Alabama Hospice Care of Tuscaloosa

“Based on observations, medical record (MR) review, agency policy and procedure, and interviews it was determined the agency failed to ensure all current medications were included in the Plan of Care (POC). This affected one of three Home Visits (HV) patients including HV # 1 and had the potential to affect all patients admitted to this hospice. Findings include: Agency Policy: Medication Management Policy Number: 2.004 Revised: 2/1/22 ...Policy: ...At each visit the medications will be reviewed, changes made when medically necessary, and orders communicated to the trained Administrative Support Staff. Procedure: ...Monitor medications at each patient visit to ensure medications lists (including OTC [over the counter] medications) and drug allergies are updated... 1. HV # 1 was admitted on 11/6/23 and recertified from 2/4/24 to 5/3/24 with diagnoses including Unspecified Severe Protein-Calorie Malnutrition and Type 2 Diabetes Mellitus Without Complications. A HV was conducted on 4/16/24 to observe care provided by Employee Identifier (EI) # 5 Registered Nurse (RN), PCM (Patient Care Manager). During the HV, a review of the medications was conducted with EI # 5 and HV # 1. The following discrepancies were identified: a. Potassium Chloride 20 Meq (milliequivalent) tablets, prescription filled on 3/26/24, were in the home and not on the Medication List. A review of the Medication List dated 4/16/24 revealed orders for Potassium Chloride 20 Meq/15 ml (milliliters) take 30 ml twice daily. HV # 1 stated he/she has been taking the Potassium tablets but would rather have the liquid form. b. Vitamin D2, prescription filled 3/25/24, was in the home but not listed on the Medication List. HV # 1 stated he/she takes one per week on Sundays. c. Magnesium 250 mg (milligram) tablet, take one daily was on the Medication List but not in the home. HV # 1 stated he/she was not aware he/she was supposed to be taking Magnesium. d. Memantine 28 mg capsule, take one two times a day was on the Medication List but not in the home. HV # 1 stated he/she was not aware he/she was supposed to be taking Memantine. An interview was conducted on 4/18/24 at 5:00 PM with EI # 1, Executive Director, who confirmed the medications were not reconciled per agency policy.”

“Based on observations, medical record (MR) review, Potter and Perry Fundamentals of Nursing, and interviews it was determined the agency failed to ensure patient and caregiver education was provided for oxygen safety to include signage in the home. This affected one of three Home Visit (HV) patients with oxygen in use including HV # 1 and had the potential to negatively affect all patients admitted to this agency. Findings include: Reference: Potter and Perry Fundamentals of Nursing Fifth Edition Copyright: 2001 ...page 1176...Safety Precautions with Oxygen Therapy... With increasing use of home oxygen therapy, clients...must be aware of the dangers of combustion. The nurse should promote safety by using the following measures: “No smoking” signs should be placed on the clients room door and over the bed. The client, visitors and roommates, and all personnel should be informed that smoking is not permitted in areas where oxygen is in use... 1. HV # 1 was admitted on 11/6/23 and recertified from 2/4/24 to 5/3/24 with diagnoses including Unspecified Severe Protein-Calorie Malnutrition and Type 2 Diabetes Mellitus Without Complications. A HV was conducted on 4/16/24 at 2:50 PM to observe care provided by Employee Identifier (EI) # 5 Registered Nurse (RN), Patient Care Manager (PCM). Review of the Hospice IDG (Interdisciplinary Group) Comprehensive Assessment and Plan of Care Update Report dated 4/10/24 revealed orders for Oxygen at 2 - 4 liters per minute as needed for mild to severe shortness of breath. During the HV on 4/16/24 Oxygen was observed in use by HV # 1 at 2 liters per minute via nasal cannula. There were no signs in the room or on the door indicating Oxygen was in use. An interview was conducted on 4/18/24 at 8:00 AM with EI # 5 who confirmed there were no “No Smoking” or “Oxygen in use” signs in the home.”

