Gmc Professional Hospice Care, Inc.

“Based on interview and record review, the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure that all staff members had attended to annual training for emergency and disaster preparedness drills. This deficient practice had the potential for the staff to not to respond effectively during an emergency/disaster situation. During a concurrent interview and record review on 12/21/23 at 1:30 p.m. with the Administrator (ADM), the Emergency Preparedness binder was reviewed and there was no documented evidence that all staff had participated in the emergency preparedness training/disaster drill the year 2021 to 2023.The ADM stated that not all staff were able to be trained since some of the staff had to visit patients and some were not able to attend. The ADM stated that it was important for all staff to participate in the emergency drill to prepare them in case an emergency situation emerge in the future. The ADM stated, “;The drill allows the staff to practice so they would know what to do in a fire, earthquake, or other emergencies.” A review of the agency’s policy titled, “;Emergency Management Plan,” revised December 2018, indicated that organization leadership will provide for orientation and education of all personnel regarding participation in the emergency management plan. Education will be provided during orientation and annually.”

“Based on observation, interview and record review, the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to maintain an accurate, current medication profile for three of 14 sampled patients (Patient 1, Patient 2, and Patient 8). This deficient practice had the potential in placing Patient 1, Patient 2, and Patient 8 at risk for medication errors and adverse drug reactions, Findings: c. During a review of Patient 8’s face sheet indicated a start of care date of 10/25/2023, with a terminal diagnosis of heart failure, unspecified (a chronic condition in which the heart does not pump blood as well as it should). During a review of Patient 8s Physician Orders/Plan of care dated 10/25/2023, indicated the frequency of visits of skilled nurse (SN) to one visit per week and as needed for pain, symptom management and crisis intervention, and to reconcile medications with patient/family/caregiver in accordance with updated medication profile. During a joint home visit conducted on 12/20/2023 at 10:05 a.m. at Patient 8’s residence with the registered nurse (RN 1), Patient 8 was observed lying in hospital bed, asleep but arousable. The patients caregiver (Pcg 1) was present at bedside. During a review of Patient 8s current medication on 12/20/2023 at 10:45 a.m. with RN 1, there was a bottle of atropine sulfate 1% (medicine used to reduce saliva and fluid in the respiratory tract) 2 drops every 4 hours as needed for secretion, filled date 10/25/2023 found together with the rest of Patient 8s medication. However, the patients current medication profile provided by the HA indicated patient was not taking the medication. Patient 8s current medication profile also indicated Patient 8 was on hyoscyamine (used to treat many different stomach and intestinal disorders) 0.125 milligram (mg) sublingual every 4 hours as needed for excessive secretions. However, the medication bottle was not found. During an interview with Pcg 1, she stated they never received hyoscyamine medication from the pharmacy. During an interview on 12/21/2023 at 12:25 p.m. with the Director of Patient Care Services Designee (DPCSD), the DPCSD stated nursing staff need to review patients current medication on every visit and update the medication profile in the patients clinical record. During a review of the hospice agencys policy and procedure titled, “;Medication Profile”, revised November 2022, 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. a. A review of Patient 1s face sheet indicated a start of care date (SOC) of 8/14/23 with diagnoses that included unspecified dementia (a condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems) and atherosclerotic heart disease (heart disease that is caused by the buildup of fats, cholesterol, and other substances in and on the artery walls). A review of Patient 1s physician orders, dated 8/14/23, indicated that Patient 1 had a Skilled Nurse (SN) visit once a week and as needed for pain, symptom management, and crisis intervention. During a joint home visit with the Director of Patient Care Services Designee (DPCSD) on 12/20/23 at 11:50 a.m., which was conducted via FaceTime, Patient 1 was observed lying in bed with his eyes closed. According to Family Member 1 (FM 1), Patient 1 was sleeping. A medication review with the DPCSD was completed during