Every finding on record at Visiting Nurse Service and Hospice of Suffolk, Inc.

Based on clinical record review, policy review and staff interview, the Hospice failed to ensure the patient's rights to timely and effective pain management related to the terminal illness of Chronic Hepatic Failure without Coma, and Unspecified Cirrhosis of Liver. This was evident in one (1) of three (3) records reviewed (Patient # 1). Failure to ensure timely and effective pain management measures, has the potential for serious negative patient outcomes. --- The Hospice failed to ensure the patient rights to timely and effective pain management of a high-risk terminally ill Hospice patient that has pertinent diagnoses of Chronic Hepatic Failure without coma, Unspecified Cirrhosis of Liver, Ascites, Unspecified Atrial Fibrillation, Unspecified Asthma, Gastro-Esophageal Reflux Disease, Depression, Hypothyroidism, Benign Prostatic Hyperplasia and Dependence on supplemental Oxygen. [L512] The Hospice failure to ensure the immediate delivery of the STAT pain medication is likely to have a serious outcome to the patients pain management. [L512]

Based on clinical record review and staff interview, the Hospice failed to ensure the timely and effective pain management related to the terminal illness of Chronic Hepatic Failure without coma, Unspecified Cirrhosis of Liver. This was evident in one (1) of three (3) records reviewed (Patient # 1). Failure to ensure timely and effective pain management measures, has the potential for serious negative patient outcome. --- 1. Patient #1 has a start of care date of 02/17/2024 with diagnoses of Chronic Hepatic Failure without coma, Unspecified Cirrhosis of Liver, Ascites, Unspecified Atrial Fibrillation, Unspecified Asthma, Gastro-Esophageal Reflux Disease, Depression, Hypothyroidism, Benign Prostatic Hyperplasia and Dependence on supplemental Oxygen as documented on the "Hospice Plan of Care" for certification period 02/17/2024 to 05/16/2024. The "Hospice Plan of Care" for certification period 02/17/2024 to 05/16/2024 documents an order for "Skilled Nurse to assess and evaluate 02/17/2024 through 02/21/2024", Skilled Nurse 1 PRN (one as needed visit) for expected decline and pronouncement. Skilled Nurse 2 wk 13 wk, 3 PRN for expected decline and pronouncement; beginning during week of 02/18/2024 ending week 05/16/2024". Skilled Nurse to "Assess pain level and discomfort with use of FLACC scale if patient is non-verbal or unable to use pain 0-10 pain scale. Skilled Nurse to "Teach pain management and comfort measures". Medications include ";Morphine 5 milligram tablet, disintegrating. Take 5.0 milligrams sublingually every 4 hours, Comfort Pack- for pain or dyspnea. start date 02/17/2024". The Hospice start of care Nursing Assessment is dated 02/17/2024. The Registered Nurse documents the patient assessment pain scale as ";0" (zero). The Registered Nurse documents that the patients daughter was present during the visit and reported that the patient was ";restless and moaning all through the night". The Registered Nurse contacted the Nurse Practitioner and obtained an order for ";Comfort Pack" that includes ";Morphine 5mg tablet sublingual every 4 hours" for pain or dyspnea. The Comfort pack was ordered on 02/17/24 at approximately 10:30 AM as a STAT order. The On-Call Nurse report dated 02/17/2024 documents that patients daughters called the Hospice on 02/17/2924 at 02:13 PM to report that medications have not been delivered and patient is ";agitated". A second call was made by the daughter at 04:18 PM to inform the Hospice that the medications had not arrived. The Hospice contacted the Pharmacy on 02/17/2024 at 2:15 PM regarding delay in medication. The Pharmacy dispatcher was not aware the medication was a STAT order. The medication was delivered on 02/17/2024 at 05:55PM. The Hospice Medication/Variance report (ZOHO report) is dated 2/19/2024, documents medication variance of delay delivery. The Pharmacy ";Client/Accident" report" is dated 03/07/2024 documents delay in medication STAT order due to dispatcher unaware of STAT request. There is no documented evidence of Patient # 1 receiving effective and timely pain and symptom management on 02/17/2024 from 10:30 AM to 05:55 PM, resulting in the patient waiting over seven hours to obtain the necessary pain medication of Morphine 5mg tablet sublingual every 4 hours. The clinical record lacks documented evidence of a follow - up Registered Nurse visit on 02/17/2024 after 04:18 PM to re-assess the patients status including the patient's immediate pain severity, medication delivery, medication administration, and medication effectiveness. The clinical record lacks documented evidence of the Hospice ensuring the effective pain management of the Hospice patient, including alternative pain relief measures while awaiting the delivery of pain medications, pain and symptoms management related to the terminal illness, and measures to ensure the immediate and timely delivery of the STAT medication. The Hospice did not ensure the immediate delivery of the STAT pain medication. There in no documented evidence of the Hospice having measures in place to ensure the patients pain, and all other distressing symptoms, are controlled effectively 24 hours a day/7days per week. The survey findings were reviewed with the Hospice Director of Patient Services on 04/25/2024 at 02:30 PM, and an interview conducted on 04/26/2024 at 02:28 PM. No explanation was provided.

