Hope Hospice & Healthcare, Inc.

“Based on observation, interview, and record review, the agency failed to ensure the medication listed in the patient’s current Plan of Care (POC) and medication profile were updated, accurate, and with the right dosage and frequency, for one of three patients reviewed for medication reconciliation (Patient 8), when the prescription bottle of medication Seroquel (an antipsychotic medication used to treat mental health conditions) in Patient 8’s home had a different prescription administration instruction to use, which was not listed in Patient 8’s current medication profile.This failure increased the potential for patient’s primary care giver (PCG) to administer the wrong dosage of Seroquel to Patient 8. Findings:On April 21, 2025, Patient 8’s record was reviewed. Patient 8 was admitted to the agency with the start of care (SOC) date of August 11, 2023, with diagnoses which included senile degeneration of the brain (outdated term for dementia - significant and progressive decline in cognitive abilities), end stage renal disease (ESRD - kidney failure) requiring hemodialysis (a life saving treatment that filters a patient’s blood when their kidneys are no longer functioning properly), and dependence on renal dialysis three times a week, with arteriovenous fistula left arm (AV fistula - a surgical connection between an artery and a vein used for hemodialysis access).A review of Patient 8’s current medications listed in the agency’s form “CURRENT TREATMENT / MEDICATION / DME LIST (Durable Medical Equipment),” indicated, the medication Seroquel as: - “Seroquel 25 milligram (mg - a unit of measurement) tablet, 1 tablet oral at bedtime for agitation; and - Seroquel 50 mg tablet, 1 tablet oral at bedtime for agitation...”On April 22, 2025, at 8:43 a.m., a home visit was conducted for Patient 8 with the Registered Nurse (RN). Patient 8’s primary caregiver (PCG) was present during the visit. The PCG signed the consent for home visit with permission from Patient 8’s Power of Attorney (POA - a person with authority to make medical, legal, or financial decisions for another person).Patient 8 was observed lying in bed, awake, alert, and able to verbalize his needs in Spanish. Patient 8 was observed with dressing on his left lower arm. The PCG stated Patient 8 had a hemodialysis treatment yesterday.During the medication reconciliation at 9:50 a.m., and a concurrent interview conducted with the RN, the RN stated a pill box was set up for Patient 8’s daily medications.The current medication profile reviewed with the RN listed the medication Seroquel as “Seroquel 25 mg, 1 tablet oral at bedtime, and Seroquel 50 mg, 1 tablet oral at bedtime”. The prescription bottle containing the medication Seroquel indicated, “Quetiapine Fumarate 25 mg tablet. Take 3 tabs (75 mg) po (by mouth) at bedtime for agitation”.The RN stated he was not aware Patient 8 had a new prescription bottle of Seroquel. The RN stated the medication profile should have been updated when the pharmacy delivered a new prescription bottle of Seroquel. On April 22, 2025, at 10:08 a.m., a concurrent interview and record review was conducted with the Director of Patient Care Services (DPCS). The DPCS stated the Skilled Nurse (SN) who visited Patient 8 should have known the new prescription bottle of Seroquel instruction. The DPCS stated the medication reconciliation should be done on every visit by the SN. She stated the current medication list should have been updated with the new dosage and frequency of Seroquel.A review of the delivery receipt provided by the agency indicated the medication Seroquel (Quetiapine Fumarate) 25 mg was delivered in Patient 8’s home on April 10, 2025. A review of the agency’s policy and procedure titled, “Medication Profile,” dated October 2014, indicated, “...Patients receiving medications administered by hospice will have current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications...”A review of the agency’s policy and procedure titled, “Identification Of Medication For Administration,” dated October 2014, indicated, “...To provide general guidelines for the safe administration of medications in the home...The nurse will review the medication label for name, additional patient identifier, drug, dosage, and prescription...””

