Every finding on record at Unc Hospice

Based on agency policy, clinical record review and staff interviews the agency failed to include the patients representative in developing the plan of care for 1 of 3 patients admitted for general inpatient care. (#2) Findings included: --- A policy, Inpatient IDT Care Planning Process (revised 02/2021) was received from the clinical manager on 11/06/2023 at approximately 2:50 P.M. The policy stated, ";All care and services furnished to patients and their families follows an individualized written plan of care established by the IDT [Interdisciplinary Development Team] in collaboration with the attending physician (if any), the patients or patient representative..." The Hospice Rights of the Patient (revised 12/2021) was signed on 09/22/2023 by the patients legal representative and a hospice representative. The Hospice Rights of the Patient stated, ";Be informed and participate in the development of his or her plan of care [patient/representative]." Patient #2 was admitted on 09/22/023 with a diagnosis of neurosarcoidosis (inflammation and abnormal cell deposits in the nervous system). The plan of care (POC) for 09/22/2023-09/24/2023 included orders for 24-hour nursing. On 09/24/2023 at 2:16 A.M. RN (registered nurse) #3 stated, ";Pt [patient] given prn [as needed] medications several times... for severe agitation. MD [medical doctor] consulted and orders changed to meet needs. Thorazine [anti-psychotic] added and Haldol [anti-psychotic], hydromorphone [opioid] and Ativan [anti-anxiety] doses adjusted to create a range to accommodate pts needs." There was no evidence in the clinical record of the patients spouse being contacted about the changes to the POC. An interview was conducted with RN #3 on 11/06/2023 at approximately 2:15 P.M revealed that the patients spouse was not contacted before the change to the POC. RN #3 stated, ";I think the family is supposed to be involved in the Plan of Care." An interview was conducted on 11/06/2023 at approximately 2:25 P.M. with the clinical manager. The clinical manager stated, ";If its just a medication adjustment we would not contact the spouse at 2:00 AM, if it wasnt a new medication."

Based on agency policy, clinical record review, and staff interviews the agency failed to allow a patients representative to refuse care or treatment for 1 of 1 patient refusing treatment. (Patient #2) Findings included: --- The Hospice Rights of the Patient (revised 12/2021) was signed on 09/22/2023 by the patients legal representative and a hospice representative. The Hospice Rights of the Patient stated, ";Refuse care or treatment [patient/representative]." Patient #2 was admitted on 09/22/023 with a diagnosis of neurosarcoidosis (inflammation and abnormal cell deposits in the nervous system). The plan of care (POC) for 09/22/2023-09/24/2023 included orders for 24-hour nursing and lorazepam (Ativan, anti-anxiety) 1mg intravenously every hour PRN (as needed.) The lorazepam dose was changed on 09/24/2023 to 2mg intravenously every hour PRN. On 09/23/2023 at 5:13 P.M. RN #3 stated, ";Family left bedside...and requested minimal medications be given." On 09/23/2023 at 7:03 P.M. RN #3 stated, ";Ativan [lorazepam] given for repeated calling out." On 09/24/2023 at 2:16 A.M., RN #3 stated, ";Pt [patient] given prn [as needed] medications several times... for severe agitation. MD [medical doctor] consulted and orders changed to meet needs. Thorazine [anti-psychotic] added and Haldol [anti-psychotic], hydromorphone [opioid] and Ativan [anti-anxiety] doses adjusted to create a range to accommodate pts needs." On 09/23/2023 at 2145 and 2330 PRN lorazepam 1mg was administered to patient #2. An interview with RN #3 on 11/06/2023 at approximately 2:15 P.M. revealed that patient #2s family was opposed to lorazepam being administered to the patient. There was no evidence in the clinical record of a doctor being notified of the concerns to obtain new orders. An interview was conducted with the clinical manager on 11/06/2023 at approximately 2:25 P.M. The clinical manager stated, ";I think that we would do everything that we could to honor their [family] wishes, if symptoms are not being controlled with other medications, we would give the Ativan [lorazepam] to keep the patient comfortable."