Sequoia Hospice East Bay

“Upon patient record review, 2 of 14 (Patient #1,9) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring #1-The medication profile dated 10/18/25 includes and order for polyethylene glycol 17gm oral powder packet daily. There are no orders for reconstitution. #9-The medication profile dated 02/21/25 includes an order for MiraLAX Powder 17gm oral powder packet daily. There are no orders for reconstitution.”

“Based on observation, interview, and record review, for 3 (Patients 4, 5 and 6) of 8 sampled patients, the Hospice Agency failed to meet the Condition of Participation for IDG, Care Planning and Coordination of Services when the Agency did not administer necessary medications needed for end-of-life symptoms, follow the established plans of care, notify the doctor for uncontrollable symptoms, ensure medications were available and educate caregivers on the use of hospice medications. Refer to deficiencies at L544, L549, L555 and L557. The cumulative severity and intensity of these deficiencies resulted in the failure of the agency to meet 418.56, IDG, Care Planning and Coordination of Services.”

“Based on interview and record reviews the hospice agencys licensed nursing staff did not provide the necessary care to manage end-of-life symptoms for 3 of 8 sampled patients (Patients 4, 5 and 6). Patients exhibited signs of difficulty breathing. This resulted in unnecessary respiratory distress. The following five changes constitute objective evidence of the end of life: diminished daily living performance, decreased food intake, changes to consciousness and increased sleep quantity, worsening of respiratory distress, and end-stage delirium.” [End-of-Life Assessments and Communication for Dying Patients and their Families; Journal of Hospital Palliative Care v. 24 (3) 2021 Sept 1. NIH: National Library of Medicine Record review of the document “;Care of the Dying Patient,” dated May 2023, showed “;Hospice interdisciplinary group members recognize the importance of each patient and family/caregivers unique and individual needs within the hospice setting. Within this framework, responsive and respectful care for the dying patient will be planned, implemented and monitored in order to: 1. Optimize the patients comfort and dignity 2. Manage pain and symptoms through interventions that alleviate and/or control pain and asses the patients level of pain control.” Record review of the document “;Hospice Certification and Plan of Care” showed Patient 4s start of care was 6/30/24 with the current certification period 6/30/2024 – 8/28/2024. Diagnoses included respiratory failure. Review of the goals showed “;Patients respiratory status will be stabilized to comfort.” Review of the medication list showed Morphine had been prescribed by the doctor. During an interview on 7/24/2024 at 9:40 a.m., the Director of Clinical Services (DCS) stated staff control end-of-life respiratory distress by administering morphine. There are different dosages available for each level of distress. Review of the document “;Visit Note Report,” dated 6/30/2024, showed Patient 4 had labored breathing and an oxygen saturation of 67% (normal range 95%-100%). Review of the document “;Visit Note Report,” dated 7/1/2024, showed Patient 4s saturation was 71% and she had “;dyspnea” (shortness of breath). There was no documentation in the clinical record which showed morphine had been administered. During an interview on 7/23/2024 at 10:47 a.m. with DCS, DCS confirmed morphine had not been administered. During an interview on 7/24/2024 at 1:30 p.m. with Registered Nurse 1 (RN 1), RN 1 stated she had not given the morphine. Record review of the document “;Hospice Certification and Plan of Care” showed Patient 5s Start of Care was 5/10/2024 with the current certification period 5/10/2024 to 8/7/2024. Diagnoses included cerebral infarction (stroke). Goals included “;Patients respiratory status will be stabilized to comfort as possible.” The medication list included morphine. Record review of the document “;Visit Note Report,” dated 5/10/2024, showed Patient 5 had “;abnormal breath sounds.” Review of the “;Visit Note,” dated 5/11/2024, showed respirations were “;shallow.” Current respiratory status was described as “;No change since last visit.” The narrative visit note showed Patient 5s respirations were “;labored.” There was no documentation which showed morphine had been administered to ease the labored breathing. During an interview on 7/23/2024 at 10:47 a.m. with DCS, DCS confirmed there was no documentation in the clinical record which showed the morphine had been administered. During an interview on 7/24/2024 at 1:30 p.m. with RN 1, RN 1 stated she had not given the morphine. Record review of the document “;Hospice Certification and Plan of Care” showed Patient 6s start of care was 7/15/2024 with the current certification period 7/15/2024 – 10/12/2024. Diagnoses included respiratory failure. Goals included “;Patients respiratory status will be stabilized to comfort as possible.” Record review of the document “;Pharmacy Dispensing Occurrence Report,” dated 7/25/2024, showed morphine had been ordered for Patient 6 on 7/15/2024. Record review of the document “;Visit Note