St Vincent Hospice Services, Inc.

“Based on interview and record review, the Hospice Agency (HA) failed to ensure one of 18 sampled patients (Patient 13) caregiver was involved in the plan of care with regards to psychotherapeutic medications (medication that affect the brain and body functions). This deficient practice resulted in violation of patient rights. A review of Patient 13s record titled, “;Personal Information”, indicated a start of care on 12/12/2023, with a primary diagnosis of Alzheimers disease (a brain disorder that slowly destroys memory and thinking skills). Further review of the record indicated Patient 13 passed away on 1/31/2024. A record review of Patient 13s record titled, “;Comprehensive Nursing Assessment”, dated 12/12/2023, indicated Patient 13 was awake, minimally responsive, and disoriented. Further review of the record indicated Patient 13 was confused, anxious, combative, agitated, and depressed. During a concurrent interview and record review on 4/18/2024, Registered Nurse 1 (RN1) reviewed Patient 13s records titled, “;POC/IDG Review”, dated 12/15/2023, 12/29/2023, 1/12/2024, and 1/26/2024. RN 1 stated the daughters of Patient 13 informed the agency on 12/26/2023 that the primary decision maker, Patient 13s wife had passed away and the daughters would be the primary decision makers of Patient 13s care (CG 3). RN 1 reviewed the records and stated there was no documented evidence the IDG group was aware of the changes. RN 1 stated it was important for HA to know who was involved in the care to know what the patient’s will was and to know who to contact about the discussion of the plan of care. During a concurrent interview and record review on 4/18/2024, at 12:20 p.m., RN 1 reviewed Patient 13s record titled, “;POC/IDG Review”, dated 12/15/2023. RN 1 stated medication, “;Seroquel” (an antipsychotic/psychotherapeutic medication) was started on admission to hospice because Patient 13 was agitated. RN 1 stated the medication had a black warning label (highest safety relating warning, bringing attention to the major risks of the drug), which meant there was an increased risk of death among the elderly. RN 1 stated Patient 13 was impossible to control because he was combative and that was why the doctor prescribed the medication. RN 1 stated the doctor was supposed to explain to CG 3 about the risks, benefits, and alternatives to the medication. The explanation was supposed to be documented in the medical record. During an interview on 4/18/2024, at 12:42 p.m. the Chief Executive Officer (CEO) stated he reviewed Patient 13s record and there was no documented evidence the doctor had spoked to Patient 13s CG 3 to explain the risks, benefits, and alternatives to the medication. During a concurrent interview and record review on 4/18/2024, at 12:58 p.m., RN 1 reviewed Patient 13s record titled, “;POC/IDG Review”, dated 1/12/2024. The record indicated medication dosage and frequency changes had occurred for medication “;Seroquel”, and there was a new medication added, “;Haldol” (use to treat nervous, emotional, and mental conditions). RN 1 stated the medication changes were done by the doctor because Patient 13 was uncontrollable, combative, unable to shower, and staff could not take care of him. RN 1 stated CG 3 was involved in the discussion of the medication changes but there was no documented evidence about the event. RN 1 stated it was important for the Patient 13s CG3 to be informed of the medication risk, benefits, and alternatives so the family can make the right decision about the care. During a review of facilitys policy and procedure titled “;High Risk/Alert Medications” revised 4/2017, indicated “;Agency personnel will use the following strategies to improve the safety of High Risk/Alert medication use: Educate patients.”

