Every finding on record at Visiting Nurse Association of Cape Cod, Inc.

Based on interviews, review of surveillance camera video footage and records reviewed, for one of three sampled patients (Patient #1), the Hospice failed to ensure Patient #1's rights were respected when Nurse #3 copied video footage from the Hospice's surveillance camera system from 10/14/22 which included Patient #1, depicted care and treatment he/she received from staff. Nurse #3 then distributed the captured video footage via text message to the personal cell phones of Nurse #4, Nurse #5 and the Dietician. --- Findings include: Review of the Visiting Nurse Association (VNA) Hospice Patient and Family Guide, dated 1/2020, indicated that Patient Rights and Responsibilities included the right to have their property and person treated with respect. During interviews with Nurse #3 on 5/03/23 at 4:00 P.M. and 5/04/23 at 9:00 A.M., Nurse #3 said that on 10/14/22, she recorded video footage on her personal cell phone from the Hospice's video surveillance system. Nurse #3 said that the video footage which she captured depicted Patient #1 in bed, receiving care from Nurse #1. Nurse #3 said that she recorded the video surveillance footage on her personal cell phone because she had concerns about the care that Nurse #1 provided to Patient #1. Nurse #3 said she texted portions of the video footage that she captured to the personal cell phones of Nurse #4, Nurse #5 and the Dietician. Review of the surveillance camera video footage recorded by Nurse #3 indicated that she captured footage from 10/14/22 which which showed Patient #1 in bed with Nurse #1 at his/her bedside. The video footage depicted Patient #1 dressed in a Johnny, with his/her head, arms and legs uncovered while he/she was experiencing episodes of agitation. The video clips were time stamped as follows: - 6:13:01 A.M. to 6:13:09 A.M., - 6:13:17 A.M. to 6:13:49 A.M., - 6:37:36 A.M. to 6:38:18 A.M., and, - 6:39:48 A.M. to 6:41:07 A.M. During an interview on 5/09/23 at 10:30 A.M. Nurse #4 said that Nurse #3 texted 15 to 30 seconds of video footage to her personal cell phone. Nurse #4 said that the video footage which Nurse #3 texted her depicted Patient #1 in a bed and Nurse #1 at his/her bedside holding Patient #1s arms to his/her abdomen with a pillow or blanket. During an interview on 5/09/23 at 11:00 A.M., Nurse #5 said that Nurse #3 texted about two minutes of video footage to her personal cell phone. Nurse #5 said that the video footage depicted Patient #1 in bed experiencing agitation and Nurse #1 at his/her bedside holding Patient #1 in the bed with a pillow. During an interview on 5/05/23 at 9:00 A.M., the Dietician said that Nurse #3 texted video footage to her personal cell phone which was dated 10/14/22 and which depicted Patient #1 in bed receiving care from Nurse #1.

Based on interviews and records reviewed, for one of three sampled patients (Patient #1), the Hospice failed to ensure they obtained written statements during an investigation of an allegation that Nurse #1 abused Patient #1 on 10/14/22, in accordance with the Hospices Patient Abuse, Neglect, Mistreatment or Misappropriation Policy. --- Findings include: Review of the Hospices Patient Abuse, Neglect, Mistreatment or Misappropriation of Patient Property by Individuals Employed by or Working for the Visiting Nurse Association (VNA) of Cape Cod Policy, dated originated 1/01/98 and last revised 5/24/22, indicated that upon receiving a report regarding patient abuse, the Hospice would immediately initiate an internal investigation into the allegation. The Policy indicated that the Hospices internal investigation would include interviewing all witnesses and obtaining their written statements whenever possible. During an interview on 4/26/23 at 9:00 A.M., the Surveyor asked the VNA President and the Human Resource (HR) Manager for a copy of the internal investigation of an allegation that Nurse #1 abused Patient #1. Review of the Hospices internal investigation file indicated that the Hospice documented a series of meetings and interviews held between 10/17/22 and 10/20/22. The meetings and interviews were held by the Director of Hospice, the HR Manager, the VNA President and/or the Hospice Clinical Manager with various Hospice staff members. The unsigned documentation from the meetings and interviews indicated that Nurses #1, #2, #3, #4 and #5 and Hospice Aide #1 were interviewed by the Director of Hospice, the Human Resources Manager, the VNA President and/or the Hospice Clinical Manager during these meetings. The Surveyor asked the HR Manager and the President for written statements from staff members who had been interviewed as part of the Hospices internal investigation of the allegation that Nurse #1 abused Patient #1 and they said that the Hospice did not obtain written statements from the staff members who were interviewed.

