Every finding on record at Vitas Healthcare Corporation of California

Based on interview and record review, the hospice agency did not effectively manage the pain for one of three sampled patients (Patient 1). Patient 1 was experiencing pain and was given increasing amounts of pain medication. Staff did not elevate his care to continuous status in order to better control the pain. This resulted in unnecessary pain for Patient 1 and distress for his family and caregivers. --- ";Hospice is a type of medical care that is offered to an individual who is in the late stages of a terminal illness. Disease modifying or curative treatments are felt to be no longer helpful or beneficial and the patient and physician have decided to focus care on supporting quality of life and symptom management." National Institute of Health - ccnigh.gov/palliative-care/hospice care Record Review of the document ";Symptom Management," dated 6/3/2022, showed ";The patient has a right to the following: Receive effective pain management and symptom control from the hospice for conditions related to the terminal illness." Review of the document ";Job Descriptions," dated 8/23/2023, showed the job duties of the Agencys Registered Nurses included ";Coordinates all service delivery including review of entries in the record made by after hours, patient and family education, dispatching of interdisciplinary visits, and coordination of services with external vendors and resources as needed." Review of the document ";Continuous Care," dated 9/4/2024, showed ";Special coverage requirements (a) Periods of crisis. Nursing care may be covered on a continuous basis for as much as 24 hours a day during periods of crisis as necessary to maintain an individual at home. Frequent changes in the POC (plan of care) support intensive symptom management and the need for CC (continuous care). 1. Changes in medication." Record review of the document ";Case Sheet" showed the agency admitted Patient 1 on 3/30/2024. Diagnoses included prostate cancer. Review of the document ";Telecare Call," dated 4/1/2024, showed the med tech at the assisted living facility where Patient 1 resided called the agency to ";...request a nurse visit as the patient is in pain." Review of the document ";Focus Visit" (nurse visit), dated 4/1/2024, showed Patient 1 was experiencing 7 out 10 pain. (pain scale ";1" is the lowest, ";10" is the highest) Review of the document ";Interdisciplinary Plan of Care Revision/Physician Orders" (IPCRPO), dated 4/1/2024, showed the doctor ordered morphine (pain medication) 1 tablet (30 mg) every 3 hours as needed for pain. Review of the document ";Focus Visit," dated 4/2/2024, showed Patient 1 continued to have 7 out of 10 pain. A second "Focus Visit" on 4/2/2024 showed Patient 1 had 8 out of 10 pain. Review of the IPCRPO, dated 4/2/2024, showed methadone (pain medication) was ordered to be given (10 mg) twice per day for pain. Review of the document ";Telecare Call," dated 4/3/2024, showed a second med tech at the assisted living facility called to report ";The patient is in a lot of pain..." Review of the document ";Nursing-Updated Comprehensive Assessment" (NUCA) showed a visit took place on 4/5/2024 and Patient 1 was complaining of 7 out of 10 pain and was ";Agitated due to pain" during the visit. Review of the IPCRPO, dated 4/5/2024, showed Patient 1s pain medication was changed from ";as needed" to scheduled (around-the-clock). The doctors orders showed Patient 1 was to receive morphine 30 mg every 8 hours routinely for pain and methadone 10mg 3 times a day for pain. Review of the NUCA showed a visit took place on 4/5/2024 and Patient 1 complained of 7 out of 10 pain and was agitated ";Due to pain during visit." Review of the document ";Telecare Call" showed the agency placed a call to the assisted living facility on 4/6/2024. Staff reported Patient 1 was ";In a lot of pain."" Review of the document ";Psychosocial/Spiritual Updated Comprehensive Assessment," dated 4/11/2024, showed Patient 1 reported his pain as a 4 out of 10. Review of the Focus Visit, dated 4/12/2024, showed Patient 1 had 3 out of 10 pain. Review of the document ";Telecare Call," dated 4/13/2024, showed Family Member 1, (FM 1) called the agency to say Patient 1 was in a lot of pain ";...In spite of being medicated." Further review showed on 4/13/2024, the agency received a call from the assisted living facility med tech who reported Patient 1 had ";...constant pain – requesting for additional pain medication..." Review of the Telecare Call log, dated 4/14/2024, showed another med tech called the agency to report Patient 1 had a change in condition and was ";In pain and hallucinating." There was no documentation in the clinical record which showed staff requested a continuous care (CC) order from the doctor in order to provide more nursing hours of care to help control Patient 1s pain. During an interview at 12:00 p.m. on 10/1/2024 with Patient Care Administrator (PCA), PCA confirmed there was no documentation which showed the agency staff had reached out to the doctor to obtain orders for