Every finding on record at Vitas Healthcare Corporation Atlantic

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over-the-counter (OTC) drugs. 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 clinical record review, document review, and interview. Agency policy "Standard- Obtaining Orders" (no date) stated in part, "E3 Ordering: All initial and refill medication dispense orders may only be ordered via the E3 app (application)." In 1 of 30 (3%) clinical records reviewed, the agency did not ensure that the patient's medication (drug) profile contained all prescribed medications. Clinical Record 18: The patient elected the hospice benefit on 06/11/2024 with a diagnosis of chronic respiratory failure. The initial plan of care dated 06/11/2024 ordered continuous oxygen at 4 liters via nasal cannula. On 07/25/2024, the oxygen order increased to 5 liters continuously via nasal cannula. The drug profile, effective from 06/11/2024 to the present, did not include the prescribed oxygen. During an interview on 08/15/2024, the Patient Care Administrator stated that the patient's drug profile was created by entering the medication into the E3 app and confirmed that oxygen should be included as a prescription medication. The PCA stated that the E3 system was used to enter all prescription and over-the-counter medications into the hospice pharmacy system to create the comprehensive medication (drug) profile.

It is required that each patient’s individualized written plan of care: reflects patient and family goals; [and] identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 1 of 30 (3%) clinical records reviewed, the agency did not ensure that the patient’s plan of care included planned interventions based on the problems identified in the comprehensive assessments. Clinical Record 6: The patient elected the hospice benefit on 12/21/2021 with a diagnosis of heart failure. The patient resided in an assisted living facility (ALF). The following RN notes were documented on the agency form “Plan of Care Review for Recertification” used for updates: on 05/29/2024, the RN documented “increased weakness, wheelchair dependent, fall 05/24/2024;” on 06/05/2024, “recent fall, missed chair;” on 06/19/2024, “recent falls (3 in 1 month). Education ongoing;” on 07/03/2024, “increased weakness, recent falls;” on 07/17/2024, “Stand and pivot. No ambulation. Hunched posture;” and on 07/31/2024, “Weak, stooped posture with bowed legs. Holds furniture to stand and pivot.” The RN focus visit dated 08/06/2024 documented, “follow-up related to report of fall… Per staff patient was attempting to stand and pivot independently and slid to floor onto buttocks...staff educated and recommendation to keep patient’s walker in a different part of room to reduce likelihood of attempt to get up independently.” The patient’s plan of care, initiated on 05/22/2024, documented the outcome and interventions “maintain safety” and “assess level of function…educate patient on body positioning and DME (durable medical equipment) use to prevent falls.” A clinical record review revealed no updated plan of care interventions and safety measures since 05/22/2024 to address the patient’s increased number and frequency of falls and promote patient safety. During an interview and a joint review of the plan of care, plan of care updates, and nursing visit documentation on 08/15/2024, the Patient Care Administrator (PCA) confirmed that the specific interventions and education provided to the patient and facility staff were not listed on the plan of care. The PCA and the General Manager confirmed that with the patient continuing to experience falls, the plan of care updates should have included additional interventions to promote patient safety. The PCA also reported that a call was placed to the patient’s RN case manager, who stated, “The facility won’t allow bed alarms or fall mats, but the patient does wear a neck pendant to call for help.” The PCA reported they were unsure why the plan of care did not provide the specific interventions but was sending the RN out today to visit the patient to identify all fall/safety-related interventions and update the plan of care.

Based on clinical record review, agency documentation and interview with hospice personnel, for one of twenty patients (Patient #17) in the survey sample, the hospice agency failed to ensure the plan of care addressed the patient's needs. The findings include: Patient #17 elected the hospice benefit on 10/22/21. The patient's diagnoses included cerebral atherosclerosis, dementia and hypertension. The physician's orders dated 10/22/21 included nursing visits 2 times per week for assessments, hospice aide services 2 times per week personal care and social work services for emotional support. The patient resided in an assisted living facility (ALF). Review of the ALF documentation with the Administrator on 12/15/21 at 10 AM identified that the patient was receiving Home Care services from 10/08/21 for wound care to the right lower extremity skin tear, cleansing with saline and applying alginate covered with Mepilex dressing two times a week. Furthermore, on 10/19/21, the ALF Advanced Practice Registered Nurse/APRN documented that a discussion was held with the Home Care agency about the patient's decline, becoming weaker with more skin breakdown weekly including skin tears and a stage I on the coccyx. Interview and review of the initial RN comprehensive assessment dated 10/22/21 with RN #1 on 12/08/21 at 10:30 AM indicated that the patient's legs were wrapped due to weeping edema and the coccyx had a reddened non-blanchable intact area. Interview and review of the physician-certified plan of care dated 10/22/21 with the Administrator on 12/15/21 at 11 AM failed to identify treatment orders for wound care to the bilateral legs and coccyx.

Based on clinical record review, agency documentation and interview with hospice personnel, for one of twenty patients (Patient #17) in the survey sample, the hospice RN failed to provide the necessary services. The finding includes: Patient #17 elected the hospice benefit on 10/22/21. The patient's diagnoses included cerebral atherosclerosis, dementia and hypertension. The physician's orders dated 10/22/21 included nursing visits 2 times per week for assessments, hospice aide services 2 times per week personal care and social work services for emotional support. The patient resided in an assisted living facility (ALF). Interview and review of the clinical record with the Administrator on 12/15/21 at 11 AM identified that after the initial RN assessment on 10/22/21, the next on 10/25/21 was conducted by LPN #1 and failed to identify the visit was conducted by the RN case manager to ensure that the nursing needs of the patient were met as identified in the initial assessment.

