Mission Hospice

“Based on observation, interview, and record review the Hospice Agency (HA - agency providing care to terminally ill patients who have six months or less to live) staffs failed to reconcile (the process of comparing a patient’s medication orders to all of the mediations that the patient has been taking) medications for three of 14 sampled patients (Patient 1, Patient 2, and Patient 9) and update their medication profiles with the currently used medications. This failure had the potential to place patients at risk for medication errors and adverse drug reactions. 1. During a review of Patient 1’s Patient Face Sheet indicated Patient 1 had a start of care date on 5/16/2024, with a terminal diagnosis of hypertensive heart disease with heart failure (heart unable to pump blood to the body effectively). During a concurrent observation, interview, and record review on 6/3/2025, at 2:40 p.m., Licensed Vocational Nurse 2 (LVN 2) reviewed Patient 1’s medication with Licensed Vocational Nurse 4 (LVN 4) using the Medication Profile record, dated 6/2/2025. LVN 4 stated Patient 1 was no longer taking the following medications listed in the Medication Profile: -Albuterol-Ipratropium (a medication that makes breathing easier) 2.5 mg- (mg-milligram, unit of measurement) 0.5 mg/3ml (ml-milliliter, unit of measurement) inhalation (taking my inhaling-smelling deeply through the nose) solution. LVN 4 stated the medication was discontinued on 8/26/2024.-Metoprolol Tartrate (heart medication) 25 mg oral tablet. LVN 4 stated the medication was discontinued on 10/24/2024. During a further review of the medication record indicated Patient 1 was taking Lorazepam (to treat anxiety) 2 mg/ml. 0.25 ml by mouth every 4 hours as needed. This medication was not listed in the Medication Profile. A review of the Medication Profile indicated, there was incorrect information listed: -Promethazine (treats allergies, nausea) 6.25 mg 15 mg/5ml syrup. Patient 1 was taking the 5 mg/5ml concentration.-Bisac-Evac (a laxative) 10 mg rectal suppository, administer 1 suppository rectally every 3 days as needed for constipation. The directions of frequency Patient 1 was taking every 24 hours.-Milk of magnesia (for constipation) 24% oral concentrate, administer 15 ml oral once a day as needed for constipation. Patient 1 was taking 1200mg/15 ml concentration. The dosage of administration was 30 ml.-Acetaminophen (pain reliever) mg oral tablet 500 mg oral tablet, take 2 tablets oral 3 times a day. Patient 1 was taking the medication twice (2) a day for pain management.-Acetaminophen (pain reliever) 500 mg oral tablet take 1 tablet every 6 hours as needed for mild pain. At Skilled Nursing Facility (SNF), take 1 tablet every 8 hours as needed for mild pain.-Morphine (a strong pain reliever) 20 mg/ml oral concentrate. Administer 0.25 ml orally every 2 hours as needed for severe pain/shortness of breath (SOB). At the SNF, the concentration of medication was 100 mg/5ml bottle, take 0.25 ml every 2 hours as needed for severe pain/SOB. LVN 4 stated last time Patient 1 took the medication was on 2/6/25. During an interview on 6/3/2025, at 3:00 p.m., LVN 2 stated, LVN 2 had been trying to review the medication every visit. LVN 2 stated, LVN 2 was supposed to review the medications every visit to prevent medication errors. LVN 2 stated, it was important to make sure patients were receiving right medication and right dose for their health and safety. 2. during a review of Patient 2’s Face Sheet indicated Patient 2 had a start of care date on 12/19/2024, with a terminal diagnosis of senile degeneration of the brain (brain not functioning properly). During a concurrent observation, interview, and record review on 6/3/2025, at 2:25 p.m., LVN 2 reviewed Patient 2’s medication with Licensed Vocational Nurse 3 (LVN 3) using the Medication Profile record, dated 6/2/2025. LVN 3 stated Patient 2 was taking the following medication, not listed in the Medication Profile: Tylenol 325 mg, 1 tab let by mouth every 4 hours as needed for mild pain. LVN 3 stated Patient 2 was no longer taking the following medications listed in the Medication Profile: -Levothyroxine (treats the thyroid) 125 mcg (mcg-micrograms, unit of measurement) oral tablet.-Hydroxyzine hydrochloride (helps control anxiety) 25 mg oral tablet.-Lorazepam (to treat anxiety) 0.5 mg. LVN 3 stated Patient 2 had not taken this medication in 2025. LVN 3 stated medication was automatically discontinued if patient had not taken the medication after the 14th day.-Tylenol 500 mg oral tablet. LVN 3 stated medication was discontinued on 12/2024. 3. During a review of Patient 9’s Face Sheet indicated Patient 9 had a start of care date on 7/27/2024, with a principal diagnosis of Alzheimer’s disease (a brain disorder that affects memory, manifested by gradual memory loss). During a concurrent observation and interview on 6/3/2025, at 10 a.m., during Patient 9’s home visit, with RN 1 and LVN1, RN1 and LVN1 conducted a physical assessment on Patient 9. RN1 discussed Patient 9’s medications with Patient 9’s home nurse. RN1 did not compare Hospice Agency medication list with labels on Patient 9’s medication bottle. RN1 stated it was important to complete patients’ medication reconciliation to prevent medication errors. During an interview on 6/4/2025 at 10:45 a.m. with the Director of Patient Care Services/Administrator Designee (DD/AD), the DD/AD stated patients’ medications should be reconciled by a visiting nurse on a weekly basis. DD/AD stated that the visiting nurse reconciled medications while the patient was living at home by reviewing all medications with the patient and/or family and asking the patient and/or the family if there was any change. The visiting nurse should compare the existing medications with current physician orders. DD/AD stated that the visiting nurse should reconcile medications while the patient was living at a facility by reviewing the patient’s facility medication administration record with the facility staff. The DD/AD stated the visiting nurse should also read the labels on patient’s medication bottles for the expiration date and errors. DD/AD stated the reason to reconcile patients’ medications were to prevent medication errors. DD/AD stated patients’ health could be affected if medications were not provided as ordered. During a review of the HA’s Policy and Procedure (P&P), titled “Medication Reconciliation”, dated 1/1/2016, the P&P indicated, “The Registered Nurse (RN) or Licensed Vocational Nurse (LVN) shall perform medication reconciliation at each patient visit. This is a required clinical practice that supports continuity of care, reduces the risk of medication errors, and promotes optimal therapeutic outcomes.””