“Based on observation, interview and record review, the Hospice Agency (HA) staff failed to review, reconcile, and update two of 18 sample patients (Patient 1 and Patient 2) medication profiles. This failure had the potential to put the patient at risk for medication errors and adverse drug reactions. During a record review of Patient 1s medical record titled “;Personal Information” indicated a Start of Care (SOC) date of 11/25/2022 with a primary diagnosis of cerebral infarction due to thrombosis of precerebral artery (brain tissue damage due to a blocked artery). During a review of Patient 1s medical record titled “;POC (Plan of Care) Summary” indicated “;Medication – Aspirin 81 mg (milligrams) 1 tab oral daily”. During a review of Patient 1s medical record titled “;Current Treatment/Medication/DME List” indicated “;Aspirin 81 mg (milligrams) 1 tab oral daily”. During a joint home visit on 4/17/2024 at 9 a.m. with License Vocational Nurse 1 (LVN1) at Patient 1s home, LVN1 reconciled Patient 1s medications. LVN1 stated Patient 1s Aspirin medication bottle label was not the same of what was written on Patient 1s HAs medication profile. Patient 1s Aspirin medication bottle indicated “;ASA (aspirin) EC (enteric coated – tablet coated to prevent aspirin from dissolving and absorbed in the stomach). LVN1 stated patients medications should be reconciled at every nursing visit to ensure patients are taking their prescribed medications. During a concurrent interview and record review on 4/18/2024 at 10:45 a.m. with Registered Nurse 1 (RN1) of Patient 1s Electronic Medical Record (EMR), RN1 stated Patient 1s medication profile should have indicated she was being administered enteric coated aspirin. RN1 stated it was an overlooked by the HA. RN1 stated patients medications were to be reconciled at every skilled nursing visit. During a record review of Patient 2s “;Personal Information” indicated a Start of Care (SOC) date of 1/18/2024 with a primary diagnosis of Alzheimers Disease (gradual memory loss). During a review of Patient 2s medical record titled “;POC (Plan of Care) Summary” indicated “;Medication – Docusate Sodium with Sennosides (anti constipation medication) 50mg-8.6mg tablet, 1 tab oral daily – hold for loose stool.” The form also indicated “;Bisacodyl (Dulcolax – anti constipation medication) Suppository 10 mg 1 suppository rectal once daily.” During a review of Patient 2s medical record titled “;Current Treatment/Medication/DME List” indicated “;Docusate Sodium with Sennosides (anti constipation medication) 50mg-8.6mg tablet, 1 tab oral daily – hold for loose stool.” The form also indicated “;Bisacodyl (Dulcolax – anti constipation medication) Suppository 10 mg 1 suppository rectal once daily.” During a joint home visit on 4/17/2024 at 10:20 a.m. with LVN1 at Patient 2s home, LVN1 reconciled Patient 2s medications. LVN1 stated Patient 2s medication profile should have state to administer Bisacodyl suppository on an as needed basis and not as a daily dose. LVN1 stated Bisacodyl could potentially cause Patient 2 to have diarrhea and become dehydrated if administered daily. During a concurrent interview and record review on 4/18/2024 at 11 a.m. with RN1 of Patient 2s EMR, RN1 stated the visiting skilled nurse should have called the medical director for clarification. During a review of facilitys policy and procedure titled “;Medication Profile” revised April 2017, indicated “;Medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications. For accuracy and to completely reconcile medications across the continuum of care....””

“Based on interview and record review the Hospice Agency (HA) failed to ensure all care services furnished followed an individualized plans of care (POC – an individualized plan that maps out the needs and services supplied to patient and their care givers) by not conducting wound treatment as indicated in the POC for one of 18 sampled patients (Patient 2). This deficient practice resulted in the patients not receiving care/services from the home visits and placed the patients at risk for worsening of wound and infection. During a record review of Patient 2s “;Personal Information” indicated a Start of Care (SOC) date of 1/18/2024 with a primary diagnosis of Alzheimers Disease (gradual memory loss). During a review of Patient 2s medical record titled “;POC (Plan of Care) Summary” indicated “;Treatment – Traumatic ulceration of left anterior foot... dressing 3 times a week...” During a review of Patient 2s medical record titled “;Current Treatment/Medication/DME List” indicated “;Traumatic ulceration of left anterior foot... dressing 3 times a week...” During a joint home visit on 4/17/2024 at 10:20 a.m. with LVN1 at Patient 2s home, License Vocational Nurse 1 (LVN1) performed Patient 2s left foot treatment as ordered. LVN1 stated her and a Register Nurse (RN) visit Patient 2 on alternate week. LVN1 stated Patient 2s foot treatment should be done three times a week, according to her POC to prevent infection and from getting worst. During an interview on 4/17/2024 at 10:40 a.m. with Patient 2s Care Giver 1 (CG1), CG1 stated Patient 2s foot treatment is done weekly by the visiting nurse. During a concurrent interview and record review on 4/18/2024 at 11 a.m. with Registered Nurse 1 (RN1) of Patient 2s Electronic Medical Record (EMR), RN1 stated that according to Patient 2s medical order, her left foot treatment should be done three times per week. RN1 stated it was important to follow the orders to prevent infection. During a review of facilitys policy and procedure titled “;The Plan of Care” revised November 2022, indicated “;The care provided to the patient must be in accordance with the plan of care. The patient and family/caregiver will be encouraged to participate in the development of and continued updating of the plan of care.” Based on interview and record review the Hospice Agency (HA) failed to ensure all care services furnished followed individualized plans of care (POC – an individualized plan that maps out the needs and services supplied to patient and their care givers) by not conducting wound treatment as indicated in the POC for one of 18 sampled patients (Patient 2). This deficient practice resulted in the patients not receiving care/services from the home visits and placed the patients at risk for worsening of wound and infection.”

