Sacred Life Hospice

“Observed in Patient Home. In 1 of 3 home visits conducted, the surveyor observed organization staff had not followed organization policies related to infection prevention as evidenced by skin assessment and diarrhea clean up during HOSHV2. During HOSHV2 the SN had not followed infection control policy and during cleaning loose stool from an immunocompromised cancer patient with multiple rashes and skin breaks from scratching. The surveyor observed the SN clean patient with diarrhea while having false nails on and a yarn/rope type bracelet that hung down into cleaning area multiple times. The issue was observed, discussed and confirmed with DPCS.”

“Based on observation, interview, and record review, the Hospice Agency (HA) failed to ensure three of fourteen sampled patients (Patient 1, Patient 5 and Patient 10) received their prescribed medication as ordered by the Medical Doctor (MD). This failure had the potential to disrupt these patients medication regimen and effect their health and safety. a.during a review of Patient 5’s “;face sheet” it indicated he was admitted to the hospice agency on 7-9-22, with a primary diagnosis of cerebral infarction (type of ischemic stroke resulting from a blockage in the blood vessels supplying blood to the brain) During a review of patient 5s “;staff assignments” it indicated he had skilled nursing visits 2-3 times per week. During a review of PT 5s “;Patient Medication Record” on 10-18-24 at 0810 it indicated an order for acetaminophen oral tablets 325MG (LS) 1 Tab every 4 hours for moderate pain noted or observed. No bottle/container was present on medication reconciliation during home visit. On the same visit, another order for acetaminophen oral tablet 325mg, as needed. 2 tabs every 6 hours as needed, (on the Patient Medication Record) the label reads take two tablets (650mg) by mouth every 4 hours. MAR indicates every 6 hrs as needed, label on the bottle indicates every 4 hrs as needed. During a home visit for patient 5 that was conducted on 10-18-24 at 10:00am, an observation of no acetaminophen oral tablets 325MG (LS) 1 Tab every 4 hours for moderate pain was found. In addition, (2) bottles of acetaminophen oral tablet 325mg were found in home (different instructions on timing) 2 tabs every 6 hrs as needed (on patient Medication record) 2 tabs every 4 hrs. as needed (on medication label) During an interview on 10-18-24 at 1:45pm the DPCS stated that the patient medication Record for my home visit was a little different than the medication labels that was on the bottles of my home visit. During a review of the agencys policy entitled “;medication profile” with a revised date of April 2012 it indicated patients receiving medications administered by hospice will have current, accurate medication profile in the clinical record. B. During a record review of Patient 1s Personal Profile, the Personal Profile indicated a start of care on 5/4/2021, with a primary diagnosis of Alzheimers Disease, unspecified (a progressive disease that destroys memory and other important mental functions). During a review of Patient 1s Plan of Care, dated 10/10/2024 the Plan of Care indicated a skilled nursing visit frequency of one to two times a week, hospice aide visit frequency of twice a week. During a review of Patient 1s Patient Medication Record, dated 8/16/2024 to 10/14/2024, the Patient Medication Record indicated an order Hydrocodone/Acetaminophen (pain medication) Oral Tablet 5/325 mg (unit of measurement) dose 1 tablet every 6 hours as needed to treat moderately severe pain. The start date for this medication is 5/4/2021. There is no indication or documentation this medication was ever discontinued. During an observation on a joint visit on 10/17/2024 at 10:00 am with Licensed Vocational Nurse 1 (LVN 1) at the Assisted Living Facility Patient 1 resides in, Patient 1 was observed in an electrical wheelchair with a caregiver, nonverbal, awake, with contracted upper and lower extremities. During a concurrent observation and interview on 10/17/2024 at 11:15 am with Assisted Living Facility LVN and LVN 1, there was no Hydrocodone-Acetaminophen observed in Patient 1s medication cabinet. Assisted Living Facility LVN stated, “;we must have destroyed this medication because it was going to expire.” When how often the hospice agency and the assisted living facility nurses review Patient 1s medications, assisted living facility LVN stated, “;we do the medication reconciliation almost every visit with the hospice agency LVN.” LVN 1 stated, “;thats so strange, this medication should have been here. I saw it last time. We review all the medications almost every visit.” When asked if the medication was discontinued, LVN 1 stated, “;no this medication is active.” During a record