Hospice of Health First Inc.

“Based on observation, interview, and record review, the hospice agency failed to effectively manage chronic pain and intervene promptly to alleviate moderate pain that interfered with the quality of life for 1 of 6 patients reviewed for pain management, out of a total sample of 28 patients, (#14). Findings: Review of the medical record revealed patient #14, a 99-year-old female, was admitted to the hospice agency on 3/15/21 with a terminal diagnosis of liver cancer. Her secondary diagnoses included left kidney cancer, cardiovascular disease, and pain. Patient #14 became a resident of a skilled nursing facility (SNF) on 11/07/23, where she continued to receive services from the hospice agency. Review of a Registered Nurse (RN) Recertification document dated 12/12/23 revealed patient #14s secondary diagnoses, including pain, were related to her terminal diagnosis. The Pain Assessment indicated she exhibited a non-verbal pain indicator, “;rubbing (massaging affected area).” The primary site of pain was patient #14s left knee. The document revealed the pain was increased by movement, relieved by rest and Lidocaine cream, and interfered with her quality of life. She described the pain as intermittent, aching, dull, and nagging. Patient #14 set her target pain goal at level 4 a 0 to 10 scale and she determined a pain level of 5 warranted further attention. The document read, “;Patient reports intermittent pain to left knee, reports utilizing lidocaine cream [as needed] with positive effect. Unable to report how many times it was utilized over the past week.” The Nurse Case Manager, RN M, noted patient #14 required considerable assistance with activities and frequent medical care and was alert, forgetful, and confused in new or complex situations. The Summary/Comments section read, “;Patient continues to complain of pain to her left knee when walking and standing, more painful in the mornings.” Lidocaine is a topical anesthetic or numbing medication that is used to stop pain (retrieved on 2/17/24 from www.drugs.com/mtm/lidocaine-topical.html). Review of the Plan of Care Order dated 12/20/23 included a summary of patient #14s interdisciplinary group (IDG) findings and interventions since admission to hospice services. The IDG meeting notes indicated on 10/25/23 she had left knee pain, which was treated with Lidocaine cream, and on 12/20/23 the note showed she had swelling in both legs which made application of her left knee brace difficult. The document revealed patient #14 received a minimum of once weekly skilled nursing services for symptom management and medication changes. The Plan of Care Order included a care plan for Pain, initiated on 7/20/22, with interventions to assess and monitor her pain level, administer pain medications as ordered, evaluate effectiveness of pain medication, and educate the patient and/or caregivers on pain medication regimen. The goal read, “;Patient verbalizes acceptable level of pain relief at 3/10 or less and ability to engage in desired activities.” Review of the hospice agencys Medication Profile for patient #14 revealed a physician order dated 5/01/23 for Lidocaine External Cream 4%. The topical cream was to be applied to the affected area twice daily. There was a physician order dated 5/23/23 for Tylenol 325 milligrams, give two tablets three times daily as needed for pain. Review of the Aide Care Plan dated 1/22/24 revealed RN M noted the patient had functional limitations related to ambulation and endurance and could be up as tolerated with a walker. On 2/12/24 at 2:43 PM, RN M arrived at the SNF to complete patient #14s weekly visit. She stopped at the nurses station, spoke to the patients assigned nurse, and requested a copy of the facilitys current medication orders. RN M received report on the patients general status which did not include any negative findings. On 2/12/24 at 2:49 PM, patient #14 was seated on the bench seat of her rolling walker in a common area. She was pleasant and alert and both her lower legs were swollen. She wore a black knee sleeve which covered the area from her left ankle to below her knee. Patient #14 agreed to RN Ms request to return to her room for the nursing assessment, but she asked RN M to push her to the room while she remained seated on the rolling walker due to pain in her legs when she walked. On 2/12/24 at 2:52 PM, RN M completed a comprehensive physical assessment with patient #14 seated on her walker. The patient rubbed her noticeably swollen left knee, and in response to RN Ms question, she rated her pain level as 5/10. RN M asked patient #14 if she asked for pain medication and she said, “;Never.” RN M did not ask the patient if she wanted to have pain medication to relieve her current level 5 pain. RN M confirmed the hospice medication profile included a physician order for Lidocaine which was to be applied twice daily. Patient #14 stated neither she nor the nurses applied medicated ointment to her left knee. RN M checked the patients bedside table drawer and confirmed the topical cream was not there. On 2/12/24 at 3:05 PM, patient #14 stated her knee pain bothered her especially in the morning when she started moving around, and then in the afternoon after she had been up for a while. She explained she usually forgot to ask for pain medication. Patient #14 said, “;I would like it to hurt less so I can walk around more. I have to stop and sit when it gets too painful to walk.” On 2/12/24 at 3:40 PM, the assigned day shift facility nurse confirmed she gave patient #14 all her scheduled medications but did not apply any creams or ointments to her knees during the shift. On 2/12/24 at 3:49 PM, the assigned evening shift facility nurse checked patient #14s medical record and informed RN M there was no physician order for Lidocaine to treat the patients knee pain. On 2/12/24 at 3:55 PM, the facilitys West Wing Unit Manager (UM) researched patient #14s SNF order