Adventhealth Hospice Care Central Florida

“Based on record review and staff interview, the facility failed to maintain the fire alarm system in accordance with National Fire Protection Association (NFPA) 101. Maintaining the fire alarm system ensures proper operation and lessens the chance of delayed alarm activation or failure under hazardous conditions which could affect 16 of 16 patients. Findings: On 6/09/26 between 8:10 AM and 9:00 AM, a request was made when reviewing records, to review the biannual smoke detector sensitivity test. During this time period the facility was unable to produce any records regarding the biannual smoke detector sensitivity test. An interview was conducted with the Director of Maintenance who advised that he was unaware of the testing requirements. The Director of Maintenance was present when the deficiency was identified. NFPA 101 (2012 Edition) 4.6.12.1NFPA 72 (2010 Edition) 14.4.5.3.2”

“Based on interview and record review, the hospice agency failed to promote the right to peace, comfort, and dignity at the end of life by ensuring life-sustaining measures were withdrawn in a timely manner, in accordance with the wishes of 2 of 4 patients reviewed for Patient Rights, out of a total sample of 4 patients, (#1 & #2). The cumulative effect of this systemic practice resulted in the agencys failure to ensure patients with an Implantable Cardioverter Defibrillator (ICD) were able to die in comfort without unnecessary pain and preventable suffering. Cross reference L0512.”

“Based on interview and record review, the hospice agency failed to ensure the interdisciplinary group (IDG) developed, reviewed, and revised the plan of care to reflect the goals of patients and/or caregivers regarding withdrawal of life-sustaining treatment; failed to identify and implement interventions to promote a comfortable and dignified dying process; failed to ensure necessary medical equipment was accessible; and failed to maintain effective communication to support coordination of services for 2 of 4 patients reviewed for end-of-life care and services, out of a total sample of 4 patients, (#1 & #2). The cumulative effect of this systemic practice resulted in the agencys failure to ensure the IDG communicated effectively to arrange, direct, coordinate, and supervise care and services to meet the needs of patients with an Implantable Cardioverter Defibrillator (ICD), according to admission and comprehensive assessment findings. Cross reference L0545, L0550, L0552, and L0554.”

“Based on interview and record review, the hospice agency failed to promote the right to peace, comfort, and dignity at the end of life by ensuring life-sustaining measures were withdrawn in a timely manner, in accordance with the wishes of 2 of 4 patients reviewed for Patient Rights, out of a total sample of 4 patients, (#1 & #2). Findings: Cross reference L0500. 1. Review of the medical record revealed patient #1, a 77-year-old male, was admitted to the hospice agency on 3/10/23 with a terminal diagnosis of Chronic Obstructive Pulmonary Disease. His secondary diagnoses included coronary artery disease, pulmonary fibrosis, pulmonary hypertension, cardiomyopathy, and diabetes. Patient #1 died at home on 4/11/23. On 1/29/24 at 11:36 AM, in a telephone interview, patient #1s wife explained she and her husband chose hospice services to ensure he would remain comfortable at home and be well cared for until he died. The patients wife explained prior to discharge home from the hospital, she informed hospice admissions staff that he had a pacemaker/defibrillator implanted in his chest. She stated the hospice staff assured them the device would not pose a problem as it would be disabled. Patient #1s wife stated her husbands end of life journey was traumatic instead of peaceful as the defibrillator was never deactivated. She tearfully explained that she felt her husband was tortured when he received at least five excruciatingly painful electrical shocks from his defibrillator as it attempted to restart his heart over a 4-hour period preceding his death. According to the American Heart Association, an Implantable Cardioverter Defibrillator (ICD) is a battery-powered generator, about the size of a pocket watch, that is implanted under the skin of the chest, often just below the collarbone. The purpose of the device is to detect an abnormal heartbeat and restore it to a normal rhythm. If the heart beats too slowly, the pacemaker feature sends small electric signals to the heart to increase the heart rate. If the heartbeat is too fast or erratic, the device gives defibrillation shocks to stop the abnormal rhythm (retrieved on 2/02/24 from www.heart.org/en/health-topics/arrhythmia/prevention--treatment-of-arrhythmia/implantable-cardioverter-defibrillator-icd). Patient #1s wife provided a written timeline of the events on 4/11/23 which indicated at approximately 6:32 PM she was seated in a chair next to her husbands bed when he screamed out in pain. She noted his eyes were closed and she immediately called the hospice agency, reported what happened, and requested a nursing visit. The wife stated while she waited for the nurse to arrive, her husband had a second incident when he screamed out in pain. The document read, “;I witnessed the third shock. It was immediately apparent to me what was happening. He was dying but his defibrillator was firing to restart his heart. I heard him scream out. I saw his body raise up off the bed from the electrical shock. I told [name of patient] I knew what was happening, that his defibrillator was firing. I apologized to him and told him the nurse was on the way and I would get the defibrillator turned off.” Patient #1s wife noted the nurse who arrived at about 8:00 PM witnessed the fourth shock at 9:00 PM, and her husband again screamed out in pain. She indicated the nurse left to get a magnet to disable the ICD and the fifth shock occurred soon after she returned, just prior to placement of the magnet on her husbands chest at 10:35 PM, four hours after the first shock. On 1/29/24 at 1:00 PM, Director of Clinical Services (DCS) J stated the hospice agencys process was to start the conversation about deactivation of an ICD at the time of admission. She said, “;Truthfully, 98% say no at that time.” DCS J explained the patients Registered Nurse (RN) Case Manager was expected to continue education as he/she built a relationship with the patient and caregiver(s). She acknowledged the goal was to deactivate the ICD, which was not compatible with the natural dying process, to promote a comfortable and peaceful death. DCS J stated once the decision was made to deactivate the device, the RN Case Manager would obtain a physicians order and make the appropriate arrangements with the pacemaker provider to deactivate the device at the bedside. She explained a magnet should be secured on top of the device to disable it until the provider arrived to deactivate the ICD. Review of patient #1s hospital record revealed a Palliative Care Division Consult Note dated 3/08/23. The palliative care providers assessment showed the patient had an irregular, rapid heartbeat, and an overall poor prognosis due to exacerbation of his cardiac and pulmonary conditions. The document indicated patient #1 had an ICD. The palliative care provider discussed hospice care and services with the patient and his wife and wrote, “;Patient and wife state they would like hospice support at home, consult pending. Patient states he has been struggling for 30+ years and is tired/ ready for hospice.” The note revealed patient #1 had chosen Do Not Resuscitate (DNR) status if his heart stopped. Review of a Hospice Consult progress note dated 3/09/23 revealed RN F, a hospital-based hospice admission nurse, met with patient #1 and his wife. The document indicated the patient and his spouse no longer wanted aggressive treatments and recurrent hospitalizations, instead they desired symptoms management in the comfort of their home. RN F documented that patient #1 had an ICD and DNR code status. A Hospice Consult progress note dated 3/10/23 revealed RN F visited patient #1 again, prior to his discharge home, and discussed his preferences for cardiopulmonary resuscitation and other life-sustaining treatments. However, the document did not include any details regarding the patients preference or timeline for deactivation of the life-sustaining ICD device which conflicted with his DNR status and treatment goal of no further aggressive interventions. Review of the RN Hospice Admission note dated 3/11/23 revealed patient #1s comprehensive admission assessment was done by RN G in the patients home, on the morning after he was discharged from the hospital. The section for Cardiovascular Assessment findings indicated the patient had a permanently implanted pacemaker/ICD. The document showed RN G discussed preferences for life-sustaining treatments with the patient and/or his wife and confirmed the DNR status, but neither the narrative note, nor the care plans initiated reflected any interventions regarding education, decisions, or arrangements regarding deactivation of the defibrillator. Review of patient #1s medical record revealed the assigned Nurse Case Manager, RN B, visited his home and assessed him on 3/13/23, 3/16/23, 3/22/23, 3/28/23, 4/04/23, 4/07/23, and 4/10/23. RN B completed an RN Hospice Visit note for each visit and documented interventions such as medication changes, medical equipment, and education on medication administration and symptom management. The Hospice Visit notes showed no evidence RN B discussed the deactivation of patient #1s ICD with him, nor contacted the physician for an order to disable the device to ensure his right to a peaceful and comfortable death was honored. Review of a Hospice Physician Oversight progress note dated 3/30/23 revealed during his assessment, the physician noted patient #1 had a pacemaker but there was no finding noted regarding a defibrillator. During the visit, the physician adjusted the patients medication, educated the wife about the changes, and answered her questions. The progress note did not show any discussion of patient #1s DNR status, the conflict posed by a functioning ICD, and its potential to create undesirable events at the end of life. Review of a Hospice Cardiopulmonary Visit Note dated 4/07/23 revealed Advanced Practice Registered Nurse (APRN) H assessed patient #1 and reviewed the history of his illness which included the ICD. She noted patient #1 had DNR status and documented that she addressed his