Bella Terra Hospice of the Desert

“Based on observation, interview, and record review, the agency failed to ensure the medications listed in the patient’s current plan of care (POC) and current medication profile were updated accurately with the hold/discontinued medication and the medication was readily available for use for two of four patients reviewed (Patients 1 and 3). These failures had the potential for the patients not to receive the medications as ordered by the physicians, and placing the patients at risk for potential adverse effects, drug interactions, including ineffective drug therapy, and noncompliance with the prescribed medications. 2. On August 27, 2024, Patient 3’s record was reviewed. Patient 3 was admitted to the agency on January 15, 2024, with diagnoses which included hypertensive heart disease with heart failure (high blood pressure causing the heart to not pump blood as well as it should). Patient 3’s POC and medication profile included the medication Celebrex (an anti-inflammatory drug) 100 mg capsule by mouth, twice a day. On August 28, 2024, at 11:30 a.m., a home visit was conducted with Registered Nurse (RN) 1 for Patient 3. Patient 3 was observed alert and oriented and ambulating independently in her home. During a concurrent medication reconciliation review and interview with RN 1 on August 28, 2024, at 11:45 a.m., RN 1 stated the Celebrex medication was on hold (medication should not be taken). RN 1 acknowledged Celebrex was listed as active (medication ready to be taken) in Patient 3’s current medication profile and the current POC. On August 28, 2024, at 11:48 a.m., Patient 3 was interviewed. Patient 3 stated she stopped taking the Celebrex medication due to nosebleed, after consultation with the physician. On August 28, 2024, at 11:50 a.m., RN 1 was interviewed. RN 1 stated she received a verbal order from the physician on August 22, 2024, to hold the Celebrex medication, but did not enter it in the physicians orders system. RN 1 stated the Celebrex medication should have been on hold on Patient 3’s current medication list and POC, as ordered by the physician. A review of Patient 3s Client Coordination Note Report, dated August 22, 2024, indicated: “;...Patient (Patient 3) has not taken Celebrex since Saturday (August 17, 2024). Patient was taking Celebrex due to possible gout pain in legs. Patient has no complaints of increased pain in legs over this week without taking medication. Consulted with MD (physician). Instructed to hold medication for another week and reassess at next visit...” During a concurrent interview and record review, on August 29, 2024, at 10:30 a.m., with the agency’s ADMIN/DPCS, she stated if the medication Celebrex for Patient 3 was put on hold by the physician, an order should have been entered by RN 1, and the current POC and medication profile for Patient 3 should have indicated the hold status. The facility’s policy and procedure, titled, “Medication Profile,” revised May 2022, was reviewed. The policy indicated, “...Patients receiving medications administered by the organization will have a current, accurate medication profile in the clinical record. The medication profiles will be updated for each change to reflect current medications, and new and/or discontinued medications...” Findings: 1. On August 27, 2024, Patient 1’s record was reviewed. Patient 1 was admitted to the agency with the Start of Care (SOC) date of January 1, 2024, with diagnoses which included Alzheimer’s disease (a progressive disease that destroys the memory and mental functions) and muscle weakness. Patient 1 resides in the Skilled Nursing Facility (SNF) and Family Members (FM) had the power of attorney (someone with authority to act in behalf of the patient). Patient 1’s POC and medication profile included the medication Bisacodyl (a laxative) 10 milligram (mg - a unit of measurement) rectal suppository, one suppository daily as needed. On August 28, 2024, at 9 a.m., a SNF visit was conducted with the Licensed Vocational Nurse (LVN) 1 for Patient 1. Patient 1 was observed lying in bed awake and responsive to verbal call. During a concurrent interview and medication reconciliation review (a process of comparing a patient’s medication orders with the medications the patient has been taking) on August 28, 2024, at 9:50 a.m., with the SNF staff and LVN 1, the facility staff stated she was not able to find the Bisacodyl 10 mg rectal suppository in Patient 1’s prn (as needed) supply. The facility staff stated the Bisacodyl suppository was listed in Patient 1’s electronic Medication Administration Record (e MAR). LVN 1 acknowledged the Bisacodyl suppository was listed in Patient 1’s current medication profile and the current POC. On August 28, 2024, at 10:19 a.m., LVN 1 was interviewed. LVN 1 stated she was not aware the Bisacodyl 10 mg suppository was not available for use during her visit on August 27, 2024. LVN 1 stated the medication listed in Patient 1’s current POC and medication profile should always be available for use. During a concurrent interview and record review, on August 28, 2024, at 4:25 p.m., with the agency’s Administrator/Director of Patient Care Services (ADMIN/DPCS), the ADMIN/DPCS stated the medications listed in Patient 1’s current POC and medication profile should always be available for use in the facility. The ADMIN/DPCS stated the Bisacodyl 10 mg suppository should have been refilled when the medication was not available.”