history and discovered Lidocaine cream had never been ordered for the patient. RN M confirmed there was an active order dated of 5/01/23 for the medication on the hospice medication list. She said, “;I definitely think it would help with her left knee pain. I thought she was using it twice a day.” RN M was asked if it was possible to obtain an order for scheduled pain medication such as Tylenol since patient #14 forgot to ask for it. RN M explained patient #14 might not accept scheduled pain medication as she had challenges in the past with this patient and medications. She verified she could contact the hospice physician for orders at any time; however she provided the facilitys UM with a written order for Lidocaine and closed out her nursing visit without initiating an immediate intervention to address patient #14s pain. On 2/12/24 at 4:19 PM, after the visit was completed, RN M stated she visited patient #14 weekly over the past two to three months. She explained the patients left knee pain was unchanged during that period and acknowledged the pain affected her quality of life as it made it hard for her to get around. RN M acknowledged she had never checked to see if the Lidocaine was at the patients bedside or verified that the patient or facilitys nurses administered the drug as ordered. RN M validated a pain level of 5 was something she should have addressed with an immediate intervention while in the facility. She said, “;We usually shoot for 4 or below. I would hope the Lidocaine will be effective in decreasing her pain.” On 2/12/24 at 4:47 PM, the Hospice Quality Manager was informed patient #14 reported her pain level as 5/10 during the visit with RN M. She explained each patient was different and interventions would be based on the acceptable level of pain as determined by the patient. On 2/13/24 at 1:12 PM, the Director of Patient Care Services stated her expectation was nurses would assess pain levels and follow up appropriately. She was informed patient #14s care plan for pain indicated her pain goal was a level 3/10 but her pain level at the time of the visit was 5/10. The Director of Patient Care Services validated RN M should have verified the patients goal related to acceptable pain level and addressed her discomfort as a priority at that time. Review of the hospice agencys website revealed the organization prioritized comfort and quality of life through management of common symptoms such as chronic or acute pain (retrieved on 2/17/24 from www.hf.org/healthcare-home/departments-services/hospice/hospice-services#hospice-care-comes-to-you).”

“Based on interview and record review, the hospice agency failed to appropriately monitor the administration of pain medication and evaluate the effectiveness of pharmacological interventions to ensure the coordination and provision of necessary care and services for 1 of 1 patient who resided in a skilled nursing facility (SNF), out of a total sample of 28 patients, (#14). Findings: Review of the medical record revealed patient #14, a 99-year-old female, was admitted to the hospice agency on 3/15/21 with a terminal diagnosis of liver cancer. Her secondary diagnoses included left kidney cancer, cardiovascular disease, and pain. Patient #14 became a resident of a SNF on 11/07/23, where she continued to receive services from the hospice agency. Review of a Registered Nurse (RN) Recertification document dated 12/12/23 revealed patient #14s secondary diagnoses, including pain, were related to her terminal diagnosis. The Pain Assessment indicated the primary site of pain was patient #14s left knee. The document revealed the pain was increased by movement, relieved by rest and Lidocaine cream, and interfered with her quality of life. She described the pain as intermittent, aching, dull, and nagging. Patient #14 set her target pain goal at level 4 a 0 to 10 scale and she determined a pain level of 5 warranted further attention. The document read, “;Patient reports intermittent pain to left knee, reports utilizing lidocaine cream [as needed] with positive effect. Unable to report how many times it was utilized over the past week.” The Nurse Case Manager, RN M, noted patient #14 required considerable assistance with activities and frequent medical care and was alert, forgetful, and confused in new or complex situations. The Summary/Comments section read, “;Patient continues to complain of pain to her left knee when walking and standing, more painful in the mornings.” Lidocaine is a topical anesthetic or numbing medication that is used to stop pain (retrieved on 2/17/24 from www.drugs.com/mtm/lidocaine-topical.html). Review of the Plan of Care Order dated 12/20/23 included a care plan for Pain, initiated on 7/20/22, with interventions to assess and monitor her pain level, administer pain medications as ordered, evaluate effectiveness of pain medication, and educate the patient and/or caregivers on pain medication regimen. On 2/12/24 at 2:43 PM, RN M arrived at the SNF to complete patient #14s weekly visit. She stopped at the nurses station, spoke to the patients assigned nurse, and obtained a copy of the facilitys current medication orders. RN M did not request or review the facilitys pain monitoring and medication administration records with the facility nurse to determine if the patient had pain issues on any shift and received pain medication as ordered since the last skilled nursing visit. On 2/12/24 at 2:52 PM, during a comprehensive physical assessment, patient #14 informed RN M her pain level was a level 5. RN M asked patient #14 if she ever asked for pain medication and she said, “;Never.” She confirmed the hospice medication profile included a physician order for Lidocaine which was to be applied twice daily. Patient #14 stated neither she nor the nurses applied medicated ointment to her left knee. RN M checked the patients bedside table drawer and confirmed the Lidocaine cream was not there. However, she discovered four