a higher level of care. PCA stated staff now forget to reach out and, even though the CC team is smaller than it used to be, ";The need is still there" and ";This is hospice. They should not be in pain." Review of the document ";Focus Visit," dated 4/14/2024, showed Patient 1 was ";Imminent" (close to death). Review of the telecare notes, dated 4/14/2021, showed a facility med tech had called and stated Patient 1 was ";In pain and hallucinating." Review of the document ";Continuous Care shift Care note -Nurse," showed Patient 1 was admitted into CC care on 4/16/2024, two days after the med tech had last called the agency. Review of the document ";Telecare Call" showed Patient 1 passed away on 4/17/2024. During an interview and concurrent record review with PCA, PCA stated, on 4/14 Patient 1 was having pain with secretions and making noises. He was transitioning (getting close to death) at that point and staff ";Needed to stay." PCA confirmed CC care did not start until 4/16/2024, 2 days later. During an interview on 10/16/2024 at 1:51 p.m. with Registered Nurse 1 (RN 1), RN 1 stated she believed it would have been helpful to have placed Patient 1 into CC earlier ";Due to the increased needs for pain medication and the changes in dosages."

Based on interview and record review, the hospice agency did not provide care according to the plan of care for one of three sampled patients (Patient 1). Patient 1 had uncontrolled pain. This resulted in unnecessary pain for Patient 1 and distress for his family and caregivers. --- ";Hospice is a type of medical care that is offered to an individual who is in the late stages of a terminal illness. Disease modifying or curative treatments are felt to be no longer helpful or beneficial and the patient and physician have decided to focus care on supporting quality of life and symptom management." National Institute of Health - ccnigh.gov/palliative-care/hospice care Record Review of the document ";Symptom Management," dated 6/3/2022, showed ";The patient has a right to the following: Receive effective pain management and symptom control from the hospice for conditions related to the terminal illness." Review of the document ";Job Descriptions," dated 8/23/2023 showed the job duties of the Agencys Registered Nurses included ";Delivers care in accordance with the patients plan of care." Record review of the document ";Case Sheet" showed the agency admitted Patient 1 on 3/30/2024. Diagnoses included prostate cancer. Review of the document ";Interdisciplinary Plan of Care Revision/Physician Orders – Updated Comprehensive Assessment," dated 3/30/2024, showed staff were to ";Provide comfort and palliative care." (palliative: type of care focused on relief from the symptoms and stress of an illness) Review of the document ";Telecare Call," dated 4/1/2024, showed the med tech at the assisted living facility where Patient 1 resided called the agency to ";...request a nurse visit as the patient is in pain." Review of the document ";Focus Visit" (nurse visit) dated 4/1/2024, showed Patient 1 was experiencing 7 out 10 pain. (pain scale ";1" is the lowest, ";10" is the highest) Review of the document ";interdisciplinary Plan of Care Revision/Physician Orders" (IPCRPO), dated 4/1/2024, showed the doctor ordered morphine (pain medication) 1 tablet (30 mg) every 3 hours as needed for pain. Review of the document ";Focus Visit" dated 4/2/2024, showed Patient 1 continued to have 7 out of 10 pain. A second ";Focus Visit" on 4/2/2024 showed Patient 1 had 8 out of 10 pain. Review of the IPCRPO, dated 4/22024, showed methadone (pain medication) was ordered to be given (10 mg) twice per day for pain. Review of the document ";Telecare Call," dated 4/3/2024, showed a second med tech at the assisted living facility called to report ";The patient is in a lot of pain..." Review of the document ";Nursing-Updated comprehensive Assessment" (NUCA) showed a visit took place on 4/5/2024 and Patient 1 was complaining of 7 out of 10 pain and was ";Agitated due to pain" during the visit. Review of the IPCRPO, dated 4/5/2024, showed Patient 1s pain medication was changed from ";as needed" to scheduled (around-the-clock). The doctors orders showed Patient 1 was to receive morphine 30 mg every 8 hours routinely for pain and methadone 10mg 3 times a day for pain. Review of the NUCA showed a visit took place on 4/5/2024 and Patient 1 complained of 7 out of 10 pain and was agitated ";Due to pain during visit." Review of the document ";Telecare Call" showed the agency placed a call to the assisted living facility on 4/6/2024. Staff reported Patient 1 was ";In a lot of pain."" Review of the document ";Psychosocial/Spiritual Updated comprehensive Assessment," dated 4/11/2024, showed Patient 1 reported his pain as a 4 out of 10. Review of the ";Focus Visit", dated 4/12/2024, showed Patient 1 had 3 out of 10 pain. Review of the document ";Telecare Call," dated 4/13/2024, showed Family Member 1, (FM 1) called the agency to say Patient 1 was in a lot of pain ";...In spite of being medicated." Further review showed, on 4/13/2024, the