Suncrest Hospice Sacramento, LLC

“Based on interview and record review, the facility failed to ensure Patient 1 was not subjected to verbal or physical abuse of any kind. The deficient practice had the potential to result in emotional and psychological harm to the patient. Patient 1 was admitted to the hospice on 2/12/24 and primary diagnoses was peripheral vascular disease. During a review of Patient 1s “;Hospice Certification and Plan of Care,” for the certification period 5/12/24-8/9/24, contained a physician order for “;Chaplain; 1-2 m (month) 4 m 4 PRN (as needed): Chaplain will provide 1-2 visits per month for Spiritual/emotional care and support for Pt (patient) and for her family and 4x monthly PRN visits for crisis management and/or any requested SCP support from family upon request...” During a telephone interview on 8/12/24 at 9:04 a.m. with the hospices General Counselor, he stated the hospice received a telephone call on 8/7/24 regarding the incident (sexual assault of Patient 1). The hospice contacted the Sheriff’s Department and are coordinating and cooperating with the Sheriff Department. Chaplain 1 was put on administration leave and then terminated. The General Counselor stated according to the Sheriffs Department, after they reviewed the tape, stated Chaplain 1 exposed Patient 1s breasts, touched Patient 1s breasts and then covered Patient 1s breasts with his mouth. The General Counselor stated they have not been able to get a hold of Chaplain 1 due to being arrested on Thursday (8/8/24), then he posted bail and not answering telephone calls. The General Counselor stated they do not have a copy of the surveillance video and have not seen it. During an interview on 8/12/24 at 9:36 a.m., with the hospice Executive Vice President (EVP), she stated the hospice has had no complaints regarding Chaplain 1 from any other patients and/or family members. The EVP stated they immediately sent out a nurse to assess Patient 1, no injuries or bruising was noted. According to the EVP Patient 1s son had installed a Ring camera a couple weeks ago. On Wednesday 8/7/24, the Ring camera went off and Patient 1s son, saw in real time, Chaplain 1 in Patient 1s room sexually assaulting her. Review of the hospices policy and procedure titled, “;Bill of Rights,” revised June 2022, indicated, “;1. The Bill of Rights statement defines the right of the patient to:...I. Be free from mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries from unknown source, and misappropriation of patient property...””

“It is required that the comprehensive assessment includes consideration of the following factors: symptoms and symptom severity, including skin integrity. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #1-015, “Ongoing comprehensive assessments” (revised June 2022), stated in part, “During each home visit, the case manager or other discipline will evaluate the patient according to the problems identified during the initial assessment and thereafter the comprehensive assessment...The nurse will complete on each visit as relevant: skin integrity.” In 1 of 9 (11%) clinical records reviewed of patients receiving wound care, the hospice did not ensure the comprehensive assessments included consideration of symptoms and symptom severity, including skin integrity. Clinical Record 10: The patient elected hospice on 04/11/2023 with a diagnosis of congestive heart failure (CHF). A review of the clinical record for 11/22/2023 through 12/27/2023 revealed multiple wounds: an unstageable wound to the right hip, stage II wounds to the right back; and right toe, and two (2) wounds to the inner buttocks, all requiring dressing changes, two (2) times a week and pro re nata (as needed/PRN). The Skilled Nursing (SN) assessments dated 11/21/2023 and 11/28/2023 did not include documentation of an evaluation of the wounds according to the wound problems identified in the comprehensive assessments, as required by agency policy. During the joint review of the clinical record and interview on 01/25/2024, the Corporate Compliance Director confirmed the missing evaluations of the wounds. Policy, “Ongoing comprehensive assessments”, policy no. 1-015, revised June 2022, stated in part, “During each home visit, the case manager or other discipline will evaluate the patient according to the problems identified during the initial assessment and thereafter the comprehensive assessment” and “The nurse will complete on each visit as relevant: skin integrity”.”