Based on interviews, records reviewed and review of surveillance camera video footage, the Hospice failed to ensure Patient #1s right to receive effective symptom control was respected when, on 10/14/22 from approximately 4:00 A.M. through 7:00 A.M., Nurse #1 and Nurse #2 failed to effectively address Patient #1s symptoms when medications administered failed to relieve his/her agitation. --- Findings include: Review of the General Inpatient Care Admission Guidelines for Symptom Control, dated as last revised 2/02/21, indicated that the Hospice ensured symptom management through access to general inpatient care for patients in need of pain control or symptom management that cannot be provided in the home. Review of the Initial Hospice Plan of Care/Assessment and Ongoing Patient Care Planning Policy, dated as last revised 2/02/23, indicated that an individualized plan of care will be established and maintained for each patient admitted to Hospice. The Policy indicated that the patient's response to the care/services will be assessed throughout the patient's stay and review of the Plan of Care is based on patient assessment needs and requests or significant changes in the patient's condition. The Policy indicated that all changes will be reported to the patient's physician. Review of Patient #1s medical record indicated he/she was admitted to the Hospice during October 2022 with diagnoses which included malignant neoplasm of the trachea, restlessness and agitation, disorientation, pain and dyspnea. Patient #1s Hospice Plan of Care for services provided 9/08/22 through 12/06/22 indicated that Patient #1s agitation and delirium would be effectively managed as demonstrated by no verbal or non-verbal signs and symptoms of agitation or delirium. The Plan of Care interventions included assessing the effectiveness of interventions for agitation/delirium, evaluating potential factors contributing to patients hallucinations and instructing patient/caregiver regarding non-pharmacologic and pharmacologic strategies for managing agitation. Review of the Physician Orders indicated the following medications had been ordered for Patient #1 at the time of his/her admission and remained in effect during the overnight shift of 10/13/22 into 10/14/22: - Phenobarbital Sodium Injection Solution (a sedative and anti-seizure medication) 65 milligrams (mg) injection every 4 hours as needed for severe agitation, - Haldoperidol Lactate Oral Concentrate (an atypical antipsychotic medication) 1 to 2 mg/ml (millileter) by mouth or sublingual every 4 hours as needed for moderate agitation/delirium, and, - Lorazepam Injection Solution (an antianxiety medication) 2mg/ml, inject 2 mg via IV or intramuscular injection every 2 hours as needed for anxiety/agitation. Review of Patient #1s Progress Note for the 11:00 P.M. to 7:00 A.M. shift beginning on 10/13/22 and ending on 10/14/22 indicated that at 4:00 A.M., Patient #1 displayed extreme agitation and was medicated with very little effect. Review of Patient #1's Medication Administration Record for 10/14/22 indicated that at 3:45 A.M. Nurse #1 administered Phenobarbital to Patient #1, at 4:00 A.M. Nurse #1 administered Haloperidol and Lorazepam to Patient #1 and at 6:00 A.M. Nurse #1 administer Lorazepam to Patient #1. Review of the Progress Note, dated 10/14/22, indicated that Patient #1 received one to one observation by staff members from 4:00 A.M. to 7:00 A.M. because of extreme agitation which included kicking, yelling momma, trying to bite, throwing pillows and stuffed animals, attempting to get out of bed and pulling at his/her Foley catheter and intravenous line. Review of the surveillance camera video footage from 4:00 A.M. through 7:00 A.M. on 10/14/22 depicted Patient #1 in bed at the Hospice interacting with Nurse #1 and Nurse #2. The video footage depicted Patient #1 attempting to get out of bed multiple times, including almost constant attempts between 5:51 A.M. and 6:54 A.M., and Nurse #1 and Nurse #2 using pillows and blankets to keep Patient #1 lying in bed. The video footage depicted Patient #1 kicking his/her legs at Nurse #1 and Nurse #2, flailing his/her arms and banging the side rail. During interviews on 5/11/23 a 9:00 A.M. with Nurse #1 and on 5/05/23 at 8:09 A.M. with Nurse #2 , they said the following; they cared for Patient #1 during the 11:00 P.M. to 7:00 A.M. shift beginning on 10/13/22 and ending on 10/14/22; at about 4:00 A.M., Patient #1 woke up and displayed extreme agitation; Nurse #1 medicated Patient #1 and he/she did not respond to the medication; Patient #1 repeatedly tried to get out of bed and tried to pull out his/her intravenous lines and catheter.; Patient #1 flailed his/her arms so much that Nurse #2 worried he/she would break a bone on the side rail, and, Patient #1 called out "mom, mom, mom" and was inconsolable. The Surveyor asked Nurses #1 and #2 whether they contacted Patient #1s physician or the Hospice Clinical Manager (a nurse practitioner) when Patient #1s agitation did not respond to the medications that were administered to him/her and Nurses #1 and #2 said that they had not. During an interview on 5/04/23 at 5:16 P.M., the Hospice Clinical Manager said that she was a Nurse Practitioner and she cared for Patient #1 at the Hospice. The Clinical Manager said that when she arrived to the Hospice on 10/14/22 at 7:00 A.M., Nurses #1 and #2 told her that Patient #1 had been agitated since 4:00 A.M. and said they had administered all of the medications that the physician had ordered for him/her without effect. The Clinical Manager said that Nurses #1 and #2 should have called her or the Physician when Patient #1s agitation did not respond to the medications that were administered. The Clinical Manager said that the goal was for hospice patients not to experience any period of time without symptoms being managed.