diagnosis, prognosis, disease progression, and the treatment plan. The progress note did not indicate APRN H approached patient #1 and his wife about deactivation of the ICD. The document did not reflect advocacy regarding patient #1s right to a comfortable and peaceful death by providing education regarding complications associated with a life-sustaining device during the dying process. On 1/29/24 at 2:02 PM, the Director of Patient Access stated after the hospice agency received a referral, admissions staff met with patients and/or caregivers to discuss and identify their needs. She explained if a patient had an ICD, hospice staff would provide education on the possible outcomes of life-sustaining treatments, then the decision to maintain or deactivate the device would be made by the patient and/or caregiver. The Director of Patient Access confirmed the result of the discussion should be clearly documented in the medical record. She reviewed patient #1s medical record and verified RN Fs notes indicated an ICD was present, but there were no details to show the result of discussions regarding the deactivation of the device. She stated since the patients ICD was not deactivated in the hospital, her expectation was the clinical team would follow up in his home. The Director of Patient Access was informed patient #1s ICD was never deactivated during over four weeks on hospice services, and he suffered electrical shocks prior to his death. She said, “;It saddens me that the patient experienced that. It must have been difficult for the spouse to see that. It bothers me.” On 1/30/24 at 9:32 AM, RN F recalled during the admission process in the hospital, patient #1s wife asked her what the hospice agency would do about her husbands ICD. She stated she explained to the wife that it was standard operating procedure to deactivate the device. RN F stated there was no specific decision made regarding when the device was to be deactivated, but she believed the goal was for patient #1 to be stable during transport between the hospital to home. RN F explained she expected the patients clinical home team to review the admission notes and arrange for the ICD to be deactivated according to his wishes. She confirmed it was not good that he was shocked by the defibrillator and acknowledged that occurrence did not support the goals of hospice care. On 1/29/24 at 2:19 PM, RN B, patient #1s Case Manager, stated she was never aware patient #1 had a defibrillator and did not recall any conversations on the subject with the patient or his wife. RN B stated she contacted the patients wife after she learned of his death and recalled the wife was tearful as she described how her husband screamed as he was shocked by his defibrillator. RN B verified she would have thoroughly explained the consequences of an active ICD at the end of life and recommended or arranged for deactivation of the device, if she had known it was there. On 1/29/24 at 4:23 PM, in a telephone interview, RN I stated on 4/11/23 she was dispatched to conduct an after-hours visit for patient #1 in response to the caregivers report that he was yelling out in pain. RN I stated initially the patients wife thought his pain was associated with a urinary catheter that was removed the day before. However, when she arrived at the patients home at approximately 8:00 PM, the wife was at the door waiting. RN I recalled the wife came to her car and told her to come inside quickly as her husbands defibrillator was firing and shocking him, causing pain, and she wanted it turned off. She explained she called the physician at 8:55 PM and obtained an order to deactivate the defibrillator but there was no other nurse available at the time to bring the required magnet to disable the device. RN I confirmed while she was in the home, she witnessed patient #1 with jerking of the upper extremities, and he moaned and yelled out. RN I stated she left patient #1s home at approximately 9:40 PM to retrieve a magnet, returned almost one hour later, and secured the magnet to his chest at about 10:35 PM. She acknowledged as a hospice nurse she wanted her patients to have a comfortable death. RN I said, “;He was not comfortable if the defibrillator was firing.” On 1/30/24 at 11:47 AM, the Yellow Team physician explained the decision to deactivate an ICD was one to be made by the patient or family. He stated factors to be considered included the goals of care and the patients code status. The physician confirmed if patient #1 had a DNR order, the ICD would need to be addressed, and it was not usually something the clinical team missed. When informed patient #1 was shocked by the device during the hours preceding death, the physician acknowledged it was concerning and he said, “;Thats pretty big.” On 1/31/24 at 9:35 AM, after review of the investigative findings with the hospice agencys Administrator, she acknowledged there was a delay in provision of care and services for patient #1. 2. Review of the medical record revealed patient #2, a 92-year-old male, was admitted to the hospice agency on 4/14/23 with a terminal diagnosis of hypertensive heart failure. His secondary diagnoses included coronary artery disease, valve stenosis, embolism, and an ICD. Patient #2 died at home on 4/22/23. On 1/30/24 at 4:02 PM, in a telephone interview, patient #2s son stated during the hospice admission process, he initiated the discussion with the nurse regarding his fathers ICD. He recalled about a week after admission, his father was very confused and appeared to be dying, so he called the hospice to request a nursing visit. The son stated he had to call a second time to notify hospice staff that the ICD shocked his father, and he remembered thinking that someone should have done something about the device before that happened. Patient #2s son said, “;It was terrible! I had to watch him getting shocked and there was nothing I could do. It was rough. . .He was shocked at least three or four times that I saw, and when I got in a panic mode, I might have missed more. . . He was dying and it brought him back.” The son explained his father suffered throughout the entire experience as he winced and gritted his teeth in obvious pain. He stated his father was alert after the incident and told him he did not want to go through that ever again. Patient #2s son emphasized that the experience did not meet their expectations for his fathers final days on hospice services. The son described the last week of his fathers life as Hell on Earth and said, “;The last thing he needed was some [expletive] thing in his chest shocking him and then keeping him alive after he should have died.” Review of patient #2s medical record revealed a RN Hospice Admission note dated 4/14/23, completed by RN L. The section for Cardiovascular Assessment findings showed the patient had a pacemaker/defibrillator. The document indicated RN L discussed preferences for life-sustaining treatments with the patient and/or his son, and she wrote, “;Hospice care needed now for comfort.” The note revealed patient #2s code status was DNR, and his son agreed to deactivation of the ICD. The Hospice Admission assessment showed no care plan was developed for the implanted cardiac device at that time, and there was no evidence of arrangements to obtain a magnet as an interim intervention until the ICD was deactivated. A RN Hospice Visit note dated 4/17/23 revealed patient #2s Case Manager, RN E completed a comprehensive assessment and noted she advised the patients son that she would communicate with the team physician regarding deactivation of the ICD. RN E did not initiate a care plan for the ICD to include approaches to avoid complications. Review of Telephone Encounter notes dated 4/20/23 revealed patient #2s son called the hospice agency at 10:09 AM, to report his father was mumbling incoherently and had very low oxygen level. The note indicated the son said, “;Hes bad. This is really bad. I dont know what to do.” The son was informed a nurse would be in touch. Approximately one hour later, at 11:02 AM, patient #2s son called again. The note revealed he was tearful and reported his father was close to passing, “;but he thinks his defibrillator is going off and keeping him alive. He says hes suffering terribly right now, and he wants it to end. He wants it turned off ASAP.” A RN Hospice Visit note dated 4/20/23 at 12:11 PM, revealed RN F arrived at patient #2s home and identified the patients problem as “;Caregiver states the Most Important Thing today is to [turn] aicd off.” The note showed another hospice staff member delivered a magnet shortly after RN Fs arrival. RN F obtained a physician order for placement of a magnet on the patients ICD and she educated the son on the procedure. On 1/30/24 at 4:27 PM, DCS J was informed patient #2 was shocked by his defibrillator despite the sons agreement for the device to be deactivated. She reviewed the patients medical record and verified nurses documented the sons wish for the ICD to be deactivated on admission and again three days before he was shocked. On 1/31/24 at 9:58 AM, in a telephone interview, RN E was informed her visit note on 4/17/23 indicated she planned to address deactivation of patient #2s defibrillator, but there was no documentation over the next three days to show she followed up. She recalled she was informed the device shocked him, but she could not remember or explain why she did not address the identified need to deactivate patient #2s ICD in a timely manner. RN E acknowledged a shock from an ICD was not a desired outcome for a hospice patient and she described her response to the request to deactivate the device as “;too slow.” Review of the hospice agencys Hospice Caregiver Guide revealed a Patient Bill of Rights. The document revealed the hospice patient had the right to complete life with peace and dignity and receive hospice care and services with the understanding that life-prolonging measures were not part of the hospice plan of care. The Patient Bill of Rights indicated the patient had the right to effective and timely pain management and symptom control, and the right to respect for the sanctity of his/her body. Review of the hospice agencys Implantable Cardiac Defibrillators (ICDs) Deactivation and Disabling Process, updated on 7/30/20, revealed ICD shocks were painful and might look and feel like a kick in the chest. The document indicated a functioning ICD was inconsistent with DNR status as it would attempt to resuscitate the dying patient by shocking the heart into a normal rhythm.”