“Observed in Record Review. In 2 of 19 patient records reviewed, the written plan of care was not based on the patient’s goals and the time frames, settings, and services required to meet those goals. In the chart for RRDC#15, the patient was newly ordered to be on oxygen, yet there was no associated goal on the plan of care related to the patient’s knowledge of safe oxygen use. In the chart for RRNHV#12, the patient’s medications were changed due to severe pain with nausea and vomiting. The plan of care was not updated to include any goals for pain and nausea. This was discussed with the Clinical Manager.”

“Observed in Record Review. In 3 of 19 patient records reviewed, the plan of care did not include a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs. In the chart for RRHV#4, the plan of care did not include the volunteer visits. There was an order marked late entry written at the end of the month which described the volunteer visit frequencies that had previously occurred. In the charts for RRNHV#5 and RRDC#16, the dietician had interventions/goals yet no visit frequency on the recert POC. This was confirmed with the Clinical Manager.”

“Observed in Record Review. In 2 of 19 patient records reviewed, the plan of care did not include clear and complete orders for all services needed for the palliation and management of the terminal illness and related conditions. In the chart for RRHV#4, the patient had MiraLAX, Senna and Bisacodyl suppository all ordered prn for constipation without further direction as to when one medication was to be taken vs another. In the chart for RRDC#15, while oxygen safety had been taught, this was not included on the patient’s plan of care. This was discussed with the Clinical Manager.
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“Observed in Record Review. In 4 of 19 patient records reviewed, the plan of care revisions were not based on information from updates to the patient’s comprehensive assessment and did not address the patient’s progress toward goals and outcomes. In the chart for RRHV#1, the patients current plan of care included goals which all were anticipated to have been met before the end of the previous benefit period. The patient has been on service for 9 months and there remain educational goals since admission such as patient/caregiver will verbalize understanding of pain management program without an indication if that goal had been met yet. In the chart for RRHV#4, progress toward goals was not documented as all SN goals on the current plan of care were to be met prior to the beginning of the current benefit period. In the chart for RRDC#16, a wound care goal was that the caregiver would demonstrate proper wound care by a date more than 3 months prior to the date of the survey. There was no documented progress toward this goal other than moving the goal date out each time the order was renewed every 2 weeks. In the chart for RRNHV#5, all SN goals were to be met prior to the current benefit period. The goal patient/caregiver will verbalize understanding of pain management regimen remained on the plan of care 6 months post admission. This was discussed with the Clinical Manager.”

“Observed in HR File Review. In 1 of 1 hospice aide personnel files, at the time of hire, the supervisor had not evaluated the following areas by observing a hospice aide’s performance of the tasks with a patient or pseudo-patient as part of a simulation: appropriate and safe techniques in personal hygiene and grooming that include bathing. The initial competency evaluation for the hospice aide was documented as completed 2 months post hire. It included only a bed bath as the bathing option with a bed shampoo. The first documented competency of a shower bath was 9 months post-hire. This was discussed with the Clinical Manager and Administrator.”