the home visit, at 12:20 p.m. During medication review, it was noted the following medications, which were listed in Patient 1s medication profile, were not available at Patient 1s home: - Zofran 4 mg oral tablet sublingual. - Milk of Magnesia 30 ml. - Hyoscyamine 0.125 mg sublingual. - Duoneb. - Dulcolax 10 mg suppository It was also noted Atropine Sulfate 1% solution sublingual (a medication to reduce secretion) and Albuterol Sulfate 2.5 mg/3 ml (used to prevent and treat difficulty breathing, wheezing, shortness of breath, coughing, and chest tightness) were found at home, but not listed in the medication profile: During an interview with FM 1 on 12/20/23 at 12:20 p.m., FM 1 stated that Patient 1 never received Zofran 4 mg (anti-nausea medication), Duoneb (a medication to help open the airway in the lungs), and Hyoscyamine 0.125 mg (a medication that reduces the amount of sweat, saliva, and stomach acid). FM 1 stated that Patient 1 finished taking the Milk of Magnesia 30 ml (a medication to treat constipation, upset stomach, and heartburn) on 12/1/23. According to FM 1, Patient 1 ran out of Dulcolax 10 mg suppository (a medication for constipation); FM 1 was not sure when the medication ran out. FM 1 stated that Atropine Sulfate and Albuterol Sulfate were never administered. b. A review of Patient 2s face sheet indicated a start of care date (SOC) of 6/8/23 with diagnoses that included unspecified dementia (a condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems) and malignant neoplasm of upper lobe, right bronchus or lung (lung cancer). A review of Patient 2s physician orders, dated 6/8/23, indicated that Patient 1 had a Skilled Nurse (SN) visit once a week and as needed for pain, symptom management, and crisis intervention. During a joint home visit with the Director of Patient Care Services Designee (DPCSD) on 12/20/23 at 9:35 a.m., which was conducted via FaceTime, Patient 2 was observed sitting in a wheelchair, awake and alert. A medication review with the DPCSD was completed during the home visit, at 10 a.m. During medication review, it was noted the following medications, which were listed in Patient 2s medication profile, were not available at Patient 2s home: - Zoloft 25 mg oral tablet. - Zofran 4 mg oral tablet sublingual. - Risperidone 0.5 tablet. - Calcium Carbonate 600 mg. - Lidocaine patch. - Hyoscyamine 0/125 mg sublingual. - Duoneb. - Dulcolax 10 mg rectal suppository - Dorzolamide 2% ophthalmic solution The following medications were found at Patient 2s residence but were not listed in her medication profile: - Atropine Sulfate 1% solution. - Albuterol Sulfate 2.5 mg/3 ml. - Ipratropium bromide nasal spray 0.06%. Dose discrepancy was noted for the following medications: - In the medication profile: Metoprolol tartrate 25 mg (as metoprolol succinate 23.75 mg). Available at home: Metoprolol succinate ER 50 mg. Date filled on label: 8/27/23. - In the medication profile: Vitamin D3 1000 unit oral tablet. Available at home: Vitamin D3 2000 unit oral tablet. During an interview with Family Member 2 (FM 2) on 12/20/23 at 10 a.m., FM 2 stated that Patient 2 had stopped taking Zoloft 25 mg a long time ago. FM 2 stated that Patient 2 stopped taking Zofran 4 mg about 3 months ago. FM 2 also stated that Patient no longer used Lidocaine patch in the last 2 months since she no longer had back pain. When asked if Patient 2 was still taking Calcium Carbonate 600 mg, FM 2 stated she stopped taking it 6 months ago. FM 2 stated she did not remember when Patient 2 stopped taking Risperidone. According to FM 2, she never received Hyoscyamine, Duoneb, Dulcolax, and Dorzolamide. During an interview with the DPCSD on 12/20/23 at 10:40 a.m., the DPCSD stated that it was very important that patient had a current medication profile that reflected all the medications the patient was taking. The DPCSD stated that an updated medication profile would allow the nurses to monitor for side effects and for medication efficacy. When asked who was supposed to check the patients medications, the DPCSD stated the visiting nurse was supposed to check patients medications with every visit since the patient received weekly visit. According to the DPCSD, the nurse was supposed to update the medication profile if there was a new medication, discontinued medication, or dose change. A review of the agencys policy, titled “;Medication Profile,” revised December 2018, indicated that patients receiving medications administered by the organization will have a current, accurate medication profile in the clinical record. The medication profile will be updated for each change to reflect current medications, and new and/or discontinued medications.”

