Every finding on record at Trinity Home Health Services

Based on clinical record review, review of agency policies and interviews with hospice personnel, for one of one patient (Patient #1) who received hospice services, the hospice agency failed to ensure effective symptom control for a condition related to the terminal illness. The finding includes: --- Patient #1 elected the hospice benefits on 05/13/2024 with diagnoses of left kidney cancer with metastases to the lungs, protein calorie malnutrition and sepsis. The physician's orders dated 05/13/2024 included nursing services weekly for assessments, social work services and chaplain services. Patient #1 had been residing in a skilled nursing facility but requested to return home for the management of the terminal illness. Review of Patient #1’s coordination note report dated 05/10/2024, identified the social worker from the skilled nursing facility requested the hospice agency contact the Patient’s responsible party to discuss hospice care and determine if the Patient would remain at the skilled nursing facility or be discharged to home. Review of Patient #1’s coordination note report dated 05/11/2024, identified the hospice agency spoke with the Patient’s responsible caregiver to provide additional hospice information and philosophy. The hospice agency ordered the Patient’s durable medical equipment which would be delivered to the Patient’s home on 05/13/2024. Review of Patient #1’s coordination note report dated 05/13/2024, identified the social worker from the skilled nursing facility reported the skilled nursing facility would attempt to discharge the patient home on 05/13/2024. Review of Supervisor of Clinical Services (SCS) #1’s nursing admission note dated 05/13/2024 at 3:42 PM, identified the Patient was discharged to home on 05/13/2024 from a skilled nursing facility. The Patient was received lying in a hospital bed in the living room. The Patient presented with facial grimacing with repositioning, brief episodes of hyperventilation and intermittent moaning. Patient #1 was on two (2) liters of oxygen via nasal cannula continuously for comfort. SCS #1 ordered Morphine and Lorazepam from a local pharmacy for the Patient’s responsible caregiver to obtain, and ordered the Patient’s hospice Comfort Pak (a pre-packaged set of medications provided to the patient to manage common end of life symptoms) to be delivered to the home. Physician’s orders for the hospice Comfort Pak directed to administer Haloperidol Lactate 2 mg/milliliter (ml) oral concentrate 0.5 ml every six (6) hours as needed for severe agitation, Hyoscyamine 0.125 mg sublingual tablet every four (4) hours as needed for increased secretions, Lorazepam 0.5 mg one (1) tablet every three (3) hours as needed for mild anxiety, Lorazepam 0.5 mg two (2) tablets every three (3) hours as needed for moderate anxiety, Lorazepam 0.5 mg four (4) tablets every three (3) hours as needed for severe anxiety, Morphine Concentrate 20 mg/ml 0.25 ml every three (3) hours by mouth as needed for mild pain or shortness of breath, Morphine Concentrate 20 mg/ml 0.5 ml every three (3) hours by mouth as needed for moderate pain or shortness of breath, Morphine Concentrate 20 mg/ml 1 ml every three (3) hours by mouth as needed for severe pain or shortness of breath, Prochlorperazine maleate 10 mg one (1) tablet every four (4) hours as needed for nausea or vomiting and Oxygen two (2) liters as needed for comfort. Review of RN #1’s nursing note dated 05/14/2024 at 12:52 PM identified Patient #1 was lying in a hospital bed on his/her left side with two (2) liters of oxygen via nasal cannula in place. Patient #1 was unresponsive to verbal or tactile stimuli, respirations were deep, and swallow and he/she received Morphine and Lorazepam every three (3) hours with effectiveness. Review of Patient #1’s coordination note report dated 05/14/2024 at 6:45 PM by the hospice’s on-call RN #2, identified the Patient had terminal secretions (the accumulation of saliva and mucus in the upper airway of a patient nearing the end of life which is treated with positioning, mouth swabs and medication) but had no medication in the home to treat the secretions and a nursing visit was planned for the morning. Review of Patient #1’s coordination note report dated 05/14/2024, identified the Patient had expired and a nursing visit was scheduled. Review of Patient #1’s nursing note dated 05/14/2024 at 9:15 PM, identified the Patient #1 was pronounced at 9:15 PM by the nurse, the Morphine and Lorazepam was discarded and emotional support was provided. Interview with the Administrator and SCS #1 on 07/23/2025 at 11:30 AM, failed to identify on-call RN #2 followed the Agency Service Hours and After-Hours Process policy, as on-call RN #2 identified the Patient had not received the hospice Comfort Pak medication to treat the Patient’s terminal secretions, but failed to provide additional interventions such as contacting the primary physician for an additional order, or the scheduling of an on-call hospice clinician to perform an after-hours visit for the management of the terminal illness end of life symptoms. Review of the Agency Service Hours and After-Hours Process policy, identified the hospice after-hour visits may be unscheduled, initiated through the after-hours system, or scheduled to accommodate a particular patient’s need or request. During a patient call to the answering service/ Virtual Care Center RN, the RN would medically triage the patient call and recommend clinical interventions based on the hospice plan of care or contact the primary physician for additional orders or schedule on-call hospice clinicians to perform an after hours visit. The hospice staff would offer a home visit when the patient’s pain or other symptoms are not controlled and require intervention.