review of Patient 1s Controlled Drug Record, undated, indicated Hydrocodone-Acetaminophen 5-325 mg expired 10/22/2023 and was destroyed 11/1/2023. During a telephone interview on 10/17/2024 at 11:30 am with pharmacy staff 1, pharmacy staff 1 stated, “;we are the pharmacy who supply all medications for the hospice agency and Patient 1.” When asked about Patient 1s missing medication Hydrocodone/Acetaminophen 5/325 mg, pharmacy staff 1 stated, “;the last time Patient 1 received the Hydrocodone/Acetaminophen 5/325 mg was April of 2023 and the expiration date on the label of this prescription is October 22nd, 2023. We have not filled this prescription after that.” During an interview on 11/18/2024 at 11:45 am with Director of Patient Care Services (DPCS), DPCS stated, “;our nurses are to do medication reconciliation on every visit. If there are any medications that need to be refilled, the nurses are expected to coordinate with the assisted living facility and the pharmacy to make sure the patients have all prescribed medications available. For Patient 1s Hydrocodone/Acetaminophen 5/325 mg, this was missed.” During a record review of the Hospice Agencys (HA) policy and procedure titled, “;Ongoing Comprehensive Assessments”, revised April 2012, the policy and procedure indicated “;2. The nurse will assess the patient on each visit for: compliance with treatment and medication regimen. 6. The physician will be notified to verify any changes in medications, including over the counter medications, and treatments/interventions that require physician approval.” During a record review of the HA’s policy and procedure titled, “;Medication Profile”, revised April 2012, the policy and procedure indicated, “;5. During subsequent Hospice visits, the medication profile will be used as a care planning and teaching guide to ensure that the patient and family caregiver, as well as other clinicians, understand the medication regimen. This includes, but will not be limited to: A. Using the medication profile to evaluate the use of the drugs in the home setting B. Using the medication profile to teach drug purposes, dosages, routes, times, side effects, and contraindications see. C. Using the medication profile as a communication tool for other clinicians involved in care.” During a record review of HA’s policy and procedure titled, “Medication Monitoring”, revised April 2012, the policy and procedure indicated, “Ongoing patient medication monitoring will use a collaborative approach among the clinicians, physicians, pharmacists, and patients and family/caregivers. The result of medication monitoring will be used to improve the patient’s medication regimen. The ongoing monitoring will occur in accordance with the established goals of therapy and be used to: 1. Evaluate the continued use of a medication at current regimen 2. Evaluate patients adherence to the prescribed medication regimen.” a. During a review of Patient 5’s “;Face sheet” it indicated he was admitted to the hospice agency on 7/9/22, with a primary diagnosis of cerebral infarction (type of ischemic stroke resulting from a blockage in the blood vessels supplying blood to the brain) During a review of patient 5s “;staff assignments” it indicated he had skilled nursing visits 2-3 times per week. During a review of PT 5s “;Patient Medication Record” on 10-18-24 at 8:10 it indicated an order for acetaminophen oral tablets 325MG (LS) 1 Tab every 4 hours for moderate pain noted or observed. No bottle/container was present on medication reconciliation during home visit. On the same visit, another order for acetaminophen oral tablet 325mg, as needed. 2 tabs every 6 hours as needed, (on the Patient Medication Record) the label reads take two tablets (650mg) by mouth every 4 hours. MAR indicates every 6 hrs as needed, label on the bottle indicates every 4 hrs as needed. During a home visit for patient 5 that was conducted on 10-18-24 at 10:00am, an observation of no acetaminophen oral tablets 325MG (LS) 1 Tab every 4 hours for moderate pain was found. In addition, (2) bottles of acetaminophen oral tablet 325mg were found in home (different instructions on timing) 2 tabs every 6 hrs as needed (on patient Medication record) 2 tabs every 4 hrs. as needed (on medication label) During an interview on 10-18-24 at 1:45pm the DPCS stated that the patient medication Record for my home visit was a little different than the medication labels that was on the bottles of my home visit. During a review of the agencys policy entitled “;medication profile” with a revised date of April 2012 it indicated patients receiving medications administered by hospice will have current, accurate medication profile in the clinical record. B. During a record review of Patient 1s Personal Profile, the Personal Profile