“Based on observation, interview, and record review, the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to furnish care and services following an individualized written plan of care for two of 14 sampled patients (Patient 1 and Patient 2). This deficient practice had the potential to prevent patients from achieving the optimum health status to meet their care goals. a. A review of Patient 1s face sheet (admission record) indicated a start of care date (SOC) of 8/14/2023 with diagnoses that included unspecified dementia (a condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems) and atherosclerotic heart disease (heart disease that is caused by the buildup of fats, cholesterol, and other substances in and on the artery walls). A review of Patient 1s “;Initial Orders and Plan of Care,” dated 8/14/2023, indicated that interventions for Patient 1 included the following: - Review patients prescriptions and over the counter drug profile for effectiveness, duplication, interactions, and side effects. - Reconcile medications with patient/family/caregiver in accordance with updated medication profile. A review of Patient 1s physician orders, dated 8/14/2023, indicated that Patient 1 had an order for comfort kit, which included the following medications. - Hyoscyamine 0.125 mg sublingual, every 4 hours as needed for excessive secretion. - Lorazepam 2 mg/1 ml sublingual, 0.25 ml every 4 hours as needed for anxiety. - Morphine 20 mg/1 ml sublingual, 0.25 ml every 4 hours for moderate and severe pain. - Zofran 4 mg tablet sublingual, every 4 hours nausea and vomiting. - Acetaminophen 650 mg suppository, every 4 hours for temperature greater than 100 F. - Dulcolax 10 mg rectal suppository, if no bowel movement in 3 days. - Duoneb 1 packet inhalation every 4 hours for congestion. During a joint home visit with the Director of Patient Care Services Designee (DPCSD) on 12/20/2023 at 12:20 p.m., a medication review was performed. Upon medication review, it was observed that 4 of the medications in the comfort kit were not available at Patient 1s residence. The unavailable medications were as follows: - Hyoscyamine 0.125 mg - Zofran 4 mg tablet - Dulcolax 10 mg - Duoneb It was also noted Atropine Sulfate 1% solution sublingual (a medication to reduce secretion) and Albuterol Sulfate 2.5 mg/3 ml (used to prevent and treat difficulty breathing, wheezing, shortness of breath, coughing, and chest tightness) were found at home, but not listed in the medication profile. During an interview with FM 1 on 12/20/2023 at 12:20 p.m., FM 1 stated that Patient 1 never received Zofran 4 mg (anti-nausea medication), Duoneb (a medication to help open the airway in the lungs), and Hyoscyamine 0.125 mg (a medication that reduces the amount of sweat, saliva, and stomach acid). According to FM 1, Patient 1 ran out of Dulcolax 10 mg suppository (a medication for constipation); FM 1 was not sure when the medication ran out. FM 1 stated that Patient 1 was often constipated and that caused him to run out of the Dulcolax suppository. During an interview with the DPCSD on 12/20/2023 at 12:45 p.m., the DPCSD stated, “;There could be negative outcome if patient ran out of medication. In his case, he might have prolonged constipation without the Dulcolax. This patient lives far, the pharmacy is located in LA, which is more than 2 hours away. So even after the nurse orders the refill, it will take time to deliver it.” b. A review of Patient 2s face sheet indicated a start of care date (SOC) of 6/8/2023 with diagnoses that included unspecified dementia (a condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems) and malignant neoplasm of upper lobe, right bronchus or lung (lung cancer). A review of Patient 2s “;Initial Orders and Plan of Care,” dated 6/8/2023, indicated that interventions for Patient 1 included the following: - Review patients prescriptions and over the counter drug profile for effectiveness, duplication, interactions, and side effects. - Reconcile medications with patient/family/caregiver in accordance with updated medication profile. A review of Patient 2s physician orders, dated 6/8/23, indicated that Patient 2 had an order for comfort kit, which included the following medications: - Hyoscyamine 0.125 mg sublingual, every 4 hours