Based on review of surveillance camera video footage, interviews and records reviewed, for one of three sampled patients (Patient #1) the Hospice failed to ensure Patient #1 was free from abuse when, during the 11:00 P.M. to 7:00 A.M. shift starting on 10/13/22 and ending on 10/14/22, Nurse #1 repeatedly responded to symptoms of Patient #1's agitation by pushing and pulling his/her arms, shoulder and legs to keep him/her lying on his/her back in bed. --- Findings include: Review of the Visiting Nurse Association (VNA) Hospice Patient and Family Guide, dated 1/2020, indicated that patient's have the right to be free from verbal, mental, sexual abuse, neglect and misappropriation of property. Review of Patient #1s medical record indicated he/she was admitted to the Hospice during October 2022 with diagnoses of malignant neoplasm of the trachea, restlessness and agitation, disorientation, pain and dyspnea. Review of Patient #1s Hospice Plan of Care for services provided 9/08/22 through 12/06/22 indicated that Patient #1s agitation and delirium would be effectively managed as demonstrated by no verbal or non-verbal signs and symptoms of agitation or delirium. The Plan of Care interventions included assessing the effectiveness of interventions for agitation/delirium, evaluating potential factors contributing to patients hallucinations and instructing patient/caregiver regarding non-pharmacologic and pharmacologic strategies for managing agitation. Review of Patient #1s Progress Note for the 11:00 P.M. to 7:00 A.M. shift beginning on 10/13/22 and ending on 10/14/22 indicated that at 4:00 A.M., Patient #1 displayed extreme agitation and was medicated with very little effect. The Note indicated that Patient #1 was on one to one observation by staff members until 7:00 A.M. for extreme agitation which included kicking, yelling momma, trying to bite, throwing pillows and stuffed animals, attempting to get out of bed and pulling at his/her Foley catheter and intravenous line. Review of surveillance camera video footage from 4:00 A.M. through 7:00 A.M. on 10/14/22 indicated Patient #1 was in bed and interactions with Nurse #1 were as follows; - at 4:09, Nurse #1 pushed Patient #1 back to the center of the bed when he/she reached out of the bed toward an item on the floor next to the bed. - between 5:51 and 6:54 Nurse #1 pushes Patient #1 to lie down in the bed by pushing or pulling on his/her shoulders, arms or legs about about forty-five times (5:58, 5:49, 6:00, 6:08, 6:10, 6:12, 6:13, 6:14, 6:16, 6:27, 6:19, 6:20, 6:21, 6:22, 6:23, 6:25, 6:29, 6:30, 6:32, 6:34, 636, 6:38, 6:40, 6:41 and 6:42). During an interview on 5/11/23 at 9:00 A.M., Nurse #1 said that she provided one to one care to Patient #1 from 4:00 A.M. to 7:00 A.M. on 10/14/22. Nurse #1 said that Patient #1 was experiencing agitation and she wanted to keep him/her in bed because he/she was at risk to fall and get hurt if he/she got out of bed. Nurse #1 said that when Patient #1 moved to the edge of the bed, she would scoop him/her up and put him/her back into the center of the bed by placing one arm beneath his/her legs and the other arm around his/her back. Nurse #1 said that she thought she scooped Patient #1 back to the center of the bed about fifty times during the shift and she was exhausted and at risk to get hurt. The Surveyor asked Nurse #1 about the instances on the video footage which depicted her pushing and pulling on Patient #1's arms, shoulders and/or legs while he/she was in bed. Nurse #1 said that she moved Patient #1 in this way because he/she was trying to get out of bed, he/she was going to get hurt, she had already picked him/her up and she was feeling exhausted. Nurse #1 said that each time that Patient #1 moved him/herself to the edge of the bed, she had to move him/her further in order to get him/her back lying on the center of the mattress which put her and Patient #1 at risk for injury. Nurse #1 said that she could not pick up Patient #1 every five seconds and that moving him/her to keeping him/her lying back in the center of the mattress was the easiest way to keep him/her safe without hurting her back. Although Patient #1's mental status was impaired on 10/14/22, an unimpaired individual would experience physical pain and mental anguish when a caregiver repeatedly pushed or pulled on their arms, shoulders or legs.