“Based on interview and record review, the hospice agency failed to ensure the interdisciplinary group (IDG) developed individualized plans of care that reflected the goals of patients and/or caregivers regarding withdrawal of a life-sustaining treatment, based on initial and comprehensive assessment findings for 2 of 4 patients reviewed for end-of-life care and services, out of a total sample of 4 patients, (#1 & #2). Findings: Cross reference L536. Review of the hospice agencys policy and procedures for Plan of Care – Interdisciplinary Team, effective 4/01/22, revealed care and services would follow an individualized, written plan of care that was established by the IDG. The document indicated IDG would include, but not be limited to, a physician, a Registered Nurse, a Social Worker, and Pastoral or other counselor. The plan of care was to reflect the goals of the patient and family goals and specify interventions to meet the needs identified in assessments. The content of the plan of care was to include measurable outcomes expected from implementing and coordinating care and describe medical supplies and appliances needed to realize the patients goals. The policy revealed the IDG would meet weekly and review each patients plan of care at least every two weeks, “;to continually monitor the care and services provided to the patient. . .” The document indicated the hospice agency would develop a system of communication to ensure care and services were based on all assessments and provided in accordance with the plan of care. 1. Review of the medical record revealed patient #1, a 77-year-old male, was admitted to the hospice on 3/10/23 with terminal diagnosis of Chronic Obstructive Pulmonary Disease. His secondary diagnoses included coronary artery disease, pulmonary fibrosis, pulmonary hypertension, cardiomyopathy, and diabetes. Patient #1 died at home on 4/11/23. On 1/29/24 at 11:36 AM, in a telephone interview, patient #1s wife explained she and her husband chose hospice services to ensure he would remain comfortable at home and be well cared for until he died. The patients wife explained prior to discharge home from the hospital, she informed hospice admissions staff that he had a pacemaker/defibrillator implanted in his chest. She stated the hospice staff assured them the device would not pose a problem as it would be disabled. Patient #1s wife stated her husbands end of life journey was traumatic instead of peaceful as the defibrillator was never deactivated. She tearfully explained that she felt her husband was tortured when he received at least five excruciatingly painful electrical shocks from his defibrillator as it attempted to restart his heart over a 4-hour period preceding his death. According to the American Heart Association, an Implantable Cardioverter Defibrillator (ICD) is a battery-powered generator, about the size of a pocket watch, that is implanted under the skin of the chest, often just below the collarbone. The purpose of the device is to detect an abnormal heartbeat and restore it to a normal rhythm. If the heart beats too slowly, the pacemaker feature sends small electric signals to the heart to increase the heart rate. If the heartbeat is too fast or erratic, the device gives defibrillation shocks to stop the abnormal rhythm (retrieved on 2/02/24 from www.heart.org/en/health-topics/arrhythmia/prevention--treatment-of-arrhythmia/implantable-cardioverter-defibrillator-icd). Review of a Hospice Consult progress note dated 3/09/23 revealed Registered Nurse (RN) F, a hospital-based hospice admission nurse, documented patient #1s goal for hospice care was to have his symptoms managed in the comfort of his home and not pursue aggressive treatments and hospitalizations. The note showed the patient had an ICD and Do Not Resuscitate (DNR) code status. A Hospice Consult progress note dated 3/10/23 revealed RN F visited patient #1 again, prior to his discharge home, and discussed his preferences for cardiopulmonary resuscitation and other life-sustaining treatments. However, the document did not include any details regarding the patients preference for deactivation of the life-sustaining ICD device which conflicted with his DNR status and treatment goal of no further aggressive interventions. On 1/29/24 at 2:57 PM, the Yellow Team Manager explained deactivation of an ICD should be addressed with the patient and/or caregiver as soon as possible. She confirmed the discussion was to be initiated on admission and the assigned RN Case Manager would continue education, follow up regularly, and elicit assistance from other IDG members such as the Social Worker. She stated the IDG met weekly and every patient on the team was discussed at least every two weeks, but more often if necessary. The Yellow Team Manager showed an email from the Admission department nurse, RN F, dated 3/10/23 at 2:35 PM, with information on newly admitted patient #1. She validated the email did not include the patients pacemaker/ICD. Review of the RN Hospice Admission note dated 3/11/23 revealed RN G completed patient #1s comprehensive admission assessment in his home. The section for Cardiovascular Assessment findings indicated the patient had a permanently implanted pacemaker/ICD. The document indicated RN G discussed preferences for life-sustaining treatments with the patient and/or his wife and confirmed the DNR status, but neither the narrative note nor the care plans that were initiated reflected any interventions regarding education, decisions, or arrangements regarding deactivation of the defibrillator. Review of patient #1s medical record revealed the assigned Nurse Case Manager, RN B, visited his home and assessed him on 3/13/23, 3/16/23, 3/22/23, 3/28/23, 4/04/23, 4/07/23, and 4/10/23. RN B neither developed a care plan for the implanted cardiac device, nor contacted the team physician for an order to disable the device. A Hospice Physician Oversight progress note dated 3/30/23 revealed patient #1 had DNR status and a pacemaker, but there was no finding regarding a defibrillator. On 1/30/24 at 10:15 AM, Nurse Mentor RN C confirmed patient #1s plan of care should have included a problem area for the ICD and appropriate goals and interventions as detailed in the hospice agencys process. She explained the purpose of the plan of care was to ensure the patients needs and goals were addressed, and to make important information accessible to members of the IDG. On 1/30/24 at 11:47 AM, the Yellow Team physician explained if a patient had an ICD and DNR code status, deactivation of the device needed to be addressed by the IDG. He verified it was essential for team members to discuss important issues that might affect patients at the end of life. Review of the Hospice Initial Plan of Care dated 3/10/23, revealed the IDG met to review patient #1 as a new admission and create a plan of care to identify problems based on assessment findings. There was no care plan developed for his ICD although RN F, who participated in the meeting, noted the device in the Hospice Consult notes. The IDG continued to discuss patient #1 over the next month during IDG meetings held on 3/14/23, 3/28/23, and 4/11/23. The Hospice Plan of Care Update notes made by RN B showed patient #1’s declining status, but never addressed his implanted cardiac device. 2. Review of the medical record revealed patient #2, a 92-year-old male, was admitted to the hospice agency on 4/14/23 with a terminal diagnosis of hypertensive heart failure. His secondary diagnoses included coronary artery disease, valve stenosis, embolism, and an ICD. Patient #2 died at home on 4/22/23. On 1/30/24 at 4:02 PM, in a telephone interview, patient #2s son stated during the hospice admission process, he initiated the discussion with the nurse regarding his fathers ICD. He explained despite more than one request to get the device deactivated, it was not done, and his father was shocked by the ICD. Patient #2s son recalled thinking that someone should have done something about the device before that happened. The son said, “;It was terrible! I had to watch him getting shocked and there was nothing I could do. It was rough. . .He was shocked at least three or four times that I saw, and when I got in a panic mode, I might have missed more. . . He was dying and it brought him back.” The son explained his father suffered throughout the entire experience as he winced and gritted his teeth in obvious pain. He stated his father was alert after the incident and told him he did not want to go through that ever again. Patient #2s son emphasized that the experience did not meet their expectations for his fathers final days on hospice services. The son described the last week of his fathers life as Hell on Earth and said, “;The last thing he needed was some [expletive] thing in his chest shocking him and then keeping him alive after he should have died.” Review of patient #2s medical record revealed an RN Hospice Admission note dated 4/14/23, completed by RN L. The section for Cardiovascular Assessment findings showed the patient had a pacemaker/defibrillator which was implanted on 7/09/19. The document indicated RN L discussed preferences for life-sustaining treatments with the patient and/or his son, and she wrote, “;Hospice care needed now for comfort.” The note revealed patient #2s code status was DNR, and his son agreed to deactivation of the ICD. The Hospice Admission assessment showed no care plan was developed for the implanted cardiac device at that time, and there was no evidence of arrangements to obtain a magnet as an interim intervention until the ICD was deactivated. A RN Hospice Visit note dated 4/17/23 revealed patient #2s Case Manager, RN E completed a comprehensive assessment and noted she advised the patients son that she would communicate with the team physician regarding deactivation of the ICD. RN E did not initiate a care plan for the ICD to reflect the son’s request and the patient’s goal related to the device. On 1/30/24 at 4:27 PM, DCS J reviewed patient #2s medical record and confirmed the Admission RN and the Nurse Case Manager, RN E, both documented he had an ICD that needed to be deactivated, but neither nurse developed a care plan with goals and interventions regarding the device. She verified the care plan was developed only after patient #2 got shocked. Review of the hospice agencys Implantable Cardiac Defibrillators (ICDs) Deactivation and Disabling Process, updated on 7/30/20, read, “;The functioning of an ICD is generally inconsistent with a Do-Not-Resuscitate order. . .” as it is a life-sustaining device. The procedure involved identifying patients with ICDs on admission and documenting the device type, manufacturer, and model in the care plan. The document indicated discussions with the patient and/or caregiver related to deactivation of the device should be documented in a nursing progress note and the care plan. The nurse was expected to arrange for deactivation with the ICDs manufacturer and document the information in a note and the care plan. The process revealed when temporarily disabling an ICD, a magnet should be retrieved from the hospices Inpatient Unit and taped directly over the device on the patients chest.”

