Every finding on record at Wuesthoff Health System Brevard Hospice and Palliative Care

Based on interview and record review, the hospice agency failed to maintain an after-hours response system that provided access to essential patient information to promote the right to timely treatment for 1 of 3 residents reviewed for grievances out of a total sample of 25 patients, (#20). --- Findings: Review of the medical record revealed patient #20, a 66-year-old male, resided in a skilled nursing facility (SNF). He was admitted to hospice services on 1/19/24 with a terminal diagnosis of moderate protein-calorie malnutrition. The Patient Information Form indicated patient #20 selected Full Code or full resuscitation status if he had a medical emergency, to include all lifesaving measures such as chest compressions, electric shocks to the heart, and mechanical ventilation. The Hospice Certification and Plan of Care dated 1/19/24 revealed the hospice physician assessed patient #10 and certified he was terminally ill and had a life expectancy of six months or less if his disease followed its normal course. The document indicated the patients advance directive was be resuscitated. Review of the medical record revealed patient #20 signed a Do Not Resuscitate Order (DNRO) on 1/19/24. The order was signed by the physician on 1/25/24. A Narrative Note dated 1/25/24, written by patient #20s Case Manager Registered Nurse (RN) D, read, ";When I asked about his full code status, he became irate and [yelled] at me. How many people do I have to tell! He wants to remain Full Code." Review of a Triage Coordination Note, dated 2/28/24 at 6:09 AM, revealed a SNF nurse called hospice triage to inform them patient #20 died at 6:00 AM. The facility nurse stated to her knowledge, the patient had full code status. The note indicated a few minutes later at 6:12 AM, the hospice triage staff relayed a message to the hospice after-hours nurse, Licensed Practical Nurse (LPN) E and then returned to the call with the facility nurse. The triage nurse wrote that she informed the facility nurse, ";She [LPN E] states that the paperwork she has states that he does not desire resuscitative measures." Review of a Death Visit note dated 2/28/24, written by LPN E, revealed she received a call from triage staff who informed her patient #10 was discovered in bed unresponsive and not breathing. The noted indicated LPN E called the hospice agencys visit scheduling service before she headed to the facility. The document read, ";I thought the chart uploaded to my tablet. . .Had a DNR on file. . ." Review of a Complaint Report dated 2/28/24 revealed the SNF Administrator called the hospice agency to make a complaint. The document indicated the SNF Administrator was ";. . .very upset because when they called our on call last night regarding [name of patient #20] . . .they said he was a DNR. The facility asked for confirmation because they had him as a Full Code. At that point the on-call nurse said they could not access the full chart." The hospice agencys Executive Director (ED) documented a follow-up call to the SNF Administrator who reported she initiated an investigation regarding whether CPR was stopped on the patient. On 4/15/24 at 11:52 AM, the hospice agencys ED reviewed the grievance filed by the SNF. She explained her investigation showed the facility called hospice as they were looking for a DNRO. The ED explained the hospice agency had its own triage staff who handled after-hours telephone calls, but if they were all occupied with patients, the calls would roll over to a third-party answering service. The ED confirmed when the nurse at the SNF called to report patient #10s status, the patient's advance directive was apparently not available. The ED said, ";To my knowledge, the facility did not start CPR at first." On 4/17/24 at 12:32 PM, the ED offered additional information regarding the inaccurate advance directive information that LPN E provided to the SNF nurse. The ED explained the issue was that neither triage staff nor the third-party answering service had the ability to schedule a visit and make patient information fully accessible on the on-call nurses tablet. She stated the process was for triage to inform the after-hours nurse of the need to make a visit, and then the nurse would call another number to reach a third-party on-call service that scheduled visits. The ED explained LPN E called to request a visit but checked her tablet before patient #10s information loaded. She stated LPN E saw the advance directive was DNR and notified the SNF nurse of the order. The ED stated LPN E checked the tablet again after the visit was assigned and fully uploaded and noted patient #10 was actually Full Code status. The ED acknowledged the use of third-party answering and scheduling services contributed to the communication of inaccurate information regarding patient #10s code status and possibly delayed the timely and continuous performance of CPR. The ED verified the hospice agency promised patients and their caregivers that hospice services would be available 24 hours daily, seven days a week. She validated the use of a third-party answering service and the inability of on-call nurses to have immediate access to essential patient information did not ensure the promised care. The ED said, ";In some ways it ties our hands." On 4/17/24 at 3:38 PM, in a telephone interview, LPN E recalled on the morning of 2/28/24, the triage nurse connected her to the SNF nurse on a 3-way telephone call. She stated the SNF nurse informed her patient #10 had a Full Code order in the facilitys medical record but she was confused as she knew he signed a DNRO on admission to hospice services. LPN E explained the information she had at that time showed the resident was not to be resuscitated. She said, ";I did not have him on my tablet yet, so I was not able access anything about him. . .She [the SNF nurse] was not sure of what she should be doing. I really dont know, but I dont believe she started CPR yet." LPN E stated the patients chart completed uploading as she drove to the facility and when she saw that he had Full Code status, she called the SNF nurse to relay the correct information. Review of the hospice agencys policy and procedures for On-Call & Back-Up Services, revised on 11/01/17 revealed a purpose ";to ensure that essential services will be available to all hospice patients at all times, 24 hours daily, 7 days a week." The document indicated at the time of admission to hospice services, patients and their representatives would be informed of the availability of on-call staff after regular office hours. The policy read, ";Information regarding all active patients and available staff will be given to the on-call staff."