agency received a call from the assisted living facility med tech who reported Patient 1 had ";...constant pain – requesting for additional pain medication..." Review of the Telecare Call log, dated 4/14/2024, showed another med tech called the agency to report Patient 1 had a change in condition and was ";In pain and hallucinating." There was no documentation in the clinical record which showed staff requested a continuous care (CC) order from the doctor to manage Patient 1s continued pain. (CC: when an RN remains with the patient at their residence and provides around the clock care to manage the symptoms) During an interview at 12:00 p.m. on 10/1/2024 with Patient Care Administrator (PCA), PCA confirmed there was no documentation which showed the agency staff had elevated Patient 1's level of care to obtain pain relief. During an interview on 10/16/2024 at 1:51 p.m. with Registered Nurse 1 (RN 1), RN 1 stated she believed it would have been helpful to have elevated Patient 1's level of care so his pain could have been relieved.

It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient's family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and considered in the bereavement plan of care. This standard was not met as evidenced by clinical record review, document review, and interview. In 1 of 23 (4%) clinical records reviewed, the agency did not ensure that the comprehensive assessment included an initial bereavement assessment of the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Agency policy "VS-Bereavement Visit" (dated 02/19/2016) stated in part, "Pre-Death Bereavement Assessment...The Bereavement Assessment in both the nursing and the psychosocial/spiritual assessments pertains to the caregiver's anticipatory grief and psychosocial and spiritual symptoms. In the case there are no anticipatory grief or caregiver symptoms, we will still open the Bereavement Plan of Care to plan for interventions after the death If there is no anticipatory grief then the level of concern is "0" and 'Assessed, no bereavement symptoms' noted should be checked...The nurse doing the assessment in the first 24 hours after admission opens the Initial Bereavement Plan of Care... She/he almost always opens the first three interceptions which all bereaved receive after death... " The hospice's policy "VS Care Planning" (dated 05/16/2023) stated in part, "Plan of Care...Care planning begins with the Admission Orders completed by the RN...Bereavement...initiated by the RN at the time of the Initial Comprehensive Assessment. Describes the outcomes and interventions related to bereavement for the caregiver(s)… Includes a required intervention for nursing, SW and chaplain to contact eh primary caregiver following each visit..." Clinical Record 13: The patient elected the hospice benefit on 11/10/2023. The initial comprehensive assessment completed by the Registered Nurse (RN) dated 11/10/2023 documented bereavement needs as assessed by checking the box. No bereavement symptoms were identified. The initial Social Work visit note dated 11/16/2023 did not document a bereavement risk assessment, and the initial Chaplain assessment dated 11/20/2023 did not document a bereavement risk assessment. The "Initial General Plan of Care" dated 11/10/2023 did not address bereavement needs. No "Initial Bereavement Plan of Care" form was documented in the clinical record. The Interdisciplinary Group Meeting/Plan of Care Reviews dated 11/22/2023, 12/06/2023, 01/03/2023, 01/17/2024, 01/31/2024, 02/14/2024, 02/28/2024, 03/13/2024, 03/27/2024, and 04/10/2024 all documented the box for bereavement as checked, but without developed interventions per the agency's policy. During a joint record review and interview on 04/17/2024, the Patient Care Administrator confirmed that there was no initial bereavement risk assessment that included a risk score and no assessment data developed into a pre-death bereavement care plan.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene and safe handling of soiled items in the patient’s care environment. This standard was not met as evidenced by document review, interview, and observation. Agency policy "VS Hand Hygiene" (dated 06/18/2012) stated in part, "Indications for Hand Antisepsis or Hand-Washing... Wash hands with soap and water using anti-microbial soap or plain soap in the following circumstances... hands are visibly soiled with blood or other body fluids... Decontaminate the hands using an alcohol-based hand rub... when hands are not visibly soiled and... before having direct contact with patients... after all direct patient contact... Considerations...CDC-Recommendations of the Healthcare Infection Control Practices Advisory Committee...Healthcare personnel should use an alcohol-based hand rub or wash with soap and water the following clinical indications...Before moving from work on a soiled body site to a clean body site on the same patient... After contact with blood, body fluids, or contaminated surfaces..." In 1 of 6 (17%) home visits observed, the agency did not ensure hand hygiene was performed, as indicated, according to the agency's policy. Home Visit 3: During the home visit with the Hospice Aide (HA) [Personnel Record 9], the HA donned gloves and removed the patient's pullup before showering the patient. The HA disposed of the used pullup in the trash can. Donning the same gloves, the HA returned to the patient, touched the shower head and faucet, and proceeded to shower the patient. The HA did not sanitize their hands after contact with the used pullup and the trash can and before resuming direct contact with the patient. During an interview after the visit observation, the HA gave no reason for not changing the gloves but appreciated the education.

