Kaiser Foundation Hospital Hospice - Martinez

“Based on interview and record review, the hospice agencys licensed staff did not take the steps necessary to ensure end of life symptom relief (end of life symptoms include pain, shortness of breath, restlessness) for one (Patient 9) of 13 sampled patients. Patient 9s symptoms were not being managed effectively in the home and staff did not explore available alternative levels of care. This resulted in Patient 9 experiencing unnecessary pain, shortness of breath, and anxiety leading up to his death. Review of Patient 9s “;Hospice Plan of Care,” dated 12/27/23, showed Patient 9s start of care was 12/27/2023 with the current certification period, 12/27/2023 to 12/31/2023. Patient 9s diagnosis included cancer. One problem identified was “;End of Life Symptoms.” The goal was to “;Eliminate Symptoms.” During a record review of Patient 9s home visits and telephone calls showed the following: 12/20/2023: Patient 9 called the agency at 3:45 a.m. and stated he was feeling short of breath. Licensed agency staff advised Patient 9 on the use of in-home hospice medications for relief. 12/21/2023: A home visit was made by Registered Nurse 1 (RN 1). Patient 9 reported “;Worsening Pain” and expressed “;Frustration” with his pain. RN 1 reviewed the medications and how to get ahead of the pain so it would not grow in intensity. RN 1 noted Patient 9 had been taking 20 mg (milligram) of Morphine during “;Severe breakthrough episodes,” as opposed to the required 60 mg. Patient 9 expressed he was “;Struggling” taking more pain medication despite the severe pain. 12/22/2023: A home visit was made by licensed nursing staff (RN). Patient 9 was described as “;Not taking morphine when needed...” Patient 9s pain was 10 out of 10 (highest level of pain) when the registered nurse arrived for the visit. The nurse notified the doctor and made changes to the medication regime. The RN then educated both Patient 9 and his sister of these changes. 12/29/2023: A home visit was made by a licensed social worker (SW). Under the section, “;MSW Caregiving Plans,” the SW described “;Conflict about caregiving plan. Conflict resolution, Patient/family conference, Plan is unrealistic.” Patient 9 was described at the time as being able to meet his own needs but the “;Care plan is not adequate for patient as he declines.” Patient 9 verbalized his understanding of the familys responsibility to provide 24/7 care as his symptoms progress. The caregiver was unavailable to discuss, “;Willingness and/or ability to meet patients care needs through EOL (end-of-life).” Patient 9 was described as “;Apathetic about setting goals or solidifying caregiving plans.” 12/29/2023: A home visit was made by an RN at 4:48 p.m. Patient 9 was described as having “;Terminal restlessness.” Patient 9s sister stated she had not given any medication to combat the restlessness since the day before. 12/29/2023: A phone call was made by Patient 9s sister to the agency at 9:05 p.m. (3 hours and 48 minutes following the home visit). The sister stated Patient 9 was irritated, agitated, would not sleep, and not “;Sleeping most of the day.” The last pain medication given was at 12:44 p.m. The sister was advised to give medication at the time of the call. 12/30/2023: A telephone call was made to the agency. Patient 9s sister described how she got Patient 9 up out of bed but “;Could not stand him back up...” 12/31/2023: A telephone call was made to the agency by Patient 9s sister at 8:57 p.m. who described Patient 9 as “;Gasping for air.” No morphine had been given. Staff advised the sister to give the medication at the time of the call. Patient 9s sister stated she was “;Unable” to give the medication and that his friend would give it. 12/31/2023: Patient 9 passed away at 8:45 p.m. During an interview on 3/13/2024, at 11:01 a.m., with the Director of Hospice (DOH), DOH stated Patient 9s caregivers should not have been trying to get him up out of bed while experiencing end-of-life symptoms and the symptoms were not well controlled because the family did not hire outside help. DOH stated Patient 9 was not eligible for General Inpatient Services (or GIP: inpatient services with 24/7 nursing care to help control symptoms-utilized when symptoms cannot be managed in the home). DOH further stated Patient 9 was not eligible