indicated a start of care on 5/4/2021, with a primary diagnosis of Alzheimers Disease, unspecified (a progressive disease that destroys memory and other important mental functions). During a review of Patient 1s Plan of Care, dated 10/10/2024 the Plan of Care indicated a skilled nursing visit frequency of one to two times a week, hospice aide visit frequency of twice a week. During a review of Patient 1s Patient Medication Record, dated 8/16/2024 to 10/14/2024, the Patient Medication Record indicated an order Hydrocodone/Acetaminophen (pain medication) Oral Tablet 5/325 mg (unit of measurement) dose 1 tablet every 6 hours as needed to treat moderately severe pain. The start date for this medication is 5/4/2021. There is no indication or documentation this medication was ever discontinued. During an observation on a joint visit on 10/17/2024 at 10:00 am with Licensed Vocational Nurse 1 (LVN 1) at the Assisted Living Facility Patient 1 resides in, Patient 1 was observed in an electrical wheelchair with a caregiver, nonverbal, awake, with contracted upper and lower extremities. During a concurrent observation and interview on 10/17/2024 at 11:15 am with Assisted Living Facility LVN and LVN 1, there was no Hydrocodone-Acetaminophen observed in Patient 1s medication cabinet. Assisted Living Facility LVN stated, “;we must have destroyed this medication because it was going to expire.” When how often the hospice agency and the assisted living facility nurses review Patient 1s medications, assisted living facility LVN stated, “;we do the medication reconciliation almost every visit with the hospice agency LVN.” LVN 1 stated, “;thats so strange, this medication should have been here. I saw it last time. We review all the medications almost every visit.” When asked if the medication was discontinued, LVN 1 stated, “;no this medication is active.” During a record review of Patient 1s Controlled Drug Record, undated, indicated Hydrocodone-Acetaminophen 5-325 mg expired 10/22/2023 and was destroyed 11/1/2023. During a telephone interview on 10/17/2024 at 11:30 am with pharmacy staff 1, pharmacy staff 1 stated, “;we are the pharmacy who supply all medications for the hospice agency and Patient 1.” When asked about Patient 1s missing medication Hydrocodone/Acetaminophen 5/325 mg, pharmacy staff 1 stated, “;the last time Patient 1 received the Hydrocodone/Acetaminophen 5/325 mg was April of 2023 and the expiration date on the label of this prescription is October 22nd, 2023. We have not filled this prescription after that.” During an interview on 11/18/2024 at 11:45 am with Director of Patient Care Services (DPCS), DPCS stated, “;our nurses are to do medication reconciliation on every visit. If there are any medications that need to be refilled, the nurses are expected to coordinate with the assisted living facility and the pharmacy to make sure the patients have all prescribed medications available. For Patient 1s Hydrocodone/Acetaminophen 5/325 mg, this was missed.” During a record review of the Hospice Agencys (HA) policy and procedure titled, “;Ongoing Comprehensive Assessments”, revised April 2012, the policy and procedure indicated “;2. The nurse will assess the patient on each visit for: compliance with treatment and medication regimen. 6. The physician will be notified to verify any changes in medications, including over the counter medications, and treatments/interventions that require physician approval.” During a record review of the HA’s policy and procedure titled, “;Medication Profile”, revised April 2012, the policy and procedure indicated, “;5. During subsequent Hospice visits, the medication profile will be used as a care planning and teaching guide to ensure that the patient and family caregiver, as well as other clinicians, understand the medication regimen. This includes, but will not be limited to: A. Using the medication profile to evaluate the use of the drugs in the home setting B. Using the medication profile to teach drug purposes, dosages, routes, times, side effects, and contraindications see. C. Using the medication profile as a communication tool for other clinicians involved in care.” During a record review of HA’s policy and procedure titled, “Medication Monitoring”, revised April 2012, the policy and procedure indicated, “Ongoing patient medication monitoring will use a collaborative approach among the clinicians, physicians, pharmacists, and patients and family/caregivers. The result of medication monitoring will be used to improve the patient’s medication regimen. The ongoing monitoring will occur in accordance with the established goals of therapy and be used to: 1. Evaluate the continued use of a medication at current regimen 2. Evaluate patients adherence to the prescribed medication regimen.””