Based on interview and record review, the hospice agency failed to develop, implement, and evaluate performance improvement projects (PIPs) to adequately address identified gaps in care and services related to medication reconciliation, collaboration with Skilled Nursing Facilities (SNFs) regarding accuracy of advance directives, and timely after-hours access to essential information for all patients. --- Findings: On 4/15/24 at 11:52 AM and 4/17/24 at 12:32 PM, the hospice agencys Executive Director (ED) discussed an incident noted on the Complaint Log regarding a possible delay in initiation of CPR for a hospice patient who resided in a SNF. She explained the SNF nurse found the unresponsive patient and called the hospice to validate his advance directive status. The ED stated the SNF had documentation of Full Code or full resuscitation status, but neither the triage staff nor the assigned on-call nurse could verify code status as they did not have timely access to the patients medical record. She confirmed the on-call nurse initially misinformed the SNF nurse that the patient had a Do Not Resuscitate Order (DNRO), but when the medical record eventually uploaded, the nurse discovered the patient wanted to be resuscitated. The ED explained if hospice triage staff were busy, telephone calls rolled over to a third-party answering service that might not have full access to the patients medical record. She confirmed there was also a delay as on-call nurses had to call a third-party scheduling service to receive access to patient information. She stated she reported her concerns to the hospice agencys compliance department, but the triage and on-call procedures had not yet been revised. The ED validated the same situation could therefore have reoccurred during the last six weeks. She explained after the incident, the hospice agency developed a PIP related to verification of code status. On 4/15/24 at 12:40 PM, the ED provided documentation of a DNR Audit Action Plan dated 3/04/24 which indicated the hospice agency would verify code status of SNF patients because of the incident when the ";facility was uncertain of patient code status." The PIP revealed 100% of all DNROs in charts and in the hospice binders at the SNFs were to be audited to ensure accuracy of advance directives. The document showed the hospice agency would offer training to SNFs to include printed materials, and all education and audits were to be completed by 3/31/24. Review of the DNR Audit Tool form indicated hospice Social Workers (SWs) provided 20 SNFs with printed copies of the document Hospice Advance Directives Education on 3/11/24 and 3/13/24. The document included a signature page to be completed by the SW who delivered the material and the SNF representative who received the printed education. The Audit Tool showed columns designated for dates the signature pages were returned and reviewed by the ED, and a column for whether compliance was achieved were all blank. On 4/16/24 at 10:26 AM, during a visit to a SNF, the hospice agencys Registered Nurse (RN) Case Manager reviewed the hospice binders for her assigned patients who resided in the building. She verified the three patients had DNROs, but when she checked the hospice binders, she discovered only one contained a DNRO form. The RN Case Manager explained she had not been educated or instructed to audit the binders for DNROs. On 4/16/24 at 10:33 AM and 10:45 AM, the SNFs Director of Nursing (DON) stated her nurses did not rely on DNRO forms placed in the hospice binders. She explained the facilitys nurses followed physician orders for code status in the electronic medical record. The DON stated she did not receive printed or verbal education from the hospice agency regarding advance directives. On 4/16/24 at 10:52 AM, the SNFs Social Services Director (SSD) confirmed she was the designated liaison between the facility and hospice providers. She explained she was responsible for verification of code status for all patents in the facility. The SSD stated she had not received any education from the hospice agency regarding DNROs or any other topic. On 4/16/24 at 10:57 AM, the SNFs Administrator verified the hospice agency never discussed or provided her with printed educational material on advance directives, and she was never made aware of the need for hospice binder audits. On 4/17/24 at 2:32 PM, SW F reviewed the DNR Audit Tool which had her initials adjacent to the names of six facilities. She confirmed she had never been provided with printed educational material for distribution to those facilities. On 4/17/24 at 3:33 PM, SW C, whose initials were noted on the DNR Audit Tool beside the names of four SNFs, denied providing printed education on advance directives to facility staff. On 4/17/24 at 12:32 PM and 1:27 PM, the ED was informed of the above findings during the visit to the SNF. She reiterated SWs were instructed to visit all SNFs and carry out the required education. She verified all nurses had not been included in the training and audits. The ED acknowledged she had not followed up on the DNR Audit Tool and did not have any signed forms to show education was completed for the SNFs. She explained the PIP was not reviewed in the last Quality Assurance and Performance Improvement (QAPI) meeting held on 3/19/24. The ED stated she had monthly QAPI meetings with the Regional Hospice Quality and Patient Experience Coordinator, but the hospice agency managers and other staff were not included in these meetings. She stated the discussions focused on current PIPs and trends, but she had never really utilized the concern log as a source to identify areas for improvement. The ED confirmed there was an ongoing PIP for medication