Report,” dated 7/15/2024, showed Patient 6s respirations were “;shallow” and he was short of breath. Review of the “;Visit Note,” dated 7/19/2024, showed Patient 6 had been using his “;accessory muscles” (when muscles other than the diaphragm are used for breathing) while breathing with rapid respirations. Saturations were between 78%-97%. (use of accessory muscles indicated a struggle to breath). There was no documentation in the clinical record which showed the morphine had been administered. During an interview on 7/23/2024 at 10:47 a.m. with DCS, DCS confirmed there was no documentation which showed morphine had been administered. DCS stated “;This patient was struggling.” DCS stated she would have expected staff to “;stabilize” the patient. Record review of the document “;Visit Note Report,” dated 7/20/2024, showed Patient 6s respiratory status was described as “;No change from last visit.” The previous visit on 7/19/2024 showed Patient 6 had been using his accessory muscles to breath. During a concurrent interview on 7/24/2024 at 1:41 p.m. with Licensed Vocational Nurse 1 (LVN 1), LVN 1 was asked how she had addressed the difficulty breathing. LVN 1 stated she repositioned Patient 6 but should have given him morphine since that would have helped to “;slow the breathing.” LVN 1 stated the use of accessory muscles indicated difficulty breathing.”

“Based on observation, interview, and record review, the Hospice Agency (HA) did not ensure caregivers for one of eight sampled patients (Patient 6) were educated on symptom management to provide comfort at end-of-life. This failure resulted in Patient 6s unnecessary suffering from respiratory distress (condition manifested by rapid breathing, shortness of breath, wheezing, or a feeling of tightness in the chest) at end-of-life. Based on observation, interview, and record review, the Hospice Agency (HA) did not ensure caregivers for one of eight sampled patients (Patient 6) were educated on symptom management to provide comfort at end-of-life. This failure resulted in Patient 6s unnecessary suffering from respiratory distress (condition manifested by rapid breathing, shortness of breath, wheezing, or a feeling of tightness in the chest) at end-of-life. A review of Patient 6s “;Hospice Certification and Plan of Care” for certification period 7/15/24 to 10/12/24, indicated Patient 6 had a Start of Care (SOC) with HA on 7/15/24 with multiple diagnoses including chronic obstructive pulmonary disease (COPD, refers to a group of diseases that cause airflow blockage and breathing-related problems. It includes emphysema and chronic bronchitis.) and aspiration pneumonia (lung infection that occurs when food, liquid, or vomit is inhaled into the lungs). The “;Hospice Certification and Plan of Care” also indicated “;Instruct caregiver on comfort measures.” A review of Patient 6s “;Visit Note Report,” from 7/15/24 to 7/22/24, indicated licensed nurses visited Patient 6 five times and had communications with Patient 6s caregivers. During a home visit observation on 7/24/24 at 11:00 a.m. in Patient 6s room at a residential facility, Patient 6 was lying in bed in a semi-fowlers (head of bed elevated at an angle of 30-45 degrees) position, flushed face, dozing off, and non-verbal. Patient 6 was breathing fast through his mouth in room air and visible rise of shoulder and chest during deep inhalation (breathing in). Patient 6 was also observed with a respiratory rate (RR-number of breaths a person takes per minute) of 30 (normal 12-20) breaths/minute. During an interview on 7/24/24 at 11:15 a.m. with Director of Support Professionals of the residential facility (DSP), DSP stated he was aware that Patient 6 was on hospice and his breathing had improved from three days ago. DSP stated he did not know what symptoms to watch for and when call to HA. DSP also stated he was not trained to give medications to Patient 6. During an interview on 7/24/24 at 11:43 a.m. with residential facilitys caregiver (CG), CG stated he had limited experience in providing care to a hospice patient. CG stated he would call hospice agency for elevated body temperature and no bowel movement for three days. CG further stated he did not received training from HA on management of end-of-life symptoms and what medications to give. During an interview on 7/24/24 at 12:30 p.m. with Registered Nurse (RN) 1, RN 1 stated she did not provide detailed instructions on symptom management such as what and when comfort care medications can be use. During an interview on 7/25/24 at 10:00 a.m. with DCS, DCS stated that hospice symptom management education and training for care givers was an ongoing process and licensed nurses should teach caregivers every visit to ensure Patient 6s comfort. During a review of agencys policy and procedure (P&P) titled “;Patient Education Process,” dated May 2023, the P&P indicated, “;To provide guidelines for giving specific instruction and information to patients and family/caregivers regarding hospice services...Education will be the responsibility of each interdisciplinary group member and will focus on, as appropriate: 3.Increasing patient and family/caregiver potential to follow the plan of care...10.Pain and symptom management.””