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review, observation, and interview. In 1 of 19 (5%) clinical records reviewed in which Hospice Aide services were provided, the agency did not ensure that the Hospice Aide provided services that were included in the plan of care (POC). Clinical Record 17/Home Visit 3: The patient elected the hospice benefit on 01/17/2024. The "Addendum - Initial General Plan of Care Visit Frequency Grid" ordered Hospice Aide services twice weekly for the weeks of 03/28/2024, 04/04/2024, and 04/11/2024. During the home visit with the Hospice Aide (HA) [Personnel Record 9] on 04/18/2024, the HA performed a shower with a shower chair. The Hospice Aide Care Plan, effective 01/18/2024, did not assign the HA the relevant tasks of a bath or shower. During a joint record review and interview on 04/19/2024, the Registered Nurse (RN)/Patient Care Administrator confirmed that there was no intervention for a bath or shower included on the Hospice Aide Plan of Care Request for this patient.

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 clinical record review, document review, observation, and interview. Agency policy "VS - Supervision, Delegation, and Coordination" (dated 07/15/2019) stated in part, "HA (Hospice Aide).. contacts the RN with all changes in condition or inability to follow the POC. Documents communication and direction received from RN in clinical note." In 4 of 19 (21%) clinical records reviewed in which Hospice Aide services were provided, the agency did not ensure that the Hospice Aide (HA) reported changes in the patient’s needs to the Registered Nurse (RN). Clinical Record 6: The patient elected the hospice benefit on 03/27/2024 with the primary diagnosis of cerebral atherosclerosis. The "Addendum - Initial General Plan of Care Visit Frequency Grid" ordered Hospice Aide services weekly for the weeks of 03/27/2024, 04/03/2024, and 04/10/2024. The RN documented on 03/28/2024 that the patient was alert and oriented to person and place only. On 04/05/2024, the RN documented the patient was alert, oriented to self only, and was confused. The HA care plan effective 03/28/2024 documented that the patient was forgetful, confused, and oriented to person and place only. The HA care plan assigned the HA the relevant tasks: showering the patient with a bath chair, sponge bathing, providing perineal care, shampooing hair, inspecting and applying lotion to the patient's skin, shaving the patient, inspecting feet, brushing teeth, dressing the patient, and brushing or combing the patient's hair, and instructed the HA to observe and notify the RN for changes in breathing or congestion, change in pain level, fall or injury, change in leg swelling, lack of bowel movement, change in skin condition, change in the patient's ability to participate in ADLs, or any new symptom or concern. The HA visit notes dated 03/28/2024, 04/05/2024, and 04/12/2024 documented that the assigned tasks of sponge bath, bath with a shower chair, and perineal care were not performed/declined. In the section of the note labeled "update to caregiver/report to nurse," the HA documented "Not answered." There was no documentation that the HA notified the RN that the assigned tasks were not performed. Clinical Record 12: The patient elected the hospice benefit on 09/15/2023 with the primary diagnosis of lung cancer. The "Addendum - Initial General Plan of Care Visit Frequency Grid" ordered Hospice Aide services weekly for the weeks of 03/27/2024, 04/03/2024, and 04/10/2024. The RN documented on 03/28/2024 that the patient was oriented to person and place only and experienced confusion. The HA care plan effective 11/24/2023 documented that the patient was forgetful, confused, oriented to person and place only and assigned the HA the relevant tasks: obtaining a pain rating, showering with a bath chair, inspecting feet, shampooing the patient's hair, providing perineal care, applying protective cream, inspecting and applying lotion to the patient's skin, cleaning dentures, dressing the patient, brushing or combing the patient's hair, and instructed the HA to observe and notify the RN for changes in breathing or congestion, change in pain level, fall or injury, change in leg swelling, lack of bowel movement, change in skin condition, change in the patient's ability to participate in ADLs, or any new symptom or concern. The HA visit note dated 03/28/2024 documented