Pathways Home Health and Hospice

“Based on interview and record review the Hospice Agency did not provide services based on the needs for one of 13 sampled patients (Patient 5) when Patient 5 was not fully assessed for end-of-life symptoms and had no access to end-of-life medications (comfort kit). This failure placed Patient 5 at high risk and high probability of experiencing unnecessary agitation and falls. During a record review of the admission booklet, “;Patient Handbook for Hospice Services” dated 11/2024, the booklet showed “;Hospice care is aggressive management of symptoms which allows the patient to live with the highest possible quality of life. Constant, proactive and timely management means that the patient rarely needs to be hospitalized for symptom control.” During a record review of the document “;Admission Criteria Process and Initial Hospice Assessment dated 1/30/2025, the document showed, “Hospice accepts patients based on their care needs. A reasonable expectation must exist that Hospice can adequately take care of the patient at home.” “;Patients referred to home hospice are terminally ill and generally experience a variety of symptoms as their condition progresses and their health declines. These symptoms include pain, dyspnea, nausea/vomiting, delirium, anxiety...Symptoms may develop quickly and unexpectedly, often at night or on the weekends. Prompt relief of symptoms can be facilitated by timely access to medications.” [National Institute of Health. National Library of Medicine pmc.ncbi.nim.nih.gov/articles/PMC4118704/] During a record review of the document “;Visit Note Repor(VNR)...RN Hospice Start of Care” dated 11/16/2024, the VNR showed the hospice agency admitted Patient 5 on 11/16/2024 with diagnoses which included dementia (a loss of brain function that occurs with certain diseases, affecting one or more brain functions such as memory, thinking, language, judgment, or behavior). During a record review of the documents,” Visit Note Report(s)” (nursing visit notes), the VNR showed the following: VNR dated 11/24/2024: Patient 5 had experienced a fall. VNR dated 11/30/2024: Patient 5 had tried to get out of his wheelchair and fell against the pole/divider, which created an abrasion and bleeding to his philtrum. (vertical indentation in the middle area of the upper lip) VNR dated 12/13/2024: Patient 5 had been “;Found on the floor” that morning. VNR dated 12/27/2024: Patient 5 was found on the floor and sustained an injury to his forehead. Patient 5 had continued to “;...Attempt to stand without assist...” There was no documentation in the clinical record which showed agency staff assessed Patient 5 for end-of-life agitation or discussed providing medication to control the symptoms and potentially prevent future falls. During an interview on 1/28/2025 at 1:53 p.m. Registered Nurse 1 (RN 1) confirmed there was no documentation in the clinical record which showed she had evaluated the reasons for the falls or if it had possibly been due to end-of-life agitation. RN 1 stated the facility staff had reported to her that Patient 5 had been sent to the emergency department a couple of times per day for his falls and had fallen again that morning on 1/28/2025. During an interview on 1/30/2025 at 11:21 a.m. with the Manager of Clinical Services (MCS), MCS stated Patient 5 had fallen several times and staff should have been assessing why it continued to happen. The MCS stated the facility where Patient 5 resided did not allow the agency to keep a comfort kit on hand. The MCS stated it was important to have a comfort kit present in the facility so symptoms can be controlled, and potential falls prevented.”

“Based on interview and record review, the hospice agencys staff did not coordinate care to address frequent falls for one of 13 sampled patients (Patient 5) when Patient 5 sustained falls with injuries and staff did not coordinate a care conference to discuss ways to prevent the falls. This resulted in unnecessary falls with injuries for Patient 5. During record review of the document “;Interdisciplinary Group Coordination of Care” (IDG) dated 1/28/2025, the document showed the purpose was to “;Ensure the coordination of services for each Hospice patient. The IDG will initiate changes as the patient, caregiver and/or family needs evolve during the terminal illness. It is the responsibility of the IDG to facilitate communication about changes in the patients status among all assigned employees.” During a review of the document “;Job Description”, the document showed the duties of the Medical Social Worker included, based on the comprehensive assessment, “;...Develops a comprehensive psychosocial plan of care, including individualized goals, interventions, and projected visit frequencies. Continually reviews and updates psychosocial plan of care. Integrates input from other disciplines to create a comprehensive interdisciplinary plan of care.” During a record review of the document, “;Visit Note Report...RN Hospice Start of Care” dated 11/16/2024, the report indicated Patient 5 had a history of falls which required visits to the Emergency Department. He had weakness in his legs which required “;Maximal Assistance” while transferring from the bed to chair. Record review of the documents, “;Visit Note Report(s)” (VNR) (nursing visit notes) showed the following: VNR dated 11/24/2024: Patient 