“Based on interview and record review, the hospice agency failed to ensure the plan of care included the arrangement of services with pacemaker manufacturers to deactivate implantable cardiac defibrillators, and provision of magnets to disable the devices until deactivated for 2 of 4 patients reviewed for end-of-life care and services, out of a total sample of 4 patients, (#1 & #2). Findings: Cross reference L536. Review of the hospice agencys policy and procedures for Plan of Care – Interdisciplinary Team, effective 4/01/22, revealed care and services would follow an individualized, written plan of care that was established by the IDG. The document indicated IDG would include, but not be limited to, a physician, a Registered Nurse, a Social Worker, and Pastoral or other counselor. The plan of care was to reflect the goals of the patient and family goals and specify interventions to meet the needs identified in assessments. The content of the plan of care was to include measurable outcomes expected from implementing and coordinating care and describe medical supplies and appliances needed to realize the patients goals. The policy revealed the IDG would meet weekly and review each patients plan of care at least every two weeks, “;to continually monitor the care and services provided to the patient. . .” The document indicated the hospice agency would develop a system of communication to ensure care and services were based on all assessments and provided in accordance with the plan of care. Review of the hospice agencys Implantable Cardiac Defibrillators (ICDs) Deactivation and Disabling Process, updated on 7/30/20, revealed the nurse was expected to arrange for deactivation with the ICDs manufacturer and document the information in a note and the care plan. The process revealed when temporarily disabling an ICD, a magnet should be retrieved from the hospices Inpatient Unit and taped directly over the device on the patients chest. 1. Review of the medical record revealed patient #1, a 77-year-old male, was admitted to the hospice on 3/10/23 with terminal diagnosis of Chronic Obstructive Pulmonary Disease. His secondary diagnoses included coronary artery disease, pulmonary fibrosis, pulmonary hypertension, cardiomyopathy, and diabetes. Patient #1 died at home on 4/11/23. On 1/29/24 at 11:36 AM, in a telephone interview, patient #1s wife explained she and her husband chose hospice services to ensure he would remain comfortable at home and be well cared for until he died. The patients wife explained prior to discharge home from the hospital, she informed hospice admissions staff that he had a pacemaker/defibrillator implanted in his chest. She stated the hospice staff assured them the device would not pose a problem as it would be disabled. Patient #1s wife stated her husbands end of life journey was traumatic instead of peaceful as the defibrillator was never deactivated. She tearfully explained that she felt her husband was tortured when he received at least five excruciatingly painful electrical shocks from his defibrillator as it attempted to restart his heart over a 4-hour period preceding his death. According to the American Heart Association, an Implantable Cardioverter Defibrillator (ICD) is a battery-powered generator, about the size of a pocket watch, that is implanted under the skin of the chest, often just below the collarbone. The purpose of the device is to detect an abnormal heartbeat and restore it to a normal rhythm. If the heart beats too slowly, the pacemaker feature sends small electric signals to the heart to increase the heart rate. If the heartbeat is too fast or erratic, the device gives defibrillation shocks to stop the abnormal rhythm (retrieved on 2/02/24 from www.heart.org/en/health-topics/arrhythmia/prevention--treatment-of-arrhythmia/implantable-cardioverter-defibrillator-icd). Review of a Hospice Consult progress note dated 3/09/23 revealed Registered Nurse (RN) F, a hospital-based hospice admission nurse, documented patient #1s goal for hospice care was to have his symptoms managed in the comfort of his home and not pursue aggressive treatments and hospitalizations. The note showed the patient had an ICD and Do Not Resuscitate (DNR) code status. Review of the RN Hospice Admission note dated 3/11/23 revealed RN G completed patient #1s comprehensive admission assessment in his home. The care plans that were initiated reflected no interventions regarding arrangements with the device’s manufacturer regarding deactivation of the defibrillator function. The note showed RN G did not discuss provision of a magnet to temporarily disable the device until it could be deactivated. Review of patient #1s medical record revealed the assigned Nurse Case Manager, RN B, visited his home and assessed him on 3/13/23, 3/16/23, 3/22/23, 3/28/23, 4/04/23, 4/07/23, and 4/10/23. RN B’s Hospice Visit notes did not indicate she discussed or made arrangements for deactivation of patient #1s ICD with him or his wife. There was no documentation regarding provision of a magnet to ensure the device was disabled until deactivated. On 1/30/24 at 10:05 AM, Director of Clinical Services (DCS) J confirmed a magnet could be used to temporarily disable the defibrillator function of a pacemaker/ICD until arrangements were made for permanent deactivation. She said, “;We have lots of magnets and each team manager has one. We can get as many as we want. It is not a matter of cost or availability.” However, DCS J explained the hospice agency did not provide magnets to RN Case Managers, and magnets were not left in homes as necessary equipment for patients with active ICDs. On 1/30/24 at 10:54 AM, in a telephone interview, patient #1s wife stated hospice staff knew about her husbands ICD and their wish for it to be deactivated from the beginning of hospice services. Patient #1s wife stated she felt they should have been provided with a magnet until proper arrangements were made. She said, “;That would have prevented his suffering.” 2. Review of the medical record revealed patient #2, a 92-year-old male, was admitted to the hospice agency on 4/14/23 with a terminal diagnosis of hypertensive heart failure. His secondary diagnoses included coronary artery disease, valve stenosis, embolism, and an ICD. Patient #2 died at home on 4/22/23. On 1/30/24 at 4:02 PM, in a telephone interview, patient #2s son stated during the hospice admission process, he initiated the discussion with the nurse regarding his fathers ICD. He explained despite more than one request to get the device deactivated, it was not done, and his father was shocked by the ICD. Patient #2s son recalled thinking that someone should have done something about the device before that happened. The son said, “;It was terrible! I had to watch him getting shocked and there was nothing I could do. It was rough. . .He was shocked at least three or four times that I saw, and when I got in a panic mode, I might have missed more. . . He was dying and it brought him back.” The son explained his father suffered throughout the entire experience as he winced and gritted his teeth in obvious pain. He stated his father was alert after the incident and told him he did not want to go through that ever again. Patient #2s son emphasized that the experience did not meet their expectations for his fathers final days on hospice services. The son described the last week of his fathers life as Hell on Earth and said, “;The last thing he needed was some [expletive] thing in his chest shocking him and then keeping him alive after he should have died.” Review of patient #2s medical record revealed an RN Hospice Admission note dated 4/14/23, completed by RN L. The note revealed patient #2s code status was Do Not Resuscitate, and his son agreed to deactivation of the ICD. The Hospice Admission assessment showed no care plan was developed for the implanted cardiac device at that time, and there was no evidence of arrangements to obtain a magnet as an interim intervention until the ICD was deactivated. A RN Hospice Visit note dated 4/17/23 revealed patient #2s Case Manager, RN E completed a comprehensive assessment and noted she advised the patients son that she would communicate with the team physician regarding deactivation of the ICD. RN E did not initiate a care plan for the ICD to include the interventions necessary to avoid complications such as provision or application of a magnet. On 1/30/24 at 4:27 PM, DCS J reviewed patient #2s medical record and confirmed the Admission RN and the Nurse Case Manager, RN E, both documented he had an ICD that needed to be deactivated, but neither nurse developed a care plan for the device. She verified the care plan was developed on the day patient #2 got shocked, and she acknowledged a magnet was provided only after the son called the hospice agency to report that his father was being shocked. On 1/31/24 at 9:58 AM, in a telephone interview, RN Es visit note dated 4/17/23 was read to her. She could not explain why she identified the need to deactivate the patients ICD on 4/17/23 but failed to address the concern. She acknowledged cardiac events were unpredictable and the interventions to disable or deactivate an ICD should be done in a timely manner.”