“Based on observation, interview, and record review the Hospice Agency (HA) failed to ensure two of 18 sampled patients (Patient 1 and Patient 2) Care Givers (CG) be provided with their plan of care (POC) which provided information on the services/care being provided by the HA and their current medication list. This failure had the potential to result in placing the patients at risk for not receiving the services/care stated in their individualized POC. During a record review of Patient 1s medical record titled “;Personal Information” indicated a Start of Care (SOC) date of 11/25/2022 with a primary diagnosis of cerebral infarction due to thrombosis of precerebral artery (brain tissue damage due to a blocked artery). During a review of Patient 1s medical record titled “;POC (Plan of Care) Summary” indicated “;Medication – Aspirin 81 mg (milligrams) 1 tab oral daily”. During a review of Patient 1s medical record titled “;Current Treatment/Medication/DME List” indicated “;Aspirin 81 mg (milligrams) 1 tab oral daily”. During a joint home visit on 4/17/2024 at 9 a.m. with License Vocational Nurse 1 (LVN1) at Patient 1s home, LVN1 reconciled Patient 1s medications. LVN1 stated Patient 1s Aspirin medication bottle label was not the same of what was written on Patient 1s HAs medication profile. LVN1 stated patients and their CG need their POC at home to be aware of what care will be provided. LVN1 stated patients POC was an overview of the care the HA will provide. During an interview on 4/17/2024 at 9:50 a.m. with Patient 1s Care Giver (CG2), CG2 stated Patient 1s HAs plan of care and medication list were provided by CG1 yesterday. During a record review of Patient 2s “;Personal Information” indicated a Start of Care (SOC) date of 1/18/2024 with a primary diagnosis of Alzheimers Disease (gradual memory loss). During a review of Patient 2s medical record titled “;POC (Plan of Care) Summary” indicated “;Medication –Bisacodyl (Dulcolax – anti constipation medication) Suppository 10 mg 1 suppository rectal once daily.” During a review of Patient 2s medical record titled “;Current Treatment/Medication/DME List” indicated “;Bisacodyl (Dulcolax – anti constipation medication) Suppository 10 mg 1 suppository rectal once daily.” During a joint home visit on 4/17/2024 at 10:20 a.m. with LVN1 at Patient 2s home, LVN1 reconciled Patient 2s medications. LVN1 stated Patient 2s medication profile should have indicated to administer Bisacodyl suppository on an as needed basis and not as a daily dose. During an interview on 4/17/2024 at 10:50 a.m. with CG1, CG1 stated Registered Nurse 1 brought Patient 1 and Patient 2s POC and their medication profile yesterday. During an interview on 4/18/2024 at 10:45 a.m. with Registered Nurse 1 (RN1), RN1 stated patients and their CGs should be provided with patients individualized POC so they can follow their treatment plan. RN1 stated, “;when the POC is not provided, it disconnects the family from the care, family is not involved”. RN1 stated she took Patient 1 and Patient 2 POC to their home yesterday. RN1 stated both patients POC were amended on 4/5/2024 during their interdisciplinary meeting. During a review of facilitys policy and procedure titled “;Rights/Responsibilities” revised November 2022, indicated “;The patient, authorized decision-maker or legal representative will be informed during the initial assessment visit, in advance of furnishing care, of: The goals of hospice, the interventions that support those goals and the identification of the staff providing services. The right to be informed of his/her condition, to participate in all aspects of care including development on their plan of care, and the right to refuse all or part of his/her care to the extent permitted by law.” During a review of facilitys policy and procedure titled “;The Plan of Care” revised November 2022, indicated “;The patient and family/caregiver will be encouraged to participate in the development of and continued updating of the plan of care. All appropriate staff will have access to the plan of care.””

“Based on observation, interview, and record review the Hospice Agency (HA) failed to ensure one of 18 sample patients (Patient 2) were supplied with a suction machine as ordered and indicated in their individualized plan of care. This failure had the potential to result in Patient 2 not being able to get immediate relief from being suctioned when there was a buildup of secretions in their airway. During a record review of Patient 2s “;Personal Information” indicated a Start of Care (SOC) date of 1/18/2024 with a primary diagnosis of Alzheimers Disease (gradual memory loss). During a review of Patient 2s medical record titled “;POC (Plan of Care) Summary” indicated “;PCG (patient care giver) / Skilled Nurse (SN) to perform oral suctioning as needed to remove excessive oral secretions with suction machine unis Yankauer or suction catheter. SN to validate PCG skills with return demonstration.” During a joint home visit on 4/17/2024 at 10:20 a.m., with License Vocational Nurse 1 (LVN1) at Patient 2s home, LVN1 was not able to locate/demonstrate Patient 2s suction machine. Patient 2s Care Giver 1 (CG1) stated the HA did not provide Patient 2 with a suction machine. LVN1 stated, “;It should be here with the patient in their home for them to use if and when it is needed. If the patient is actively aspirating, it can cause hypoxia and to relieve congestion.” During a concurrent interview and record review on 4/18/2024 at 11 a.m. with Registered Nurse 1 (RN1) of Patient 2s Electronic Medical Record (EMR), RN1 stated the need for a suction machine was listed on Patient 2s plan of care. RN1 stated, “;Its important to offer the suction machine in case the patient starts declining. I saw her on Monday, she is being treated for an upper respiratory infection. I did not check for her suction machine when I was there on Monday.” During a review of facilitys policy and procedure titled “;Durable Medical equipment and Supplies” revised November 2022, indicated “;Those supplies required for optimal comfort, care, and management of the hospice patient will be obtained from the hospice stock supplies or approved company if the patient is receiving the Medicare, Medicaid, or private insurance hospice benefits. During a review of facilitys policy and procedure titled “;Patient Education Process” revised November 2022, indicated “;Patients and family/caregiver will receive education in verbal, visual, and written format, as appropriate. The scope of teaching will be determined by the assessed needs, abilities, learning preferences, and readiness to learn of the patient and family/caregiver, as well as by the plan of care.”