Mission Hospice Services of San Diego LLC

“Based on an interview and record review, the agency failed to update the plan of care to include specific interventions for managing an indwelling catheter (a tube inserted into the bladder to drain urine into a collection bag) for one of three sampled patients (Patient 1). This failure led to inconsistent catheter care and confusion among the staff. Findings: Per the Hospice Certification and Plan of Care (POC), dated 6/28/24 through 9/25/24, Patient 1 was admitted to the agency on 6/28/24 with diagnoses that included obstructive and reflux uropathy (a condition that blocks urine flow, causing the urine to back up). A review of Patient 1’s clinical record was conducted. Per the Skilled Nursing Facility (SNF) Order Summary, dated 6/27/24, the following orders were listed to manage or care for Patient 1’s indwelling catheter:Change the indwelling catheter with size French (F) 16 with a five milliliter (ml) balloon as needed (PRN) when pulled out, leaking, or clogged (blocked),Cleanse site with warm soap and water, rinse, then pat dry every shift,Measure and record urine output every shift,Irrigate (to supply with) 100 ml of normal saline, as needed when clogged,Monitor that it remains intact and functioning throughout every shift.Per the agency’s POC, under Orders of Discipline and Treatments, indicated that the skilled nurse (SN) was responsible for the administration or maintenance of the indwelling catheter with a 16F and 10 ml balloon, and to be changed PRN. There were no other orders and treatments related to the indwelling catheter care or irrigation. A further review of Patient 1’s clinical record was conducted. Per the Visit Note Report, the following event happened:On 7/1/24, SN 1 documented that the Genitourinary (urinary and genital organ) assessment was made, and the indwelling catheter was to be changed every 30 days or PRN, and irrigated with 30 ml of sterile water weekly. However, there was no documented evidence that the physician was made aware of this treatment or that the POC was revised. On 8/20/24, SN 1 changed the indwelling catheter as a routine procedure. Indicated that the indwelling catheter was to be changed monthly or PRN. However, there was no documented evidence that the physician was made aware of this treatment or that the POC was revised. On 9/19/24, SN 2 documented that a visit was conducted, but the catheter was not changed. On 9/21/24, SN 3 documented a PRN visit, and the catheter was changed because Patient 1 complained of pain “down there” and catheter leakage. On 10/22/24, SN 2 documented a visit, but the catheter was not changed. On 10/23/24, SN 4 documented a PRN visit because Patient 1 complained of pain at the catheter site. On 4/24/25 at 3:24 P.M., an interview was conducted with SN 2. SN 2 stated that he reviewed the POC for every home visit conducted with Patient 1, and the POC indicated to change the indwelling catheter PRN. SN 2 further said he was just following the POC. SN 2 stated that if there was any change in the POC, the physician should have been notified and the POC should be updated. On 4/24/25 at 4:25 P.M., an interview was conducted with SN 1. SN 1 stated that the order was for the indwelling catheter to be changed PRN for Patient 1, and there was no order for the irrigation. SN 1 further noted that the family member requested a monthly change and weekly irrigation. SN 1 stated she explained the risks of changing the indwelling catheter frequently, and the family member kept asking. SN 1 stated that she did not inform the physician of the family’s request, and changed the indwelling catheter on 8/20/24, she should have informed the physician of the request and update the care plan. . On 9/18/25 at 5:40 P.M., an interview was conducted with the Director of Patient Care Services (DPCS). The DPCS stated plan of care should be clear and completed. The plan of care was based on the initial assessment and updated on an ongoing basis. The DPCS stated that Patient 1’s plan of care should have been updated to reflect the care and services being provided, ensuring that the care was in alignment with Patient 1’s care needs. Per the agency’s policy and procedure, dated 4/7/15, titled The Plan of Care, “...A written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care...””

“It is required that the documented comprehensive assessment includes a drug profile that contains the patient’s current: prescription and over-the-counter (OTC) drugs, supplements. herbal remedies, and other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: the effectiveness of drug therapy; drug side effects; actual or potential drug interactions; duplicate drug therapy; drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and, as appropriate, preventive measurements are implemented to manage the side effects.The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review, interview, and observation. In 2 of 23 (9%) clinical records reviewed and home visits observed, the hospice did not ensure that the comprehensive assessment included a drug profile that contained the patient’s current medications. Clinical Record 5/Home Visit 5: The patient elected hospice care on 09/21/2023. During the home visit with the Hospice Aide (HA) [Personnel Record 10] on 03/26/2024, the hospice medication orders were reviewed with the patient’s husband. During an interview, the patient’s husband stated, “Yes, I have a comfort medication box here.” The hospice comfort kit included Morphine, Lorazepam, and Hyoscyamine with a dispense date of 12/2022 and an expiration date of 12/20/2023. The husband stated the medications were there from the previous admission to hospice. The Hospice medication profile did not include orders for Morphine, Lorazepam, and Hyoscyamine. The Morphine, Lorazepam, and Hyoscyamine in the home expired on 12/20/2023. During an interview on 03/26/2024, the Hospice Executive Director stated, “The hospice Registered Nurse (RN) has already obtained the medication orders for the Morphine, Lorazepam, and Hyoscyamine, and the pharmacy has sent out updated medications to replace the expired medications in the home.” There was no evidence that the medications were reviewed during the review of the patient medication regimen. Clinical Record 3/Home Visit 3: The patient elected hospice care on 11/11/2023 and resided in a skilled nursing facility (SNF). During the home visit with the Hospice RN [Personnel Record 5] on 03/26/2024, the Hospice medication orders were reviewed with the Hospice RN and the SNF nurse. The Hospice medication profile documented Hyoscyamine 0.125 mg, one tablet every 2 hours PRN ordered on 11/11/2023. A joint review of the SNF medication orders revealed that Hyoscyamine was discontinued in the SNF orders on 02/28/2024 and did not match the ordered Hyoscyamine on the Hospice medication profile. During an interview, the Hospice RN stated, “The facility nurses usually tell me when a medication needs to be discontinued. I will get the order for the Hyoscyamine today and get the order to the facility.” During the interview, the SNF medication nurse stated, “Yes, the Hyoscyamine was discontinued on 2/28/24 in the SNF chart and most likely because the pharmacy discontinued it.””

“It is required that drugs and biologicals are labeled and stored in accordance with state law and regulation, as well as accepted standards of practice. At a minimum, labels include: the patient’s full name; generic, trade, or brand name of the medication, as well as amount dispensed; directions for use, including route, rate, frequency, and method of administration; prescriber’s name; expiration date; [and] cautionary instructions. This standard was not met as evidenced by clinical record review, interview, and observation. In 1 of 6 (9%) home visits observed, the hospice did not ensure the removal and disposal of expired medications. Home Visit 5/Clinical Record 5: The patient elected hospice care on 09/21/2023. During the home visit on 03/26/2024, the hospice medication orders were reviewed with the patient’s husband. During an interview, the patient’s husband stated, “Yes, I have a comfort medication box here.” The hospice comfort kit included Morphine, Lorazepam, and Hyoscyamine with a dispense date of 12/2022 and an expiration date of 12/20/2023. The Morphine, Lorazepam, and Hyoscyamine in the home expired on 12/20/2023. The husband stated the medications were there from the previous admission to hospice. During an interview on 03/26/2024, the Hospice Executive Director stated, “The hospice Registered Nurse (RN) has already obtained the medication orders for the Morphine, Lorazepam, and Hyoscyamine, and the pharmacy has sent out updated medications to replace the expired medications in the home.””