scale) warranted attention. During an interview at a home visit on 04/05/2023, from 8:30 AM-9:40 AM, caregiver/significant other 1 indicated the patient was not taking hydrocodone or tramadol for pain and was only using the fentanyl pain patch. During an interview on 04/06/2023, at 3:10 PM, patient #1s family member 2, stated patient #1 had indicated caregiver/significant other 1 had hurt /him/her and pushed him/her into a tv stand causing bruising to hand which was shown to family member 2. During an interview on 04/06/2023, at 1:57 PM, the Clinical Supervisor indicated APS (adult protective services) were notified of the alleged abuse incident. The Clinical Supervisor indicated the hospice agency would not increase nursing visits, and the social worker could see the patient if it was deemed necessary by the social worker. During an interview on 04/12/2023, at 3:14 PM, the medical director indicated the physician should be notified of patient having any pain and prior to pain level reaching 8, 9, or 10 (on a pain scale) to prevent severe pain symptoms. 6. Clinical record review for patient #10 of nursing visit notes dated 03/21/2023, 03/23/2023, 03/24/2023, 03/25/2023, 03/26/2023, 03/27/2023, 03/29/2023, and 03/30/2023, indicated the patients elevated pain level was 7-9 (on a 0-10 pain scale). Review for patient #10, start of care 03/20/2023, evidenced an agency document dated 03/20/2023, titled, "RN Initial Assessment," which indicated the patient was confused, bedbound, dependent in 6/6 ADLs (activities of daily living) with a primary diagnosis of Alzheimers disease, and previously resided in a skilled nursing facility prior to being brought to a family members home. Review of the RN initial assessment on 03/20/2023, indicated the patients pain level was 2 and a level of 5 (on a pain scale) warranted further attention. Review of nursing visit notes evidenced the patients pain level on 03/21/2023 was 9, 03/23/2023 was 9, 03/24/2023 was 7, 03/25/2023 was 7, 03/26/2023 was 7, 03/27/2023 was 8, 03/29/2023 was 8 and 03/30/2023 was 8 with pain to the back and hip area which worsened with repositioning and movement. Clinical record review failed to evidence a pain assessment was completed on the 03/31/2023, nurses visit note. Morphine 0.5 ml (milliliters) was administered by LPN (licensed practical nurse) 1 at the 03/21/2023, 03/23/2023, and 03/24/2023, visit, morphine 0.5 ml was administered by the Clinical Supervisor at the 03/25/2023, and 03/26/2023, visits. Morphine 0.75 ml was given by LPN 1 at the 03/27/2023 visit. Morphine 0.75 ml was given by the Clinical Supervisor at the 03/29/2023, and 03/30/2023 nursing visits. Record review failed to evidence how the patients pain level was being controlled in the absence of the hospice nurse in the home. Clinical record review of the home health aide visit notes indicated the patient had pain during care on 03/21/2023, aide care included bed bath, bed sheet and clothing change. The hospice aide note dated 03/22/2023, indicated care included range of motion and turning, and on 03/23/2023, care included bed bath. Review indicated on 03/29/2023, the hospice aide was unable to complete the bed bath due to the ";high level of pain," and only peri care, mouth care and skin care was completed. Review evidenced a hospice aide visit note dated 03/30/2023, that indicated the patient was in pain when turned or moved. Review of a hospice aide visit note dated 03/31/2023, indicated the patient was screaming in pain when turned or moved. Review of hospice aide visit notes dated 03/21/2023, 03/22/2023, 03/23/2023, 03/29/2023, 03/30/2023, and 03/31/2023, failed to evidence the Clinical Supervisor was notified of the patients pain during the hospice aide visits. Review of a nurse visit note dated 04/03/2023, indicated the patient was alone in the home, and had a large wound to both buttocks, which were observed draining serosanguinous (thin, watery fluid pink in color due to presence of red blood cells) and purulent (thick gray to green in color considered a sign of infection) drainage. Review of the nursing visit notes failed to evidence the wound was measured or the physician was notified of the new wound findings. Review of hospital/entity 4 documentation dated 03/14/2023, titled, ";Plan of Care," indicated patient had a deep tissue injury on 03/14/2023, to the right distal leg and left anterior foot. Review of the RN initial assessment dated 03/20/2023, indicated the patients skin was intact upon hospice admission. Review of nursing notes failed to evidence the physician was notified of wound or wound care was provided to patient. Review of the interdisciplinary groups notes dated 03/21/2023, and 04/05/2023, indicated the patients average pain level was 2 (on a pain scale). During an observation on 04/05/2023, from 6:00 PM-6:51 PM, of the interdisciplinary group meeting, observation failed to evidence discussion of the patients pain level, wound, or patient being left alone in the home for an extended period. During an interview on 04/05/2023, at 9:40 AM, registered nurse 1 indicated the patient was alone in the home on 04/03/2023, and he/she did notify the Clinical Supervisor, adult protective services, and called the police. During an interview on 04/10/2023, at 11:19 AM, home health aide 1 indicated the patient was often in pain during care and repositioning, and the caregiver was to give pain medication prior to the home health aide visit. Hospice Aide 1 indicated there were 2 home visits where the patient was at home alone. Hospice Aide 1 indicated the caregiver would leave the door open for him/her to enter the home, and Hospice Aide 1 indicated there was a dressing to the buttock wound, and the nurse was aware of the wound approximately one week after start of care date 03/20/2023. During an interview on 04/10/2023, at 1:35 PM, the Clinical Supervisor indicated the patients caregiver worked out of the home on Monday and Friday. During an interview on 04/10/2023, at 1:38 PM, the Clinical Supervisor indicated the physician was only notified if the patient required more than 1ml of morphine per dose and the caregiver was not providing morphine every 2 hours as needed for pain. During an interview on 04/10/2023, at 2:51 PM, LPN 1 indicated the physician should be notified if pain level was 7, 8, or 9 out of a pain scale of 0-10, and if the family was unable to give morphine to control the pain a fentanyl patch was often ordered. During an interview on 04/10/2023, at 5:15 PM, social worker 1, indicated the caregiver needed additional help to provide for the patient, and entity 3 was contacted to evaluate patient for additional care. The social worker 1 indicated the caregiver did work outside of the home and asked other relatives to sit with the patient when he/she was at work, if possible, but they were not able to provide any help to the caregiver. Social worker 1 indicated respite care was not offered to the family and was by request only due to care not covered by insurance. During an interview on 04/12/2023, at 11:00 AM, LPN 2 indicated the patient had increased pain with movement and did not see a wound to the buttocks. During an interview on 04/12/2023, at 1:47 PM, the Clinical Supervisor indicated the physician should be notified of new wounds or change in wounds, a wound assessment should be completed at each nursing visit, and wound measurements should be done weekly. During an interview on 04/12/2023, at 3:14 PM, the medical director indicated the physician should be notified of patient having any pain and prior to pain level reaching 8, 9, or 10 to prevent severe pain symptoms. The medical director indicated the physician should be notified of all patients change in condition, including any new wounds, and changes in wounds. 