Every finding on record at Visiting Nurse Health Service-Hospice

Based on record review and staff interview, it has been determined that the hospice failed to conduct a full-scale exercise or a tabletop exercise to test the emergency plan vulnerabilities identified in the hazard assessment conducted by the facility. --- Findings are as follows: Record review failed to reveal evidence that the hospice conducted a full-scale exercise or a tabletop exercise to test their emergency plan. During a surveyor interview on 12/18/2024 at 12:39 PM with the Director of Quality and Compliance, she acknowledged that the required exercises to test the emergency plan were not completed.

Based on record review and staff interview, it has been determined that the agency failed to ensure that care and services are provided in accordance with the plan of care for 2 of 2 patients reviewed relative to weekly measurements of pressure wounds, Patient ID #s 6 and 7, and for 2 out of 4 patients reviewed for home visits with medication reconciliation, Patient ID #s 2 and 4. --- Findings are as follows: Review of the agency policy, titled ";Provision of Care, Treatment, and Services" revealed in part, ";...To provide guidelines to the clinical staff in the management of wounds and ulcers...Document assessment of wound on each visit and measure wound weekly..." a. Record review of the wound report for Patient ID #6 revealed that s/he has a deep tissue injury (DTI, damage to the soft tissue beneath the skin caused by pressure or shear forces) on his/her right second toe with an onset date of 9/30/2024. Further review failed to reveal evidence of DTI measurements on the following weeks: - 9/29/2024 through 10/5/2024 - 10/13/2024 through 10/19/2024 - 11/3/2024 through 11/9/2024 - 11/10/2024 through 11/16/2024 - 11/17/2024 through 11/23/2024 - 11/24/2024 through 11/30/2024 - 12/1/2024 through 12/7/2024 - 12/8/2024 through 12/14/2024 During a surveyor interview on 12/19/2024 at approximately 8:45 AM with the Director of Hospice, she acknowledged that the DTI was not measured weekly. b. Record review of the wound report for Patient ID #7 revealed s/he had a start of care date of 11/30/2024 and was admitted with an unstageable wound on his/her sacrum (a triangular-shaped bone located at the base of the spine, forming the posterior wall of the pelvis) and a right pretibial (front of the shin bone) stage 2 wound (a shallow, open wound that occurs when the skin breaks and exposes the dermis, or the layer of skin below the top layer). Further review failed to reveal evidence that wound measurements were obtained during the initial visit on 11/30/2024. Further review of the wound report failed to reveal evidence that the unstageable wound was measured during the week of 12/8/2024 through 12/14/2024. During a surveyor interview on 12/19/2024 at 3:25 PM with the Director of Hospice, she revealed that she would expect the measurements of the wound to be obtained upon admission and then weekly thereafter. 2. Record review of the agency policy, titled ";Medication Reconciliation" revealed in part, ";...Purpose: To provide a complete list of current medication, including over the counter as well as prescription medications to avoid unintended medication errors... ...To ensure the most accurate, safe, effective and patient centered medication list and resolve any discrepancies of all medications that the patient is taking...by comparing the medical record to an external list of medications obtained from a patient, hospital or other provider, with the current medications the patient has in the home..." a. Review of the medication report for Patient ID #2, a resident of a skilled nursing facility, revealed s/he is prescribed the following medications that includes but is not limited to: - Started 11/21/2024: Bumetanide (diuretic) 0.5 mg (milligram) tablet, give once daily for fluid retention (occurs when parts of your body swell due to a build-up of trapped fluid) - Started 12/5/2024: Duloxetine hydrochloride (antidepressant) 60 mg delayed release capsule, give once daily for depression/pain Review of the hospice plan of care for the patients current ordered medications revealed the following: - Started 8/1/2024: Bumetanide 0.5 mg, give two times daily for fluid retention - Started 10/27/2024: Duloxetine 40 mg delayed release capsule, give once daily for chronic pain During a surveyor interview on 12/19/2024 at 3:29 PM with the Director of Hospice, she revealed that she would expect the patients medications to be reconciled on each visit to address any discrepancies, and that his/her hospice plan of care would match the other providers medication report. b. Review of the hospice plan of care for Patient ID #4 revealed s/he was prescribed Vitamin C 500 mg tablet once daily starting on 2/20/2024, and Dextromethorphan-Guaifenesin oral liquid (medication used to suppress cough) on 8/28/2024. Surveyor observation on 12/19/2024 at 10:57 AM of Registered Nurse, Staff A, reconciling the patients medications in his/her home against the patients current ordered medications in his/her hospice care plan revealed that the patient has stopped taking his/her Vitamin C supplement, and that s/he was taking Guaifenesin instead of the Dextromethorphan-Guaifenesin A subsequent interview was conducted with the patient in which it was indicated that s/he stopped taking the supplement ";...for a while...", no longer takes the liquid Dextromethorphan-Guaifenesin, and is now taking Guaifenesin 400 mg tablets. Additionally, Staff A then interviewed the patients daughter via telephone and she indicated that the patient has stopped taking the supplement, however she was unsure how long. She then confirmed that the patient stopped taking the liquid Dextromethorphan-Guaifenesin and is only taking the Guaifenesin 400 mg tablets. During a surveyor interview on 12/19/2024 at 3:29 PM with the Director of Hospice, she revealed that she would expect the patients medications to be reconciled on each visit, and that his/her hospice care plan would match the medications that s/he is currently taking.