“Based on observation, interview, and record review, the Hospice Agency (HA) failed to manage symptoms related to terminal illness for one of eight sampled patients (Patient 6) in a timely manner, when hospice comfort kit (contains medicines that can help relieve common end-of-life symptoms) was not available. This failure resulted in Patient 6s unnecessary suffering from respiratory distress (condition manifested by rapid breathing, shortness of breath, wheezing, or a feeling of tightness in the chest) at end-of-life. “;End-of-life care is the term used to describe the support and medical care given during the time surrounding death. This type of care does not happen only in the moments before breathing ceases and the heart stops beating. Older people often live with one or more chronic illness and need significant care for days, weeks, and even months before death. Breathing problems, shortness of breath, or the feeling that breathing is difficult is a common experience at the end of life.” [Providing Care and Comfort at the End of Life | National Institute on Aging (nih.gov)] A review of Patient 6s “;Hospice Certification and Plan of Care” for certification period 7/15/24 to 10/12/24, indicated Patient 6 had a Start of Care (SOC) with HA on 7/15/24 with multiple diagnoses including chronic obstructive pulmonary disease (COPD, refers to a group of diseases that cause airflow blockage and breathing-related problems. It includes emphysema and chronic bronchitis.) and aspiration pneumonia (lung infection that occurs when food, liquid, or vomit inhaled into the lungs). The “;Hospice Certification and Plan of Care” also indicated “;Patients Respiratory status will be stabilized to comfort as possible.” A review of Patient 6s “;Visit Note Report,” dated 7/15/24, indicated on respiratory status assessment Patient 6 had a shortness of breath and abnormal breath sounds. The note indicated an intervention of oxygen and other medication was initiated for shortness of breath (SOB). Further review of the note did not indicate what medication was administered and effectiveness of oxygen was not assessed. A review of Patient 6s “;Client Coordination Note Report...Admission Narrative,” dated 7/16/24, indicated comfort kit was ordered. A review of Patient 6s “;Visit Note Report,” dated 7/19/24, indicated Patient 6 experienced breathing problems manifested by use of accessory muscles to breath and fast and shallow respirations with a respiratory rate (RR-number of breaths a person takes per minute) of 38 (normal 12-20 breaths per minute). Patient 6 had rhonchi (an abnormal lung sounds caused by obstruction or narrowing of airways of the lungs). Patient 6 received continuous oxygen to manage symptom but no indication of relief. Further review of the visit note did not indicate other measures of giving medication to relieve the symptom. The note also indicated Patient 6 was placed on a daily visit because of declining status. A review of Patient 6s “;Visit Note Reports,” dated 7/22/24 and 7/23/24, indicated Patient 6 again experienced respiratory distress manifested by increased RR of 32-34, breathing fast and shallow. Patient 6 received oxygen to manage symptom, but no indication of relief and no medication was administered. During an interview on 7/23/24 at 1:43 p.m. with Director of Clinical Services (DCS) in HAs office, DCS stated Patient 6 was on a daily visit due to actively dying status and was scheduled for a home visit on 7/24/24 in the morning by RN 1. During a home visit observation on 7/24/24 at 11:00 a.m. in Patient 6s room at a residential facility, Patient 6 was lying in bed in a semi-fowlers (head of bed elevated at an angle of 30-45 degrees) position, flushed face, dozing off and non-verbal. Patient 6 was breathing fast through his mouth on room air with visible rise of shoulder and chest during deep inhalation (breathing in). Patient 6 was also observed with a RR of 30 breaths/minute. During a concurrent interview and record review on 7/24/24 at 11:05 a.m. with residential facilitys Direct Support Professional (DSP), facilitys electronic “;Medication Administration Record (MAR),” from 7/23/24 until 7/24/24 for Patient 6 was reviewed. DSP stated Patient 6 received nebulizer treatment for SOB last night and no other medication was administered. Further review of Patient 6s “;MAR,” from 7/15/24 until 7/22/24, indicated Patient 6 had been experiencing SOB and wheezing on the following dates 7/15/24, 7/18/24, 7/19/24 and 7/21/24. Patient 6 received nebulizer treatments on those dates. There was