for GIP because he had caregivers available in the home. During an interview on 3/13/2024 at 11:41 a.m., with the social worker assigned to the case (SW 1), SW 1 stated, if she had been made aware of the lack of symptom control, she would have intervened and explored options for the family. SW 1 stated she would have helped them look into hiring outside care. SW 1 further stated GIP was an option as well as continuous care (when the hospice agency provides a nurse who can remain in the home overnight to help stabilize the symptoms). Furthermore, SW 1 stated she would have consulted with the team and possibly make a report to APS (Adult Protective Services). During an interview on 3/13/2024 at 12:14 p.m., with the Registered Nurse Case Manager (RNCM), RNCM stated Patient 9 had 10 out of 10 pain (highest pain level) but did not qualify for GIP status. RNCM stated he had not notified the supervisor or social worker regarding Patient 9s lack of symptom control. Record review of the “;Admission For General Inpatient Services,” dated 5/31/2023, showed “;One (1) or more of the following clinical criteria must be present in order for the patient to be considered appropriate for admission for general inpatient care.” Criteria included, “;Pain control that is unable to be managed appropriately in the home setting.” Review of the “;The Plan of Care,” dated 5/31/2023, showed “;Each patient will be monitored for his/her response to care or services provided against established patient goals and patient outcomes to evaluate progress toward goals.” Review of the “;Job Description,” dated 11/15/2023, showed the duties of the Medical Social Worker included, “;Assist patient and family in placing patient in higher level of care as determined by team and patient, if applicable.””

“Based on interview and record review, the hospice agencys licensed staff did not coordinate care in order to manage end-of-life symptoms (EOL), such as pain, restlessness, and shortness of breath for one (Patient 9) of 13 sampled patients. The licensed nursing staff and social workers did not communicate and coordinate with each other regarding Patient 9s caregivers inability to provide the necessary medication. This resulted in Patient 9 experiencing unnecessary pain, shortness of breath, and anxiety. Record review of Patient 9s “;Hospice Plan of Care,” dated 12/27/23, showed Patient 9s start of care was 12/27/2023 with the current certification period, 12/27/2023 to 12/31/2023. Patient 9s diagnosis included cancer. Record review of the “;MSW Initial Assessment” showed the agencys licensed social worker had visited Patient 9 on 12/15/2023. Staff had identified a primary caregiver which the social worker was unable to reach by phone. The second primary caregiver was identified as Patient 9s sister who had recently reconnected with Patient 9 “;After 20 years” and lived in another state. Under “;Comments,” the social worker discussed the caregiver requirements and “...emphasized that hospice is not custodial care and that the family is responsible to assist with daily needs when such care is necessary or they can also decide to hire a caregiver at his own expense.” Patient 9 lived with a roommate but was “;Not involved with patients care...” Patient 9 was described as being capable at that time of caring for himself but did not have a plan in place for the future. Record review of Patient 9s home visits and telephone calls showed the following: 12/20/2023: Patient 9 called the agency at 3:45 a.m. and stated he was feeling short of breath. Licensed agency staff advised Patient 9 on the use of in-home hospice medications for relief. 12/21/2023: A home visit was made by Registered Nurse 1 (RN 1). Patient 9 reported “;Worsening Pain” and expressed “;Frustration” with his pain. RN 1 reviewed the medications and how to get ahead of the pain so it would not grow in intensity. RN 1 noted Patient 9 had been taking 20 mg of Morphine during “;Severe breakthrough episodes” as opposed to the required 60 mg. Patient 9 expressed he was “;Struggling” taking more pain medication despite the severe pain. 12/22/2023: A home visit was made by licensed nursing staff (RN). Patient 9 was described as “;Not taking morphine when needed and he needs reminder.” Patient 9s pain was 10 out of 10 (highest level of pain) when the registered nurse arrived for the visit. The nurse notified the doctor and made changes to the medication regime. The registered nurse then educated both Patient 9 and his sister of these changes. 