5 had experienced a fall. VNR dated 11/30/2024: Patient 5 had tried to get out of his wheelchair and fell against the pole/divider, which created an abrasion and bleeding to his philtrum. (vertical indentation in the middle area of the upper lip). VNR dated 12/13/2024: Patient 5 had been “;Found on the floor” that morning. VNR dated 12/27/2024: Patient 5 was found on the floor and sustained an injury to his forehead. Patient 5 had continued to “;...Attempt to stand without assist...” During a review of patient 5’s clinical records, there was no documentation in the clinical record which showed agency staff had reported the incidences to the social worker so a care conference could be coordinated with the assisted living facility and the family in order to address the continued falls. During an interview on 1/28/2025 at 1:15 p.m. the agencys Manager of Clinical Services (MCS) stated there was no documentation under “;Coordination Notes” which showed the falls had been addressed. During an interview on 1/28/2025 at 1:53 p.m. with RN1, Registered Nurse 1 (RN 1) confirmed there was no documentation in the clinical record which showed she had communicated with the family or the agencys social worker the need for a care conference to address the continued falls. RN1 stated Patient 5 had again fallen that morning on 1/28/2025. During a record review of the VNRs for the Agencys Medical Social Worker dated 11/18/2024 and 1/6/2025, the VNR’s showed no documentation regarding Patient 5s falls. During a record review of the documents, “;Hospice IDG comprehensive Assessment and Plan of Care Update Report(s)” dated 11/29/2024, 12/13/2024 and 12/27/2024, the records indicated no documentation regarding a plan to address the falls. During an interview on 1/30/2025 at 12:36 p.m. with Agencys Medical Social Worker (MSW, MSW stated he knew about the falls and typically, when there is a safety concern, he alerts the case manager and brings together the caregiver and the facility to address the problem. The MSW confirmed no coordinated meeting had taken place in regard to Patient 5s falls and injuries. During record review of the document “;Interdisciplinary Group Coordination of Care” (IDG) dated 1/28/2025, the document showed the purpose was to “;Ensure the coordination of services for each Hospice patient. The IDG will initiate changes as the patient, caregiver and/or family needs evolve during the terminal illness. It is the responsibility of the IDG to facilitate communication about changes in the patients status among all assigned employees.” During a review of the document “;Job Description”, the document showed the duties of the Medical Social Worker included, based on the comprehensive assessment, “;...Develops a comprehensive psychosocial plan of care, including individualized goals, interventions, and projected visit frequencies. Continually reviews and updates psychosocial plan of care. Integrates input from other disciplines to create a comprehensive interdisciplinary plan of care.” During a record review of the document, “;Visit Note Report...RN Hospice Start of Care” dated 11/16/2024, the report indicated Patient 5 had a history of falls which required visits to the Emergency Department. He had weakness in his legs which required “;Maximal Assistance” while transferring from the bed to chair. Record review of the documents, “;Visit Note Report(s)” (VNR) (nursing visit notes) showed the following: VNR dated 11/24/2024: Patient 5 had experienced a fall. VNR dated 11/30/2024: Patient 5 had tried to get out of his wheelchair and fell against the pole/divider, which created an abrasion and bleeding to his philtrum. (vertical indentation in the middle area of the upper lip). VNR dated 12/13/2024: Patient 5 had been “;Found on the floor” that morning. VNR dated 12/27/2024: Patient 5 was found on the floor and sustained an injury to his forehead. Patient 5 had continued to “;...Attempt to stand without assist...” During a review of patient 5’s clinical records, there was no documentation in the clinical record which showed agency staff had reported the incidences to the social worker so a care conference could be coordinated with the assisted living facility and the family in order to address the continued falls. During an interview on 1/28/2025 at 1:15 p.m. the agencys Manager of Clinical Services (MCS) stated there was no documentation under “;Coordination Notes” which showed the falls had been addressed. During an interview on 1/28/2025 at 1:53 p.m. with RN1, Registered Nurse 1 (RN 1) confirmed there was no documentation in the clinical record which showed she had communicated with the family or the agencys social worker the need for a care conference to address the continued falls. RN1 stated Patient 5 had again fallen that morning on 1/28/2025. During a record review of the VNRs for the Agencys Medical Social Worker dated 11/18/2024 and 1/6/2025, the VNR’s showed no documentation regarding Patient 5s falls. During a record review of the documents, “;Hospice IDG comprehensive Assessment and Plan of Care Update Report(s)” dated 11/29/2024, 12/13/2024 and 12/27/2024, the records indicated no documentation regarding a plan to address the falls. During an interview on 1/30/2025 at 12:36 p.m. with Agencys Medical Social Worker (MSW, MSW stated he knew about the falls and typically, when there is a safety concern, he