Sutter Care at Home

“Based on interview and record review, licensed nursing staff did not respect the rights of 1 of 3 sampled patients (Patient 1). Patient 1 had been prescribed oxycodone (opioid for pain) along with Baclofen (muscle relaxant) and Lyrica (for nerve pain) while in hospice (end-of-life care for a terminal illness.) While moving through the stages of hospice care Patient 1 could no longer swallow her pain pills. Agency staff did not confirm the exact date/time Patient 1 stopped being able to swallow the pain medication nor did they have a plan in place to address withdrawal symptoms from her long-term use of pain medications. Refer to deficiency at L512The cumulative severity and intensity of this deficiency resulted in the failure of the facility to meet §418.52 Condition of Participation: Patient’s rights. Refer to deficiency at L512”

“Based on interview and record review, licensed nursing staff did not respect the rights of 1 of 3 sampled patients (Patient 1). Patient 1 had been prescribed oxycodone (opioid for pain) along with Baclofen (muscle relaxant) and Lyrica (for nerve pain) while in hospice (end-of-life care for a terminal illness.) While moving through the stages of hospice care Patient 1 could no longer swallow her pain pills. Agency staff did not confirm the exact date/time Patient 1 stopped being able to swallow the pain medication nor did they have a plan in place to address withdrawal symptoms from her long-term use of pain medications.This resulted in Patient 1 experiencing unnecessary pain, agitation and distress. Record review of a National Institute of Health article indicated “Abrupt cessation of short-acting opioids (e.g. Heroin, hydrocodone, and oxycodone) is associated with severe OWS (opioid withdrawal symptoms) that typically begin within 12 hours after a missed dose, peak at 36-72 hours, and gradually taper off over the following 4-7 days. Opioid withdrawal symptoms: aches/pain, muscle spasms/twitching/tension, tremor, abdominal cramps, nausea/spasms/twitching/tension, tremor, abdominal cramps, nausea/vomiting/diarrhea, anxiety/restlessness, irritability…” [Review article: Effective management of opioid withdrawal symptoms: A gateway to opioid dependence treatment. NIH: National Library of Medicine: January 31, 2019: pmc.ncbi.nim.nih.gov/articles/PMC5590307] “Baclofen is a widely prescribed drug used for the treatment of spasticity. Abrupt cessation of both intrathecal and oral baclofen can result in severe withdrawal symptoms that may be life threatening.” [Oral Baclofen Withdrawal Resulting in Progressive Weakness and Sedation Requiring Intensive Care Admission” Bret D. Alvis. Christopher M. Sobey. Neurohospitalist 2016 Mar 14; 7 (1):39-40 NIH National Library of Medicine] “Since pregabalin (Lyrica) withdrawal can occur even with regular doses and short‐term use, clinicians must carefully reduce the dose of pregabalin when reducing or discontinuing treatment, paying close attention to withdrawal symptoms.” [Pregabalin withdrawal in patients without psychiatric disorders taking a regular dose of pregabalin: A case series and literature review. Hayahito Ishikawa, Masahiro Takeshima, Hiroyasu Ishikawa, Naoko Ayae, Hidenobu Ohta, Kazuo Mishima. Neuropsychopharmacology Reports 2021 Aug 12; 434-439. NIH National Library of Medicine] Record review of the Agency’s policy and procedure “HO: The Plan of Care” dated 1/5/2023 showed “The plan of care will identify the patient’s needs and services to meet those needs, including the management of pain and discomfort and symptom relief.” Record review of the Agency’s policy and procedure “SVNAH: Pain Assessment and Management” dated 2/21/2025 showed “During the initial assessment and on an ongoing basis, the patient will be asked a general screening question regarding current or recent pain as part of the baseline data.” The in-depth pain assessment included “Pain management history, to include medication history, past interventions (pharmacologic and non-pharmacologic) and response, use of analgesics, manner of expressing pain, and presence of common barriers to reporting pain.” Record review of the document “Patient Information” showed Patient 1’s start of care was 4/7/2025 with the current benefit period 4/7/2025 to 7/5/2025. Diagnoses included “Long-term opiate analgesic use” and “Personal history of disorder of nervous system and sense organs.” During a review of Patient 1’s clinical document titled “Order Summary Report” (from the skilled nursing facility where she resided or SNF) dated 4/1/2025, the document indicated, staff were to administer to Patient 1 Baclofen 5 milligrams 3 times per day, (start date 12/18/2023), Lyrica 75 milligrams 3 times per day (start date 2/10/2025) and Oxycodone 10 milligrams 4 times a day for pain management(start date 1/2/2024). During