12/29/2023: A home visit was made by a licensed social worker (SW). The “;MSW Caregiving Plans” by SW described “;Conflict about caregiving plan. Conflict resolution, Patient/family conference, Plan is unrealistic.” Patient 9 was described at the time as being able to meet his own needs but the “;Care plan is not adequate for patient as he declines.” The caregiver was unavailable to discuss, “;Willingness and/or ability to meet patients care needs through EOL.” Patient 9 was described as “;Apathetic about setting goals or solidifying caregiving plans.” 12/29/2023: A home visit was made by an RN at 4:48 p.m. Patient 9 was described as having “;Terminal restlessness.” Patient 9s sister stated she had not given any medication to combat the restlessness since the day before. 12/29/2023: A phone call was made by Patient 9s sister to the agency at 9:05 p.m. (3 hours and 48 minutes following the home visit). The sister stated Patient 9 was irritated and agitated and would not sleep and was not “;Sleeping most of the day.” The last pain medication given was at 12:44 p.m. The sister was advised to give medication at the time of the call. 12/30/2023: A telephone call was made to the agency. Patient 9s sister described how she got Patient 9 up out of bed but “;Could not stand him back up...” 12/31/2023: A telephone call was made to the agency by Patient 9s sister at 8:57 p.m. who described Patient 9 as “;Gasping for air.” No morphine had been given. Staff advised the sister to give the medication at the time of the call. Patient 9s sister stated she was “;Unable” to give the medication and that his friend would give it. 12/31/2023: Patient 9 passed away at 8:45 p.m. During an interview on 3/13/2024 at 11:41 a.m., with Social Worker 1 (SW 1), SW 1 stated she had been assigned to Patient 9 but had not made any visits. SW 1 stated she was asked to do a POLST (Physician Orders for Life Sustaining Treatment) over the phone but did not feel comfortable with that as it “;Needed to be in person.” SW 1 stated she had had an injury and was on “;Modified duty” and not making home visits at that time. SW 1 stated, after reviewing the case, she would have been making visits to Patient 9 between 12/15/2023 and 12/29/2023. SW 1 stated Patient 9s girlfriend (primary care giver 1) had “;Stepped out” and his sister did not want to step on the “;Girlfriends toes.” SW 1 further stated she had not been aware of the fact that his end-of-life symptoms were not being managed and would have liked to have been there on site. SW 1 also stated she wished the nurse had notified her to let her know of the situation. SW 1 stated staff “;Could have done better here” and further investigated what was happening with the caregivers. SW 1 stated the RN case manager (RNCM) would usually call the social worker for a situation such as this, but RNCM was off work as well. SW 1 stated family are often afraid to give the medications which is common. SW 1 stated typically the RN educates the patient and family regarding how to handle the care but if this does not work, they notify social work. During an interview on 3/13/2024, at 12:14 p.m., with RNCM, RNCM stated the situation with Patient 9 was “;Complicated.” RNCM stated, Patient 9s friend was “;Essentially a roommate” and could not help with his care and whenever staff made a visit, the symptoms were out of control. RNCM stated symptoms would then get controlled but revert back to not being well managed. Furthermore, RNCM stated Patient 9s sister was not involved until “;Later on” and he had not notified the social worker or supervisor regarding the poor symptom management. Record review of the “;Interdisciplinary Group Coordination of Care,” dated 5/31/2023, showed the hospice agency “;...Will utilize a case management system to guide an interdisciplinary group to provide comprehensive, coordinated hospice care to patients and caregivers. The scope of services provided by the interdisciplinary group will be based upon the comprehensive and ongoing assessments regarding the needs of the patient and caregiver and the comprehensive plan of care that defines patient and caregiver problems goals and interventions.””