“Based on interview and record review, the HA failed to ensure clinical documentation was accurate for one of fourteen sampled patients (Patient 1). The deficient practice had the potential to result in inaccurate information or assessment being entered in the patients clinical record that could affect the patients quality of care and well-being. During a record review of Patient 1s Personal Profile, the Personal Profile indicated a start of care on 5/4/2021, with a primary diagnosis of Alzheimers Disease, unspecified (a progressive disease that destroys memory and other important mental functions). During a review of Patient 1s Plan of Care, dated 10/10/2024 the Plan of Care indicated a skilled nursing visit frequency of one to two times a week and hospice aide visit frequency of twice a week. During a review of Patient 1’s LVN Supervisory Visit, dated 10/10/2024 the LVN Supervisory Visit indicated, “Facility satisfied with care provided by CHHA (certified home health aide). CHHA providing services per plan of care.” The document was electronically signed by the DPCS on 10/10/2024. During a concurrent record review and interview on 10/18/2024 at 12:30 pm, with DPCS of the LVN Supervisory Visit, the DPCS stated, “;This is a mistake. The employee listed on this document is CHHA. This form is to do a supervisory visit for an LVN. I put the wrong employee on this form. This was my mistake.” During a record review of the HA’s policy and procedure titled, “;Entries Into The Clinical Record,” revised April 2013, the policy and procedure indicated, “;Documentation in the clinical record will be timely, detailed, accurate, and reflect the care or services provided.””

“Based on observation, interview and record review, the Hospice agency failed to coordinate with outside services to ensure accuracy and availability of the medications listed on the medication profile for two of fourteen sampled patients (Patient 1 and Patient 10). The deficient practice had the potential to result in patients not receiving medications ordered, medication errors, and negative impact on their overall health and safety. During a record review of Patient 1s Personal Profile, the Personal Profile indicated a start of care date of 5/4/2021, with a primary diagnosis of Alzheimers Disease, unspecified (a progressive disease that destroys memory and other important mental functions). During a review of Patient 1s Plan of Care, dated 10/10/2024, the Plan of Care indicated a skilled nursing visit frequency of one to two times a week, hospice aide visit frequency of twice a week. During a review of Patient 1s Patient Medication Record, dated 8/16/2024 to 10/14/2024, the Patient Medication Record indicated an order to administer Hydrocodone/Acetaminophen (pain medication) Oral Tablet 5/325 mg (unit of measurement) dose one tablet every six hours as needed to treat moderately severe pain. The start date for this medication was 5/4/2021. There is no indication or documentation this medication was ever discontinued. During an observation, while on a joint visit, on 10/17/2024 at 10 am with Licensed Vocational Nurse 1 (LVN 1) at the Assisted Living Facility Patient 1 resides in, Patient 1 was observed sitting in an electrical wheelchair with a caregiver, nonverbal, awake, with contracted upper and lower extremities. During a concurrent observation and interview on 10/17/2024 at 11:15 am with the Assisted Living Facility LVN and LVN 1, there was no Hydrocodone-Acetaminophen observed in Patient 1s medication cabinet. The Assisted Living Facility LVN stated, “;We must have destroyed this medication because it was going to expire.” When asked how often the hospice agency and the assisted living facility nurses review Patient 1s medications, the assisted living facility LVN stated, “;We do the medication reconciliation almost every visit with the hospice agency LVN.” LVN 1 stated, “;Thats so strange, this medication should have been here. I saw it last time. We review all the medications almost every visit.” When asked if the medication was discontinued, LVN 1 stated, “;No this medication is active.” During a record review of Patient 1s undated, Controlled Drug Record, indicated Hydrocodone-Acetaminophen 5-325 mg expired 10/22/2023 and was destroyed 11/1/2023. During a telephone interview on 10/17/2024 at 11:30 am with Pharmacy staff 1, Pharmacy staff 1 stated, “;We are the pharmacy who supplies all medications for the hospice agency and Patient 1.” When asked about Patient 1s missing medication Hydrocodone/Acetaminophen 5/325 mg, Pharmacy staff 1 stated, “;The last time Patient 1 received the Hydrocodone/Acetaminophen 5/325 mg was April of 2023 and the expiration date on the label of this prescription is October 22nd, 2023. We have not filled this prescription after that.” During an interview on 11/18/2024 at 11:45 am with Director of Patient Care Services (DPCS), DPCS stated, “;Our nurses are to perform a medication reconciliation on every visit. If there are any medications that need to be refilled, the nurses are expected to coordinate with the assisted living facility and the pharmacy to make sure the patients have all prescribed medications available. For Patient 1s Hydrocodone/Acetaminophen 5/325 mg, this was missed.” During a record review of the Hospice Agencys (HA) policy and procedure titled, “;Ongoing Comprehensive Assessments” revised April 2012, the policy and procedure indicated “;2. The nurse will assess the patient on each visit for: compliance with treatment and medication regimen. 