as needed for excessive secretion. - Lorazepam 2 mg/1 ml sublingual, 0.25 ml every 4 hours as needed for anxiety. - Morphine 20 mg/1 ml sublingual, 0.25 ml every 4 hours for moderate and severe pain. - Zofran 4 mg tablet sublingual, every 4 hours nausea and vomiting. - Acetaminophen 650 mg suppository, every 4 hours for temperature greater than 100 F. - Dulcolax 10 mg rectal suppository, if no bowel movement in 3 days. - Duoneb 1 packet inhalation every 4 hours for congestion. During a joint home visit with the Director of Patient Care Services Designee (DPCSD) on 12/20/2023 at 10 a.m., a medication review was performed. Upon medication review, it was observed that 4 of the medications in the comfort kit were not available at Patient 2s residence. The unavailable medications were as follows: - Hyoscyamine 0.125 mg - Zofran 4 mg tablet - Dulcolax 10 mg - Duoneb During an interview with Family Member 2 (FM 2) on 12/20/2023 at 10 a.m., FM 2 stated that she had never received Hyoscyamine, Duoneb, Dulcolax. FM 2 stated that Patient 2 stopped taking Zofran 4 mg about 3 months ago. During an interview with the DPCSD on 12/20/2023 at 10:40 a.m., the DPCSD stated, “;Our pharmacy sometimes send Atropine Sulfate instead of Hyoscyamine for secretion, probably thats whats available. But we need to get an order for Atropine, because the order that patient has is Hyoscyamine.” The DPCSD stated that it was important to follow the physician order so that patient could be monitored accordingly. A review of the agencys policy, titled “;The Plan of Care,” revised December 2018, indicated that care provided to the patient will be in accordance to the plan of care.”

“Based on observation, interview and record review, the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to develop an individualized plan of care for one out of 14 sampled patients (Patient 8), who developed a stage 1 coccyx and mid-back pressure injury (non-blanchable redness of a localized area usually over a bony prominence). This deficient practice had the potential for the patient to not have patient-centered interventions addressing the patients specific needs, potentially resulting in a decline in emotional, physical, psychosocial well-being, and quality of life. Findings: During a review of Patient 8’s face sheet (admission record) indicated a start of care date of 10/25/2023, with a terminal diagnosis of heart failure, unspecified (a chronic condition in which the heart does not pump blood as well as it should). During a review of Patient 8s Physician Orders/Plan of care dated 10/25/2023, indicated the frequency of visits of skilled nurse (SN) to one visit per week and as needed for pain, symptom management and crisis intervention, and to monitor skin for areas of redness and wounds. During a joint home visit conducted on 12/20/2023 at 10:05 a.m. at Patient 8’s residence with the registered nurse (RN 1), Patient 8 was observed lying in a hospital bed with reddened skin at his coccyx and mid-back area. During a review of Patient 8s Nursing Clinical Note dated 11/4/2023, indicated Patient 8 developed Stage 1 pressure injury to coccyx area and mid-upper back. During a further review of Patient 8’s Plan of Care/ Interdisciplinary Team (IDT, a team responsible for the holistic care of the hospice beneficiary) Review form dated 11/7/2023, did not indicate a care plan was developed for the existing Stage 1 in the coccyx area and mid-back that was being treated for Patient 8. During a concurrent interview and record review, on 12/21/2023 at 12:25 p.m. with the Director of Patient Care Services Designee (DPCSD), the DPCSD stated the license nurses failed to develop a care plan pertaining to Patient 8’s Stage 1 coccyx and mid-back pressure injury. The DPCSD stated the agency should have developed the care plan after the discovery of the pressure ulcer wound. During a review of the agency’s policy and procedure titled, “The Plan of Care”, revised December 2018, indicated 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. The plan of care will be based on the initial, comprehensive, and ongoing assessments performed by members of the interdisciplinary group and will be reviewed on a regular basis. The plan will focus on identified problems, goals, and interventions.”