7. Clinical record review for patient #9, evidenced an agency document titled, ";RN Initial Assessment," dated 11/23/2022, which indicated the patient was bedbound, dependent for 5/6 ADLs with a primary diagnosis of congestive heart failure. Review of a nursing visit note dated 02/07/2023, evidenced the patient had a right buttocks and left heel wound. Review of a physician order dated 01/10/2023, evidenced an order to cleanse left heel with normal saline and apply triple antibiotic cream and band aid to 3x3 centimeter pressure sore. Clinical record review of a nursing visit note dated 03/07/2023, indicated using medihoney to left heel and leaving wound open to air. Review of a MSW (masters in social work) note dated 11/29/2022, indicated the home was cluttered with many objects which prevented ease of movement throughout the home. Review evidenced an MSW visit note dated 02/27/2023, which indicated the social worker followed up with the caregiver on a request for assistance with home cleaning services, due to caregivers struggle to maintain the home cleanliness. Review evidenced the last in-home visit by the social worker was 12/15/2022. During an interview on 04/12/2023, at 10:50 AM, social worker 2 indicated the patient would qualify for a skilled nursing facility due to patient being bedbound and indicated he/she was notified by RN 1 of the caregiver being verbally abusive, however, he/she had not seen verbal abuse in the home and had only completed telehealth visits for last 2-3 months. Social worker 2 indicated the family was not offered respite care. Review of a nursing visit note dated 03/31/2023, indicated there was extensive clutter in the home with bad odor, patient was surround by large piles of items and the nurse had difficulty getting access to patient. The nursing note indicated there was trash on floor, and the caregiver did not show interest in performing wound care. Review of a nursing visit note dated 04/07/2023, indicated the caregiver was verbally insulting to the staff and to the patient, patient does not appear to be turned frequently, and was left alone for unknown lengths of time. Review of nursing visit notes for 03/17/2023, indicated a silicone dressing to the buttocks, 03/24/2023, indicated a silicone dressing was applied to the buttocks. A skilled nurse visit note dated 03/31/2023, indicated a hydrocolloidal dressing was applied to the buttocks. A skilled nurse visit note dated 04/07/2023, indicated an optifoam dressing was applied to the buttocks wound. Review of the 04/05/2023, interdisciplinary group meeting notes i ndicated an exoderm dressing was in use to the buttocks. Clinical record review of a nursing visit note dated 04/07/2023, indicated left heel was cleansed with spray and powder was applied and dressed with 4x4. Review failed to evidence wound assessment, measurement, orders including frequency of dressing changes. Clinical record review evidenced an agency document dated 01/24/2023, titled, ";Physician Order," which indicated RN frequency to 2 days per week signed by the Clinical Supervisor, patient failed to have a current plan of care. Review of nursing visit notes failed to evidence patients caregiver was changing dressing on the days the hospice nurse did not have a home visit. During an interview on 04/05/2023, at 9:40 AM, RN 1 indicated he/she had concerns regarding the patients dressing not being changed by caregiver on the days the hospice nurse did not have a visit. During an interview on 04/10/2023, at 5:10 PM, RN 1 indicated the patients caregiver was verbally abusive, did not reposition the patient, wouldnt medicate the patient for pain and left the patient alone in the home. Review of nursing visit notes dated 02/28/2023, 03/03/2023, 03/07/2023, 03/10/2023, 03/14/2023, and 03/17/2023, failed to evidence assessment of the wound to the heel and buttocks and failed to evidence the wounds dressings were changed. During an interview on 04/12/2023, at 10:50 AM, social worker 2 indicated the caregiver denied needing assistance in the home due to they had children to assist with patient care when needed. Social worker 2 indicated he/she had not been to the home to evaluate in 2-3 months and was unsure if patients needs were being met and had only done telehealth (healthcare remotely by means of telecommunication technology) visits. During an interview on 04/12/2023, at 1:25 PM, the Clinical Supervisor indicated the band aid to 3x3 centimeter pressure sore was an order for the buttocks wound. The Clinical Supervisor also indicated wound assessments should be completed at each nursing visit, measurements of wounds were to be done weekly, the dressing changes to the buttocks and heel were to be done daily. The Clinical Supervisor indicated a podiatrist was treating the heel wound. The Clinical Supervisor indicated there was no documentation of podiatrist notes or orders regarding the heel wound. The Clinical Supervisor indicated there were no orders regarding the buttocks wound since the 01/10/2023, order for a band aid to be applied to the open pressure sore to the buttocks. Survey for removal of Immediate Jeopardy dates: 04/20/2023-04/21/2023 Immediate Jeopardy remains unabated as of 04/21/2023. Patient census: 21 Findings include: Clinical record review failed to evidence the Clinical Supervisor completed pain assessments for 5 agency patients. Review of an untitled, undated agency document received on 04/20/2023, identified by the Clinical Supervisor as an excel spreadsheet patient wound assessment. Review failed to evidence dates of wound assessment. Review of the agencys excel spreadsheet for patient wound assessment indicated 5 patients had wounds. Clinical record review evidenced 7 patients had wounds. Review evidenced wound orders were not on the plan of care, or wound orders were not performed as ordered. Review failed to evidence 1 certified nursing assistant completed the patients right/abuse education as of 04/20/2023. Clinical record review for 17 active patients failed to evidence what interventions were used to assess for patient safety. During an interview on 04/21/2023, at 12:00 PM, the Clinical Supervisor indicated 3 patients had not been evaluated for safe environment/abuse and a MSW (masters social worker) visit is scheduled to see the patient. Clinical record review for 1 patient failed to evidence a safe environment/abuse evaluation was completed by the RN (registered nurse) on the Initial Assessment on 04/18/2023. During an interview on 04/21/2023, at 11:55 AM, the Clinical Supervisor indicated she was unsure if adult protective services (APS) were called for patient #9. The Clinical Supervisor indicated RN 1 told social worker 1 that he/she was going to call APS. Review failed to evidence any documentation of adult protective services notification. Clinical record review for patient #9, on 04/20/2023, evidenced an agency document dated 04/12/2023, titled, ";MSW Visit," indicated the patient was crying and felt left alone, the patient indicated the caregiver left and he/she was alone, the patient indicated he/she wanted to leave the home and go to nursing home, and had not eaten as of 2:45 PM. Review indicated the caregiver refused additional caregiver support and/or respite care. Review failed to evidence the patient was offered respite care services. During an interview on 04/21/2023, at 12:00 PM, the Clinical Supervisor indicated the husband refused respite and failed to have any documentation that the patient was offered respite care services. During an interview on 04/21/2023, at 12:00 PM, the Clinical Supervisor indicated the abuse assessment form should have been completed on all patients. The Clinical Supervisor indicated there was no documentation the interdisciplinary group approved the form by 04/18/2023. The hospice agency, including the administrator, Clinical Supervisor, and nurse consultant were notified on 04/21/2023, at 12:15 PM, the Immediate Jeopardy remained unremoved and an Immediate Jeopardy removal plan with completion dates will need to be resubmitted. 