no indication of symptom relief, and no indication other medications were given. During a concurrent observation and interview on 7/24/24 at 11:23 a.m. with Registered Nurse (RN) 1 in Patient 6s room, RN 1 assessed Patient 6. RN 1 stated Patient 6 was in distress because of SOB, fast breathing, and fast heartrate. RN 1 further stated she needed to administer morphine sulfate (strong drug commonly use in hospice to manage serious pain and to ease feelings of SOB) to Patient 6. RN 1 asked DSP to bring the comfort medications kit, however, DSP was unable to find the kit. During an observation on 7/24/24 at 11:43 a.m. facility caregiver (CG) walked-in Patient 6s room. RN 1 asked CG for the comfort kit. RN 1 described the comfort kit that it contained morphine, lorazepam, and other medications, and was in white bag. CG informed RN 1 that facility did not receive delivery of the comfort kit. RN 1 made a phone call to her DCS and requested for comfort kit to be reordered and delivered as soon as possible. During an interview on 7/24/24 at 12:07 p.m. with CG, CG stated Patient 6 had been experiencing SOB the past two weeks and had received nebulizer treatments, but no other medications were given to manage SOB. During an interview on 7/24/24 at 12:23 p.m. with RN 1, RN 1 stated she was unable to administer morphine sulfate to Patient 6 because comfort kit cannot be found. RN 1 stated Patient 6 should receive morphine sulfate on time to make sure he was as comfortable as possible and not to let him suffer per his plan of care. RN 1 stated on 7/19/24, Patient 6 experienced similar symptoms of SOB and RR of 30-36 bpm. RN 1 stated she should have given morphine sulfate, but she did not. RN 1 stated that she just found out the comfort medications were not available in the facility, however, it was confirmed by the DCS from HA office it was delivered. During a telephone interview on 7/24/24 at 4:30 p.m. with Administrator of Residential Facility (ARF), ARF stated there were no comfort medications delivered to the facility after Patient 6s admission on 7/15/24. During an interview on 7/25/24 at 9:15 a.m. with DCS, DCS stated licensed nurses should manage symptoms of SOB and using accessory muscles to breath with medication interventions of giving morphine sulfate. DCS also stated that RN 1 called her on 7/24/24 and was informed that Patient 6s comfort kit was not in the facility. DCS stated she and Executive Director (ED) were still investigating on the missing comfort kit. During an interview on 7/25/24 at 9:45 a.m. with DCS and Executive Director (ED), DCS stated she ordered and requested for the delivery of comfort kit medications from their contracted pharmacy on 7/15/23 at 5:33 p.m. because Patient 6 needed it. DCS was unable to provide the detailed delivery confirmation of the comfort kit. ED stated HA would provide a copy of confirmation when available. During an interview on 7/25/24 at 11:23 a.m. with ED, ED stated the comfort kit that was ordered on 7/15/24 was not delivered to Patient 6. During a review of agencys document titled “;Pharmacy Dispensing Occurrence Report,” dated 7/25/24, the report indicated comfort medications kit ordered on 7/15/24 was not delivered. During a review of agencys policy and procedure (P&P) titled “Medication Profile,” dated May 2023, the P&P indicated, “;To define the use of the medication profile in evaluating a patients medication regimen...2. A drug regimen review will be perform by a registered nurse, the review will identify: A. effectiveness... K. the need for pharmacological or non-pharmacological interventions for pain and other symptom management as applicable to the patient.” During a review of agencys policy and procedure (P&P) titled “;Care of the Dying Patient,” dated May 2023, the P&P indicated, “;Hospice interdisciplinary group members recognize the importance of each patient and family/caregivers unique and individual needs within the hospice setting. Within this framework, responsive and respectful care for the dying patient will be implemented, and monitored in order to: optimize patients comfort and dignity...identify secondary symptoms, determine patients response to treatment and take actions to limit them...D. Prompt identification and treatment-if possible and ordered by the physician-of secondary symptoms if they should occur...E. Monitoring of the response of secondary symptoms to treatment...3.With each patient visit, the hospice nurse will follow the plan of care and assess the need for changes/updates, and will document accordingly.””