alerts the case manager and brings together the caregiver and the facility to address the problem. The MSW confirmed no coordinated meeting had taken place in regards to Patient 5s falls and injuries. During record review of the document “;Interdisciplinary Group Coordination of Care” (IDG) dated 1/28/2025, the document showed the purpose was to “;Ensure the coordination of services for each Hospice patient. The IDG will initiate changes as the patient, caregiver and/or family needs evolve during the terminal illness. It is the responsibility of the IDG to facilitate communication about changes in the patients status among all assigned employees.” During a review of the document “;Job Description”, the document showed the duties of the Medical Social Worker included, based on the comprehensive assessment, “;...Develops a comprehensive psychosocial plan of care, including individualized goals, interventions, and projected visit frequencies. Continually reviews and updates psychosocial plan of care. Integrates input from other disciplines to create a comprehensive interdisciplinary plan of care.” During a record review of the document, “;Visit Note Report...RN Hospice Start of Care” dated 11/16/2024, the report indicated Patient 5 had a history of falls which required visits to the Emergency Department. He had weakness in his legs which required “;Maximal Assistance” while transferring from the bed to chair. Record review of the documents, “;Visit Note Report(s)” (VNR) (nursing visit notes) showed the following: VNR dated 11/24/2024: Patient 5 had experienced a fall. VNR dated 11/30/2024: Patient 5 had tried to get out of his wheelchair and fell against the pole/divider, which created an abrasion and bleeding to his philtrum. (vertical indentation in the middle area of the upper lip). VNR dated 12/13/2024: Patient 5 had been “;Found on the floor” that morning. VNR dated 12/27/2024: Patient 5 was found on the floor and sustained an injury to his forehead. Patient 5 had continued to “;...Attempt to stand without assist...” During a review of patient 5’s clinical records, there was no documentation in the clinical record which showed agency staff had reported the incidences to the social worker so a care conference could be coordinated with the assisted living facility and the family in order to address the continued falls. During an interview on 1/28/2025 at 1:15 p.m. the agencys Manager of Clinical Services (MCS) stated there was no documentation under “;Coordination Notes” which showed the falls had been addressed. During an interview on 1/28/2025 at 1:53 p.m. with RN1, Registered Nurse 1 (RN 1) confirmed there was no documentation in the clinical record which showed she had communicated with the family or the agencys social worker the need for a care conference to address the continued falls. RN1 stated Patient 5 had again fallen that morning on 1/28/2025. During a record review of the VNRs for the Agencys Medical Social Worker dated 11/18/2024 and 1/6/2025, the VNR’s showed no documentation regarding Patient 5s falls. During a record review of the documents, “;Hospice IDG comprehensive Assessment and Plan of Care Update Report(s)” dated 11/29/2024, 12/13/2024 and 12/27/2024, the records indicated no documentation regarding a plan to address the falls. During an interview on 1/30/2025 at 12:36 p.m. with Agencys Medical Social Worker (MSW, MSW stated he knew about the falls and typically, when there is a safety concern, he alerts the case manager and brings together the caregiver and the facility to address the problem. The MSW confirmed no coordinated meeting had taken place in regards to Patient 5s falls and injuries. During record review of the document “;Interdisciplinary Group Coordination of Care” (IDG) dated 1/28/2025, the document showed the purpose was to “;Ensure the coordination of services for each Hospice patient. The IDG will initiate changes as the patient, caregiver and/or family needs evolve during the terminal illness. It is the responsibility of the IDG to facilitate communication about changes in the patients status among all assigned employees.” During a review of the document “;Job Description”, the document showed the duties of the Medical Social Worker included, based on the comprehensive assessment, “;...Develops a comprehensive psychosocial plan of care, including individualized goals, interventions, and projected visit frequencies. Continually reviews and updates psychosocial plan of care. Integrates input from other disciplines to create a comprehensive interdisciplinary plan of care.” During a record review of the document, “;Visit Note Report...RN Hospice Start of Care” dated 11/16/2024, the report indicated Patient 5 had a history of falls which required visits to the Emergency Department. He had weakness in his legs which required “;Maximal Assistance” while transferring from the bed to chair. Record review of the documents, “;Visit Note Report(s)” (VNR) (nursing visit notes) showed the following: VNR dated 11/24/2024: Patient 5 had experienced a fall. VNR dated 11/30/2024: Patient 5 had tried to get out of his wheelchair and fell against the pole/divider, which created an abrasion and bleeding to his philtrum. (vertical indentation in the middle area of the upper lip). VNR dated 12/13/2024: Patient 5 had been “;Found on the floor” that morning. VNR dated 12/27/2024: Patient 5 was