2nd Visit for removal of Immediate Jeopardy date: 05/01/2023. Immediate Jeopardy remains unabated as of 05/01/2023. Patient census: 21 Findings include: Clinical record review of a nursing visit note for 1 patient dated 04/21/2023, failed to evidence the Clinical Supervisor, or the physician was notified of patients pain rating at 8 (on a pain scale 0=no pain and 10=worst pain) during wound treatment. Review of a nursing visit note dated 04/25/2023, failed to evidence the Clinical Supervisor, or the physician was notified of a patients pain rating of 8. Review of the nursing visit note evidenced Norco (pain medication) was given during nursing visit and upon exit the nursing visit note indicated the patients pain level was 6. Clinical record review of a nursing visit note for 1 patient dated 04/24/2023, failed to evidence the Clinical Supervisor, or the physician was notified of a pain level of 6, documentation indicated the pain level was not acceptable to the patient/caregiver. A nursing visit note for 04/25/2023, indicated the patients pain level was 5. Review of an excel spread sheet, identified by the Clinical Supervisor as pain assessment documentation, failed to evidence daily reviews for patients pain levels. During an interview on 05/01/2023, at 2:00 PM, the Clinical Supervisor indicated daily chart audits for pain were only completed if the staff notified the Clinical Supervisor of pain levels over 4. Clinical record review for 1 patient failed to evidence Elder Abuse Screening Extended Assessment Form, ";Hwalek-Sengstock Elder Abuse Screening Test," was completed. Review of nursing and social worker notes indicated the patient was bedbound, dependent in 5/6 activities of daily living who reported feeling lonely when caregiver left the patient alone in the home. Review of a nursing note dated 03/31/2023, indicated the home had a bad odor, was cluttered, nursing staff had difficulty accessing patient due to large piles of items in environment, and bedding was stained and dirty. Review of a nursing note dated 04/07/2023, evidenced patients caregiver was verbally abusive to patient and staff, and patient was not turned by caregiver. Review of an interdisciplinary meeting note dated 04/19/2023, indicated social worker was involved due to Adult Protective Services report, however, review failed to evidence documentation of report being completed with Adult Protective Services. Review of a social worker note dated 04/12/2023, evidenced the patient was crying, alone at home, had requested to go to a nursing home and a risk assessment was provided. Review of a 04/28/2023, social worker telehealth (visit completed by telephone) visit note indicated a verbal safety assessment was completed on the patient. During an interview on 05/01/2023, at 2:00 PM, the Clinical Supervisor indicated there had been no elder abuse screening assessment forms completed or Adult Protective Services referrals documented on any active patients. Clinical record review failed to evidence how in home safety/abuse assessments were completed. Clinical record review for 1 patient failed to evidence the physician wound care orders were being completed as ordered by the nurse. Clinical record review for 2 patients failed to evidence complete wound care orders. Clinical record review for 1 patient with a wound failed to evidence any wound assessment, physician notification, or wound care orders. Clinical record review for 3 patients failed to evidence wound care orders on a current plan of care. During an interview on 05/01/2023, at 10:30 AM , the Clinical Supervisor indicated there were 6 active patients with wounds and failed to indicate he/she was aware of a wound present on a patient admitted on 04/25/2023. During an interview on 05/01/2023, at 2:00 PM, the Clinical Supervisor indicated chart audits of wound patients were done only if notified by staff of patients wounds. During an interview on 05/01/2023, at 2:00 PM, the Clinical Supervisor indicated the immediate jeopardy removal corrections included all active patients including new admissions. The administrator and Clinical Supervisor were notified on 05/01/2023, at 4:05 PM, the Immediate Jeopardy would remain unabated. 3rd Visit for removal of Immediate Jeopardy date: 05/12/2023. Immediate Jeopardy remains unabated as of 05/12/2023. Patient Census: 17 Findings include: Record review of the Immediate Jeopardy removal plan dated 05/10/2023, indicated APS was notified for the 2 suspected abuse patients and documented on 04/05/2023 and 04/12/2023. Review failed to evidence documentation of APS notification of 1 suspected abuse patient. During an interview on 05/12/2023, at 2:52 PM, the Clinical Supervisor indicated there was no documentation APS was notified on 1 patient because the nurse only verbally indicated to the social worker he/she was going to call APS. Record review of the Immediate Jeopardy removal plan dated 05/10/2023, indicated daily audits of all notes would be completed to ensure documentation of wounds and pain assessments. Review failed to evidence documentation of daily chart audits on wounds and pain assessments. During an observation of a home visit on 05/12/2023, from 10:50 AM-11:20 AM, observation failed to evidence a complete skin integrity assessment was completed on patient. Review of one record of a patient who was bedbound, incontinent of bowel and bladder, and had documented poor skin turgor failed to evidence any preventative skin interventions were performed by the nurse. Review evidenced a nurses visit with documented wound care, but no wound assessment performed. The agencys wound policy indicated the wound or dressing (if left intact) should be assessed at each visit. Review of one patient record evidenced an LPN nurses note dated 5/3/2023, which indicated a patients coccyx wound, documented as a stage 2 (pressure ulcer with partial-thickness skin loss into but no deeper than the middle layer of skin, shallow with reddish base), had bone exposed and tunneling. Wound care orders for this wound as well as a second wound (documented stage 2) on the patients hip was to apply zinc oxide (a topical medication used to treatment or prevent minor skin irritations such as burns, cuts, and diaper rash) and a duoderm. Review of an RN nurses note dated 5/5/2023, indicated the nurse performed wound care to both wounds, the wound depth measured zero, and the patient tolerated wound care well. During an interview on 05/12/2023, at 4:11 PM, the patients caregiver described the coccyx wound as a hole that they couldnt see the bottom of. The caregiver indicated the patient complained that the zinc oxide burned and hurt them. Multiple attempts to reach the LPN for interview were unsuccessful. During an interview on 05/12/2023, at 4:23 PM, the RN who saw the patient 5/5/2023, documented wound care, wound assessment, and how the patient tolerated the wound care, indicated she never saw the patients wounds. Record review failed to evidence the physician was notified of the exposed bone and tunneling of the wound. When queried on 05/12/2023, at 3:07 PM, the Clinical Supervisor indicated the physician was informed because they wrote an order for wound care. Review evidenced the order was written by a 3rd nurse, who had not seen the patient. During an interview on 05/12/2023, 3:07 PM, the Clinical Supervisor indicated he/she did not know which of the 2 very different wound assessments were reported to the physician when orders were obtain, and he/she would have to go to see the patient's wound. The agency, including the administrator and the Clinical Supervisor were notified on 05/12/2023, at 4:40 PM, the Immediate Jeopardy would remain unabated.