Based on clinical record review, agency policy and interview with hospice personnel, for one of twenty patients (Patient #17) the hospice agency failed to ensure Durable Medical Equipment/DME was delivered timely. The finding includes: Patient #17 elected the hospice benefit on 10/22/21. The patient's diagnoses included cerebral atherosclerosis, dementia and hypertension. The physician's orders dated 10/22/21 included nursing visits 2 times per week for assessments, hospice aide services 2 times per week personal care and social work services for emotional support. The patient resided in an assisted living facility (ALF). Interview with Person #2 on 12/10/21 at 3:15 PM indicated that the admission nurse/RN #1 discussed on 10/22/21, ordering a hospital bed, alternating pressure mattress and a stand and tilt wheelchair for Patient #17's comfort and was disappointed that it was not delivered until 10/25/21. Interview and review of the initial RN comprehensive assessment on 10/22/21 with RN #1 on 12/14/21 at 3:20 PM indicated ordering the DME on 10/22/21 and indicated arrival is usually on the same day or the next day at the latest. Interview and review of the DME order profile with the Administrator on 12/15/21 at 12:30 PM identified that the expectation would be that the DME arrive by the next day and indicated that the DME was ordered on 10/22/21, delivered on 10/25/21 but failed to identify the delivery occurred in a timely manner. Agency policy on medical supplies directed in part that durable medical equipment related to the management of the terminal illness must be provided by the hospice while the patient is under hospice care.

Based on clinical record review, agency policy and interview with hospice personnel, for one of twenty patients (Patient #17) the hospice agency failed to develop an accurate form for the safe disposal of the patient's medications, including the controlled substances and/or the hospice nurse failed to dispose of controlled substances according to agency expectations. The finding includes: Patient #17 elected the hospice benefit on 10/22/21. The patient's diagnoses included cerebral atherosclerosis, dementia and hypertension. The physician's orders dated 10/22/21 included nursing visits 2 times per week for assessments, hospice aide services 2 times per week personal care and social work services for emotional support. The patient resided in an assisted living facility (ALF). Interview with Person #1 on 12/10/21 at 2:40 PM indicated that on 10/28/21 at 11:44 PM, after the patient's death, RN #2 disposed of the patients Morphine by squirting the four Morphine liquid syringes and the remaining Morphine solution in the bottle in the toilet and disposing the syringes in the waste basket. Interview with RN #2 on 12/10/21 at 3:06 PM indicated that controlled medications should be mixed with coffee grounds or kitty litter, indicated that s/he squirted the Morphine in the toilet and failed to follow agency expectations on the proper disposal of unwanted medications. Interview and review of RN #2 ' s nursing notes with the Administrator on 12/15/21 at 11 AM indicated that RN #2 failed to dispose of controlled substances properly.

Based on clinical record review, agency policy and interview with hospice personnel, for one of twenty patients (Patient #17) the hospice nurse failed to instruct the family regarding the destruction and safe disposal of the patient's medications, including the controlled substances. The finding includes: Patient #17 elected the hospice benefit on 10/22/21. The patient's diagnoses included cerebral atherosclerosis, dementia and hypertension. The physician's orders dated 10/22/21 included nursing visits 2 times per week for assessments, hospice aide services 2 times per week personal care and social work services for emotional support. The patient resided in an assisted living facility (ALF). The patient's medications included the controlled substance Morphine Sulfate concentrate 5 mg by mouth every four hours and every hour as needed for pain or shortness of breath. On 10/28/21, RN #2 documented that Patient #17 expired, and RN #2 destroyed the patient's controlled substance with Patient #17 's family member. Interview and review of RN #2's nursing notes with the Administrator on 12/15/21 at 11 AM indicated that RN #2 failed to follow agency policies on the destruction of controlled substances being destroyed by either the patient or the patient representative. The agency policies and procedures on drug disposal process indicated in Assisted Living Facilities, controlled substances that require destruction must be destroyed either by the patient or the patient representative. The physical destruction cannot be performed by Hospice Staff.

Based on clinical record review, agency policy and interview with hospice personnel, for one of twenty patients (Patient #17) the hospice agency failed to follow State regulations. The finding includes: Patient #17 elected the hospice benefit on 10/22/21. The patient's diagnoses included cerebral atherosclerosis, dementia and hypertension. The physician's orders dated 10/22/21 included nursing visits 2 times per week for assessments, hospice aide services 2 times per week personal care and social work services for emotional support. The patient resided in an assisted living facility (ALF). Interview with Person #1 on 12/10/21 at 2:40 PM indicated that on 10/28/21 at 11:44 PM, after the patient's death, RN #4 disposed of the patients Morphine by squirting the four Morphine liquid syringes and the remaining Morphine solution in the bottle in the toilet and disposing the syringes in the waste basket. Interview with RN #2 on 12/10/21 at 3:06 PM indicated that controlled medications should be mixed with coffee grounds or kitty litter, indicated that s/he squirted the Morphine in the toilet and failed to follow agency expectations on the proper disposal of unwanted medications. Interview and review of the admission packet insert on "How to Dispose of Unwanted Medications" updated on 4/2015 by the Connecticut Department of Energy and Environmental Protection with the Administrator on 12/15/21 directed to stop flushing medications down the toilet or sink, flushing medications down the toilet or sink causes water pollution, impacts drinking water and has adverse effects on septic systems but failed to identify an accurate form for the agency's disposal of controlled and/or prescription medications form that directed to identify the destruction method used which included flushing, crushing and mixing with unpalatable substances or other methods.