bottles of over-the-counter medication and an unused bottle of a topical menthol pain-reliever. On 2/12/24 at 3:49 PM, the assigned evening shift facility nurse checked patient #14s medical record and informed RN M there was no physician order for Lidocaine to treat the patients knee pain. On 2/12/24 at 3:55 PM, the facilitys West Wing Unit Manager (UM) researched patient #14s SNF order history and discovered Lidocaine cream had never been ordered for the patient. RN M confirmed she had an active order dated of 5/01/23 for the medication the hospice medication list. She said, “;I definitely think it would help with her left knee pain. I thought she was using it twice a day.” RN M explained the hospice order indicated patient #14 could keep the Lidocaine at her bedside, but the UM informed her the facility still required a physician order. RN M provided the UM with written orders for all the over-the counter medication found at the patients bedside and added the Lidocaine order as written on the hospice medication list. The UM stated she retrieved the bottles from patient #14s room, with her permission. She explained the patient was visually impaired and occasionally forgetful, so it was preferable for facility to administer all medication to ensure safety and accuracy. Review of active, discontinued, and completed physician orders on the SNF Order Summary Report dated 2/12/24 revealed no order for Lidocaine External Cream 4%, apply to affected area twice daily, as noted on the hospice medication list in the Plan of Care Order dated 12/20/23. Review of patient #14s medical record revealed after the RN Recertification visit by RN M on 12/12/23, she was assessed by nurses on 12/18/23, 12/25/23, 1/05/24, 1/08/24, 1/15/24, 1/22/24, 2/02/24, and 2/05/24. The notes included documentation of Lidocaine cream as an effective pain management intervention for the patients left knee pain, but there was no evidence any of the nurses reconciled the hospice medication list with the SNF medication list or validated the drug was at the bedside as noted in the hospice plan of care. On 2/12/24 at 4:19 PM, RN M stated she visited patient #14 weekly over the past two to three months. She explained she had never seen any medication in the patients room prior to todays visit. RN M stated she usually asked the facility nurse for a medication list at weekly visits to reconcile the orders, but never noticed that Lidocaine cream was not listed. She explained the oversight possibly occurred as the hospice order indicated the patient could keep the drug in her room. She acknowledged she never checked to ensure the Lidocaine was at the patients bedside or administered by facility nurses. RN M stated she was not aware patients in SNFs needed to be assessed for ability to self-administer medications in order to keep them at bedside. On 2/12/24 at 4:47 PM, the Hospice Quality Manager was informed of concerns related to a hospice physician order for Lidocaine cream for patient #14 that was missing from the SNFs medication list. She stated medication lists were to be reconciled with recertification and when new orders were obtained. The Hospice Quality Manager stated she was not certain if there was a written policy or process for medication reconciliation, but she felt best practice would be weekly reconciliation by the RN Case Manager, or at least every two weeks after the interdisciplinary group meetings. On 2/13/24 at 1:12 PM, the Director of Patient Care Services stated she expected nurses to complete medication reconciliation during every routine skilled nursing visit. She confirmed the task was very important in SNFs as medication changes could occur between visits by the hospice nurses. The Director of Patient Care Services explained in the SNF setting, there were usually an attending physician, Physician Assistants, Advanced Practice Registered Nurses, and floor nurses from staffing agencies who might initiate or obtain orders and not notify the hospice agency. She verified medication reconciliation was important to prevent medication contraindications or repeat orders. The Director of Patient Care Services validated patients medical records were communication tools and both the hospice and SNF medication lists should be accurate and reflect the same information. She stated all nurses should be aware that every medication needed a physician order, especially in a SNF, even if it was kept at the bedside. Review of the hospice agencys “;Medication Reconciliation Process” (undated) read, “;Complete medication reconciliation should be completed at each routine visit, recertification visit, and prior to any change in location. . .” Review of the hospice agencys Medication Reconciliation Procedure (undated) revealed medication reconciliation was to be done weekly with Skilled Nursing Visits, on Admission, Recertification, and when medication changes were made. The Hospice Services Agreement between the hospice agency and patient #14s SNF, dated 11/01/18, revealed the hospice RN Case Manager was responsible for coordination of service to include provision of medication information specific to each patient.”

“Based on record review and interview it was found that the facility failed to maintain the fire alarm system as per NFPA 101. This failure could result in endangerment to the patients, staff, and other building occupants. During record review with the Maintenance Director and the Systems Director of facilities on 2/5/24 at 9:45a.m., the facility failed to provide evidence of the smoke detectors and the duct detectors biennial sensitivity testing being conducted. There was no documentation of when the last testing of the detectors was done. An interview was conducted with the Systems Director of Facilities, and he stated that after calling the fire alarm vendor that the testing had not been done and acknowledged the finding. NFPA 101(2012 Edition) 19.3.4.4, 9.6.5.1 NFPA 72 (2010 Edition) 14.4.5.3.2”