Based on observation, record review and interview, the hospice agency failed to ensure the patient received effective pain management and symptom control from the hospice for conditions related to the terminal illness in 3 of 15 clinical records reviewed. (Patient #1, #10, and #14) Findings include: --- 1. Record review evidenced an agency policy dated 10/02/2021, titled, ";Patients Rights and Responsibilities," which stated, ";... The hospice staff will be responsible for knowing, observing, and implementing the patients rights and patient responsibilities on an ongoing basis. The staff also be responsible for protecting and promoting these rights ... Regarding patients rights, the patient has a right to the following: To receive effective pain management and symptom control from the Hospice for conditions related to the terminal illness ...." 2. Record review evidenced an agency policy dated 12/01/2020, titled, ";Rights and Responsibilities," which stated, ";The law provides certain rights to all hospice patients. Each patient has a right to be informed of his or her rights. These include the right to: ... Receive quality end of life care with effective pain management and symptom control for the terminal illness and related conditions ... Hospice Responsibilities: To protect and promote the exercise of patients rights ...." 3. Record review evidenced an agency policy dated 10/20/2022, titled, ";Pain and Symptom Management," which stated, ";The hospice staff are committed to pain and symptom prevention and management will respond quickly to provide effective management. The hospice will respect the patients right to receive effective pain management and symptom control related to the terminal illness. The hospice will direct patient care staff and the patient regarding pain assessment, reassessment, prevention, and management. The Interdisciplinary Group/Team (IDG/IDT) will screen, assess, and reassess pain ... Pain intensity ratings will be recorded utilizing a pain scale as determined by the Hospice ... Pain will be assessed as part of every patient contact if patient reports pain or is at risk for pain. Pain assessed to be greater than the patients goal will include an appropriate intervention be performed by nursing staff. Interventions may include but are not limited to contacting the physician for additions and/or changes in the current pain medication regimen ... When medication changes occur in relation to pain and symptom management, timely follow up by the nurse will be made to determine the effectiveness of those changes. When the IDG/IDT determines that the patients pain and symptoms cannot be adequately managed in the home, appropriate referrals will be made ...." 4. Record review evidenced an agency policy dated 10/01/2021, titled, ";On Call for Patient Care," which stated, ";Access to medications will always be available, 24 hours a day, seven days a week ... The on-call RN (registered nurse) will keep a log of all calls with information as determined by the hospice protocol. The log will be submitted to the Hospice at the completion of the on-call rotation ... Appropriate activity will be documented on communication notes for the medical records ...." 5. During a home visit observation for patient #1 on 04/05/2023, from 8:30 AM to 9:40 AM, patient #1 indicated to RN [registered nurse] 1 his/her pain level was a 9 (pain scale where 0 was no pain and 10 was worst pain). During an observation of the IDG [interdisciplinary group] meeting on 04/05/2023, from 6:00 PM-6:51 PM, the patients pain level failed to be addressed. Clinical record review evidenced an agency document dated 03/14/2023, titled, "RN Skilled Nursing Visit," indicating patient's pain level was 10, the fentanyl patch (pain patch) was not helping, and the patient was in constant pain. Review evidenced an agency document dated 02/25/2023, titled, ";RN Initial Assessment," which indicated patient #1 resided with caregiver/significant other #1 and had a primary diagnosis of malignant neoplasm of the brain. Review evidenced an agency document dated 03/14/2023, titled, "RN Skilled Nursing Visit," which indicated the patient was reluctant to take the morphine (pain medication). Review evidenced an agency document titled, ";Patient Medication Record," for benefit period 02/25/2023-05/25/2023, which indicated the patient was taking hydrocodone (pain medication) and tramadol (pain medication) as needed for pain. Review of an agency document dated 04/05/2023, titled, "IDG Meeting," indicated the patients average pain level was a 2. During an observation of an IDG meeting, RN 1 failed to notify the Clinical Supervisor, physician, or IDG of the patients increased pain level during the previously conducted skilled nursing visit on 04/05/2023. Review evidenced an agency document dated 02/25/2023, titled, "RN Initial Assessment," which indicated a pain level greater than 5 warranted attention. During an interview at a home visit on 04/05/2023, from 8:30 AM-9:40 AM, caregiver/significant other #1 indicated the patient was not taking hydrocodone or tramadol for pain and was only using the fentanyl pain patch. During an interview on 04/12/2023, at 3:14 PM, the Medical Director indicated the physician should be notified of a patient having any pain and prior to their pain level reaching 8, 9, or 10 (on a pain scale of 0-10) to prevent severe pain symptoms. 6. Clinical record review for patient #10, on 04/06/2023, evidenced an agency document dated 03/20/2023, titled, "RN Initial Assessment," which indicated the patient was confused, bedbound, dependent in 6/6 ADLs (activities of daily living) with a primary diagnosis of Alzheimers disease, and previously resided in a skilled nursing facility prior to being brought to a family members home. Review of an agency document dated 03/20/2023, titled, "RN Initial Assessment," indicated the patients pain level was 2 and a level of 5 (on a pain scale of 0-10) warranted further attention. Review of nursing visit notes evidenced the patients pain level, on a pain scale of 0-10, on 03/21/2023 was 9, 03/23/2023 was 9, 03/24/2023 was 7, 03/25/2023 was 7, 03/26/2023 was 7, 03/27/2023 was 8, 03/29/2023 was 8 and 03/30/2023 was 8 with pain to the back and hip area which worsened with repositioning and movement. Clinical record review failed to evidence a pain assessment was completed on the 03/31/2023, nurses visit note. Morphine 0.5 ml (milliliters) was administered by LPN (licensed practical nurse) 1 at the 03/21/2023, 03/23/2023, and 03/24/2023, visit, morphine 0.5 ml was administered by the Clinical Supervisor at the 03/25/2023, and 03/26/2023, visits. Morphine 0.75 ml was given by LPN 1 at the 03/27/2023 visit. Morphine 0.75 ml was given by the clinical supervisor at the 03/29/2023, and 03/30/2023 nursing visits. Record review failed to evidence how the patients pain level was being controlled in the absence of the hospice nurse in the home. Clinical record review of agency documents titled, "Aide Care Visit," indicated the patient had pain during care on 03/21/2023, aide care included bed bath, bed sheet and clothing change; aide notes dated 03/22/2023, indicated pain during care included range of motion and turning, and on 03/23/2023, pain during care included bed bath; on 03/29/2023, the hospice aide was unable to complete the bed bath due to the ";high level of pain," and only peri care, mouth care and skin care was completed; on 03/30/2023 aide's visit, the patient was in pain when turned or moved; on 03/31/2023, the aide's notes indicated the patient was screaming in pain when turned or moved. Review of hospice aide visit notes dated 03/21/2023, 03/22/2023, 03/23/2023, 03/29/2023, 03/30/2023, and 03/31/2023, failed to evidence the Clinical Supervisor was notified of the patients pain during the hospice aide visits. Review of an agency document dated 03/21/2023, and 04/05/2023, titled, "IDG Meeting," indicated the patients average pain level was 2. During an observation on 04/05/2023, from 6:00 PM-6:51 PM, of the IDG meeting, the discussion failed to address the patients pain level. During an interview on 04/10/2023, at 11:19 AM, hospice aide 1 indicated the patient was often in pain during care and repositioning, and the caregiver was to give pain medication prior to the hospice aide visit. During an interview on 04/10/2023, at 1:38 PM, the Clinical Supervisor indicated the physician was only notified if the patient required more than 1ml of morphine per dose and the caregiver was not providing morphine every 2 hours as needed for pain. During an interview on 04/10/2023, at 2:51 PM, LPN (Licensed Practical Nurse) 1 indicated the physician should be notified if pain level was 7, 8, or 9, on a pain scale of 0-10, and if the family was unable to give morphine to control the pain a fentanyl patch was often ordered. During an interview on 04/12/2023, at 11:00 AM, LPN 2 indicated the patient had increased pain with movement. During an interview on 04/12/2023, at 3:14 PM, the Medical Director indicated the physician should be notified of patient having any pain and prior to pain level reaching 8, 9, or 10, on a pain scale of 0-10, to prevent severe pain symptoms. 