“Based on interview and record review, the agency failed to ensure the frequency of visit from the various disciplines (a group of people that includes physician, nurses, hospice aides, social worker, chaplain, therapist, and volunteers) in the patient’s Plan of Care (POC) were followed. In addition the agency’s form titled, “Client Coordination Note Report,” indicating the missed visits and MD (physician) notification, the agency failed to document MD notification by phone or fax for one of three patients reviewed (Patient 12). This failure had the potential for Patient 12 not to receive the necessary care and services from each disciplines as indicated in the POC. Findings: On August 29, 2024, Patient 12’s record was reviewed. Patient 12 was admitted to the agency with the start of care (SOC) date of July 31, 2023, with diagnoses which included respiratory failure (a serious condition when the lungs can not get enough oxygen into the blood) including hypoxia (low level of oxygen in the body). The physician’s certification of terminal illness (CTI) dated August 1, 2023, indicated Patient 12 had received the home health services and was declining rapidly with oxygen saturation of 64% (level of oxygen considered very low and indicated supplemental oxygen) at room air (oxygen concentration in the air). Patient 12 had labored breathing and was using his accessory muscles (muscles that provide assistance to the main breathing muscles). Patient 12 had crackles (abnormal breath sounds) on both lungs. Patient 12’s power of attorney (POA - person with authority) opted for comfort measures and declined taking Patient 12 to the hospital for treatment. The Registered Nurse (RN) comprehensive assessment dated July 31, 2024, indicated Patient 12 was alert, arousable, and followed simple commands. Patient 12 had continuous oxygen at two liters (a unit of measurement) and had crackles in his lungs with dyspnea (shortness of breath) at rest. The POC for the certification period from July 31, 2023 to October 28, 2023, indicated the following frequency/duration of visits: - “...SN (skilled nurse) 7WK1 (seven visits for week 1), 3WK12 (three visits a week for 12 weeks) and 4 PRN (four visits as needed) for pain and symptom management; - MSW (Medical Social Worker) Effective 08/01/2023 3M1 (three visits for one month) , 2M2 (two visits a month for two months), 1PRN (one visit as needed); - HHA (Home Health Aide) 2WK13 (two visits a week for 13 weeks); and - CH (Chaplain) 1M4 (once a month for 4 months)...” The Chaplain visit note dated July 31, 2023, indicated Patient 12 had declined further Chaplain’s visit. The MSW visit note dated August 1, 2023, indicated Patient 12 was alert and oriented to person, lived alone with 24 hour caregiver. Patient 12 had designated his daughter as POA. FM requested social work, nursing services, and HHA. FM had declined Chaplain services and volunteer services at this time. On August 30, 2024, at 10:29 a.m., a concurrent interview and record view was conducted with the Administrator/Director of Patient Care Services (ADMIN/DPCS). The calendar of visits and the Client Coordination Note Reports from the SOC of July 31, 2023 to September 6, 2023, were reviewed. The following scheduled visits indicated the following: - On July 31, 2023, the RN (Registered Nurse) conducted the initial comprehensive assessment; - On August 4, 2023, the RN indicated a missed visit. The report indicated the patient and caregiver stated “enough visits this week”. The MD (doctor) was notified. - On August 7, 2023, the LVN (Licensed Vocational Nurse) indicated a missed visit. The report indicated the patient and caregiver refused. The report did not indicate the MD notification by phone or fax by the case manager; - On August 7, 2023, the HHA indicated a missed visit. The report did not indicate the reason of missed visit and the MD notification by phone or fax by the case manager; - On August 17, 2023, the HHA indicated a missed visit. The report did not indicate the reason of missed visit and the MD notification by phone or fax by the case manager; - On August 29, 2023, the MSW indicated a missed visit. The report indicated the patient and caregiver refused. The report did not indicate the MD notification by phone or fax; and - On August 31, 2023, the MSW indicated a missed visit. The report indicated the patient and caregiver refused. The report did not indicate the MD notification by phone or fax. The ADMIN/DPCS stated the missed visit notification reports should have indicated the specific reason why the patient and the caregiver refused the visits and the case manager should have notified the physician by phone or fax for the HHA missed visits. The ADMIN stated the MSW and the licensed staff could have notified the physicians. A review of the agency’s policy and procedure titled, “MISSED VISITS,” dated May 2022, indicated, “...Missed visits will be communicated to the Interdisciplinary Group (IDG) at the IDG Meeting. A missed visit will be rescheduled the same week if possible...If an aide visit is missed the aide will contact the case manager or clinical supervisor and the manager/supervisor will take the appropriate measures...””