reconciliation that was developed in response to a mock survey done in November 2023. When asked to provide the audit tools for the last five months, the ED was only able to locate incomplete documents for two months. She said, ";I do not know if the [Patient Care Managers] kept up on the audits." The ED was informed of a concern related to medication reconciliation identified during a visit to a SNF. During review of the PIP for medication reconciliation, she validated the plan focused on patients in private homes and should have included processes to collaborate with SNFs to ensure the accuracy of medication lists. The ED verified she was ultimately responsible for keeping staff accountable for completion of audits and said, ";I have struggles with completing follow through." Review of the hospice agencys policy and procedure for Hospice Quality Assurance Performance Improvement Plan, revised on 11/01/21, revealed a purpose ";to develop, implement, and maintain an effective, on-going, hospice-wide data driven quality assessment performance improvement program that reflects the complexity of the organization and services it provides." The document indicated performance improvement activities would focus on areas that impacted patient safety and quality of care. The policy revealed the ED was responsible for coordination, management, and implementation of the QAPI program. The procedure indicated the hospice agency would involve members of appropriate departments, disciplines, and programs in the planning, implementation, and evaluation of PIPs, as all staff were responsible for the quality of care and services provided to patients.

Based on interview and record review, the hospice agency failed to ensure effective coordination of care between hospice and skilled nursing facility (SNF) physicians related to changes in medication orders for 1 of 1 resident reviewed for SNF visit out of a total sample of 25 patients, (#10). --- Findings: Review of the medical record revealed patient #10, an 87-year-old female, resided in a SNF. She was admitted to hospice services on 9/25/23 with a terminal diagnosis of moderate protein-calorie malnutrition. The patients secondary diagnoses included type 2 diabetes, dementia, and anemia. The Hospice Recertification Plan of Care Update dated 3/08/24, revealed patient #10 had skilled nursing visits scheduled once weekly, with an additional three visits as needed for symptom management and changes in condition, for the benefit period 3/23/24 to 5/21/24. The patients Current Ordered Medication list included Omeprazole Delayed Release (DR) 20 milligrams (mg) capsule once daily for acid reflux. The document was electronically signed by the hospice physician on 3/14/24. Review of the medical record revealed a progress note regarding a hospice interdisciplinary group (IDG) meeting on 4/11/24. The team reviewed patient #10s current plan of care including her medications. On 4/16/24 at 9:48 AM, patient #10s hospice Case Manager, Registered Nurse (RN) A, met with the patients assigned SNF nurse. Both nurses stood at the facility nurses medication cart to reconcile the patients medications. During the process, RN A read from the hospice medication list and the SNF nurse checked the facilitys electronic medical record (EMR) to verify its accuracy. The nurses discovered a discrepancy with patient #10s Omeprazole 20 mg that was listed on the hospice medication list, but not in the facilitys EMR. On 4/16/24 at 10:17 AM, RN A researched details of the Omeprazole DR 20mg medication order and explained the hospice physician ordered the drug on 9/25/23. She said, ";It still shows on our list. Im not sure if it was ever on facilitys medication list, or if their physician discontinued it without telling us." She confirmed medication reconciliation was to be done at every visit, or at least once weekly for all patients in SNFs. RN A explained sometimes multiple providers were involved in the care of patients in SNFs, so hospice nurses needed to verify physician orders regularly to ensure effective collaboration. She stated patient #10 had only been on her caseload for two weeks and she validated she did not reconcile her medications last week. RN A acknowledged the previous hospice case manager did not note the discrepancy either. On 4/16/24 at 10:33 AM, the SNFs Director of Nursing reviewed patient #10s EMR and stated the facilitys physician discontinued the order for Omeprazole DR 20 mg on 11/17/23. She explained the drug was discontinued by the facilitys physician based on a recommendation by the facilitys consultant pharmacist. On 4/16/24 at 12:15 PM, the hospices Director of Clinical Operations was informed of patient #10s medication that was discontinued by the SNF approximately five months ago, in November 2023, but was unnoticed by hospice RNs until today. She stated her expectation was all RN case managers would reconcile medications at least weekly for patients who resided in facilities. Review of the hospice agencys policy and procedures for Monitoring Medications, revised on 11/01/17, revealed at the time of comprehensive assessments, all patients would have a drug regimen review. The document indicated nurses would then review and reconcile medications throughout the benefit period. The procedure revealed the medication list for patients who resided in SNFs would be compared to the facilitys Medication Administration Record. The document indicated all nurses who participated in the patients care were responsible for accurate medication lists through a collaborative reconciliation process. The policy read, ";The MD is contacted immediately if any discrepancies between agency information and patient medications are found."