7. Clinical record review for patient #14 on 04/10/2023, evidenced an agency document dated 06/21/2022, titled, ";RN Skilled Nursing Visit," which indicated the patients pain level at 7, on a pain scale of 0-10, patient was increasingly combative, and entity 9 was to deliver morphine that night. Review of an agency document titled, ";Plan of Care Order," for benefit period 05/17/2022-08/14/2022, indicated the patients terminal diagnosis was malignant neoplasm of tail of pancreas. Review evidenced an agency document dated 06/22/2022, titled, ";RN Skilled Nursing Visit," which indicated patient pain level at 4, morphine was administered every 2 hours, and should have delivery of morphine that night. Review evidenced an agency document dated 06/20/2022, titled, ";RN Skilled Nursing Visit," which indicated patient was experiencing hallucinations. Review evidenced an agency document dated June 2022, titled, ";Palliative Drug Care Billing Report," which indicated patient received STAT (urgent) medication delivery from entity 9 on 06/23/2022, and a STAT delivery of medication on 06/24/2022. During an interview on 04/05/2023, at 4:51 PM, family member #10 indicated the patient ran out of morphine 3 times and ran out of Ativan (anxiety medication) 1 time. Family member #10 indicated RN #3 was notified on 06/21/2022, of running low on liquid morphine and called on call answering service on 06/24/2022, early AM to notify hospice agency patient was out of morphine, but did not get a response from the agency until family member #10 texted the hospice nurse. Family member #10 indicated patient was receiving morphine every hour. Family member #10 indicated he/she was told to give remaining amount of morphine to patient, and the patient received only a partial dose of morphine at 4:00 AM, on 06/24/2022. Family member #10 indicated patient received STAT (urgent) delivery of medication from entity 9 at approximately 5:30 AM on 06/24/2022, and patient had missed dose of morphine at 5:00 AM on 06/24/2022. During an interview on 04/10/2023, at 11:28 AM, entity 9 indicated STAT delivery of morphine 30 milliliters was made on 06/21/2022, and STAT delivery of morphine 30 milliliters and lorazepam (anti-anxiety medication) was made on 06/24/2022. During an interview on 04/13/2023, at 12:08 PM, LPN 1 indicated a STAT delivery was done when patient had an urgent need for medication and entity 9 would do AM and PM deliveries to the area and STAT deliveries can take anywhere from a couple of hours to the next day to be delivered due to entity 9 was in another state. LPN 1 indicated narcotics (controlled medications) could only be ordered through entity 9 and could not be pick up at a local pharmacy for patient.

Based on observation, record review, and interview, the hospice agency failed to ensure the patient was free from mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source in 3 of 11 active clinical records reviewed. (Patient #1, #9, and #10) Findings include: --- 1. Record review evidenced an agency policy dated 10/02/2021, titled, ";Patients Rights and Responsibilities," which indicated the hospice staff will be responsible for knowing, observing, and implementing the patients rights and patient responsibilities on an ongoing basis. Regarding patients rights, the patient has a right to the following: To be free from mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriate of patient property. 2. Record review evidenced an agency policy dated 12/01/2020, titled, ";Rights and Responsibilities," which indicated patients have a right to a safe home environment in which care can be given. 3. Record review evidenced an agency policy dated 10/01/2021, titled, ";Abuse, Neglect and Exploitation," which indicated any Hospice staff who identifies or recognizes incidences of mistreatment, neglect, verbal, mental, sexual, and/or physical abuse, including injuries of unknown source, must report these findings immediately to the Hospice. The Hospice management will address any allegations of or evidence of abuse to determine if immediate care was needed, a change in the plan was indicated, or if a referral to an appropriate agency was warranted 4. During a home visit observation on 04/05/2023, from 8:30 AM to 9:40 AM, patient #1 indicated to Registered Nurse (RN) #1 that he/she was pushed down by caregiver/significant other #1. Patient #1 showed bruising to the right hand and right leg/calf area. Patient #1 indicated to RN #1 that he/she felt unsafe in the home. Record review of an agency document dated 02/25/2023, titled, "RN Initial Assessment," indicated patient #1 resided with caregiver/significant other #1 and had a primary diagnosis of malignant neoplasm of the brain. Nursing visit notes dated 03/01/2023, 03/08/2023, 03/14/2023, 03/31/2023, and 04/07/2023, indicated patient #1 was alert and oriented to person, place, and time. Nursing visit notes dated 03/15/2023, 03/16/2023, and 03/17/2023, indicated patient #1 was disoriented. An agency document dated 03/21/2023, titled, "MSW [masters social work] Visit," indicated the patient revealed caregiver/significant other #1 was controlling, paternalistic, needs were not being addressed, and caregiver/significant other #1 did not want the patient to share this information with the hospice staff. During an interview on 04/06/2023, at 3:10 PM, Patient #1s family member #2, stated Patient #1 had indicated caregiver/significant other #1 had hurt him/her and pushed him/her into a tv stand causing bruising to hand which was shown to family member #2. During an interview on 04/06/2023, at 1:57 PM, the Nursing Supervisor indicated Adult Protective Services (APS) were notified of the alleged abuse incidence. The Clinical Supervisor indicated the hospice agency would not increase nursing visits, and the social worker could see the patient if it was deemed necessary by the social worker. 5. Clinical record review for Patient #10, start of care 03/20/2023, evidenced an agency document dated 03/20/2023, titled, "RN Initial Assessment," which indicated the patient was confused, bedbound, dependent in 6/6 ADLs (activities of daily living) with a primary diagnosis of Alzheimers disease, and previously resided in a skilled nursing facility prior to being brought to a family members home. An agency document dated 04/03/2023, titled, ";RN Skilled Nursing Visit," indicated the patient was alone in the home, and had a large wound to both buttocks, which were observed draining serosanguinous (thin, watery fluid pink in color due to presence of red blood cells) and purulent (thick gray to green in color considered a sign of infection) drainage. During an interview on 04/05/2023, at 9:40 AM, RN 1 indicated the patient was alone in the home on 04/03/2023, and he/she notified the Clinical Supervisor, APS, and called the police. During an interview on 04/10/2023, at 11:19 AM, Hospice Aide #1 indicated the patient was often in pain during care and repositioning, and the caregiver was to give pain medication prior to the hospice aide visit. Hospice Aide #1 indicated there were 2 home visits where the patient was at home alone. Hospice Aide #1 indicated the caregiver would leave the door open for him/her to enter the home, and Hospice Aide #1 indicated there was a dressing to the wounds, and the nurse was aware of the wound approximately one week after start of care date 03/20/2023. During an interview on 04/10/2023, at 1:35 PM, the Clinical Supervisor indicated the patients caregiver worked out of the home on Monday and Friday. During an interview on 04/10/2023, at 5:15 PM, Social Worker #1, indicated the caregiver needed additional help to provide for the patient, and entity 3 was contacted to evaluate patient for additional care. The Social Worker indicated the caregiver did work outside of the home and asked other relatives to sit with the patient when he/she was at work, if possible, but they were not able to provide care to the patient. Social worker #1 indicated respite care was not offered to the family and was by request only due to care not covered by insurance. 