Based on review of surveillance camera video footage, interviews and records review, for one of three sampled staff members (Nurse #1), the Hospice failed to ensure its Infection Control Policy was followed when, during the 11:00 P.M. to 7:00 A.M. shift starting on 10/13/22 and ending on 10/14/22, Nurse #1 did not wear a face mask while in Patient #1's room. and physically interacting with him/her. --- Findings include: Review of the Hospice Updated Mask Guidelines, dated 2/16/22, indicated that staff working in clinical facilities should wear a face mask. Review of surveillance camera video footage on 10/14/22 from 12:02 A.M. through 6:51 A.M. indicates that Nurse #1 provided extensive care to Patient #1, including one to one care from 4:00 A.M. through 6:51 A.M., without wearing a face mask. During an interview on 5/11/23 at 9:00 A.M., Nurse #1 said that although she always wore a face mask at the Hospice, said that on 10/14/22 she entered Patient #1's room without a face mask and said she was unable to leave his/her bedside to obtain a mask at any time because of his/her agitation. Although Nurse #1 said that she could not exit Patient #1's room to retrieve a face mask, review of the video footage indicates that Nurse #1 exited Patient #1's rooms briefly and returned to his/her bedside about ten times between 12:02 A.M. through 6:51 A.M. on 10/14/22, each time without a face mask. The video footage also showed Nurse #2 entering and leaving Patient #1's room multiple times during the same time period and that Nurse #1 could have asked Nurse #2 for a face mask.

Based on interviews, review of surveillance camera video footage and records reviewed, for one of three sampled patients (Patient #1), the Hospice failed to ensure Patient #1 was free from physical restraint when, between 5:19 A.M. and 6:50 A.M. on 10/14/22, Nurse #1 and Nurse #2 repeatedly prevented Patient #1 from moving in his/her bed, sitting up in the bed or freely moving his/her hands and arms, by holding a sheet taut across his/her supine body or pressing a pillow against his/her torso and holding his/her torso onto the mattress. --- Findings include: Review of the Hospice Restraint and Seclusion Policy and Procedure, originated 1/01/20 and last revised 2/02/21, indicated that the Hospice recognized the right of each patient to be free from restraints and seclusion. The Policy indicated that the Hospice provided a restraint free inpatient environment but if a restraint would ever need to be utilized all policies related to restraint would be in effect. The Procedure indicated that the attending physician, hospice medical director or hospice physician must order the use of restraint or seclusion. Review of Patient #1s medical record indicated he/she was admitted to the Hospice during October 2022 with diagnoses of malignant neoplasm of the trachea, restlessness and agitation, disorientation, pain and dyspnea. Review of Patient #1s Hospice Plan of Care for services provided 9/08/22 through 12/06/22 indicated that Patient #1s agitation and delirium would be effectively managed as demonstrated by no verbal or non-verbal signs and symptoms of agitation or delirium. The Plan of Care interventions included assessing the effectiveness of interventions for agitation/delirium, evaluating potential factors contributing to patients hallucinations and instructing patient/caregiver regarding non-pharmacologic and pharmacologic strategies for managing agitation. Review of Patient #1s Hospice Plan of Care and Physician Orders indicated there was no documentation to support the physician having ordered restraint or seclusion for Patient #1. Review of Patient #1s Progress Note for the 11:00 P.M. to 7:00 A.M. shift beginning on 10/13/22 and ending on 10/14/22 indicated that at 4:00 A.M., Patient #1 displayed extreme agitation and was medicated with very little effect. The Note indicated that Patient #1 was on one to one observation by staff members until 7:00 A.M. for extreme agitation which included kicking, yelling momma, trying