“Based on medical record review, agency policy and procedure, and interviews, it was determined the agency failed to ensure the physician ordered wound care for each of the wounds requiring care. This affected one of three medical records of patients with wounds including Home Visit (HV) # 1 and had the potential to negatively affect all patients admitted with wounds. Findings include: Agency Policy: Wound Assessment, Documentation and Photography Policy Number: 3.029 Revised: 3/1/21 Purpose: To ensure accurate and consistent assessment and documentation of wounds. ...Procedure: ...2. Perform wound care according to physician orders specified in the patient’s plan of care... 1. HV # 1 was admitted to hospice on 11/6/23 and recertified for hospice from 2/4/24 to 5/3/24 with diagnoses including Unspecified Severe Protein-Calorie Malnutrition and Type 2 Diabetes Mellitus Without Complications. Review of the Physician’s order dated 4/16/24 revealed orders for a midline wound, clean with wound cleanser, pack with wound cleanser soaked 4 x 4, cover with dry 4 x 4, cover with abdominal pad, and secure with tape. Skilled nurse (SN) to change three times a week. Review of the Wound Care Report revealed the SN documented on 2/5/24, 2/7/24, 2/9/24, 2/13/24, 2/14/24, 2/16/24, 2/19/24, 2/19/24, 2/21/24, 2/26/24, 2/28/24, 3/1/24, 3/4/24, 3/7/24, 3/8/24, 3/11/24, 3/13/24, 3/15/24, 3/18/24, 3/20/24, 3/22/24, 3/25/24, 3/27/24, 3/29/24, 4/1/24, 4/3/24, 4/5/24, 4/6/24, 4/8/24, 4/10/24, and 4/12/24 wound # 1 Stage 4 Pressure Ulcer (PU) to midline abdomen was cleansed with wound cleanser, packed with 4 x 4 moistened with wound cleanser, covered with 4 x 4 gauze and ABD (abdominal) pad. There was no documentation of physician’s orders for wound care of the wound # 1, Stage 4 PU to the midline abdomen prior to 4/16/24. An interview was conducted on 4/18/24 at 5:00 PM, with EI # 1, Executive Director, who confirmed there were no orders prior to 4/16/24 for the wound care to the midline wound to the abdomen.”

“Based on review of agency policy and procedure, observation, and interview with staff it was determined the agency failed to follow accepted standards of practice for hand hygiene. This did affect one of three home visit (HV) observations, including HV # 3, and had the potential to negatively affect all patients served by the agency. Findings include: Agency Policy: Hand Hygiene - Infection Control Policy number: 10.002 Effective 3/01/21 Purpose: To help prevent the spread of microorganisms and infection by cross-contamination and to provide practice guidelines. Policy: Staff are required to perform hand hygiene prior to, at specified time points during, and following patient contact. Hand hygiene will be performed using soap and water or an alcohol-based hand sanitizer. Procedures: 1. Staff performs hand hygiene... e. If moving from a contaminated body site to a clean body site during patient care. f. ...before and after removing personal protective equipment (PPE) such as gloves... 1. HV # 3 was admitted on 11/7/23 and recertified for care on 3/6/24 to 5/4/24 with Senile Degeneration of Brain, Not Elsewhere Classified and Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbances, Psychotic Disturbances, Mood Disturbances and Anxiety. A HV was conducted on 4/17/24 at 8:09 AM with Employee Identifier (EI) # 3, Hospice Aide (HA) to observe care provided to the patient. During the observation of a bed bath, EI # 3 removed top bed linen and undressed HV # 3. EI # 3 removed gloves and without performing hand hygiene donned clean gloves, and washed HV # 3’s face. EI # 3 washed, rinsed, and dried HV # 3’s upper body, legs, and feet. EI # 3 removed gloves and without performing hand hygiene donned clean gloves, then removed HV # 3’s bottom bed linen, diaper and padding. EI # 3 removed gloves and without performing hand hygiene donned clean gloves, then washed, rinsed and dried HV # 3’s back, legs and buttocks. EI # 3 removed gloves and without performing hand hygiene donned clean gloves, then applied lotion to HV # 3’s back and legs. EI # 3 removed gloves and without performing hand hygiene donned clean gloves, then rolled HV # 3 on left side, replaced clean linen and under pads to the bed. EI # 3 removed gloves and without performing hand hygiene donned clean gloves, then applied deodorant to HV # 3’s underarms. EI # 3 removed gloves and without performing hand hygiene donned clean gloves, then applied barrier cream to HV # 3’s perineal area. EI # 3 removed gloves and without performing hand hygiene donned clean gloves, then washed HV # 3’s hair. EI # 3 removed gloves and without performing hand hygiene donned clean gloves, then assisted HV # 3 with mouth care. An interview was conducted on 4/18/24 at 4:40 PM with EI # 1, Executive Director (ED), who confirmed the staff failed to follow the agencys hand hygiene policy.”