6. Clinical record review for Patient #9 evidenced an agency document dated 11/23/2022, titled, ";RN Initial Assessment," which indicated the patient was bedbound, dependent for 5/6 ADLs with a primary diagnosis of congestive heart failure. An agency document dated 11/29/2022, titled, ";MSW Visit," indicated the home was cluttered with many objects which prevented ease of movement throughout the home. An agency document dated 02/27/2023, titled, ";MSW Visit," indicated the social worker followed up with the caregiver on a request for assistance with home cleaning services, due to caregivers struggle to maintain the home cleanliness. An agency document dated 03/31/2023, titled, ";RN Skilled Nursing Visit," indicated there was extensive clutter in the home with bad odor, patient was surround by large piles of items and the nurse had difficulty getting access to patient. The nursing note indicated there was trash on floor, and the caregiver did not show interest in performing wound care. An agency document dated 04/07/2023, titled, ";RN Skilled Nursing Visit," indicated the caregiver was verbally insulting to the staff and to the patient, patient does not appear to be turned frequently, and was left alone for unknown lengths of time. During an interview on 04/10/2023, at 5:10 PM, RN 1 indicated the patients caregiver was verbally abusive, did not reposition the patient, wouldnt medicate the patient for pain, and left the patient alone in the home. During an interview on 04/12/2023 at 10:50 AM, Social Worker #2 indicated the caregiver denied needing assistance in the home because they had children to assist with patient care when needed. Social Worker #2 indicated he/she had not been to the home to evaluate in 2-3 months and was unsure if patients needs were being met and had recently only done telehealth (healthcare remotely by means of telecommunication technology) visits. Social worker #2 indicated the patient would qualify for a skilled nursing facility due to patient being bedbound and indicated he/she was notified by RN 1 of the caregiver being verbally abusive, however, he/she had not seen verbal abuse in the home and had only completed telehealth visits for last 2-3 months. Social worker #2 indicated the family was not offered respite care.

Based on observation, record review and interview, the agency failed to coordinate care to ensure care provided was based on all assessments of the patient's needs in 7 of 15 clinical records reviewed. (#1, 4, 5, 7, 10, 12, 14). The findings include: --- 1. Review of an agency policy titled "Care of the Dying Patient", dated 10/1/2021, indicated interventions will be made based on patient assessments in order to provide appropriate care. 2. Review of an agency policy titled "Interdisciplinary Group Roles and Responsibilities", dated 10/1/2021, indicated the IDG (interdisciplinary group) will collaborate to provide the care and services necessary to meet the patient and / or family's needs. 3. Record review of an agency policy dated 04/04/2023, titled, ";Implementing Care and Treatment," stated, ";... The Hospice RN (registered nurse), who is a member of the IDG/IDT (interdisciplinary group/interdisciplinary team), will oversee the assignment of a Hospice Aide (HA) to a particular patient, initiating hospice aide services within time frame to meet identified patients needs as identified in the POC (plan of care) and per physician orders...." 4. Review of a skilled nurse visit note dated 3/24/2023, indicated Patient #5 had a large tumor on their chest that created a wound. The patient was tearful and complained the area was burning. In the note, the nurse indicated he/she advised the patient to put either Neosporin or petroleum gauze on the wound. Review of the visit note, all coordination notes, orders, and IDG notes failed to evidence physician notification of the patient's new complaint. During an interview on 4/14/2023 at 11:04 AM, the Clinical Supervisor indicated if a patient has a new complaint or symptom, the nurse should notify the physician. 5. Review of a skilled nurse visit note dated 3/30/2023, indicated Patient #7 had blood in their urine. Review of previous nurse visit notes failed to evidence blood in the urine. A skilled nurse visit note dated 4/06/2023, indicated the patient's urine was cloudy with blood and sediment. Review of the visit notes, all coordination notes, orders, and IDG notes failed to evidence physician notification of the change in the patient's urine. On 4/14/2023 at 12:14 PM, the Clinical Supervisor indicated the nurse should have called the physician regarding the change in patient status and documented that communication in the visit note. 6. Review of an agency document titled ,"Pain Assessment," dated 02/01/2023, signed by social worker #1, indicated Patient #12 complained their current pain medications were not providing enough relief. Review of the social worker's notes as well as all communication notes failed to evidence the social worker notified the nurse about the patient's uncontrolled pain. During an interview on 4/14/2023 at 3:17 PM, the Clinical Supervisor indicated the social worker should have informed her of the patient's uncontrolled pain. 7. Clinical record review on 04/04/2023, for Patient #1 evidenced an agency document dated 03/21/2023, titled, ";MSW [masters social work] Visit," which indicated the patient felt the caregiver was controlling and paternalistic and does not want her to leave the house. The visit note indicated the patient revealed her needs were not being addressed due to the relationship with the caregiver and that the caregiver did not want the patient to share concerns with the hospice staff. During an interview on 04/06/2023, at 1:57 PM, the Clinical Supervisor indicated social worker #1 did not notify the Clinical Supervisor of the 03/21/2023, visit note findings. During an observation of a home visit on 04/05/2023, from 8:30 AM-9:40 AM, the patient indicated their pain level was at a 9 (on a pain scale where 0=no pain and 10=worst pain). Observation of the interdisciplinary group meeting on 04/05/2023, from 6:00 PM-6:51 PM, failed to evidence discussion of patients pain level. 8. Clinical record review on 04/13/2023, for Patient #4, evidenced agency documents dated 01/28/2023 and 03/21/2023, titled, ";IDG Meeting," which indicated the patients pain level was 8 (on a pain scale). Review of an agency document dated 04/05/2023, titled, ";IDG Meeting," indicated patient had breakthrough pain from legs and lower back and had been using oxycontin more often. Review of an agency document dated 01/28/2023, titled, ";RN [registered nurse] Initial Assessment," indicated patient had bilateral tibial (leg) fractures that were not repaired by surgery. Review of an agency document titled, ";Plan of Care Order," for benefit period 01/28/2023-04/27/2023, indicated the patients average pain level was 8 with a goal for pain control to be at 0 within 2 weeks. Observation of the interdisciplinary group meeting on 04/05/2023, from 6:00 PM-6:51 PM, failed to evidenced discussion of the patients pain level. 