“Based on observation, interview, and record review, the hospice agency failed to provide drugs and treatment as ordered by the physician necessary for two of 14 sampled patients (Patient 1 and Patient 8). For Patient 1, the hospice agency failed to provide Dulcolax suppository as part of the comfort kit (a small amounts of medications that their caregivers can give them in case of urgent, distressing symptoms such as severe anxiety, agitation, delirium, nausea and more). For Patient 8, the hospice agency failed to provide wound care treatment as per physicians order. This deficient practice had the potential to cause discomfort when the medication not provided and delayed wound healing. Findings: During a review of Patient 8’s face sheet indicated a start of care date of 10/25/2023, with a terminal diagnosis of heart failure, unspecified (a chronic condition in which the heart does not pump blood as well as it should). During a review of Patient 8s Physician Orders/Plan of care dated 10/25/2023, indicated the frequency of visits of skilled nurse (SN) to one visit per week and as needed for pain, symptom management and crisis intervention, and to monitor skin for areas of redness and wounds. During a review of Patient 8s physician orders dated 11/16/2023, indicated to cleanse coccyx (a small triangular bone at the base of the spinal column) pressure ulcer stage 3 (a full-thickness loss of skin that extends to the subcutaneous [fat] tissue) with sterile wound cleanser, apply to wound bed collagen/hydrogel (gel that gently increases the moisture level within the wound, encouraging moist wound healing), cover or wrap with silicone dressing (foam wound dressing) every 2-3 days and prn spillage/moisture. It also indicated an order to cleanse mid back pressure ulcer stage 3 with sterile wound cleanser, apply to wound bed collagen/hydrogel, cover or wrap with composite dressing every 2-3 days and prn spillage/moisture. During a joint home visit conducted on 12/20/2023 at 10:05 a.m. at Patient 8’s residence with the registered nurse (RN 1), Patient 8 was observed lying in hospital bed, asleep but arousable. At 10:32 a.m., RN 1 washed her hands, wore gloves, removed the old dressing from the wound on the coccyx area and mid back. RN 1 cleansed the coccyx wound with normal saline, patted dry with dry gauze, applied vitamin A&D ointment (used as a moisturizer to treat or prevent dry, rough, scaly, itchy skin and minor skin irritations), and covered with a foam dressing. RN 1 also cleansed Patient 8s mid back wound with normal saline, patted dry, applied vitamin A&D ointment, and covered with foam dressing. During an interview with RN 1, she stated she used vitamin A&D ointment to patients wounds instead of collagen/hydrogel cream because wounds had greatly improved. RN 1 stated she should have communicated and clarified with the physician for current wound orders. During an interview on 12/21/2023 at 12:25 p.m. with the Director of Patient Care Services Designee (DPCSD), the DPCSD stated there was no current order to use vitamin A&D ointment on Patient 8s coccyx and mid back wounds, and the agencys nursing staff should have clarified with the physician if it was okay to use the ointment to patients wounds. The DPCSD stated the agency nursing staff should always follow physicians order and if the order was not clear, it should have been clarified. a. A review of Patient 1s face sheet indicated a start of care date (SOC) of 8/14/23 with diagnoses that included unspecified dementia (a condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems) and atherosclerotic heart disease (heart disease that is caused by the buildup of fats, cholesterol, and other substances in and on the artery walls). A review of Patient 1s physician orders, dated 8/14/23, indicated that Patient 1 had a Skilled Nurse (SN) visit once a week and as needed for pain, symptom management, and crisis intervention. During a joint home visit with the Director of Patient Care Services Designee (DPCSD) on 12/20/23 at 11:50 a.m., which was conducted via FaceTime, Patient 1 was observed lying in bed with his eyes closed. According to Family Member 1 (FM 1), Patient 1 was sleeping. A medication review with the DPCSD was completed during the home visit, at 12:20 p.m. During medication review, it was noted the following medications, which were listed in Patient 1s medication profile, were not available at Patient 1s home: - Zofran 4 mg oral tablet sublingual. - Milk of