“Based on review of Medical Records (MR), the Alabama Board of Nursing Administrative Code and Standards of Nursing Practice, agency policy, and interview with staff, it was determined the agency failed to ensure the nursing staff received the pronouncement of death via telecommunication with the physician as directed by the Alabama Board of Nursing. This affected one of two death records reviewed, including MR # 10. This deficient practice had the potential to negatively affect all patients admitted to the hospice. Findings include: Alabama Board of Nursing Administrative Code Chapter 610-X-6 Standards of Nursing Practice: 610-X-6-.15 Telecommunication for Pronouncement of Patient Death. (1) The licensed nurse may receive pronouncement of a patient’s death from a physician via telecommunication without a physical examination of the patient by that physician. (2) The facility policy shall specify the permissible patient conditions for which the licensed nurse in a specific health care facility or agency may receive the pronouncement of a patient’s death by telecommunication. Author: Alabama Board of Nursing Statutory Authority: Code of Ala. 1975, §§22-31-2, 34-21-2(c)(21). Agency Policy: Home Death Pronouncement Agency Policy Number: 3.013 Revision Date: 3/1/22 Purpose: To establish the process for the hospice clinician to follow when a patient dies at home. Policy: Individual state and community regulations and practices will be followed...State of Alabama guidelines, the RN (registered nurse)/ LPN (licensed practical nurse) can pronounce per verbal communication with the physician. The physician pronounces death. 1. MR # 10 was admitted to the agency on 5/7/23 with diagnoses including Malignant Neoplasm of Occipital Lobe, and Disorder of Brain Unspecified. A review of the RN Hospice Death at Home Visit Note Report dated 5/13/23 revealed no documentation the RN received pronouncement of MR # 10s death from a physician via telecommunication. An interview was conducted on 4/18/24 at 4:51 PM with Employee Identifier (EI) # 1, Executive Director. EI # 1 confirmed there was no documentation the nurse contacted the physician for the pronouncement of death as required by the Alabama Board of Nursing and agency policy.”

“Based on review of the agency On-Call Log, medical record (MR) review, agency policy and procedure, and interviews, it was determined the agency failed to ensure nursing services and medications were available 24 hours a day. This affected one of two MR’s reviewed of patients who were discharged due to revocation including MR # 12, and two patients from the on-call log including Unsampled Patient (UP) # 1, UP # 2, and had the potential to negatively affect all patients admitted to this hospice. Findings include: Agency Policy: On-Call Process Policy Number: 2.009 Revised: 11/8/17 Purpose: To establish guidelines to promote continuity of care, through 24 hr-a-day (24 hours a day) access to an agency representative by means of an on-call process for after office hours services. ...Procedure: ...2. If the agency uses an answering service for fielding and directing of after hours calls, the answering service will contact the agency on call staff member immediately and will keep a record of all calls. The on-call staff member will respond within 20 minutes of being contacted or notified... 5. On call events will be documented by the on-call staff member. This documentation will detail the timeline of event notification and follow up, reason for the call, and actions taken to resolve concerns of patient/caregiver... Agency Policy: On-Call & Back-Up Services Policy Number: 3.033 Revised: 11/1/17 ...Policy: ...The agency will have a plan for back-up on call services when the regular staff cannot report to work and during times when the office is closed. Procedure: ...5. ...If the patient/representative requests a visit, a visit should be made. ...If the answering service cannot reach the on-call nurse within 10 minutes, then the Executive Administrator/Executive Director, clinical leader or designee shall be contacted... 