“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; [and] 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, document review, interview, and observation. Agency policy #2-006, “Administration and Documentation of Medications” (revised November 2023), stated in part, “As part of the assessment process, a drug history will be taken and a comparison made between the physician’s orders and the current medications the patient is taking...Any discrepancies or contraindications should be reported to the physician for resolution.” In 1 of 23 (4%) clinical records reviewed, the hospice did not ensure the patient’s drug profile contained the patient’s current prescription. Clinical Record 2/Home Visit 2: The patient elected hospice care on 7/5/23 and resided in an assisted living facility (ALF). The patient had multiple wounds with pain issues and was alert and oriented. During the home visit with the Registered Nurse (RN) [Personnel Record 5] on 1/24/24, the hospice medication orders were compared with the patient’s medications at the ALF. An order for Fentanyl 50 mcg every 72 hours dated 01/17/2024 was transcribed onto the patient’s ALF medication administration (MAR) on 01/24/2024, with the “start date” documented as “01/27/2024.” A review of the ALF MAR revealed Fentanyl 12 mcg two (2) patches was documented as administered by the ALF medication technician on 01/21/2024 and 01/24/2024 at 8 am. In addition, the patient was taking scheduled doses of acetaminophen/hydrocodone and morphine as needed for breakthrough pain. The ALF MAR was not updated on 01/17/2024 to reflect the physician’s order for the Fentanyl. During an interview on 01/24/2024, the patient stated, “Yes, I always have pain” and reported a current pain level of “8” on the pain scale of 0-10. During an interview, the ALF medication technician stated, “Yes, the hospice nurse gave me a copy of the order dated 01/17/2024 for the Fentanyl patch that was increased to 50 mcg, but I only uploaded the dressing change procedure changes off the order and I do not know why the new Fentanyl order did not get uploaded into the system...We noticed this morning (01/24/2024) that the changed Fentanyl dosage order was not uploaded and then put it on our medication sheet.” During a joint home visit and interview on 01/24/2024, the Hospice RN stated, “Yes, I see the Fentanyl 50 mcg ordered on 01/17/2024 did not get onto the facility’s MAR until today, and the old Fentanyl dose was administered incorrectly on 01/21/2024 and this am (01/24/2024).” During the home visit the physician was notified of the medication error. Prior to leaving the facility, the patient received the breakthrough morphine ordered by the physician. Policy, “Administration and Documentation of Medications”, Policy No. 2-006, revised November 2023, included in part, “As part of the assessment process, a drug history will be taken and a comparison made between the physician’s orders and the current medications the patient is taking” and “Any discrepancies or contraindications should be reported to the physician for resolution”.”

“It is required that the update of the comprehensive assessment is completed by the hospice Interdisciplinary Group, who, in collaboration with the individual’s attending physician, if any, consider the changes that have taken place since the initial assessment. The update of the comprehensive assessment includes information on the patient’s progress toward desired outcomes and reassessment of the patient’s response to care. The assessment update is completed as frequently as the condition of the patient requires and no less frequently than every 15 days. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #9-017, “The Plan of Care” (revised March 2022), stated in part, “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 but no less than every fifteen (15) days.” In 1 of 23 (4%) clinical records reviewed, the hospice did not ensure the updated comprehensive assessment included an accurate reassessment of the patient’s response to care. Clinical Record 10: The patient elected hospice care on 04/11/2023. The clinical nursing visit notes before 11/22/2023 identified the right hip wound as stage II. The interdisciplinary reassessment of the right hip wound on the “IDT Meeting” form dated 11/22/2024 documented, “wound right hip unstageable.” The IDT meeting form did not include accurate reassessment information regarding the wound. During an interview on 01/25/2024, the Corporate Compliance Director confirmed the 11/22/2023 IDT Meeting form included “wound right hip unstageable.” During a phone interview on 01/26/2024, with the Corporate Compliance Director and Assistant DON present, the Registered Nurse (RN) who documented the right hip reassessment on the 11/22/2023 interdisciplinary team (IDT) stated, “The wound assessment on the 11/22/2023 IDT form of the “unstageable right hip wound” was not correct. I was on vacation on 11/22/2023 and did not complete the IDT form until 12/29/2023 when it was noticed in the office that the IDT nursing section was not done yet. The wound turned unstageable on 01/30/2023, not 11/22/2023.” Policy, “The Plan of Care” policy NO. 9-017, revised March 2022, stated in part, “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 but no less than every fifteen (15) days”.”