that the assigned tasks were not performed/declined: shower with a bath chair, dress patient, and clean dentures. The HA visit note dated 04/04/2024 documented the assigned tasks: showering with a bath chair, perineal care, shampooing hair, brushing/combing hair, cleaning dentures, and dressing were not performed/declined. In the section of the note labeled "update to caregiver/report to nurse," the HA documented "Not answered." There was no documentation that the HA notified the RN that the assigned tasks were not performed. Clinical Record 16: The patient elected the hospice benefit on 04/06/2023 with the primary diagnosis of cerebral atherosclerosis. The "Addendum - Initial General Plan of Care Visit Frequency Grid" ordered Hospice Aide services once a week for the weeks of 03/07/2024, 03/14/2024, 03/21/2024, 03/28/2024, 04/04/2024, and 04/11/2024. The HA care plan effective 04/11/2023 documented that the patient was forgetful and confused and assigned the HA the relevant tasks: obtaining a pain rating, sponge bathing the patient, inspecting feet, shampooing the patient's hair, providing perineal care, inspecting and applying lotion to the patient's skin, brushing the patient's teeth, dressing the patient, brushing or combing the patient's hair, and instructed the HA to observe and notify the RN for changes in breathing or congestion, change in pain level, fall or injury, change in leg swelling, lack of bowel movement, change in skin condition, change in the patient's ability to participate in ADLs, or any new symptom or concern. The HA visit note dated 03/28/2024 documented that the patient gave a verbal pain score of 7 on a scale of 1-10. In the section of the note labeled "update to caregiver/report to nurse," the HA documented "Not answered." There was no documentation that the HA notified the RN that the patient was having pain during the visit. Clinical Record 17/Home Visit 3: The patient elected the hospice benefit on 01/17/2024 with the primary diagnosis of protein-calorie malnutrition. The Initial Physician Certification of Terminal Illness for the benefit period 01/17/2024 to 03/17/2024 documented, "The patient has poor decision-making. His primary doctor... submitted a letter stating the patient did not have the capacity for medical decision making, so his daughter... is serving as DPOA..." The "Addendum - Initial General Plan of Care Visit Frequency Grid" ordered Hospice Aide services twice a week for the weeks of 02/01/2024, 02/08/2024, 02/15/2024, 02/22/2024, 02/29/2024, 03/07/2024, 03/14/2024, 03/21/2024, 03/28/2024, 04/04/2024, and 04/11/2024. The HA care plan effective 01/18/2024 documented that the patient was alert, agitated, and confused and assigned the HA the relevant tasks: to rate pain, brush teeth, shampoo hair, brush/comb hair, dress patient, file non-diabetic toenails and fingernails, clean patient's area and change the patient's bed linen, and instructed the HA to observe and notify the RN for changes in breathing or congestion, change in pain level, fall or injury, change in leg swelling, lack of bowel movement, change in skin condition, change in the patient's ability to participate in ADLs, or any new symptom or concern. The HA care plan did not include tasks for bath or shower. The HA care plan included a section for documentation of notification or reporting to the nurse or caregiver. During the home visit with the Hospice Aide (HA) [Personnel Record 9] on 04/18/2024, the HA performed a shower with a shower chair. There was no documentation that the HA notified the RN that the patient was showered. The HA visit notes dated 02/19/2024 and 02/27/2024 documented that the assigned task shampoo was not completed. The HA visit note dated 03/05/2024 documented that the assigned tasks: shampoo and dress the patient were not performed/declined. There was no documentation that the RN or caregivers were notified. During the joint record review and interview on 04/17/2024, 04/18/2024, and 04/19/2024, the Patient Care Administrator confirmed that the HA did not document notifying the hospice RN.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician: a copy of the hospice discharge summary; [and] the patient's record, if requested. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical record reviewed in which a patient revoked the election of hospice care, the agency did not ensure that the patient's discharge summary was forwarded to the patient's attending physician. Clinical Record 19: The patient elected hospice care on 08/04/2023 and revoked hospice care on 09/03/2023. It was documented that the patient/representative was seeking surgery for the patient's hip. A discharge summary was completed. There was no documentation that the discharge summary was forwarded to the attending physician. During a joint record review and an interview on 04/19/2024, the Patient Care Administrator confirmed that the discharge summary that there were no telecare notes (communication notes) documenting that the attending physician received any clinical information for the continuity of care for the patient.