Based on clinical record review, review of agency policies and interview with hospice personnel for one of one patient (Patient #1) the hospice agency failed to maintain professional management of the hospice care. The findings include: --- Patient #1 elected the hospice benefits on 05/13/2024 with diagnoses of left kidney cancer with metastases to the lungs, protein calorie malnutrition and sepsis. The physician's orders dated 05/13/2024 included nursing services weekly for assessments, social work services and chaplain services. Patient #1 had been residing in a skilled nursing facility but requested to return home for the management of the terminal illness. Review of Patient #1’s coordination note report dated 05/10/2024, identified the social worker from the skilled nursing facility requested the hospice agency contact the Patient’s responsible party to discuss hospice care and determine if the Patient would remain at the skilled nursing facility or be discharged to home. Review of Patient #1’s coordination note report dated 05/11/2024, identified the hospice agency spoke with the Patient’s responsible caregiver to provide additional hospice information and philosophy. The hospice agency ordered the Patient’s durable medical equipment which would be delivered to the Patient’s home on 05/13/2024. Review of Patient #1’s coordination note report dated 05/13/2024, identified the social worker from the skilled nursing facility reported the skilled nursing facility would attempt to discharge the patient home on 05/13/2024. Review of Supervisor of Clinical Services (SCS) #1’s nursing admission note dated 05/13/2024 at 3:42 PM, identified the Patient was discharged to home on 05/13/2024 from a skilled nursing facility. The Patient was received lying in a hospital bed in the living room. The Patient presented with facial grimacing with repositioning, brief episodes of hyperventilation and intermittent moaning. Patient #1 was on two (2) liters of oxygen via nasal cannula continuously for comfort. SCS #1 ordered Morphine and Lorazepam from a local pharmacy for the Patient’s responsible caregiver to obtain and ordered the Patient’s hospice Comfort Pak (a pre-packaged set of medications provided to the patient to manage common end of life symptoms) to be delivered to the home. Physician’s orders for the hospice Comfort Pak directed to administer Haloperidol Lactate 2 mg/milliliter (ml) oral concentrate 0.5 ml every six (6) hours as needed for severe agitation, Hyoscyamine 0.125 mg sublingual tablet every four (4) hours as needed for increased secretions, Lorazepam 0.5 mg one (1) tablet every three (3) hours as needed for mild anxiety, Lorazepam 0.5 mg two (2) tablets every three (3) hours as needed for moderate anxiety, Lorazepam 0.5 mg four (4) tablets every three (3) hours as needed for severe anxiety, Morphine Concentrate 20 mg/ml 0.25 ml every three (3) hours by mouth as needed for mild pain or shortness of breath, Morphine Concentrate 20 mg/ml 0.5 ml every three (3) hours by mouth as needed for moderate pain or shortness of breath, Morphine Concentrate 20 mg/ml 1 ml every three (3) hours by mouth as needed for severe pain or shortness of breath, Prochlorperazine maleate 10 mg one (1) tablet every four (4) hours as needed for nausea or vomiting and Oxygen two (2) liters as needed for comfort. Review of RN #1’s nursing note dated 05/14/2024 at 12:52 PM identified Patient #1 was lying in a hospital bed on his/her left side with two (2) liters of oxygen via nasal cannula in place. Patient #1 was unresponsive to verbal or tactile stimuli, respirations were deep, and swallow and he/she received Morphine and Lorazepam every three (3) hours with effectiveness. Review of Patient #1’s coordination note report dated 05/14/2024 at 6:45 PM by the hospice’s on-call RN #2, identified the Patient had terminal secretions (the accumulation of saliva and mucus in the upper airway of a patient nearing the end of life which is treated with positioning, mouth swabs and medication) but had no medication in the home to treat the secretions and a nursing visit was planned for the morning. Review of Patient #1’s coordination note report dated 05/14/2024, identified the Patient had expired and a nursing visit was scheduled. Review of Patient #1’s nursing note dated 05/14/2024 at 9:15 PM, identified the Patient #1 was pronounced at 9:15 PM by the nurse, the Morphine and Lorazepam was discarded and emotional support was provided to the caregivers. Interview with the Administrator and SCS #1 on 07/23/2025 at 11:30 AM, failed to identify the on-call RN #2 followed the Agency Service Hours and After-Hours Process policy, as on-call RN #2 identified the Patient had not received the hospice Comfort Pak medication to treat the Patient’s terminal secretions, but failed to provide additional interventions such as contacting the primary physician for an additional order or schedule an on-call hospice clinician to perform an after-hours visit for the management of the end of life symptoms of the terminal illness. Review of the Agency Service Hours and After-Hours Process policy, identified the hospice after-hour visits may be unscheduled, initiated through the after-hours system, or scheduled to accommodate a particular patient’s need or request. During a patient call to the answering service/ Virtual Care Center RN, the RN would medically triage the patient call and recommend clinical interventions based on the hospice plan of care or contact the primary physician for additional orders or schedule on-call hospice clinicians to perform an after hours visit. The hospice staff would offer a home visit when the patient’s pain or other symptoms are not controlled and require intervention.