“It is required that hospice care and services provided to patients and families follow the individualized plan of care established by the hospice IDG in collaboration with the attending physician (if any). This standard was not met as evidenced by clinical record review and interview. In 3 of 23 (13%) clinical records reviewed, the hospice did not ensure hospice care and services provided to the patient followed the individualized plan of care. Clinical Record 2/Home Visit 2: The patient elected hospice care on 7/5/23 and resided in an assisted living facility (ALF). The patient had multiple wounds with pain issues and was alert and oriented. During the home visit with the Registered Nurse (RN) [Personnel Record 5] on 1/24/24, the hospice medication orders were compared with the patient’s medications at the ALF. An order for Fentanyl 50 mcg every 72 hours dated 01/17/2024 was transcribed onto the patient’s ALF medication administration (MAR) on 01/24/2024, with the “start date” documented as “01/27/2024.” A review of the ALF MAR revealed Fentanyl 12 mcg two (2) patches was documented as administered by the ALF medication technician on 01/21/2024 and 01/24/2024 at 8 am. In addition, the patient was taking scheduled doses of acetaminophen/hydrocodone and morphine as needed for breakthrough pain. The ALF MAR was not updated on 01/17/2024 to reflect the physician’s order for the Fentanyl. During an interview on 01/24/2024, the patient stated, “Yes, I always have pain” and reported a current pain level of “8” on the pain scale of 0-10. During an interview, the ALF medication technician stated, “Yes, the hospice nurse gave me a copy of the order dated 01/17/2024 for the Fentanyl patch that was increased to 50 mcg, but I only uploaded the dressing change procedure changes off the order and I do not know why the new Fentanyl order did not get uploaded into the system...We noticed this morning (01/24/2024) that the changed Fentanyl dosage order was not uploaded and then put it on our medication sheet.” During a joint home visit and interview on 01/24/2024, the Hospice RN stated, “Yes, I see the Fentanyl 50 mcg ordered on 01/17/2024 did not get onto the facility’s MAR until today, and the old Fentanyl dose was administered incorrectly on 01/21/2024 and this am (01/24/2024).” During the home visit, the physician was notified of the medication error. Before leaving the facility, the patient received the breakthrough morphine ordered by the physician. Clinical Record 7: The patient elected hospice care on 07/17/2023. The plan of care ordered volunteer visits two (2) times a month. A review of the clinical record for 12/01/2023 through 12/31/2023 revealed (1) one extra volunteer visit in 12/2023. During the clinical record review and interview on 01/22/2024, the Regional Compliance Director confirmed the extra volunteer visit, stating, “There is no order, visit increase in the care plan, or documentation in the IDT meetings for the extra volunteer visit in December 2023.” Clinical Record 8: The patient elected hospice care on 09/22/2023. The plan of care ordered volunteer visits four (4) times a month. A review of the clinical record for 12/01/2023 through 12/31/2023 revealed there were (3) three missing volunteer visits for 12/2023. During the clinical record review and interview on 01/23/2024, the Regional Compliance Director confirmed the missing volunteer notes and stated, “There is no order, visit frequency changes, or documentation in the IDT meetings for the missing volunteer visits in December 2023.””

“It is required that the hospice provides infection control education to employees, contracted providers, patients, family members, and other caregivers that is individualized to the needs of each patient. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed of COVID-positive patients, the hospice did not ensure patients, family members, and other caregivers were provided with individualized infection control education to meet the patient’s needs. Clinical Record 13: The patient elected hospice care on 01/05/2024. A review of the clinical record revealed documentation that the patient tested positive for COVID-19 on 01/04/2024 and a physician’s order for COVID-19 isolation. There was no documented evidence that the caregiver was provided education regarding COVID-19 isolation precautions. Clinical Record 14: The patient elected hospice care on 12/15/2023. A review of the clinical record revealed documentation that the patient tested positive for COVID-19 on 12/29/2023 and a physician’s order for COVID-19 isolation. There was no documented evidence that the caregiver was provided education regarding COVID-19 isolation precautions. During an interview and joint review of the clinical record on 01/25/2024, the Corporate Compliance Director reviewed the nursing assessment, nursing visit notes, communication notes, and telephone calls, and confirmed the missing education of the caregivers. During an interview and joint review of the clinical record on 1/25/24, the Corporate Compliance Director reviewed the nursing assessment, nursing visit notes, communication notes, and/or telephone calls and confirmed the missing education of the caregivers.”