It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least a summary of the patient’s hospice stay, including treatments, symptoms, and pain management, the patient’s current plan of care, and the patient’s latest physician orders. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records reviewed in which a patient was discharged live from hospice services, the agency did not ensure that the patient's discharge summary included all the required information. Clinical Record 19: The patient elected the hospice benefit on 08/04/2023 and revoked the hospice benefit on 09/03/2023. It was noted that the patient/representative was seeking surgery for the patient's hip. The discharge summary documented that on admission, the patient presented with the symptoms/needs in the neurological, gastrointestinal, musculoskeletal, and genitourinary systems. No other symptom explanation or treatment was documented. The discharge summary documented "Course of illness including extent to which treatment goals obtained - see attached plan of care review form." There was no information or plan of care review form attached to the discharge summary. During a joint record review and an interview on 04/19/2024, the Patient Care Administrator confirmed that the discharge summary did not contain the required information.

Based on interview and record review, the hospice agency did not reassess the response to care for one of three sampled patients, Patient 1. Patient 1 expressed discomfort and resistance when staff provided ADL (activities of daily living, such as toileting and bathing) care. The staff did not develop a plan to address Patient 1's agitation and consider alternative interventions. This failure resulted in staff not managing Patient 1's resistive behavior for Patient 1. Findings: Record review of the document "Symptom Management" (not dated) showed, "The hospice must conduct and document in writing a patient-specific comprehensive assessment that identifies the patient's need for hospice care and services, and the patient's need for physical, psychological, emotional, and spiritual care." Record review of the document "Case Sheet" showed Patient 1's Start of Care was 4/13/19 with diagnoses which included, Cerebral Atherosclerosis (buildup of plaque in the blood vessels of the brain). Review of the document, "RN-Initial Comprehensive Assessment" dated 4/13/19, showed Patient 1 could get easily upset or agitated with ADL care. The plan included maintaining a quiet, safe environment and for staff to communicate with Patient 1 in a calm manner. Review of the document, "Nursing-Updated Comprehensive Assessment" (NUCA) dated 4/15/19, showed Patient 1 was resistive to ADL care. Furthermore, a call was made to the doctor and Patient 1's medications to treat agitation were increased. Review of the NUCA dated 4/27/19 showed Patient 1 became agitated when turned to change his wet brief (diaper). Review of the document, "Physician Visit Note" dated 5/29/19 showed Patient 1 was "...Not tolerating ADL care. He is somewhat abusive with his language, refuses to be shaved, and often to have his brief changed..." There was no documentation in the clinical record which showed a plan was developed to address Patient 1's continuous agitation with ADL care. In an interview on 6/18/19 at 3:51 p.m., the Registered Nurse Team Manager (RNTM 1) confirmed Patient 1's plan of care had not been updated to reflect the increase in medications to control agitation or his continued resistance to ADL care. RNTM 1 stated previous interventions had been in place to address the resistance to ADL care but she was not sure what they were. In an interview on 6/18/19 at 4:15 p.m., Registered Nurse 1 (RN 1) confirmed she had not updated the plan of care. RN 1 stated the purpose for updating the plan would be to reassess whether steps taken have been effective in reducing his agitation and possibly try new approaches.