1. MR # 12 was admitted on 5/17/23 with diagnoses including Hypertensive Heart and Chronic Kidney Disease and Chronic Combined Systolic and Diastolic Heart Failure. Review of the Hospice Certification and Plan of Care dated 5/17/23 revealed orders including Skilled Nurse (SN) two times a week for 13 weeks and to monitor pain level using pain scale each visit and report any pain score greater than the patient’s pain goal of three to the physician. Further review of the Hospice Certification and Plan of Care dated 5/17/23 revealed orders for Morphine ER (Extended Release) 15 mg (milligram) tablet, take one two times a day and Hydrocodone 10 mg-Acetaminophen 325 mg three times daily as needed. Review of the Medical Social Worker (MSW) Visit Note Report (VNR) dated 6/19/23 revealed the MSW documented MR # 12 was having pain in the left leg and back and was out of pain medications. Further review of the MSN VNR dated 6/19/23 revealed the patients report of pain was reported to the Executive Director. Review of the SN VNRs dated 7/5/23, 7/7/23, 7/12/23, 7/14/23, 7/19/23, 7/21/23, and 7/28/23, the SN documented MR # 12’s pain level was greater than three. There was no documentation the physician was notified of the pain level greater than three. Review of the SN VNR dated 8/2/23 revealed the SN documented the patient was out of pain medications Morphine and Hydrocodone and the prescriptions had been sent to a local pharmacy. Review of the Discharge From Hospice Program form dated 8/7/23 revealed MR # 12 was discharged for revocation from hospice on 8/7/23 due to being extremely dissatisfied and not having medications for 5 days. An interview was conducted on 4/18/24 at 3:58 PM with Employee Identifier (EI) # 1, Executive Director, who confirmed the agency failed to ensure medications were available for the patient 24 hours a day. 2. Review of the On-Call Log dated 12/7/23 to 12/8/23 revealed the caregiver (cg) of UP # 1 called the agency answering service on 12/7/23 at 5:49 PM and stated UP # 1 had fallen and had injuries to the left elbow and two fingers of the left hand. The cg requested an on call visit. At 5:50 PM the message was sent to the triage nurse. At 6:02 PM a message was sent to the on-call nurse, EI # 6, Registered Nurse (RN), stating UP # 1 had fallen and was requesting a nurse visit. At 6:20 PM the answering service called EI # 6, relayed the message and nurse would follow up with patient. At 6:37 PM the cg called the answering service requesting a nurse visit. At 6:39 PM the Triage Nurse attempted a call to EI # 6, there was no answer. At 6:51 PM the Triage Nurse called EI # 6, EI # 6 to call patient back and follow up. At 6:53 PM the cg of UP # 1 called the answering service stating they had not heard from anyone and were wondering when the visit would happen. At 6:56 PM, EI # 6 was called by the Triage Nurse. EI # 6 stated a visit would be made the following day. There was no documentation the on-call nurse contacted the patient within 20 minutes and no documentation a visit was made on 12/7/23 as requested by the cg. An interview was conducted on 4/18/24 at 8:17 AM with EI # 1, who confirmed there was no documentation the on-call nurse contacted the patient or cg or completed a home visit as requested by family per agency policy. 3. Review of the On-Call Log dated 2/2/24 to 2/5/24 revealed on 2/2/24 at 11:36 PM the cg of UP # 2 called the answering service stating UP # 2 was close to passing and requested a nursing visit now. On 2/2/24 at 11:36 PM the call was sent to the triage nurse. On 2/2/24 at 11:40 PM a message describing the call was sent to the On-Call Nurse, EI # 6. On 2/2/24 at 11:45 PM, EI # 6 accepted the message stating he/she would follow-up and address the patient’s needs. On 2/2/24 at 11:53 PM the cg of UP # 2 called the answering service stating he/she had spoken to EI # 6 and was told that the patient had been dying all day and he/she would come when the patient passes. The cg stated he/she needed a nurse and did not want EI # 6 to come to the home. On 2/2/24 at 11:53 PM, the cg of UP # 2 called in a complaint to the answering service stating the nurse said they could not come to the home until the patient dies. On 2/3/24 at 12:08 AM, the Triage Nurse sent a message to EI # 1 stating the cg of UP # 2 was upset, needed a nurse now, and was told by EI # 6 that he/she would come after patient passes. There was no response from EI # 1. On 2/3/24 at 12:09 AM, the Triage Nurse attempted two calls to EI # 1 and both calls were sent to voicemail. There was no response from EI # 1. On 2/3/24 at 12:14 