“It is required that a hospice aide provides services: ordered by the Interdisciplinary Group; [and] Included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 21 (10%) clinical records reviewed of patients who received hospice aide services, the hospice did not ensure the Hospice Aide visits provided services ordered by the Interdisciplinary Group. Clinical Record 19: The patient elected hospice care on 10/20/2023. The POC ordered Hospice Aide services two (2) times a week. A clinical record review revealed that one Hospice Aide visit was documented as completed the week of 12/24/2023. There was no evidence of a documented missed visit for the week of 12/24/2023. During an interview and a joint review of the clinical record on 01/25/2024, the Corporate Compliance Director confirmed the missing physician’s order or plan of care update for the missing hospice aide visit for the week of 12/24/2023. Clinical Record 23: The patient elected hospice care on 10/13/2023. The POC ordered Hospice Aide services two (2) times a week. A clinical record review revealed that one Hospice Aide visit was documented as completed the week of 12/24/2023. There was no evidence of a documented missed visit for the week of 12/24/2023. During an interview and a joint review of the clinical record on 01/25/2024, the Corporate Compliance Director confirmed the missing physician’s order or plan of care update for the missing hospice aide visit for the week of 12/24/2023.”

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum the initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes including the care and services provided. This standard was not met as evidenced by clinical record review, document review and interview. Agency policy #6-042, “Contents of the Clinical Record” (revised June 2022), stated in part, “The clinical record will contain sufficient information to identify the patient, describe the patient’s problems and needs, justify care, accurately document care provided and results in detail and facilitate continuity of care among hospice interdisciplinary group members...The following information will be available in the clinical record as applicable to care and services provided: patient and family/caregiver initial, comprehensive and ongoing comprehensive assessments, and patient and family education provided.” In 2 of 23 (9%) clinical records reviewed, the hospice did not ensure the on-call triage nursing notes were documented in the clinical record, as required by agency policy. Clinical Record 17: A review of the clinical record identified the patient elected hospice on 10/12/2021 and was discharged on 04/30/2023 to a non-contracted hospital for aggressive treatment. A review of the on-call log dated 04/30/2023 at 10:40 am identified a request for a visit. A clinical record review revealed a separate on-call nurse arrived and assessed the patient on 04/30/2023 at 3:00 pm. No on-call triage nursing note was documented in the patient’s clinical record for the call received on 04/30/2023 at 10:40 am, which included a phone call assessment and description of the patient’s needs and facilitation of the continuity of care with another on-call nurse, as required by the agency policy. Clinical Record 18: The patient elected hospice care on 05/01/2023 and expired on 01/08/2024. A review of the on-call log dated 01/06/2024 revealed the patient’s daughter called the on-call triage nurse and requested a visit at 10:35 am. The on-call log completed by the on-call triage nurse documented, “ETA 35 minutes, SN advised to wait to start medications once SN gets there.” A review of the clinical record revealed a separate on-call nurse visit note, including an assessment of the patient on 01/06/2024 at 2:00 pm. No on-call triage nursing note was documented in the patient’s clinical record for the call received on 01/06/2024 at 10:35 am, which included a phone call assessment and description of the patient’s needs and instructions given, as required by agency policy. During a joint clinical record review and interview on 01/25/2024, the Corporate Compliance Director confirmed the missing on-call triage nursing notes. During an interview on 01/26/2024, the hospice Administrator stated, “The on-call triage nurse is supposed to complete a note for the clinical record with the triage phone assessment and any instructions given.” Policy, “Contents of the Clinical Record”, policy No. 6-042, revised June 2022, included in part, “The clinical record will contain sufficient information to identify the patient, describe the patient’s problems and needs, justify care, accurately document care provided and results in detail and facilitate continuity of care among hospice interdisciplinary group members” and “The following information will be available in the clinical record as applicable to care and services provided: patient and family/caregiver initial, comprehensive and ongoing comprehensive assessments and patient and family education provided” During a joint clinical record review and interview on 1/25/24, the Corporate Compliance Director confirmed the missing on-call triage nursing notes. During an interview on 1/26/24, the hospice Administrator stated, “The on-call triage nurse is supposed to complete a note for the clinical record with the triage phone assessment and any instructions that are given”.”