Based on clinical record and policy review, the Hospice failed to ensure a comprehensive assessment was conducted to develop an effective pain management plan in one of three patients reviewed (Patient # 1) The Hospice failure to ensure the Skilled Nurse conducted a re-assessment of the patients pain status, is likely to have a serious outcome to the patients pain management. --- The Hospice failed to ensure the comprehensive assessment of the terminally ill Hospice patient, including ongoing assessment of pain severity, medication effectiveness and alternative pain relief measures. [L524] The Hospice failure to ensure the Skilled Nurse re-assessment of the patients pain status, is likely to have a serious outcome to the patients pain management. [L524]

Based on clinical record ad policy review, the Hospice failed to ensure a comprehensive assessment was conducted to develop an effective pain management plan in one of three patients reviewed (Patient # 1) Failure to ensure the Skilled Nurse re-assessment of the patients pain status, is likely to have a serious outcome to the patients pain management. --- 1. Patient #1 has a start of care date of 02/17/2024 with diagnoses of Chronic Hepatic Failure without coma, Unspecified Cirrhosis of Liver, Ascites, Unspecified Atrial Fibrillation, Unspecified Asthma, Gastro-Esophageal Reflux Disease, Depression, Hypothyroidism, Benign Prostatic Hyperplasia and Dependence on supplemental Oxygen as documented on the "Hospice Plan of Care" for certification period 02/17/2024 to 05/16/2024. The "Hospice Plan of Care" for certification period 02/17/2024 to 05/16/2024 documents an order for "Skilled Nurse to assess and evaluate 02/17/2024 through 02/21/2024", Skilled Nurse 1 PRN (one as needed visit) for expected decline and pronouncement. Skilled Nurse 2 wk 13 wk, 3 PRN for expected decline and pronouncement; beginning during week of 02/18/2024 ending week 05/16/2024". Skilled Nurse to "Assess pain level and discomfort with use of FLACC scale if patient is non-verbal or unable to use pain 0-10 pain scale. Skilled Nurse to "Teach pain management and comfort measures". Medications include ";Morphine 5 milligram tablet, disintegrating. Take 5.0 milligrams sublingually every 4 hours, Comfort Pack- for pain or dyspnea. start date 02/17/2024". The "Pain Assessment" policy (reviewed by Hospice on 09/2023), documents "pain is reassessed during every home visit, any time a patient states that their pain level has changed, and whenever pain medication or dosage is changed". Hospice "responds to the patient's pain, based on its re-assessment criteria". The Hospice start of care Nursing Assessment is dated 02/17/2024. The Registered Nurse documents the patient assessment pain scale as ";0" (zero). The Registered Nurse documents that the patients daughter was present during the visit and reported that the patient was ";restless and moaning all through the night". The Registered Nurse contacted the Nurse Practitioner and obtained an order for ";Comfort Pack" that includes ";Morphine 5mg tablet sublingual every 4 hours" for pain or dyspnea. The Comfort pack was ordered on 02/17/24 at approximately 10:30 AM as a STAT order. The ";On – Call" policy (reviewed by Hospice on 09/2023), documents ";A Home Visit should be made when: Duplicate calls are received regarding the same problem". The On-Call Nurse report dated 02/17/2024 documents that patients daughters called the Hospice on 02/17/2924 at 02:13 PM to report that medications have not been delivered and patient is ";agitated". A second call was made by the daughter at 04:18 PM to inform the Hospice that the medications had not arrived. The clinical record lacks documented evidence that a Home Visit was conducted by the Registered Nurse on 02/17/2024 after multiple calls were made to the Hospice regarding the pain medication not being delivered. The clinical record lacks documented evidence of a re-assessment of the patient's pain status, including the patient's immediate pain severity, medication delivery, medication administration, and medication effectiveness. The patient expired on 02/18/2024. The Hospice Nurse Practitioner documents on 02/19/2024 (late entry from 02/17/2024 at 04:30 PM, ";contact pt (patient) daughter regarding delay in Comfort Pack", offered for pt (patient) to come to Hospice House, but she (daughter) did not want her father to be moved at this time". The Hospice did not ensure the Skilled Nurse re-assessment of the patients pain status, is likely to have a serious outcome to the patients pain management. The survey findings were reviewed with the Hospice Director of Patient Services on 04/25/2024 at 02:30 PM, and an interview conducted on 04/26/2024 at 02:28 PM. No explanation was provided.

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current: 1. Prescription and over-the-counter (OTC) drugs; 2. Supplements; 3. Herbal remedies; 4. Other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: 1. The effectiveness of drug therapy; 2. Drug side effects; 3. Actual or potential drug interactions; 4. Duplicate drug therapy; 5. Drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and, as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by review, observation and interview. In 1 of 3 (33%) patients who received a Home Visit, the medication that was discontinued was not documented as discontinued on the medication profile. Record #37676: A home visit was performed with RN #47720 and the Hospice Educator on 2/8/2022 at 11:10am. In an interview with the patient's son, he indicated that the patient was no longer taking Lexapro and stated it had been discontinued "2 or 3 weeks ago". In review of the medication profile, both the paper copy provided to the hospice site visitor as well as the active medication profile on the RN CM's tablet, Lexapro 5 mg oral tablet; take 1 tab (s) orally every other day; for anxiety was included and the start date was documented as 1/3/2022. There was no documentation that the medication had been discontinued. In an interview with the Hospice Educator and the Hospice Director of Patient Services on 2/10/2022, no additional documentation was provided to verify compliance and it was confirmed that the medication profile was not updated to include the discontinuation of Lexapro.

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by review and interview. 1 of 10 (10%) applicable records reviewed failed to provide documentation that the home health aide notified the RN of a change related to the plan of care. Record #78469: The hospice aide care plan dated 11/1/2021 directed the hospice aide to make a visit 5XW and provide a shampoo at each visit. The hospice aide documentation for the visit completed on 2/1/2022 stated that the hospice aide did not provide a shampoo at this visit. There was no evidence that the RN CM was notified that the patient did not receive a shampoo as directed by the hospice aide care plan. In an interview with the Director of Patient Services on 2/10/2022, it was confirmed the hospice aide did not notify the RN CM that the shampoo was not provided and no additional information was provided.