“Based on observation, interview, and record review, the agency failed to include in the patient’s plan of care, the hemodialysis (a life saving treatment that filters a patient’s blood when the kidneys are no longer functioning) information, the care of patient’s Arteriovenous fistula (AV fistula - a surgical connection between an artery and a vein used for hemodialysis), the education and instruction when there are complications of the dialysis site for one of three patients reviewed (Patient 8).This failure increased the potential for Patient 8, and Patient 8’s primary caregiver (PCG) not to be educated of the signs and symptoms of fistula emergency, that can lead to serious complications and potentially life-threatening condition. Findings:On April 21, 2025, Patient 8’s record was reviewed. Patient 8 was admitted to the agency with the start of care (SOC) date of August 11, 2023, with diagnoses which included senile degeneration of the brain (an outdated term for dementia- a significant and progressive decline in cognitive abilities), and end stage renal disease (ESRD - a kidney failure) dependence on hemodialysis three times a week. The re-certification assessment dated March 20, 2024, indicated, “... PT’s (patient) left arm fistula has a moderately strengthened bruit...ESRD...dependence on renal dialysis (Left Arm AV Fistula).The physician’s Certification for Terminal Illness (CTI) dated February 1, 2025, indicated, “...PT BP (blood pressure) decreasing during dialysis treatment, leading to him not receiving full treatment and BP meds (medication) have been titrated...)The Plan of Care (POC) dated April 21, 2025, indicated Patient 8’s diagnoses which included, “...ESRD, dependence on renal dialysis...”The POC did not include the Patient 8’s hemodialysis treatment, goals and objectives to meet his needs. There was no documented evidence in the plan of care that addressed the proper care of his AV fistula after hemodialysis treatment and instruction to follow when the dialysis site had signs and symptoms of complications.On April 22, 2025, at 9:10 a.m., a home visit was conducted for Patient 8, with the Registered Nurse (RN). The Primary care giver was present during the visit. Patient 8 was observed awake, alert and able to verbalize his needs in Spanish. Patient 8 was observed with dressing on his left lower arm.During a concurrent interview and POC review with the RN, the RN stated Patient 8’s hemodialysis treatment and care of AV fistula should be included in the POC. The RN stated he had not provided specific education to the PCG related to Patient 8’s hemodialysis access site.During an interview with Patient 8’s PCG, the PCG stated Patient 8 had received heparin (blood thinner) during dialysis on March 21, 2025. The PCG stated the dialysis staff instructed her to leave the dressing on Patient 8’s left arm and remove the dressing today. The PCG stated she did not receive any education from the agency’s staff on the care of Patient 8’s hemodialysis site.On April 23, 2025, at 9:20 a.m., a concurrent interview and review of Patient 8’s POC was conducted with the Director of Patient Care Services (DPCS). The DPCS stated the patient and PCG’s education related to their current health condition should be included in the POC from the initial comprehensive assessment and during very home visit. The DPCS stated Patient 8’s hemodialysis treatment, care and services of his dialysis site should have been included in the POC.A review of the agency’s policy and procedure titled, “The Plan of Care,” dated October 14, 2025, indicated, “...The plan of care will be based on the initial, comprehensive and ongoing comprehensive assessments performed by members of the interdisciplinary group and will be reviewed on a regular basis...The Plan of care will identify the patient’s needs and services to meet those needs...As needed, the patient and family/caregiver will receive written instructions regarding treatments or aspects of care that will be the responsibility of the patient and family/caregiver to provide or follow through...The written plan off care will contain...patient and family /caregiver educational needs and assessment of their ability to learn and understand teaching...””

“Based on observation, interview, and record review, the agency failed to ensure the patient’s primary care giver (PCG) followed the standard of infection control precautions in handling and care of the patient’s oxygen nasal cannula (a device that delivers oxygen to the patient through the nose) tubing, for one of three patients reviewed with oxygen (Patient 8).This failure increased the potential for Patient 8 to be at risk for exposure to respiratory infection. Findings:On April 21, 2025, Patient 8’s record was reviewed. Patient 8 was admitted to the agency with the start of care (SOC) date of August 11, 2023, with diagnoses which included senile degeneration of the brain (an outdated term for dementia - a significant and progressive decline in cognitive abilities), and end stage renal disease (ESRD - kidney failure) requiring hemodialysis (a life saving treatment that filters a patient’s blood when their kidneys are no longer functioning properly), dependence on hemodialysis three times a week.A review of Patient 8’s current treatment and medication list, indicated a physician’s order, dated August 11, 2023, for “...Oxygen via NC (through nasal cannula) @ (at) 2LPM (two liters per minute) PRN (as needed) for mild SOB (shortness of breath), 3 LPM for moderate SOB, 4 LPM for severe SOB...”On April 22, 2025, at 9:10 a.m., a home visit was conducted with the Registered Nurse (RN) for Patient 8. The primary caregiver (PCG) was present during the visit. Patient 8 was observed lying in bed, awake, alert, and able to verbalize his needs. One oxygen concentrator was observed at the bedside, with the nasal cannula tubing coiled in front of the concentrator and was left exposed. During a concurrent observation and interview with Registered Nurse (RN), at 9:30 a.m., the RN stated he was not aware that Patient 8 had been using his oxygen. The RN acknowledged the nasal cannula tubing was undated and exposed. On April 22, 2025, at 9:35 a.m., during an interview with the PCG, the PCG stated she had been administering oxygen to Patient 8 at two and a half liters (a unit of measurement) by nasal cannula when Patient 8 arrived home from the dialysis treatment. The PCG stated she had not change the oxygen tubing for a while.On April 23, 2025, at 10:15 a.m., a concurrent interview and record review was conducted with the Director of Patient Care Services (DPCS). The DPCS stated the oxygen tubing should be kept in a Ziploc storage bag provided by the agency when not in use. The DPCS stated there would be an infection control issue when oxygen tubing was left exposed and not stored properly. A review of the agency’s policy and procedure titled, “Infection Control Precaution,” dated October 2014, indicated, “...The patient and family/caregiver will receive...information and instruction regarding infection control precautions...Ongoing assessments will continually address the use of standard precautions...”A review of the agency’s policy and procedure titled, “Safe And Appropriate Use Of Medical Equipment And Supplies,” dated October 2014, indicated, “...It is the responsibility of the clinicians, as appropriate, to instruct patients and their family/caregiver the safe and appropriate use of oxygen...””