Based on clinical record review, review of agency policies and interview with agency personnel for one of three patients (Patient #1) reviewed for premature discharge, the hospice agency failed to follow agency policies and the Regulations of Connecticut State Agencies. The finding includes. --- Patient #1 elected the Hospice benefits on 4/16/24. The patients diagnoses included hypertensive heart disease with heart failure and dementia without behaviors. The physician's orders dated 4/16/24 included nursing services two times a week for assessments, hospice aide services and social work services. Physicians orders included Morphine 5 milligrams/0.25 milliliters (mg/ml) orally twice daily and every three hours as needed for pain. On 6/02/24 at 11:35 AM, RN #1 (weekend on-call nurse) conducted an as needed visit for constipation per request of the next of kin. Registered Nurse/RN #1 spoke with the next of kin #1 prior to the visit, who was unsure of the last bowel movement, requested assistance with a transfer back to bed and indicated that despite administering Morphine 0.25 ml one half hour prior to calling the RN, the patient was in pain. RN #1 instructed the next of kin #1 to administer an additional dose of Morphine 0.25 ml prior to the visit. Upon the nurses arrival, the patient was sitting comfortably on the couch with next of kin #1 and #2 present. The patient was conversive, denied pain and made eye contact with the nurse. Prior to transfer, the nurse asked for permission from the patient to transfer him/her back to bed with the assistance of next of kin #2 and the patient indicated to RN #1 that ";s/he would fight the nurse". RN #1 asked for clarification of what was said, the patient stated, ";that is what s/he does". RN #1 explained to the patient that s/he was slipping off the couch and wanted him/her to be safe and comfortable. The patient then indicated that ";s/he would not fight" the nurse. Once the patient was transferred back to bed, RN #1 and next of kin #2 grasped the pad underneath the patient and boosted the patient up in bed, at which time, the patient swung his/her right hand and hit the nurse on the right side of the face and scratched the nurse. The nurse responded by requesting the patient not to hit him/her again and asked permission to assess the patients abdomen. Upon auscultation of the abdomen, the patient began to bend and tense his/her arm, at which time, the nurses stopped the exam and explained to the family that s/he was uncomfortable continuing with the exam. The next of kin #1 then held the patients hand and encouraged the nurse to continue with the exam. The family reported that the case manager, RN #2, also had been hit by the patient. Education provided to the family concerning the need for frequent perineal care, use of medications to prevent constipation and comfort medications to utilize. Upon exiting the home, the nurse called the weekend supervisor (RN #3) to inform him/her of being slapped during the visit. Review of RN #3s Client Coordination Note dated 6/02/24 at 6:16 PM, identified calling next of kin #3 to discuss the patient slapping RN #1 and #2 and the concern with the lack of intervention by the family. RN #3 indicated that patient and staff safety are a priority and given the severity of the incident, the agency must take appropriate measures including discharging the patient. Interview and review of the clinical record and RN #1s nursing note dated 6/02/24 with the Administrator and Hospice Program Director on 8/15/24 at 1:40 PM, indicated that upon further investigation of the patients behavior, including a hospice aide kicked in the abdomen on 5/31/24, but never reported it, and two incidents of the patient slapping the nurses, the decision was made to emergently discharge the patient, but failed to identify that the Risk Manager was contacted, a two-day notice was given and/or a termination letter informing the patient/representative of the reasons for termination of services with the names, addresses and phone numbers of other agencies which may be able to provide services, was completed according to agency discharge policies. Review of agency discharge policy directed, if hospice services can no longer be provided due to behavior issues, the hospice agency will make a serious effort to resolve the problem presented by the patients behavior or situation such as attempting to contract with the patient/family, the Risk Manager will be contacted when the hospice determines discharging the patient is necessary, will obtain a signed physicians order authorizing the discharge from the medical director, give adequate notice to the patient/representative and physician before terminating services to allow the patient to arrange for needed alternative care, and notify the patient of the impending discharge at least two (2) days in advance of the discharge date. For all patients, sends or delivers a termination letter informing the patient/representative of the reasons for termination of services and provides the names, addresses and phone numbers of other agencies which may be able to provide services.