“Based on interview and record review, the hospice agency failed to ensure the interdisciplinary group (IDG) thoroughly reviewed, revised, and updated the plan of care as indicated to reflect the presence of an implanted cardiac device, (#1), and the goals of patients and/or caregivers regarding withdrawal of a life-sustaining treatment, (#1 & #2), for 2 out of a total sample of 4 patients reviewed for end-of-life care and services. Findings: Cross reference L536. Review of the hospice agencys policy and procedures for Plan of Care – Interdisciplinary Team, effective 4/01/22, revealed care and services would follow an individualized, written plan of care that was established by the IDG. The document indicated IDG would include, but not be limited to, a physician, a Registered Nurse, a Social Worker, and Pastoral or other counselor. The plan of care was to reflect the goals of the patient and family goals and specify interventions to meet the needs identified in assessments. The content of the plan of care was to include measurable outcomes expected from implementing and coordinating care and describe medical supplies and appliances needed to realize the patients goals. The policy revealed the IDG would meet weekly and review each patients plan of care at least every two weeks, “;to continually monitor the care and services provided to the patient. . .” The document indicated the hospice agency would develop a system of communication to ensure care and services were based on all assessments and provided in accordance with the plan of care. 1. Review of the medical record revealed patient #1, a 77-year-old male, was admitted to the hospice on 3/10/23 with terminal diagnosis of Chronic Obstructive Pulmonary Disease. His secondary diagnoses included coronary artery disease, pulmonary fibrosis, pulmonary hypertension, cardiomyopathy, and diabetes. Patient #1 died at home on 4/11/23. On 1/29/24 at 11:36 AM, in a telephone interview, patient #1s wife explained she and her husband chose hospice services to ensure he would remain comfortable at home and be well cared for until he died. The patients wife explained prior to discharge home from the hospital, she informed hospice admissions staff that he had a pacemaker/defibrillator implanted in his chest. She stated the hospice staff assured them the device would not pose a problem as it would be disabled. Patient #1s wife stated her husbands end of life journey was traumatic instead of peaceful as the defibrillator was never deactivated. She tearfully explained that she felt her husband was tortured when he received at least five excruciatingly painful electrical shocks from his defibrillator as it attempted to restart his heart over a 4-hour period preceding his death. According to the American Heart Association, an Implantable Cardioverter Defibrillator (ICD) is a battery-powered generator, about the size of a pocket watch, that is implanted under the skin of the chest, often just below the collarbone. The purpose of the device is to detect an abnormal heartbeat and restore it to a normal rhythm. If the heart beats too slowly, the pacemaker feature sends small electric signals to the heart to increase the heart rate. If the heartbeat is too fast or erratic, the device gives defibrillation shocks to stop the abnormal rhythm (retrieved on 2/02/24 from www.heart.org/en/health-topics/arrhythmia/prevention--treatment-of-arrhythmia/implantable-cardioverter-defibrillator-icd). Review of a Hospice Consult progress note dated 3/09/23 revealed Registered Nurse (RN) F, a hospital-based hospice admission nurse, documented patient #1s goal for hospice care was to have his symptoms managed in the comfort of his home and not pursue aggressive treatments and hospitalizations. The note showed the patient had an ICD and Do Not Resuscitate (DNR) code status. A Hospice Consult progress note dated 3/10/23 revealed RN F visited patient #1 again, prior to his discharge home, and discussed his preferences for cardiopulmonary resuscitation and other life-sustaining treatments. However, the document did not include any details regarding the patients preference for deactivation of the life-sustaining ICD device which conflicted with his DNR status and treatment goal of no further aggressive interventions. On 1/29/24 at 2:57 PM, the Yellow Team Manager explained deactivation of an ICD should be addressed with the patient and/or caregiver as soon as possible. She confirmed the discussion was to be initiated on admission, no matter where the patient was located. The Yellow Team Manager stated if either the patient or the caregiver was not receptive to deactivation of the device, her expectation was the RN Case Manager would continue education, follow up regularly, and elicit assistance from other IDG members such as the Social Worker. She stated the IDG met weekly and every patient on the team was discussed at least every two weeks, but more often if necessary. Review of the RN Hospice Admission note dated 3/11/23 revealed RN G completed patient #1s comprehensive admission assessment in his home. The section for Cardiovascular Assessment findings indicated the patient had a permanently implanted pacemaker/ICD. The document indicated RN G discussed preferences for life-sustaining treatments with the patient and/or his wife and confirmed the DNR status, but neither the narrative note nor the care plans that were initiated reflected any interventions regarding education, decisions, or arrangements regarding deactivation of the defibrillator. On 1/30/24 at 10:15 AM, Nurse Mentor RN C confirmed patient #1s plan of care should have included a problem area for the ICD and appropriate goals and interventions as detailed in the hospice agencys process. She explained the purpose of the plan of care was to ensure the patients needs and goals were addressed, and to make important information accessible to members of the IDG. On 1/30/24 at 11:47 AM, the Yellow Team physician explained if a patient had an ICD and DNR code status, deactivation of the device needed to be addressed. He verified it was essential for IDG members to discuss and review important issues that might affect patients at the end of life. The physician acknowledged all IDG members, clinical and non-clinical, might be helpful in educating and supporting patients and families through difficult decisions such as selecting DNR status or discontinuing life-sustaining treatments. He confirmed he participated in weekly IDG meetings but did not recall discussions related to patient #1s ICD. He explained the IDG reviewed and discussed all newly admitted residents including their code status, medications, and any other issues that needed to be addressed. Review of the Hospice Initial Plan of Care dated 3/10/23, revealed the IDG met to review patient #1 as a new admission and create a plan of care to identify problems based on assessment findings. There was no care plan developed for his ICD although RN F, who participated in the meeting, noted the device in the Hospice Consult notes. The IDG continued to discuss patient #1 over the next month during IDG meetings held on 3/14/23, 3/28/23, and 4/11/23. The Hospice Plan of Care Update notes made by RN B showed patient #1’s declining status, but never addressed his implanted cardiac device. 2. Review of the medical record revealed patient #2, a 92-year-old male, was admitted to the hospice agency on 4/14/23 with a terminal diagnosis of hypertensive heart failure. His secondary diagnoses included coronary artery disease, valve stenosis, embolism, and an ICD. Patient #2 died at home on 4/22/23. On 1/30/24 at 4:02 PM, in a telephone interview, patient #2s son stated during the hospice admission process, he initiated the discussion with the nurse regarding his fathers ICD. He explained despite more than one request to get the device deactivated, it was not done, and his father was shocked by the ICD. Patient #2s son recalled thinking that someone should have done something about the device before that happened. The son said, “;It was terrible! I had to watch him getting shocked and there was nothing I could do. It was rough. . .He was shocked at least three or four times that I saw, and when I got in a panic mode, I might have missed more. . . He was dying and it brought him back.” The son explained his father suffered throughout the entire experience as he winced and gritted his teeth in obvious pain. He stated his father was alert after the incident and told him he did not want to go through that ever again. Patient #2s son emphasized that the experience did not meet their expectations for his fathers final days on hospice services. The son described the last week of his fathers life as Hell on Earth and said, “;The last thing he needed was some [expletive] thing in his chest shocking him and then keeping him alive after he should have died.” Review of patient #2s medical record revealed an RN Hospice Admission note dated 4/14/23, completed by RN L. The section for Cardiovascular Assessment findings showed the patient had a pacemaker/defibrillator which was implanted on 7/09/19. The document indicated RN L discussed preferences for life-sustaining treatments with the patient and/or his son, and she wrote, “;Hospice care needed now for comfort.” The note revealed patient #2s code status was DNR, and his son agreed to deactivation of the ICD. The Hospice Admission assessment showed no care plan was developed for the implanted cardiac device at that time, and there was no evidence of arrangements to obtain a magnet as an interim intervention until the ICD was deactivated. A RN Hospice Visit note dated 4/17/23 revealed patient #2s Case Manager, RN E completed a comprehensive assessment and noted she advised the patients son that she would communicate with the team physician regarding deactivation of the ICD. RN E did not initiate a care plan for the ICD to include the interventions necessary to avoid complications such as provision or application of a magnet. On 1/30/24 at 4:27 PM, DCS J reviewed patient #2s medical record and confirmed the Admission RN and the Nurse Case Manager, RN E, both documented he had an ICD that needed to be deactivated, but neither nurse developed a care plan for the device. She verified the care plan was developed only after patient #2 got shocked. Review of the hospice agencys Implantable Cardiac Defibrillators (ICDs) Deactivation and Disabling Process, updated on 7/30/20, read, “;The functioning of an ICD is generally inconsistent with a Do-Not-Resuscitate order. . .” as it is a life-sustaining device. The procedure involved identifying patients with ICDs on admission and documenting the device type, manufacturer, and model in the care plan. The document indicated discussions with the patient and/or caregiver related to deactivation of the device should be documented in a nursing progress note and the care plan. The nurse was expected to arrange for deactivation with the ICDs manufacturer and document the information in a note and the care plan. The process revealed when temporarily disabling an ICD, a magnet should be retrieved from the hospices Inpatient Unit and taped directly over the device on the patients chest.”