“Based on interview and record reviews, the hospice agencys licensed nursing staff did not provide care according to the plan of care for three of eight sampled patients (Patients 4, 5 and 6). Patients exhibited signs of respiratory distress which were not treated. This resulted in unnecessary distress at the end of life. Review of the document “;Coordination of Care with Contracts/Agreement,” dated May 2023, showed “;All care provided will be in accordance with the hospice plan of care and documented in the clinical record.” Record review of the document “;Hospice Certification and Plan of Care” showed Patient 4s start of care was 6/30/24 with the current certification period 6/30/2024 through 8/28/2024. Diagnoses included respiratory failure. Review of the goals showed “;Patients respiratory status will be stabilized to comfort.” During an interview on 7/24/2024 at 9:40 a.m. with Director of Clinical Services (DCS), DCS stated staff control end-of-life respiratory distress by administering morphine. There are different dosages available for each level of distress. Review of the document “;Visit Note Report,” dated 6/30/2024, showed Patient 4 had labored breathing and an oxygen saturation of 67% (normal range 95%-100%). Review of the document “;Visit Note Report,” dated 7/1/2024, showed Patient 4s saturation was 71%, and she had “;dyspnea” (shortness of breath). There was no documentation in the clinical record which showed what had been done to alleviate the respiratory distress. During an interview on 7/24/2024 at 10:47 a.m. with DCS confirmed there was no documentation which showed what was done and if the labored breathing improved. DCS stated it was important to intervene and document so the effectiveness could be assessed. During an interview on 7/24/2024 at 1:30 p.m. with Registered Nurse 1 (RN 1), RN 1 stated she could not recall what interventions she had provided for Patient 4 and if they had helped. Record review of the document “;Hospice Certification and Plan of Care” showed Patient 5s Start of Care was 5/10/2024 with the current certification period 5/10/2024 through 8/7/2024. Diagnoses included cerebral infarction (stroke). Goals included “;Patients respiratory status will be stabilized to comfort as possible.” Record review of the document “;Visit Note Report,” dated 5/10/2024 showed Patient 5 had “;abnormal breath sounds.” Review of the visit note dated 5/11/2024 showed respirations were “;shallow.” Current respiratory status was described as “;No change since last visit.” The narrative visit note showed Patient 5s respirations were “;labored.” There was no documentation which showed what steps had been taken to address the labored breathing. During an interview on 7/23/2024 at 10:47 a.m. with DCS, DCS confirmed there was no documentation in the clinical record which showed what was done to address the labored breathing and if it was effective. During an interview on 7/24/2024 at 1:30 p.m. with RN 1, RN 1 stated she could not recall what she had done to address the labored breathing or if it had been effective. Record review of the document “;Hospice Certification and Plan of Care” showed Patient 6s start of care was 7/15/2024 with the current certification period 7/15/2024 through 10/12/2024. Diagnoses included respiratory failure. Goals included “;Patients respiratory status will be stabilized to comfort as possible.” Record review of the document “;Visit Note Report,” dated 7/15/2024, showed Patient 6s respirations were “;shallow”, and he was short of breath. Review of the visit note, dated 7/19/2024, showed Patient 6 had been using his “;accessory muscles” (muscles other than the diaphragm are used for breathing) while breathing with rapid respirations. Saturations were between 78%-97%. There was no documentation in the clinical record which showed what had been done to address the difficulty breathing. In a concurrent interview and chart review, the DCS confirmed there was no documentation which showed how the difficulty breathing was addressed. She stated, “;This patient was struggling” and she would expect staff to “;stabilize” the patient. Record review of the document “;Visit Note Report,” dated 7/20/2024, showed Patient 6s respiratory status was described as “;No change from last visit.” The previous visit on 7/19/2024 showed Patient 6 had been using his accessory muscles to breath. In a concurrent interview on 7/24/2024 at 1:41 p.m. with Licensed Vocational Nurse 1 (LVN 1), LVN 1 was asked how she had addressed the difficulty breathing. LVN 1 stated she repositioned Patient 6 but should have given him morphine since that would have helped him to “;slow the breathing.” LVN 1 stated the use of accessory muscles indicated difficulty breathing.”