6. The physician will be notified to verify any changes in medications, including over the counter medications, and treatments/interventions that require physician approval.” During a record review of the HA’s policy and procedure titled, “;Medication Profile”, revised April 2012, the policy and procedure indicated, “;5. During subsequent Hospice visits, the medication profile will be used as a care planning and teaching guide to ensure that the patient and family caregiver, as well as other clinicians, understand the medication regimen. This includes, but will not be limited to: A. Using the medication profile to evaluate the use of the drugs in the home setting. B. Using the medication profile to teach drug purposes, dosages, routes, times, side effects, and contraindications see. C. Using the medication profile as a communication tool for other clinicians involved in care.” During a record review of the HA’s policy and procedure titled, “Medication Monitoring”, revised April 2012, the policy and procedure indicated, “Ongoing patient medication monitoring will use a collaborative approach among the clinicians, physicians, pharmacists, and patients and family/ caregivers. The result of medication monitoring will be used to improve the patient’s medication regimen. The ongoing monitoring will occur in accordance with the established goals of therapy and be used to: 1. evaluate the continued use of a medication at current regimen. 2. evaluate patients adherence to the prescribed medication regimen.” b. During a record review of Patient 10s Personal Profile, the Personal Profile indicated a start of care on 3/28/2024, with a primary diagnosis of combined systolic (congestive) and diastolic heart failure se, unspecified (a progressive disease that destroys memory and other important mental functions). During a review of Patient 10s Plan of Care, dated 4/1/2024 the Plan of Care indicated a skilled nursing visit frequency of one to two times a week, hospice aide visit frequency of twice a week. During a review of Patient 10s Patient Medication Record, dated 9/24/2024 to 11/22/2024, the Patient Medication Record indicated an order Mylanta Oral Suspension(indigestion medication) 200-200-20MG/5ML (unit of measurement) dose 10 ML once a day at bedtime for indigestion. The start date for this medication was 4/24/2021. During an observation on a joint visit on 10/17/2024 at 11:00 am with Director of Patient Care Services (DPCS) at the Skilled Nursing Facility (SNF) were Patient 10 resides in, Patient 10 was observed lying in bed, alert/oriented to person place and time. Patient 10 complained of nausea, stomach bloating, stated he did not eat breakfast due to stomach feeling full. During a record review on 10/17/2024 at 2pm of Patient 10s SNF form titled, “;Medication Administration Record”, indicated Mylanta Maximum Strength Oral Suspension 400-400-40MG/5ML ( a unit of measure) dose 10 ML once a day at bed time for indigestion. During an concurrent record review and interview on 10/18/2024 at 11:45 am with DPCS of Patient 10s MAR from the SNF and Patient 10s hospice agencys Patient Medication Record, the DPCS stated, “;our nurses are to do medication reconciliation on every visit. If there are any medications that need to be refilled, the nurses are expected to coordinate with the SNF to make sure all medications are onsite and available. During a record review of the Hospice Agencys (HA) policy and procedure titled, “;Ongoing Comprehensive Assessments”, revised April 2012, the policy and procedure indicated “;2. The nurse will assess the patient on each visit for: compliance with treatment and medication regimen. 6. The physician will be notified to verify any changes in medications, including over the counter medications, and treatments/interventions that require physician approval.” During a record review of the HA’s policy and procedure titled, “;Medication Profile”, revised April 2012, the policy and procedure indicated, “;5. During subsequent Hospice visits, the medication profile will be used as a care planning and teaching guide to ensure that the patient and family caregiver, as well as other clinicians, understand the medication regimen. This includes, but will not be limited to: A. Using the medication profile to evaluate the use of the drugs in the home setting B. Using the medication profile to teach drug purposes, dosages, routes, times, side effects, and contraindications see. C. Using the medication profile as a communication tool for other clinicians involved in care.” During a record review of HA’s policy and procedure titled, “Medication Monitoring”, revised April 2012, the policy and procedure indicated, “Ongoing patient medication monitoring will use a collaborative approach among the clinicians, physicians, pharmacists, and patients and family/caregivers. The result of medication monitoring will be used to improve the patient’s medication regimen. The ongoing monitoring will occur in accordance with the established goals of therapy and be used to: 1. Evaluate the continued use of a medication at current regimen 2. Evaluate patients adherence to the prescribed medication regimen.””