“Based on interview, and record review, the hospice agency failed to ensure the Interdisciplinary Group (IDG) maintained an effective system of communication to support optimal coordination of services, according to its policy and procedures, for 2 of 4 patients reviewed for end-of-life care and services, out of a total sample of 4 patients, (#1 & #2). Findings: Cross reference L536. Review of the hospice agencys policy and procedures for Plan of Care – Interdisciplinary Team, effective 4/01/22, revealed care and services would follow an individualized, written plan of care that was established by the IDG. The document indicated IDG would include, but not be limited to, a physician, a Registered Nurse, a Social Worker, and Pastoral or other counselor. The plan of care was to reflect the goals of the patient and family goals and specify interventions to meet the needs identified in assessments. The content of the plan of care was to include measurable outcomes expected from implementing and coordinating care and describe medical supplies and appliances needed to realize the patients goals. The policy revealed the IDG would meet weekly and review each patients plan of care at least every two weeks, “;to continually monitor the care and services provided to the patient. . .” The document indicated the hospice agency would develop a system of communication to ensure care and services were based on all assessments and provided in accordance with the plan of care. 1. Review of the medical record revealed patient #1, a 77-year-old male, was admitted to the hospice on 3/10/23 with terminal diagnosis of Chronic Obstructive Pulmonary Disease. His secondary diagnoses included coronary artery disease, pulmonary fibrosis, pulmonary hypertension, cardiomyopathy, and diabetes. Patient #1 died at home on 4/11/23. On 1/29/24 at 11:36 AM, in a telephone interview, patient #1s wife explained she and her husband chose hospice services to ensure he would remain comfortable at home and be well cared for until he died. The patients wife explained prior to discharge home from the hospital, she informed hospice admissions staff that he had a pacemaker/defibrillator implanted in his chest. She stated the hospice staff assured them the device would not pose a problem as it would be disabled. Patient #1s wife stated her husbands end of life journey was traumatic instead of peaceful as the defibrillator was never deactivated. She tearfully explained that she felt her husband was tortured when he received at least five excruciatingly painful electrical shocks from his defibrillator as it attempted to restart his heart over a 4-hour period preceding his death. According to the American Heart Association, an Implantable Cardioverter Defibrillator (ICD) is a battery-powered generator, about the size of a pocket watch, that is implanted under the skin of the chest, often just below the collarbone. The purpose of the device is to detect an abnormal heartbeat and restore it to a normal rhythm. If the heart beats too slowly, the pacemaker feature sends small electric signals to the heart to increase the heart rate. If the heartbeat is too fast or erratic, the device gives defibrillation shocks to stop the abnormal rhythm (retrieved on 2/02/24 from www.heart.org/en/health-topics/arrhythmia/prevention--treatment-of-arrhythmia/implantable-cardioverter-defibrillator-icd). Review of a Hospice Consult progress note dated 3/09/23 revealed Registered Nurse (RN) F, a hospital-based hospice admission nurse, documented patient #1s goal for hospice care was to have his symptoms managed in the comfort of his home and not pursue aggressive treatments and hospitalizations. The note showed the patient had an ICD and Do Not Resuscitate (DNR) code status. A Hospice Consult progress note dated 3/10/23 revealed RN F visited patient #1 again, prior to his discharge home, and discussed his preferences for cardiopulmonary resuscitation and other life-sustaining treatments. However, the document did not include any details regarding the patients preference for deactivation of the life-sustaining ICD device which conflicted with his DNR status and treatment goal of no further aggressive interventions. On 1/29/24 at 2:57 PM, the Yellow Team Manager stated if either the patient or the caregiver was not receptive to deactivation of the device, her expectation was the RN Case Manager would continue education, follow up regularly, and elicit assistance from other IDG members such as the Social Worker. She stated the IDG met weekly and every patient on the team was discussed at least every two weeks, but more often if necessary. The Yellow Team Manager showed an email from the Admission department nurse, RN F, dated 3/10/23 at 2:35 PM, with information on newly admitted patient #1. She validated the email did not include the patients pacemaker/ICD and after he died, she discovered the RN Case Manager was not aware patient #1 had a defibrillator. The Yellow Team Manager said, “;The biggest thing, most important, is to honor what the patient and family wants. . .I think it was probably a process issue and lack of communication.” Review of the RN Hospice Admission note dated 3/11/23 revealed RN G completed patient #1s comprehensive admission assessment in his home. The section for Cardiovascular Assessment findings indicated the patient had a permanently implanted pacemaker/ICD. The document indicated RN G discussed preferences for life-sustaining treatments with the patient and/or his wife and confirmed the DNR status, but neither the narrative note nor the care plans that were initiated reflected any interventions regarding education, decisions, or arrangements regarding deactivation of the defibrillator. Review of patient #1s medical record revealed the assigned Nurse Case Manager, RN B, visited his home and assessed him on 3/13/23, 3/16/23, 3/22/23, 3/28/23, 4/04/23, 4/07/23, and 4/10/23. RN B completed a RN Hospice Visit note for each visit. The Hospice Visit notes showed no evidence RN B discussed the deactivation of patient #1s ICD with him or his wife, developed a care plan for the implanted cardiac device, nor contacted the team physician for an order to disable the device. A Hospice Physician Oversight progress note dated 3/30/23 revealed patient #1 had DNR status and a pacemaker, but there was no finding regarding a defibrillator. The progress note indicated the physician coordinated the patients care and “;communication with patient care manager and case manager advised.” Review of a Hospice Cardiopulmonary Visit Note dated 4/07/23 revealed Advanced Practice Registered Nurse (APRN) H assessed patient #1 and reviewed the history of his illness which included the ICD. She noted patient #1 had DNR status and documented that she addressed his diagnosis, prognosis, disease progression, and the