“Based on interview and record reviews, the hospice agencys licensed nursing staff did not notify the doctor for a change in condition for three of eight sampled patients (Patients 4, 5 and 6). Patients exhibited signs of respiratory distress during repeated visits. This resulted in unnecessary distress and inability to re-evaluate the plan of care. Record review of the document “;Monitoring Patients Response/Reporting to Physician,” dated May 2023, showed “;Clinicians will monitor, document, and report the patients response to care and treatment provided on each hospice visit. Progress of goals will be measured at regular intervals. Clinicians will establish and maintain ongoing communication with the patients physician and the hospice Medical Director to ensure safe and appropriate care for the patient.” Record review of the document “;Hospice Certification and Plan of Care” showed Patient 4s start of care was 6/30/24 with the current certification period 6/30/2024 through 8/28/2024. Diagnoses included respiratory failure. Review of the goals showed “;Patients respiratory status will be stabilized to comfort.” Review of the document “;Visit Note Report,” dated 6/30/2024, showed Patient 4 had labored breathing and an oxygen saturation of 67% (normal range 95% -100%). Review of the document “;Visit Note Report,” dated 7/1/2024 showed Patient 4s saturation was 71%, and she had “;dyspnea” (shortness of breath). There was no documentation in the clinical record which showed the doctor had been notified. Record review of the document “;Hospice Certification and Plan of Care” showed Patient 5s Start of Care was 5/10/2024 with the current certification period 5/10/2024 through 8/7/2024. Diagnoses included cerebral infarction (stroke). Goals included “;Patients respiratory status will be stabilized to comfort as possible.” Record review of the document “;Visit Note Report,” dated 5/10/2024, showed Patient 5 had “;Abnormal breath sounds.” Review of the visit note, dated 5/11/2024, showed respirations were “;shallow.” Current respiratory status was described as “;No change since last visit.” The narrative visit note showed Patient 5s respirations were “;labored.” There was no documentation which showed the doctor had been notified. During an interview on 7/24/2024 at 1:30 p.m. with Registered Nurse 1 (RN 1), RN 1 stated she had not notified the doctor in regard to the continued labored breathing. Record review of the document “;Hospice Certification and Plan of Care” showed Patient 6s start of care was 7/15/2024 with the current certification period 7/15/2024 through 10/12/2024. Diagnoses included respiratory failure. Goals included “;Patients respiratory status will be stabilized to comfort as possible.” Record review of the document “;Visit Note Report,” dated 7/15/2024, showed Patient 6s respirations were “;shallow”, and he was short of breath. Review of the visit note, dated 7/19/2024, showed Patient 6 had been using his “;accessory muscles” (using muscles other than the diaphragm to breathe) while breathing with rapid respirations. Saturations were between 78%-97%. There was no documentation in the clinical record which showed the doctor had been notified. Record review of the document “;Visit Note Report,” dated 7/20/2024, showed Patient 6s respiratory status was described as “;No change from last visit.” The previous visit on 7/19/2024 showed Patient 6 had been using his accessory muscles to breath. In a concurrent interview on 7/24/2024 at 1:41 p.m. with Licensed Vocational Nurse 1 (LVN 1), LVN1 was asked how she had addressed the difficulty breathing. LVN 1 stated the use of accessory muscles indicated difficulty breathing and she had not called the doctor. During an interview on 7/23/2024 at 10:47 a.m. with Director of Clinical Services (DCS), DCS stated when respiratory distress persists the doctor should be notified so the plan of care can be re-evaluated.”