9. Clinical record review on 04/06/2023, for Patient #10 evidenced an agency document dated 03/20/2023, titled, ";RN Initial Assessment," which indicated the patient was confused, bedbound, dependent in 6/6 Activities of Daily Living with a primary diagnosis of Alzheimers disease. Review evidenced an agency document dated 04/03/2023, titled, ";RN Nursing Visit," which indicated the patient was alone in the home, and had a large wound to both buttocks draining serosanguinous (thin, water fluid pink in color due to presence of red blood cells) and purulent (thick gray to green in color considered a sign of infection) drainage. Review failed to evidence the nurse notified the physician of the new wound findings. Review of an agency document titled, ";Plan of Care Order," for benefit period 03/20/2023-06/17/2023, failed to evidence wound care orders for the wound to the buttocks. Review of nursing visit notes dated 03/21/2023, 03/23/2023, 03/24/2023, 03/25/2023, 03/26/2023, 03/27/2023, 03/29/2023, and 03/30/2023, evidenced pain level were 7-9 (on a pain scale). During an interview on 04/13/2023, at 11:38 AM, LPN (licensed practical nurse)1 indicated the physician should be notified of all new wounds. Observation of the interdisciplinary group meeting on 04/05/2023, from 6:00 PM-6:51 PM, failed to evidence discussion of patients pain level, large buttocks wound, or patient being left alone in the home. 10. Clinical record review for Patient #14, on 04/10/2023, evidenced an agency document dated 06/20/2022, titled, ";Physician Order," which indicated hospice aide visits to be added. Review of an agency document dated 06/20/2022, titled, ";Aide Care Plan," indicated aide frequency to be 2 times per week. Review of the record failed to evidence coordination of an aide visit was performed prior to patients passing on 06/24/2022. During an interview on 04/05/2023, at 4:51 PM, family member #10 indicated an aide did not see the patient prior to the patients passing. Family member #10 indicated hospice aide was offered prior to patients decline but never saw the patient. Family member #10 indicated the patient would have benefited from aide services. Review evidenced an agency document dated 06/23/2022, titled, ";RN Skilled Nursing Visit," which indicated the patient had a new deep tissue injury wound to right buttocks. Review failed to evidence the nurse notified the physician of the new wound findings. Review of an agency document titled, ";Plan of Care Order," for benefit period 05/17/2022-08/14/2022, failed to evidence wound care orders for the new wound to the buttocks. Review of the chart records failed to evidence wound care orders. During an interview on 04/13/2023, at 11:38 AM, LPN 1 indicated the physician should be notified of a new wound and orders should have been added to the plan of care.

Based on record review and interview the hospice agency failed to ensure the hospice aides reported changes in the patients medical, nursing, rehabilitative, and social needs to a registered nurse, as the changes related to the plan of care in 2 of 15 clinical records reviewed with a hospice aide (#10, 11). The findings include: --- 1. Record review evidenced an agency policy dated 10/01/2021, titled, ";Employee Supervision," which stated, ";... The Hospice will provide timely supervision of the following employees by qualified individuals: Hospice Aides .. The supervising Registered Nurse must assess a Hospice Aides ability to demonstrate initial and continued satisfactory performance in meeting outcome criteria that include, but is not limited to ... Reporting changes in the patients condition ...." 2. Clinical record review for patient #10 on 04/06/2023, evidenced an agency document dated, 03/21/2023, titled, ";Aide Care Visit," which indicated patient complained about general pain. Review of an agency document dated 03/22/2023, titled, ";Aide Care Visit," indicated patient was in pain during range of motion and turning. Review of an agency document dated 03/23/2023, titled, ";Aide Care Visit," indicated patient was in pain during bed bath. Review of an agency document dated 03/29/2023, titled, ";Aide Care Visit," indicated only peri care, skin care and mouth care were completed due to patients high level of pain. Review of an agency document dated 03/30/2023, titled, ";Aide Care Visit," indicated patient was in pain when aide turned or moved patient. Review of an agency document dated 03/31/2023, titled, ";Aide Care Visit," indicated patient was screaming in pain when she was turned/moved. Review failed to evidence the aide reported the patients complaint of pain during care to the clinical supervisor. During an interview on 04/10/2023, at 1:37 PM, the Clinical Supervisor indicated the aide should report any change in patients condition to the nurse. 3. Clinical record review for patient #11 evidenced an aide visit note dated 5/13/2022 which stated, "... Pt [patient] was declining when I came into home, assisted with tasks that I could." Review of all aide visit notes and all coordination notes failed to evidence the aide communicated the declining patient status to the supervising nurse. During an interview on 4/14/2023 at 3:07 PM, the Clinical Supervisor indicated if an aide observed any change in patient status, they should notify her. When informed of the findings, the Clinical Supervisor indicated the patient's record failed to evidence the aide notified anyone of the patient's declining status.

Based on record review and interview, the agency failed to ensure nursing services were provided in a manner consistent with accepted standards of practice in 5 of 6 records reviewed of patients with wounds (#4, 5, 7, 9, 15). The findings include: --- 1. Review of an agency policy titled "Standards of Practice", dated 10/1/2021, indicated the hospice will provide patient care in accordance with the state's Practice Acts for acceptable standards of practice. 2. Review of the Indiana Nurse Practice Act (IC 25-23-1-1.1, IC25-23-1-7) indicated the registered nurse shall execute regimens delegated by a physician, implement strategies to provide for patient health promotion, maintenance, and restoration. 3. Review of a skilled nurse visit note dated 3/15/2023, evidenced Patient #5 had a right underarm wound which the nurse cleansed with saline, applied petroleum gauze and covered with abdominal pads. The note indicated the patient had wounds to the sternum and left upper chest which the nurse covered with telfa pads and wrapped with kerlix (rolled dry gauze). Review of a skilled nurse visit note dated 3/24/2023, evidenced the nurse instructed the patient to put Neosporin or petroleum gauze to their chest wound. Review of a skilled nurse visit note dated 4/5/2023, evidenced the nurse performed wound care. Review of an IDG (interdisciplinary group) meeting note dated 3/21/2023, indicated the hospice would provide wound care supplies and educate the patient / caregivers on wound care. Review of the plan of care and all orders for benefit period 3/14/2023 to 6/11/2023, failed to evidence any wound care orders. During an interview on 4/14/2023 at 10:58 AM, the Clinical Supervisor reviewed the patient's record and indicated she did not see any wound care orders. 4. Clinical record review for Patient #7 evidenced a physician's order dated 1/6/2023, which indicated the patient had a suprapubic catheter (a tube inserted through the abdomen to drain the bladder) that was to be changed monthly. Review of skilled nurse visit notes for benefit period 1/6/2023 to 4/5/2023 evidenced notes dated 1/19/2023, 1/26/2023, 2/2/2023, 2/9/2023, 2/23/2023, 3/2/2023, 3/9/2023, 3/16/2023 and 3/21/2023, which failed to evidence assessment of the suprapubic catheter site and assessment of the urine. During an interview on 4/14/2023 at 12:10 PM, the Clinical Supervisor indicated if a patient has a suprapubic catheter, the nurse should assess and document the appearance of the site, patency, and description of the urine. 