Magnesia 30 ml. - Hyoscyamine 0.125 mg sublingual. - Duoneb. - Dulcolax 10 mg suppository A review of Patient 1s “;Physician Order Details,” dated 8/14/23, indicated that the physician ordered comfort kit that contained Hyoscyamine 0.125 mg, Lorazepam concentrate 2 mg/1 ml, Morphine 20 mg/1 ml, Acetaminophen 650 mg suppository, Dulcolax 10 mg suppository, and Duoneb. During an interview with FM 1 on 12/20/23 at 12:20 p.m., FM 1 stated that Patient 1 never received Zofran 4 mg (anti-nausea medication), Duoneb (a medication to help open the airway in the lungs), and Hyoscyamine 0.125 mg (a medication that reduces the amount of sweat, saliva, and stomach acid). According to FM 1, Patient 1 ran out of Dulcolax 10 mg suppository (a medication for constipation); FM 1 was not sure when the medication ran out. FM 1 stated that Patient 1 was often constipated and that caused him to run out of the Dulcolax suppository. FM 1 also stated that she only received a few suppositories from the hospice agency. During an interview with the DPCSD on 12/20/23 at 12:45 p.m., the DPCSD stated that Zofran, Hyoscyamine, and Dulcolax were part of the comfort kit that the hospice agency provided. According to the DPCS, they usually provided 4 Dulcolax suppositories in the comfort kit. The When asked if there could be any negative outcome if the patient ran out of the comfort kit medications, the DPCS stated, “;There could be negative outcome if patient ran out of medication. In his case, he might have prolonged constipation without the Dulcolax. This patient lives far, the pharmacy is located in LA, which is more than 2 hours away. So even after the nurse orders the refill, it will take time to deliver it.” A review of the agency’s policy titled, “;Comfort Kit,” undated, indicated that comfort kits will be observed directly by the hospice nurse during visits to assure that the kit has not expired and is intact and available to use.”

“Based on interview and record review, the hospice agency (HA) failed to revise (update) the plan of care for integumentary/skin of one of 14 sampled patients (Patient 8), when there was a change in the staging of the patients pressure injury (injury to skin and underlying tissue resulting from prolonged pressure on the skin) from stage 1 (non-blanchable redness of a localized area) developed into stage 3 (a noticeable wound may go into your skins fatty layer). This deficient practice has the potential to negatively affect the provision of necessary care, treatment, and services for Patient 8. Findings: During a review of Patient 8’s face sheet indicated a start of care date of 10/25/2023, with a terminal diagnosis of heart failure, unspecified (a chronic condition in which the heart does not pump blood as well as it should), During a review of Patient 8s Physician Orders/Plan of care dated 10/25/2023, indicated the frequency of visits of skilled nurse (SN) to one visit per week and as needed for pain, symptom management and crisis intervention, and to monitor skin for areas of redness and wounds. During a review of Patient 8s Wound Care Worksheet and Physician Orders, dated 11/16/2023, indicated Patient 8s coccyx and mid-back area pressure injury changed from stage 1 to stage 3 pressure injury, and a new treatment order was provided by the physician. During a review of Patient 8’s Plan of Care/ Interdisciplinary Team (IDT, a team responsible for the holistic care of the hospice beneficiary) Review form, dated 11/21/2023, indicated the care plan was not revised to reflect Patient 8s coccyx and mid-back stage 1 pressure injury changed to a stage 3 pressure injury, and did not address specific treatment, goals, and other wound interventions for the current stage 3 pressure injury. During a concurrent interview and record review, on 12/21/2023 at 12:25 p.m. with the Director of Patient Care Services Designee (DPCSD), the DPCSD stated Patient 8s plan of care for integumentary/skin was not revised and agreed that Patient 8s care plan should have been updated to reflect a change of condition of the patients pressure injury. During a review of the agencys policy and procedure titled, “;The Plan of Care” revised December 2018, indicated a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The plan of care will be reviewed and revised as frequently as deemed necessary based on the ongoing comprehensive assessments of the patient and family/caregiver. Review of the plan of care will be documented in the clinical record.”