treatment plan. The progress note did not indicate APRN H approached patient #1 and his wife about deactivation of the ICD or coordinated his care with other members of the IDG regarding the life-sustaining device. On 1/30/24 at 10:15 AM, Nurse Mentor RN C confirmed patient #1s plan of care should have included a problem area for the ICD and appropriate goals and interventions as detailed in the hospice agencys process. She explained the purpose of the plan of care was to ensure the patients needs and goals were addressed, and to make important information accessible to members of the IDG. On 1/30/24 at 10:54 AM, in a telephone interview, patient #1s wife stated she felt there was a complete systemic failure within the hospice. She explained the staff knew about her husbands ICD and their wish for it to be deactivated from the beginning of hospice services, but they did not communicate well. On 1/30/24 at 11:47 AM, the Yellow Team physician explained if a patient had an ICD and DNR code status, deactivation of the device needed to be addressed. He verified it was essential for IDG members to discuss and review important issues that might affect patients at the end of life. The physician acknowledged all IDG members, clinical and non-clinical, might be helpful in educating and supporting patients and families through difficult decisions such as selecting DNR status or discontinuing life-sustaining treatments. He confirmed he participated in weekly IDG meetings but did not recall discussions related to patient #1s ICD. He explained the IDG reviewed and discussed all newly admitted residents including their code status, medications, and any other issues that needed to be addressed. The physician showed a current IDG worksheet which was utilized during weekly meetings. The document showed a column designated for code status, but no area for life-sustaining treatments. Review of the Hospice Initial Plan of Care dated 3/10/23, revealed the IDG met to review patient #1 as a new admission and create a plan of care to identify problems based on assessment findings. There was no care plan developed for his ICD although RN F, who participated in the meeting, noted the device in the Hospice Consult notes. The IDG continued to discuss patient #1 over the next month during IDG meetings held on 3/14/23, 3/28/23, and 4/11/23. The Hospice Plan of Care Update notes made by RN B showed patient #1’s declining status, but never addressed his implanted cardiac device. 2. Review of the medical record revealed patient #2, a 92-year-old male, was admitted to the hospice agency on 4/14/23 with a terminal diagnosis of hypertensive heart failure. His secondary diagnoses included coronary artery disease, valve stenosis, embolism, and an ICD. Patient #2 died at home on 4/22/23. On 1/30/24 at 4:02 PM, in a telephone interview, patient #2s son stated during the hospice admission process, he initiated the discussion with the nurse regarding his fathers ICD. He explained despite more than one request to get the device deactivated, it was not done, and his father was shocked by the ICD. Patient #2s son recalled thinking that someone should have done something about the device before that happened. The son said, “;It was terrible! I had to watch him getting shocked and there was nothing I could do. It was rough. . .He was shocked at least three or four times that I saw, and when I got in a panic mode, I might have missed more. . . He was dying and it brought him back.” The son explained his father suffered throughout the entire experience as he winced and gritted his teeth in obvious pain. He stated his father was alert after the incident and told him he did not want to go through that ever again. Patient #2s son emphasized that the experience did not meet their expectations for his fathers final days on hospice services. The son described the last week of his fathers life as Hell on Earth and said, “;The last thing he needed was some [expletive] thing in his chest shocking him and then keeping him alive after he should have died.” Review of patient #2s medical record revealed an RN Hospice Admission note dated 4/14/23, completed by RN L. The section for Cardiovascular Assessment findings showed the patient had a pacemaker/defibrillator which was implanted on 7/09/19. The document indicated RN L discussed preferences for life-sustaining treatments with the patient and/or his son, and she wrote, “;Hospice care needed now for comfort.” The note revealed patient #2s code status was DNR, and his son agreed to deactivation of the ICD. The Hospice Admission assessment showed no care plan was developed for the implanted cardiac device at that time, and there was no evidence of arrangements to obtain a magnet as an interim intervention until the ICD was deactivated. A RN Hospice Visit note dated 4/17/23 revealed patient #2s Case Manager, RN E completed a comprehensive assessment and noted she advised the patients son that she would communicate with the team physician regarding deactivation of the ICD. RN E did not initiate a care plan for the ICD to include the interventions necessary to avoid complications such as provision or application of a magnet. On 1/30/24 at 4:27 PM, DCS J reviewed patient #2s medical record and confirmed the Admission RN and the Nurse Case Manager, RN E, both documented he had an ICD that needed to be deactivated, but neither nurse developed a care plan for the device. She verified the care plan was developed only after patient #2 got shocked. On 1/31/24 at 9:58 AM, in a telephone interview, RN Es visit note dated 4/17/23 was read to her. She could not explain why she identified the need to deactivate the patients ICD on 4/17/23 but failed to address the concern. She acknowledged cardiac events were unpredictable and the interventions to disable or deactivate an ICD should be done in a timely manner. RN E verified the need was addressed too slowly and resulted in an undesired outcome. Review of the hospice agencys Implantable Cardiac Defibrillators (ICDs) Deactivation and Disabling Process, updated on 7/30/20, read, “;The functioning of an ICD is generally inconsistent with a Do-Not-Resuscitate order. . .” as it is a life-sustaining device. The procedure involved identifying patients with ICDs on admission and documenting the device type, manufacturer, and model in the care plan. The document indicated discussions with the patient and/or caregiver related to deactivation of the device should be documented in a nursing progress note and the care plan. The nurse was expected to arrange for deactivation with the ICDs manufacturer and document the information in a note and the care plan. The process revealed when temporarily disabling an ICD, a magnet should be retrieved from the hospices Inpatient Unit and taped directly over the device on the patients chest.”