to bite, throwing pillows and stuffed animals, attempting to get out of bed and pulling at his/her Foley catheter and intravenous line. Review of surveillance camera video footage from 4:00 A.M. through 7:00 A.M. on 10/14/22 shows Patient #1 in bed at the Hospice interacting with Nurse #1 and Nurse #2 as follows: - From 5:19 A.M. to 5:38 A.M. Nurse #1 and Nurse #2 place a folded blanket across Patient #1s chest and hold the ends of the blanket to the mattress next to Patient #1, preventing Patient #1 from sitting up in the bed or freely moving his/her arms. - From 5:54 A.M. to 5:58 A.M. Nurse #1 and Nurse #2 place a pillow across Patient #1s chest and hold the ends of the pillow to the mattress, preventing Patient #1 from sitting forward in the bed, - From 6:08 A.M. to 6:15 A.M., Nurse #1 holds a pillow across Patient #1s chest by pressing the pillow into Patient #1s chest/abdomen or by holding the ends of the pillow to the mattress, preventing Patient #1 from sitting in the bed, - From 6:17 A.M. to 6:23 A.M., Nurse #1 holds a pillow across Patient #1s chest by pressing the pillow into Patient #1s chest/abdomen or by holding the ends of the pillow to the mattress, preventing Patient #1 from sitting in the bed or moving his/her arms freely, and, - From 6:25 A.M. to 6:37 A.M. Nurse #1 holds a pillow across Patient #1s chest by pressing the pillow into Patient #1s chest/abdomen or by holding the ends of the pillow to the mattress, preventing Patient #1 from sitting in the bed or moving his/her arms freely. During interviews on 5/11/23 at 9:00 A.M. with Nurse #1 and on 5/05/23 at 8:09 A.M. with Nurse #2, Nurses #1 and #2 said that they cared for Patient #1 during the 11:00 P.M. to 7:00 A.M. shift which started on 10/13/22 and ended on 10/14/22. Nurses #1 and #2 said that around 4:00 A.M., Patient #1 became really agitated. Nurses #1 and #2 said that although Nurse #1 medicated Patient #1, Patient #1's extreme agitation did not respond to the medication administered. Nurses #1 and #2 said that Patient #1 repeatedly tried to get out of the bed and they tried to keep him/her safe. The Surveyor asked Nurses #1 and #2 whether they used a pillow or a blanket to keep Patient #1 in the bed. Nurse #2 said that Patient #1 moved up in the bed toward the headboard and they placed a pillow between the headboard and Patient #1s head. Nurse #2 said that she and Nurse #1 tried to cuddle Patient #1 and reassure him/her that he/she was safe. Nurse #2 said that she and Nurse #1 held Patient #1s arms onto the mattress when he/she flailed his/her arms because his/her arms were very fragile. Although Nurse #2 said that they did not hold a pillow or a blanket across Patient #1s chest, her statement is contradicted by the surveillance camera video footage which depicted Nurse #1 and Nurse #2 holding the pillow and blanket across Patient #1's chest. Nurse #1 said that Patient #1 was at risk to hurt him/herself because of his/her attempts to get out of bed and she and Nurse #2 decided to keep him/her softly and comfortably lying back on the mattress and controlling him/her by using a soft blanket and a pillow. Nurse #1 said that while she and Nurse #2 spoke reassuringly to Patient #1 and waited for the medications administered to take effect, they used the blanket and pillow to prevent Patient #1 from sitting forward or moving toward the edge of the bed. During an interview on 4/26/23 at 9:00 A.M., the Visiting Nurse Association (VNA) President said that she had viewed video surveillance camera footage from the 11:00 P.M. to 7:00 A.M. shift which started on 10/13/22 and ended on 10/14/22. The VNA President said that the video surveillance footage depicted Patient #1 being restrained. Although Patient #1's impaired mental status minimized his/her understanding of the incident, an unimpaired individual would experience physical pain and mental anguish when a caregiver held them back onto a mattress in bed without freely being able to sit forward or to move their arm for more then forty-five minutes.