an interview on 12/3/2025 at 11:15 a.m. with the Agency’s Hospice Case Manager (HCM), the HCM stated a family member had expressed concern regarding Patient 1’s inability to swallow her pain medications as she moved through the stages of hospice. The HCM stated Patient 1 had stopped being able to swallow the pills on 4/13/2025 and the plan was to use the morphine from the comfort kit which was sliding scale. Patient 1 could receive 5, 10 or 20 mg in liquid form every hour as needed. The HCM stated she was aware Patient 1 had experienced a spinal cord injury as a teenager and had been on the pain medications for “A very long time.” When asked what she would expect to happen when a patient abruptly stops taking opioids (oxycodone) the HCM stated “One would expect breakthrough pain.” Record review of the Medication Administration Record from the SNF dated April 2025, showed the last dose of oral medication was on 4/11/2025. Patient 1 was able to swallow oxycodone at 5 p.m., Baclofen at 4 p.m. and Lyrica at 5 p.m. During a review of Patient 1’s clinical document from the SNF titled “Progress Notes *NEW*”, the progress notes indicated, on 4/12/2025 at 2:33 a.m., Patient 1 was “Resting comfortably but arousable. No complaints of pain or discomfort.” Review of the note dated 4/12/2025 at 11:07 p.m. showed Patient 1 “Appeared to be (having) multiple (episodes of) confusions and episodes of screaming during shift.” Patient 1 had “Refused most of the medications, Morphine and Ativan given…” (30 hours and 7 minutes since the last administered dose of oxycodone) (Morphine - pain medication) (Ativan - anti-anxiety medication). During a review of Patient 1’s clinical document from the SNF titled “Pulse Summary” indicated at 9:22 p.m. on 4/12/2025, Patient 1’s pulse was elevated at 98 beats per minute. Her baseline range for April 2025 showed a pulse in the 60’s and 70’s. (normal range is 60-100) Review of the document “O2 Sats Summary” showed Resident 1’s oxygen saturation at 9:22 p.m. on 4/12/2025 was 52% (amount of oxygen in the blood: normal range 95-100%) During further review of Patient 1’ s SNF progress notes showed the following:4/13/2025 at 10:43 a.m. – “Resident is having frequent episodes of restlessness, agitation and screaming. Resident is clearly in severe discomfort despite administering morphine and Ativan…”4/13/2025 at 1:50 p.m. – “Resident is still in severe discomfort and distress.”4/13/2025 at 9:55 p.m. – “Resident is in declining condition. Resident appears to be (having) episodes of confusion and screaming.” Record review of the document “Hospice Admission Plan of Care” dated 4/7/2025 showed an identified problem was “Pain/Physical Discomfort.” Staff were to “Assess Pain” and “Instruct on Management of Pain.” There was no documentation in the clinical record which showed withdrawal from the use of long-term pain medications as a potential problem. During an interview at 12:55 p.m. on 12/3/2025, the hospice Doctor (MD) stated, if opioids are suddenly stopped, Patients can go through withdrawal. Symptoms can include diarrhea, abdominal cramps, restlessness and anxiety. The MD confirmed there was no plan documented in the record to address the sudden withdrawal of the pain medications. Record review of the document “SN Hospice Visit” dated 4/13/2025 showed Patient 1 was experiencing agitation. Patient 1 was described as “Lethargic, verbal, patient was repeatedly calling names and saying words at the start of visit.” The licensed nurse at the facility reported to Registered Nurse 1 (RN 1) she had administered 1 milliliter of morphine just prior to the visit. The facility staff reported to RN 1 “Patient was screaming last night. No longer able to swallow pills and food.” During an interview at 1:16 p.m. on 12/3/2025 RN 1 stated the HCM and the facility staff had informed her Patient 1 could no longer swallow the pain medications. RN1 stated she did not know the specific dates/times when she could no longer swallow the medications. RN 1 stated it would be important to have this information so “We can reach out to the doctor to look at alternatives.” Record review of the Agency’s Skilled Nursing Visit Note dated 4/13/2025 showed Registered Nurse 2 (RN 2) found Patient 1 “Lethargic with eyes closed during visit but was repeatedly making incomprehensible vocalizations.” During an interview at 1:32 p.m. on 12/3/2025 with RN 2, RN2 stated when she arrived at the facility at 3 p.m. on 4/13/2025, Patient 1 was in pain. RN 2 advised the staff nurse to give an additional dose of morphine. RN 2 stated there was “No relief from that second dose” and it was “Difficult to get on top of her symptoms.” Record review of Patient 1’s clinical document from the SNF titled “Progress Notes *NEW* dated 4/14/2025 showed Patient 1 passed away on 4/14/25 at 1:40 p.m.”