found on the floor and sustained an injury to his forehead. Patient 5 had continued to “;...Attempt to stand without assist...” During a review of patient 5’s clinical records, there was no documentation in the clinical record which showed agency staff had reported the incidences to the social worker so a care conference could be coordinated with the assisted living facility and the family in order to address the continued falls. During an interview on 1/28/2025 at 1:15 p.m. the agencys Manager of Clinical Services (MCS) stated there was no documentation under “;Coordination Notes” which showed the falls had been addressed. During an interview on 1/28/2025 at 1:53 p.m. with RN1, Registered Nurse 1 (RN 1) confirmed there was no documentation in the clinical record which showed she had communicated with the family or the agencys social worker the need for a care conference to address the continued falls. RN1 stated Patient 5 had again fallen that morning on 1/28/2025. During a record review of the VNRs for the Agencys Medical Social Worker dated 11/18/2024 and 1/6/2025, the VNR’s showed no documentation regarding Patient 5s falls. During a record review of the documents, “;Hospice IDG comprehensive Assessment and Plan of Care Update Report(s)” dated 11/29/2024, 12/13/2024 and 12/27/2024, the records indicated no documentation regarding a plan to address the falls. During an interview on 1/30/2025 at 12:36 p.m. with Agencys Medical Social Worker (MSW) stated he knew about the falls and typically, when there is a safety concern, he alerts the case manager and brings together the caregiver and the facility to address the problem. The MSW confirmed no coordinated meeting had taken place in regards to Patient 5s falls and injuries. Based on interview and record review, the hospice agencys staff did not coordinate care to address frequent falls for one of 13 sampled patients (Patient 5). Patient 5 sustained falls with injuries. Staff did not coordinate a care conference to discuss ways to prevent the falls. This resulted in unnecessary falls with injuries for Patient 5. Record review of the document “;Interdisciplinary Group Coordination of Care” (IDG) dated 1/28/2025 showed the purpose was to “;Ensure the coordination of services for each Hospice patient. The IDG will initiate changes as the patient, caregiver and/or family needs evolve during the terminal illness. It is the responsibility of the IDG to facilitate communication about changes in the patients status among all assigned employees.” Review of the document “;Job Description” showed the duties of the Medical Social Worker included, based on the comprehensive assessment, “;...Develops a comprehensive psychosocial plan of care, including individualized goals, interventions, and projected visit frequencies. Continually reviews and updates psychosocial plan of care. Integrates input from other disciplines to create a comprehensive interdisciplinary plan of care.” Record review of the document “;Visit Note Report...RN Hospice Start of Care” dated 11/16/2024 showed Patient 5 had a history of falls which required visits to the Emergency Department. He had weakness in his legs which required “;Maximal Assistance” while transferring from the bed to chair. Record review of the documents “;Visit Note Report(s)” (VNR) (nursing visit notes) showed the following: VNR dated 11/24/2024: Patient 5 had experienced a fall. VNR dated 11/30/2024: Patient 5 had tried to get out of his wheelchair and fell against the pole/divider, which created an abrasion and bleeding to his philtrum. (vertical indentation in the middle area of the upper lip) VNR dated 12/13/2024: Patient 5 had been “;Found on the floor” that morning. VNR dated 12/27/2024: Patient 5 was found on the floor and sustained an injury to his forehead. Patient 5 had continued to “;...Attempt to stand without assist...” There was no documentation in the clinical record which showed agency staff had reported the incidences to the social worker so a care conference could be coordinated with the assisted living facility and the family in order to address the continued falls. During an interview on 1/28/2025 at 1:15 p.m., the agencys Manager of Clinical Services (MCS) stated there was no documentation under “;Coordination Notes” which showed the falls had been addressed. During an interview on 1/28/2025 at 1:53 p.m. Registered Nurse 1 (RN 1) confirmed there was no documentation in the clinical record which showed she had communicated with the family or the agencys social worker the need for a care conference to address the continued falls. RN 1 stated Patient 5 had again fallen that morning on 1/28/2025. Record review of the VNRs for the Agencys Medical Social Worker dated 11/18/2024 and 1/6/2025 showed no documentation regarding Patient 5s falls. Record review of the documents “;Hospice IDG comprehensive Assessment and Plan of Care Update Report(s)” dated 11/29/2024, 12/13/2024 and 12/27/2024, showed no documentation regarding a plan to address the falls. During an interview on 1/30/2025 at 12:36 p.m., the Agencys Medical Social Worker (MSW) stated he knew about the falls and typically, when there is a safety concern, he alerts the case manager and brings together the caregiver and the facility to address the problem. The MSW confirmed no coordinated meeting had taken place in regards to Patient 5s falls and injuries.”