Based on record review and staff interview it has been determined that the hospice failed to meet the Condition of Participation relative to drugs and biologicals for 1 of 3 patients reviewed, Patient ID #1. --- Findings are as follows: The hospice failed to ensure that the patient or caregiver were educated regarding the measures to provide safe medication management related to Patient ID #1s morphine order. (Refer to L696)

Based on record review and staff interview it has been determined that the hospice failed to discuss the hospice policies and procedures for managing the safe use and disposal of controlled drugs with the patient or representative and the family in a language and manner that they understand to ensure that these parties are educated regarding the safe use and disposal of controlled drugs for 1 of 3 patients, Patient ID #1. --- Findings are as follows: Review of the agencys policy under the area titled, ";Identification of Patient/Caregiver Education Needs in Home Care and Hospice" revealed in part, ";...All patients/caregivers receive information and instruction in the following areas...medication use, storage and disposal...Learning needs are assessed at each visit. The patients/ family knowledge and performance of skills are documented. Understanding and retention of information and instructions are also assessed and documented..." Review of the agencys policy under the area titled, ";Hospice/ Palliative Care Symptom Management" revealed in part, ";The hospice team provides assistance to the patient/family in pain and symptom management in collaboration with the patients physician. Pain and symptom management is based on the assessment of the Nurse Case Manager or designee and the needs of the patient...Patients and families are instructed in measures to provide safe symptom management...The nurse assesses and documents response to treatment as well as patient/family teaching regarding symptom management on the nursing visit note..." Review of the agencys policy under the area titled, ";Patient Instructions Regarding Medications (Home Care and Hospice) revealed in part, ";...The information on the Medication List is explained to the patient/caregiver and, in addition, the following information is explained as applicable...Special directions and precautions for the preparation, self administration and use of medication...appropriate administration techniques when applicable...significant side effects, interactions...and/or therapeutic contraindications...actions to take in event of wrong or missed dose..." Record review for the patient revealed a start of care date of 3/3/2023 with diagnoses including but not limited to, malignant neoplasm of unspecified part of right bronchus or lung, secondary malignant neoplasm of brain, anxiety disorder and major depressive disorder. Record review of the ";Client Episode Coordination Notes Report" revealed in part: 3/4/2023- A Narrative note written by Registered Nurse (RN) Staff A, revealed in part, "...Patient is Alert and Oriented x 3- mildly confused at times especially when discussing medication..." 3/6/2023-A clinical note written by Registered Nurse (RN) Staff C, revealed in part, ";...Call from [patients] Brother...requesting a Comfort Pak Stated [patient] did not sleep well last night, with coughing and pain..." Record review revealed a physician order with a start date of 3/6/2023 for morphine concentrate 100mg/5ml (milligram/ milliliter) with a dose of 0.25 ml every 2 hours as needed for pain or shortness of breath. Review of the ";Visit Note Report" written by RN Staff B, for the visit dated 3/6/2023 under ";Narrative" revealed in part, ";...Patient upstairs lying down...Brother present during visit. Alert x 3 [person, place and time] with some confusion. Patient reports chest pain [bilaterally] [related to] coughing all night ...Also recommended lorazepam for sleep...No comfort kit in home..." Under ";Medication Understanding Changes" there was no evidence that teaching related to measures to provide safe symptom management relative to the patients Morphine order were discussed. Record review of the visit calendar revealed one Registered Nurse visit on 3/6/2023, the next visit was not until 3/8/2023. Record review of a Care coordination note dated 3/8/2023 revealed, ";Patients Brother...called to request RN visit for today. He reports that patient is in distress with [his/her] breathing." Review of the ";Visit Note Report" written by RN Staff B, for the visit dated 3/8/2023 under ";Narrative" revealed in part, ";This RN received a call from scheduling stating patients brother called reporting patient having trouble with [his/her] breathing. This RN called and spoke with Brother who informed this RN patient had been having issues with breathing x 2 days and had taken a lot of morphine and patient was catatonic [in an immobile or unresponsive stupor]. Upon arrival patient found on second floor couch unresponsive with copious amounts of green sputum on [him/her] and couch...Brother stated he gave patient [his/her] first dose of morphine on Monday night and patient stated [s/he] felt much better Brother reports he hide the morphine on the kitchen counter but patient must have found it. Brother states patient took the whole bottle...Brother feels patient May have just kept taking the morphine because it was making [him/her] feel better...Time of death of 1014..." During a surveyor interview on 3/10/2023 at 1:44 PM with RN Staff C, she revealed that she was the one who obtained the order for the Morphine for the patient, after receiving a call requesting a ";comfort pak" from the patients brother. She could not provide evidence that any follow up teaching was provided regarding safe morphine administration, or that a PRN (as needed) teaching visit was scheduled. During a surveyor interview on 3/10/2023 at approximately 2:00 PM with RN Staff B, she acknowledged that she had failed to provide teaching to the patient regarding morphine administration. She stated at the time of her visit on 3/6/2023 the medication wasnt present in the home.