“It is required that each patient’s individualized written plan of care reflects patient and family goals and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy “The Plan of Care” (revised 01/05/2023) stated in part, “The plan of care will be based on the initial, comprehensive, and ongoing comprehensive assessments ... This plan will focus on identified problems, goals, and intervention and include all services necessary for the palliation and management of the terminal illness and related conditions...The plan of care will identify the patient’s needs and services to meet those needs ... Any change in the patient’s condition must result in a change in the plan of care...The written plan of care will contain, but will not be limited to ...individualized interventions to assist with end-of-life care; Patient and family/caregiver educational needs ... statement of treatment goals ... measurable outcomes anticipated from implementing and coordinating the plan of care ...” In 2 of 27 (7%) clinical records reviewed, the agency did not ensure that the patient’s plan of care identified planned interventions based on problems identified in the initial and updated comprehensive assessments. Clinical Record 17: The patient elected the hospice benefit on 12/04/2023 with a diagnosis of hemiplegia following a cerebral infarction, with comorbid conditions including neurocognitive disorder with Lewy bodies, and supraventricular tachycardia, and orthostatic hypotension. The patient resided in an assisted living facility (ALF). In the visit note completed by the Registered Nurse (RN) dated 05/15/2024, the RN documented a reported episode of hypotension with systolic blood pressure readings of 78 to 100. The patient takes Midodrine one (1) tab, (1) one to (2) two times daily as needed. The recertification visit note dated 06/13/2024 documented the patient’s blood pressure was 100/64, heart rate was 85, and the “Last benefit period Midodrine change from routine to PRN due to hypotension SBP 70 to 80, spouse notified caregiver to give Midodrine 4x per day. Despite Midodrine, pt continues to have systolic blood pressure (SBP) 100...” The visit note completed by the RN on 07/05/2024 documented the patient’s blood pressure was “122/74,” pulse “66,” and the “Patient was sleeping but nonverbal. Max assist to all ADLs. Arms and legs severely contracted...Takes Midodrine PRN about 1 tab 1 to 2 daily...” The patient’s medication list included Midodrine 10mg by gastric tube three times daily for orthostatic hypotension dated 07/27/2024. The initial dosage dated 12/05/2023 included Midodrine 2.5mg by gastric tube three times daily for low blood pressure. The order was changed on 03/22/2024 to Midodrine 2.5mg by gastric tube three times daily, but hold if systolic blood pressure is less than 120mmHg. The instructions were changed on 05/16/2024 to Midodrine 2.5mg per gastric tube three times daily as needed for a systolic blood pressure reading of less than 120 mmHg. On 07/16/2024, the orders were changed to Midodrine 5mg twice a day per gastric tube for orthostatic hypotension. The previously identified cardiac and circulatory problem was discontinued effective 01/03/2024. The plans of care dated 05/02/2024 to 06/30/2024 and 07/01/2024 to 08/29/2024 did not identify interventions to address the patient’s assessed problem of ongoing hypotension. Clinical Record 26: The patient elected the hospice benefit on 04/08/2024 with a diagnosis of metastatic cancer to the bone and dysphagia. The visit note completed by the RN on 05/10/2024 documented that the patient was “...lethargic, no verbal response during visit ... Patient’s intake is decreasing to about 1/4 to 1/2 cup of food 2-3 times a day. He is eating more liquified food, such as rice porridge. Spouse reports that patient is coughing more with meals. Discussed about thickening up food/fluids due to patient higher risk for aspiration from general decline...” On 05/13/2024, the RN visit note documented that the patient had “dysphagia and was on a pureed diet...He is currently only taking sips of fluids but is having increasing difficulty in swallowing thin liquids. Obtained order for thick it from Dr. ... Educated spouse and grandson on elevating HOB, giving small sips, only offering fluids when patient is awake and aware and to stop if patient coughs after swallowing liquids...” On 05/13/2024, the physician ordered Thick-It. The patient’s plan of care dated 04/08/2024 to 07/06/2024 documented: “Need for skilled teaching of altered nutrition/hydration. Intervention: Instruct on normal appetite reduction at the end of life. Goal: Patient is in control of what, how much, and when to eat. Patient/Caregiver/Family verbalize understanding of appropriate oral care.” The plan of care did not identify interventions to address the patient’s potential for aspiration, teaching the family about the patient’s position during meals, the required pureed diet, and the need for Thick-it added to fluids. During an interview on 08/09/2024, the Director of Patient Care Services and the Director of Quality confirmed that the plans of care were not updated with identified problems and individualized interventions.”