5. Clinical record review for Patient #4 on 04/13/2023, evidenced an agency document dated 03/29/2023, titled, ";RN [registered nurse] Skilled Nursing Visit," which indicated the patient had a sacral wound that was fragile but not open and nurse gave hydrocolloid dressing to the caregiver. Review of an agency document dated 04/03/2023 and 04/07/023, titled, ";RN Skilled Nursing Visit," indicated the patient had a sacral spot with a foam dressing. Review of an agency document titled, ";Plan of Care Order," for benefit period 01/28/2023-04/27/2023, failed to evidence a wound care order for a dressing to be applied. Review of the patients chart evidenced an agency document dated 03/17/2023, titled, ";Physician Order," which indicated cleanse open area on buttocks with wound cleanser, apply zinc oxide and leave open to air. Review failed to evidence the physician wound care orders were being followed from 03/17/2023 on. 6. Clinical record review on 04/06/2023, for patient #9, evidenced an agency document dated 02/07/2023, titled, ";LPN [licensed practical nurse] Skilled Nursing Visit," which indicated the patient had a stage II (skin loss with a pink wound bed) open pressure injury to the right buttock/hip area and a left open heel wound. Review indicated the left heel was cleansed and triple antibiotic cream, bandage and kerlix were applied. Review indicated the right buttock/hip area had an exoderm dressing applied. Review of agency documents dated 02/22/2023, 02/24/2023, and 02/28/2023, titled, ";LPN Skilled Nursing Visit," indicated the nurse applied medahoney to the left heel wound and left the wound open to area and an exoderm dressing was applied to the right buttocks wound. Review of agency documents dated 03/03/2023, 03/07/20203, 03/10/2023, 03/14/2023, 03/17/2023, and 03/24/2023, titled, ";LPN Skilled Nursing Visit," indicated medahoney being applied to left heel wound and being left open to air and silicone dressing applied to right buttocks area for stage II pressure injury. Review of an agency document dated 03/28/2023, titled, ";RN Skilled Nursing Visit," indicated the patients sacral wound area was cleaned and hydrocolloid dressing placed. Review of an agency document dated 03/31/2023, titled, ";RN Skilled Nursing Visit," indicated left heel wound care had powder applied, and hydrocolloid to sacral area applied. Review of an agency document dated 04/04/2023, titled, ";RN Skilled Nursing Visit," indicated wound to sacral area was cleaned and optifoam dressing applied. Review of an agency document dated 04/07/2023, titled, ";RN Skilled Nursing Visit," indicated left heel cleaned with spray, applied powder, dressing applied, and wound to sacral area cleaned and dressed with optifoam. Review of an agency document titled, ";Plan of Care Order," for certification period 11/23/2022-02/20/2023, failed to evidence wound care orders for the left heel or sacral wound. Review failed to evidence a current/updated plan of care. Review of an agency document dated 01/18/2023, titled, ";Physician Order," indicated triple antibiotic ointment to left heel and band aid to wound opening. Review failed to evidence the wound care orders were being followed. During an interview on 04/12/2023, at 1:30 PM, the Clinical Supervisor indicated the clinician would just follow the old plan of care if there was no current plan of care. During an interview on 04/12/2023, at 1:30 PM, the Clinical Supervisor indicated there were no current wound orders, the last wound orders were from 01/18/2023, which indicated triple antibiotic ointment to left heel and indicated the band aid was to sacral wound opening. The Clinical Supervisor indicated a podiatrist had seen patient and gave orders for left heel wound care however, there was no documentation of wound orders. 7. Clinical record review on 04/13/2023, for patient #15, evidenced an agency document dated 03/31/2023, titled, ";RN Skilled Nursing Visit," which indicated the patient had dressing to wound with no open areas, but skin was fragile, the visit note failed to document location of wound. Review of an agency document dated 03/20/2023, titled, ";RN Recertification," indicated the patient had a fragile wound to the buttocks covered with hydrocolloid dressing. Review of an agency document titled, ";Plan of Care Order," for benefit period 01/22/2023-03/22/2023, failed to evidence wound care orders. Review failed to evidence an updated/current plan of care. Review of an agency document dated 03/03/2023, titled, ";Physician Order," indicated cleanse coccyx pressure sore with wound cleanser, pat dry with 4x4 and apply exoderm every 3 days. Review of an agency document dated 03/7/2023, titled, ";LPN Skilled Nursing Visit," indicated preventative to coccyx area zinc oxide and abd [abdominal] pad changed daily by caregiver. Review failed to evidence orders for exoderm dressing every 3 days being followed. During an interview on 04/12/2023, at 1:30 PM, the Clinical Supervisor indicated the clinician would just follow the old plan of care if there was no current plan of care. 8. During an interview on 04/13/2023, at 11:38 AM, LPN 1 indicated a wound should have orders entered on the plan of care from the physician. 9. During an interview on 04/12/2023, at 10:00 AM, agency staff #3 indicated there was no wound care policy.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician: A copy of the hospice discharge summary [and] the patient's record if requested. This standard was not met as evidenced by a review of clinical records and interviews. In 1 of 3 (33%) of applicable records of discharged patients revealed no documentation that a discharge summary was sent to the attending physician. There was no documented evidence that RN Case Manager had provided a discharge summary for the attending physician to assist to another setting. In an interview with the Director of Nurses (DON) on 1/23/2023, it was stated that the physician had been notified by telephone but a discharge summary had not been offered. . Clinical Record 2 For the Benefit Period, 6/13/2022 through 9/10/2022, diagnosis included Chronic Obstructive Pulmonary Disease, Hypertensive Heart Disease, Unspecified Atrial Fibrillation, Type 2 Diabetes Mellitus, Acute Kidney Failure, Unspecified. The SN note, dated 6/24/2022, documented that the patient's son had requested the patient be sent to a local hospital due to wanting treatment at this time. The Revocation was signed by the son on 6/24/2022. There was no documented evidence that the attending physician was offered or provided a discharge summary.

It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least the following a summary of the patient’s hospice stay, including treatments, symptoms, and pain management; the patient’s current plan of care; the patient’s latest physician orders; and any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. This standard was not met as evidenced by a review of clinical records and interviews. In 1 of 3 (33%) applicable records of discharged patients revealed that the discharge summary did not contain the current Plan of Care, current Physician Orders, the status of problems identified at admission and during the client’s period of service detailing provisions of care, the resolution of identified problems, continuing symptom management, or a summary of care or services provided to the patient. There was no documented evidence that RN Case Manager had provided a discharge summary for the attending physician to assist to another setting. In an interview with the Director of Nurses (DON) on 1/23/2023, it was stated that the discharge summary had not been completed. . Clinical Record 2 For the Benefit Period, 6/13/2022 through 9/10/2022, diagnosis included Chronic Obstructive Pulmonary Disease, Hypertensive Heart Disease, Unspecified Atrial Fibrillation, Type 2 Diabetes Mellitus, Acute Kidney Failure, Unspecified. The SN note, dated 6/24/2022, documented that the patient's son had requested the patient be sent to a local hospital due to the client " wanting treatment at this time.” The Revocation was signed by the son on 6/24/2022. There was no documented evidence that the agency provided a Discharge Summary to the receiving facility. In addition, the status of problems identified at admission, including the provisions of care, the resolution of identified problems, continuing symptom management, a Summary of Care or services provided, the patient’s current Plan of Care, and the patient's latest Physician Orders, were not forwarded to the facility receiving this client upon Revocation of Hospice Services.