Prohealth Home Care, Inc.

“Based on interview and record review the Agency’s licensed nursing staff did not address the need for Lorazepam (anti-anxiety medication) for one of 11 sampled patients (Patient 11). Patient 11’s caregiver reported to staff he was getting up several times at night. Staff did not discuss the indications for Ativan as part of end-of-life care. This resulted in unnecessary anxiety for Patient 11. “Anxiety is common in adults with advanced life-limiting disease, adversely affecting quality of life, social relationships and daily functioning at a critical time. It impairs the individual’s ability to cope with their illness, erodes their trust in physicians, reduces treatment compliance and makes physical symptoms more difficulty to manage.” [National Institute of Health; National Library of Medicine; “Worried to death”: the assessment and management of anxiety in patients with advanced life-limiting disease, a national survey of palliative medicine physicians” N. Atkin, V. Vickerstaff, B. Candy December 2027]Record review of Patient 11’s clinical document “Hospice Comfort Kit” (Agency’s list of hospice comfort medications) showed, “Lorazepam 0.5 milligrams every 4 hours as needed for anxiety manifested by restlessness.”Record review of Patient 11’s clinical document “Hospice Plan of Care” showed, Patient 11’s start of care was 12/6/2025. Diagnoses included “Senile Degeneration of Brain.”Record review of Patient 11’s clinical document “Hospice Nursing Clinical Note” (HNCN) dated 2/12/2026 showed Patient 11’s caregiver reported to Registered Nurse 2 (RN 2) “Patient had a restless night, awakening 3-4 times…” Review of the HNCN dated 2/16/2026 showed Patient 11’s caregiver reported to RN 2 Patient 11 had a “Poor night’s sleep getting up 4-5 times.” There was no documentation which showed RN 2 discussed the indications for lorazepam.During an interview on 2/20/2026 at 11:25 a.m. RN 2 confirmed she had not discussed the need for Lorazepam during the visits on 2/12/2026 and 2/16/2028 because she did not see “Getting up and down 4-5 times per night as agitation.””

“Based on interview and record review the Agency’s licensed nursing staff did not notify the doctor for a change of condition and document the physical status according to professional standards for one of 11 sampled Patients (Patient 2). Staff did not notify the physician when Patient 2 was reported to be unresponsive with shakiness. There was no documented complete physical assessment which showed what part of the body was shaking or degree of shakiness.This resulted in the potential for Patient 2 to be unable to attain healthcare goals. Record review of the document “Monitoring Patient’s Response/Reporting to Physician” dated 2024 showed “The patient’s physician and/or the hospice Medical Director will be contacted on the same day when any of the follow occur: A. changes in the patient’s condition.”“Professional nursing documentation of a patient’s shakiness (tremor) requires objective, descriptive, and timely charting that adheres to legal requirements of accuracy and completeness. Rather than using subjective, vague terms like “shaky” or “tremors,” nurses should describe the movement’s characteristics, location, timing, and impact on function.” [National Institute of Health; National Library of Medicine; Approach to a Tremor Patient: Soumya Sharma, Sanjay Pandey Ann. Indian Acad. Neurol: 2016]Record review of Patient 2’s clinical document “Hospice Plan of Care” showed, Patient 2’s Start of Care was 10/6/2025. Diagnoses included “Degenerative disease of Nervous System.” Goals included “Patient will remain safe in environment.”Record review of Patient 2’s clinical document “Hospice Nursing Clinical Note” dated 2/6/2026 showed Patient 2 was alert with “shakiness.” Registered Nurse 1 (RN 1) administered scheduled medications which Patient 2 “Tolerated well.” Skilled nursing received a call later that day at approximately noon from Patient 2’s daughter stating Patient 2 “Was not responding.” RN 1 made a second visit on 2/6/2026 and described Patient 2 as alert but “Still a bit shaky.” There was no documented assessment of the movement characteristics. There was no documentation the doctor had been notified regarding the report of unresponsiveness or shaking. During an interview on 2/19/2026 at 12:01 p.m. RN 1 stated, during the visit on 2/6/2026 Patient 2’s hand was shaking and he had never seen him do that before. RN 1 stated he had not notified the doctor regarding the shaking or the report from family he had been unresponsive earlier in the day. RN 1 stated the benefit to calling the doctor for a change in condition was to review the plan of care and possibly revise it.During an interview on 2/19/2026 at 10:30 a.m. the Director of Patient Care Services (DPCS) confirmed there was no documentation in the clinical record which showed RN 1 had notified the doctor regarding the shaking and unresponsiveness. She confirmed the visit note did not clearly specify what “shaky” meant and one could not “Assume it was a seizure.” The DPCS stated staff should have notified the doctor to provide an update and discuss a potential change to the plan of care.”