“Based on observation, interview, and record review, the agency failed to revise and update the patient’s Plan of Care (POC) when the patient was transitioned to a higher level of care, for one of four patients reviewed (Patient 2). This failure had the potential for Patient 2 not to receive the individualized plan of care necessary to meet her current needs and management of current conditions towards the achievement of specific goals. In addition Patient 2’s primary caregiver (PCG) and family member (FM) had the potential not to be informed of Patient 2’s revised POC containing all pertinent diagnoses, including mental status, functional limitations, types of services and equipment required, frequency of visits, rehabilitation potential, medications and treatments, safety measures, teachings, goals, objectives, and all appropriate discharge plans based on the updated comprehensive assessment. Findings: On August 27, 2024, Patient 2’s record was reviewed. Patient 2 was admitted to the agency with the start of care (SOC) date of June 19, 2024, with diagnoses which included heart failure (a chronic condition in which the heart does not pump blood as well as it should), squamous cell skin cancer (type of skin cancer), post radiation (a type of cancer treatment) to the left lower leg, and wound to the left lower leg. Patient 2’s comprehensive assessment dated June16, 2024, indicated Patient 2 was alert and oriented x 4 (person, place, time and event). Patient 2 had heart failure and did not wish to continue with specialists and with the primary doctor. Patient 2 had received radiation therapy on her left lower leg and developed wound on the mid area of the left lower leg. Patient 2 was becoming weaker and was independent two months ago, able to manage her own medications and needed more assistance with her activities of daily living (ADL). Patient 2 was at the Assisted Living Facility (ALF) receiving Skilled Nursing (SN) visit three times a week. The physician’s order dated June 24, 2024, at 9:36 a.m., indicated “... SN to cleanse radiation wound...with NS (normal saline), pat dry, apply Santyl (a type of wound medication) to wound bed...3 x weekly...” The physician’s order dated July 19, 2024, at 2:08 p.m., indicated “...Santyl 250 unit/gram (a unit of measurement) 1 inch 3 times a week topical for wound care...” The physician’s order dated August 13, 2024, indicated “...Wound Care to LLE (left lower extremity) cancer wound - SN to cleanse with wound cleanser, pat dry, dress with urgoclean AG (a wound dressing that contain silver), adhesive (sticky surface) down, cover with abdominal pad...3 x weekly...” The nurse’s visit note dated August 26, 2024, indicated Patient 2 was alert and oriented x 2 (person is aware of who they are and where they are, but not what time it is or what is happening). Patient 2 had become more dependent for her care, unable to ambulate independently and spent more time in bed. Patient 2 was moving from ALF to a board and care facility. The nurse’s visit note dated August 27, 2024, indicated a new wound treatment of “...Cleanse with wound wash, pat dry, apply medihoney (a type of wound treatment) to the wound bed, cover with urgoclean AG adhesive down...SN to provide wound care 2 x weekly. Notify MD for any signs and symptoms of infection...” The POC for the certification period from June 19, 2024 to September 16, 2024, was reviewed. The POC did not contain Patient 1’s current medications, frequency/duration of visits, orders of disciplines and current wound treatments. On August 28, 2024, at 1:25 p.m., a home visit was conducted with Registered Nurse (RN) 2 at the board and care facility for Patient 2. Patient 2 was observed sitting on her wheelchair at the facility’s dining area, alert and able to verbalize her needs. RN 2 propelled Patient 2’s wheelchair to her private room. Patient 2 was observed with wound dressing on her left lower leg. Patient 2 stated she had physical therapy today. RN 2 stated Patient 2’s dressing was changed yesterday by a wound nurse using the Medihoney for wound treatment. Patient 2’s room was observed with a hospital bed, walker, raised toilet seat, shower chair, and an oxygen concentrator (a machine that takes air from the surroundings and filter it into purified oxygen) located in the closet. During a concurrent interview and medication reconciliation review, on August 28, 2024, at 1:55 p.m., with RN 2, RN 2 stated Patient 2 did not have the medication Robitussin 10 mg (a unit of measurement)-650 mg/20 ml (milliliter- a unit of measurement) oral liquid 20 ml every four hours as needed for cough. RN 2 stated the medication Robitussin had not been used by Patient 2 for a long time. RN 2 acknowledged the medication Robitussin liquid was still listed in Patient 2’s current medication profile. RN 2 stated the current wound treatment included the Medihoney 100% (percent) topical paste to be used two times a week and the Santyl Ointment had been discontinued. RN 2 acknowledged the Santyl ointment was still listed as active in Patient 2’s current medication profile. She stated the frequency of visit was changed to twice a week for SN to perform wound care and dressing changes, the HHA (Home Health Aide) was discontinued. RN 2 stated the POC did not contain Patient 2’s current medications and treatments, frequency/duration of visits for SN, PT (Physical Therapy), MSW (Medical Social Worker), During a concurrent interview and record review of Patient 2’s POC and medication profile, on August 29, 2024, at 10:30 a.m., with the Administrator/Director of Patient Care Services (ADMIN/DPCS), the ADMIN/DPCS stated Patient 2’s POC should have been revised and updated when the patient was moved from the ALF to a board and care facility on August 26, 2024. The agency’s policy and procedure titled, “THE PLAN OF CARE,” dated May 2022, 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 be reviewed and revised as frequently as deemed necessary...Revision dates will be noted on the plan of care...The written plan of care will contain...DME and medical supplies, Detailed statement of scope and frequency of services...drugs and treatments...information from the patient’s updated comprehensive assessment...””