Based on interview and record review, the hospice agency did not maintain the responsibility to coordinate care for one of three sampled patients (Patient 1). There was no plan for staff to monitor and evaluate Patient 1's response to increases of his psychoactive (affects mood, thinking, behavior) medications. This failure contributed to Patient 1 experiencing side effects related to several prescribed psychoactive medications and had sustained a fall. Findings: Record review of the document "Case Sheet" showed Patient 1's Start of Care was 4/13/19 with diagnoses that included Cerebral Atherosclerosis (buildup of plaque in the blood vessels of the brain) and received home health services at theAssisted Living Facility (ALF). Record review of the "Interdisciplinary Care Plan" dated 4/13/19, showed the agency was to provide the "Services to adequately address symptoms/concerns..." Record review of the "Interdisciplinary Plan of Care Revision/Physician Orders" dated 4/15/19, showed the agency's nursing staff were to "Maintain safety. To notify (name of hospice agency) of changes/worsening behavior." Record review of the "RN-Initial Comprehensive Assessment" dated 4/13/19, showed Patient 1 was alert with periods of confusion. The plan of care indicated, "Patient will be comfortable, free from injury." Record review of the document "Admissions Orders/Hospice Certification. Initial Plan of Care" dated 4/13/19, showed Patient 1's medications included Quetiapine (Seroquel) Furmarate 25 mg (milligram) two tablets every night at bedtime. Quetiapine is an antipsychotic medication with side effects that include aggressive, angry, violent behavior and suicidal thought. [Reference: www.fda.gov]. The doctor also ordered another antipsychotic medication, Haldol which could cause drowsiness and lethargy. [Reference: www.nlm.nih.gov]. Record review of the document, "Nursing-Updated Comprehensive Assessment" (NUCA) dated 4/15/19, showed licensed nursing staff notified the doctor regarding Patient 1's behavior which included, "Periodical angry outburst, yelling." Further review of the interventions indicated the doctor ordered Patient 1 to receive Depakote (mood stabilizer) 500 mg. Depakote side effects included dizziness, weakness, and headache. [Reference: www.depakote.com] twice a day. In addition, Seroquel 12.5 mg every morning was newly prescribed. The "Response to Care" showed the "Facility staff agreed to the plan of care. Will continue to monitor behavior." Review of the NUCA dated 4/23/19 showed Patient 1 fell while walking from his kitchen area at the ALF) for independent senior living. Review of the medication orders dated 4/25/19 showed further increases in medication dosages as follows: Ativan one tablet twice a day for anxiety. Seroquel 25 mg take 3 tablets at bedtime. Depakote 500 mg. Take one tablet three times a day for agitation. Review of the NUCA dated 4/26/19 showed Patient 1 was lethargic, had slurred speech, and had an unwitnessed fall. Agency staff documented, "Instructed staff to check on patient frequently and notify (hospice name) of any changes." In an interview 6/18/19 at 3:51 p.m. with the agency's Registered Nurse Team Manager (RNTM 1), RNTM 1 stated there were medical technicians at the ALF who could check on Patient 1 every two hours. In an interview on 6/18/12 at 4:15 p.m., Registered Nurse 1 (RN 1) stated she told the ALF staff about the increases to Patient 1's medication dosages and asked them (ALF) to "Monitor" Patient 1 for side effects. In an interview on 6/19/19 at 1:25 p.m., the agency's Vice President of Pharmacy Services (VPPS) stated staff should be monitoring patients on antipsychotic medications, and looking for drug interactions, QT elevations (changes on an EKG or electrocardiogram machine that records the electrical activity of the heart), and changes in behavior or drowsiness. In an interview on 7/8/19 at 11:10 a.m., the Health Services Director (HSD) at the ALF stated the ALF is not a medical setting. Staff are available around-the-clock but not at the bedside and could not commit to providing one to two hour checks. Record review of the policy and procedure titled, "Interdisciplinary Team (IDT) Policies Assessment dated 11/15/16 indicated, "To identify changes that have taken place since the initial assessment and includes information on the patients progress toward desired outcomes, as well as a reassessment of the patient's response to care."