AM, the Triage Nurse attempted a call to EI # 1 and sent to voicemail. There was no response from EI # 1. On 2/3/24 at 12:17 AM, the Triage Nurse attempted two calls to EI # 6 and a message was left. On 2/3/24 at 12:22 AM, EI # 6 responded to the message stating he/she would follow-up and address the patient’s needs. On 2/3/24 at 12:28 AM the cg of UP # 2 called the answering service asking for an alternate nurse to come visit. On 2/3/24 at 12:35 AM, the Triage Nurse called EI # 6 and relayed the information. On 2/3/24 at 12:35 AM, the Triage Nurse sent a message to EI # 1. There was no response from EI # 1. On 2/3/24 at 12:41 AM, the Triage Nurse called EI # 1 and left a voicemail. There was no response from EI # 1. On 2/3/24 at 12:42 AM, the Triage Nurse sent a message to EI # 6 asking to respond ASAP (as soon as possible). There was no response form EI # 6. On 2/3/24 at 12:44 AM, the Triage Nurse sent a message to EI # 1. There was no response from EI # 1. On 2/3/24 at 12:51 AM, the Triage Nurse sent a message to EI # 1 asking to respond ASAP. There was no response from EI # 1. On 2/3/24 at 12:55 AM, the Triage Nurse called EI # 6. EI # 6 stated he/she could have made the visit but he/she can not stay there with the patient and this is what the family wants is for someone to be there until the patient expires. On 2/3/24 at 12:56 AM, a call was attempted by the Triage Nurse to EI # 1, a voicemail was left. On 2/3/24 at 1:08 AM, a call was attempted by the Triage Nurse to EI # 1, a voicemail was left. On 2/3/24 at 1:37 AM, a call was attempted by the Triage Nurse to EI # 1, a voicemail was left. On 2/3/24 at 2:08 AM the Triage Nurse called the family and explained that there were no other nurses on at the time and that a visit would be made the next day. An interview was conducted on 4/18/24 at 8:17 AM with EI # 1, who confirmed the agency failed to have a nurse available for the patient 24 hours a day when requested.”

“Based on medical record (MR) review, agency policy and procedure, and interviews it was determined the agency failed to ensure wound assessments and care were documented accurately. This affected one of three MR’s reviewed of patients with wounds including Home Visit (HV) # 1 and had the potential to negatively affect all patients admitted to this agency. Findings include: Agency Policy: Wound Assessment, Documentation, and Photography Policy Number: 2.2.001 Revised: 8/1/22 ...Procedure: ...3. Document the following in the medical record: a. Wound type (pressure injury, stasis ulcer, abscess, surgical wound... b. Location and laterality c. Stage or Thickness: Stage pressure injuries according to the National Pressure Ulcer Advisory Panel (NPUAP) Pressure Injury Stages... HV # 1 was admitted on 11/6/23 and recertified from 2/4/24 to 5/3/24 with diagnoses including Unspecified Severe Protein-Calorie Malnutrition and Type 2 Diabetes Mellitus Without Complications. Review of the Physician’s Order dated 2/5/24 revealed orders for wound care to the Stage 2 Pressure Ulcer (PU) to the second toe of the right foot by skilled nurse (SN) on Monday, Wednesday, and Friday. Review of the Hospice IDG (Interdisciplinary Group) Comprehensive Assessment and Plan of Care Update Report dated 4/10/24 revealed the physician documented HV # 1 had a Stage 4 PU to midline abdomen, there was no documentation of orders for the care of the wound. Review of the Visit Note Reports (VNR) dated 2/5/24, 2/7/24, 2/9/24, and 4/8/24, revealed the SN provided care to wound # 1, anterior midline upper abdominal, midline surgical incision. The SN documented wound care was provided to a Stage 4 PU to the midline abdomen. The SN failed to document the accurate assessment of the wound type. Further review of the VNRs dated 2/5/24, 2/7/24, 2/9/24, and 4/8/24 revealed the SN provided care to wound # 3, anterior left second toe, Stage 3 PU. The SN documented wound care was provided to a Stage 2 PU to the second toe of the right foot. The SN failed to document the accurate location and stage of the wound. An interview was conducted on 4/18/24 at 5:00 PM with EI # 1, Executive Director, who stated wound # 1 was a surgical wound and not a pressure ulcer and wound # 3 was a Stage 3 PU to the left foot. EI # 1 confirmed the staff failed to document accurate assessment and location of all wounds per policy.”