“Based on interview and record review, the agency failed to provide the bereavement services to the bereaved family member (FM) for one of three patients reviewed (Patient 12). This failure had the potential for the bereaved FM not to receive the emotional support and necessary services to meet the FM’s psychosocial and psychological needs during the grief period from the loss of Patient 12. Findings: On August 29, 2024, Patient 12’s record was reviewed. Patient 12 was admitted to the agency with the start of care (SOC) date of July 31, 2023, with diagnoses which included respiratory failure (a serious condition when the lungs can not get enough oxygen into the blood) including hypoxia (low level of oxygen in the body). The physician certification of terminal illness (CTI) dated August 1, 2023, indicated Patient 12 had received home health services and was declining rapidly with oxygen saturation of 64 % (low oxygen level and requiring supplemental oxygen at room air (oxygen concentration in the air). Patient 12 had labored breathing and was using his accessory muscles (muscles that provide assistance to the main breathing muscles). Patient 12 had crackles (abnormal breath sounds) on both lungs. Patient 12’s power of attorney (POA - person with authority) opted for comfort measures and declined taking Patient 12 to the hospital for treatment. The Registered Nurse (RN) comprehensive assessment dated July 31, 2023, indicated Patient 12 was alert, arousable, and followed simple commands. Patient 12 had continuous oxygen at two liters (a unit of measurement), and had crackles in his lungs with dyspnea (shortness of breath) at rest. The Chaplain initial visit dated July 31, 2023, indicated Patient 12 had declined further Chaplain’s visit. The Medical Social Worker (MSW)/Bereavement Coordinator (BC) initial visit dated August 1, 2023, indicated Patient 12 was alert and oriented to person, lived alone with 24 hour caregiver. Patient 12 had designated his daughter as POA. The POA requested social work, nursing services and HHA (Home Health Aide) services. The physician order dated September 1, 2023, indicated daily SN (Skilled Nurse) visit daily times five days due to Patient 12’s actively transitioning (dying). The agency’s form titled “Client Coordination Note Report,” from September 1, 2023 to September 6, 2023, were reviewed. The notes indicated, “...On 09/06/24 patient breathing shallow 7 breaths per minute...unable to obtain blood pressure...no heart sounds...eyes do not react to light...time of death 12:54 p.m...” There was no documented evidence of the MSW/Bereavement coordinator notes after September 6, 2023 to October 6, 2023. The agency’s form titled “Client Episode Coordination Notes Report,” dated October 7, 2023, indicated the MSW missed a visit due to “NO ANSWER...DOOR/PHONE...” There was no documented evidence the MSW/ Bereavement Coordinator had attempted to call Patient 12’s FM for bereavement services from October 7, 2023 to February 2024. On August 30, 2024, at 10 a.m., a concurrent interview and record review wad conducted with the Bereavement Coordinator (BC). The BC stated there was no documentation of the bereavement services when Patient 12 expired on September 6, 2023. She stated the previous MSW/Bereavement Coordinator had a missed visit on October 7, 2023. The BC stated there was no MSW notes after October 7, 2023. She stated the bereavement plan and services was not initiated after Patient 12 expired on September 6, 2023. On August 30, 2024, at 10:45 a.m., the Administrator (ADMIN)/Director Of Patient Care Services (DPCS) was interviewed. The ADMIN/DPCS stated there was no documentation the bereavement plan and services was initiated after Patient 12 had expired on September 6, 2023. She stated the MSW should have contacted Patient 12’s FM to offer condolences and the agency’s bereavement services. She stated the Chaplain or case manager should have initiated calling Patient 12’s FM to express condolences and offer the bereavement services. A review of the agency’s policy and procedure titled, “BEREAVEMENT SERVICES,” dated May 2022, indicated, “...Bereavement services will be coordinated, in so far as possible, with the individual’s clergy, if any, as well as with other community resources judged to be useful and beneficial to the family/caregiver...After a death has occurred the bereavement assessment will be updated and the family/caregiver needs will be discussed at the next interdisciplinary group meeting...Within two weeks after the death of a sympathy card will be sent to the bereaved...Within three to five weeks after the patient’s death, a bereavement assessment...will be completed by the bereavement counselor...””