“Based on interview and record review, the hospice agencys Quality Assurance and Performance Improvement (QAPI) program failed to utilize and monitor data from the medical record related to end-of life experiences to ensure patient and caregiver goals were met and care and services were delivered according to the agencys standards. Findings: Cross reference L500, L536, L591, and L650. Review of the hospice agencys policy and procedure for the Quality Assessment and Performance Improvement (QAPI) Program, effective 4/01/22, revealed data may be obtained from internal sources such as documentation, records, staff, patients, observations, and risk assessments. The document indicated the result of the data analysis would be used to identify performance improvement opportunities that could improve the quality of patient care. On 1/29/24 at 4:09 PM, the Director of Corporate Responsibility and Quality discussed findings regarding a patient who suffered electrical shocks at the end of his life because hospice staff failed to deactivate an implanted cardiac device according to the patients wishes. He stated he only learned of the incident recently, over nine months after it occurred. He verified the expectation was staff would report any unexpected events or traumatic circumstances surrounding a death, either verbally or through the official concern process. The Director of Corporate Responsibility and Quality acknowledged if the agencys Administration had informed the QAPI team of the situation, a designated committee would have created a performance improvement plan based on the results of investigation and team discussion, to prevent the situation from occurring again. However, review of randomly selected medical records revealed a second resident experienced a similar outcome less than two weeks later as his device was not deactivated when requested. On 1/31/24 at 10:50 AM, the Director of Corporate Responsibility and Quality explained his responsibilities included fostering a culture of compliance and promoting overall quality of care within the hospice agency. He stated the Quality Assurance and Performance Improvement (QAPI) department received information from different sources including verbal conversations with and email communications from staff, patients, caregivers, and others, and the Consumer Assessment of Healthcare Provider Systems (CAHPS) surveys mailed to caregivers after the patients death. He stated the response rate to the CAHPS survey mailings was only about 20%, possibly due to the length of the document. He stated the agencys Risk Manager reviewed team emails to identify potential issues and from those she generated concern forms which were sent to appropriate staff members for responses and feedback. The Director of Corporate Responsibility and Quality explained his staff conducted random reviews of patients medical records to verify orders were in place and appropriate care plans were developed and implemented, and to ensure interdisciplinary group (IDG) meetings were held in the required timeframe and attended by the required members. The Director of Corporate Responsibility and Quality acknowledged the concerns identified during the complaint investigation survey related to the hospice agencys failure to attain patients goals of comfort, peace, and dignity during the dying process were not identified during the QAPI teams data collection activities. He verified internal data gathering and random audits by the QAPI team did not detect the absence of appropriate care plans and orders for implanted cardiac devices for both patients. 1/31/24 at approximately 10:56 AM, Director of Clinical Services (DCS) J and the Director of Corporate Responsibility and Quality confirmed the hospice agencys goal was to deliver high quality care that promoted comfort during the end-of-life journey. They were asked if the hospice agency reviewed the actual circumstances of each death or events preceding and surrounding the death to verify patients and the hospice agency truly met their common goal a comfortable, peaceful, and dignified death. They explained that information was not reviewed by a specific person or department. The Director of Corporate Responsibility and Quality acknowledged there was room for improvement in that area and said, “;Even if care is great throughout the patients time on hospice services, if it is not good in the last moments, then thats what they remember.” On 1/31/24 at 11:01 AM, DCS J explained the interdisciplinary group (IDG) reviewed patients death discharge notes at the first meeting after the death, but no one reviewed documentation from the days prior to the death to monitor whether symptoms were well-managed and identify any issues that caused any type of distress to the patient or caregiver. DCS J acknowledged neither the Nurse Case Managers nor Team Managers assigned to the patients who were shocked included the information in discharge notes or discussions in the IDG meetings when their deaths were reviewed by the team, so Administration and QAPI were not aware. DCS J explained the last few days of life was often the period that required revised or new approaches and additional support as end-of-life symptoms might be distressing. She acknowledged review of progress notes from this period would provide valuable information on things that did not go as expected.”

“Based on interview and record review, the hospice agency failed to provide appropriate nursing services, according to professional standards, to meet the needs of 1 of 4 patients reviewed for end-of-life care and services, out of a total sample of 4 patients, (#1). Findings: Review of the hospice agencys Services Guide (undated) revealed a Hospice Care Team would deliver individualized care to patients and their caregivers. The team members included a Nurse Case Manager who would coordinate the patients care with the physician and other members of the team. The booklet indicated nurses would meet with the patient to assess symptoms, review the plan of care, and arrange for delivery of necessary supplies to ensure the patient was as comfortable as possible. Review of the medical record revealed patient #1, a 77-year-old male, was admitted to the hospice on 3/10/23 with terminal diagnosis of Chronic Obstructive Pulmonary Disease (COPD). His secondary diagnoses included coronary artery disease, pulmonary fibrosis, pulmonary hypertension, cardiomyopathy (a disease of the heart muscle), and Implantable Cardioverter Defibrillator (ICD). Patient #1 died at home on 4/11/23. According to the American Heart Association, an ICD is a battery-powered generator, about the size of a pocket watch, that is implanted under the skin of the chest, often just below the collarbone. The purpose of the device is to detect an abnormal heartbeat and restore it to a normal rhythm. If the heart beats too slowly, the pacemaker feature sends small electric signals to the heart to increase the heart rate. If the heartbeat is too fast or erratic, the device gives defibrillation shocks to stop the abnormal rhythm (retrieved on 2/02/24 from www.heart.org/en/health-topics/arrhythmia/prevention--treatment-of-arrhythmia/implantable-cardioverter-defibrillator-icd). On 1/29/24 at 11:36 AM, in a telephone interview, patient #1s wife explained prior to discharge home from the hospital, she informed hospice admissions staff that he had a pacemaker/defibrillator implanted in his chest. She stated the hospice staff assured them the device would not pose a problem as it would be disabled. Patient #1s wife stated her husbands end of life journey was traumatic instead of peaceful as the defibrillator was never deactivated. She tearfully explained she felt her husband was tortured when he received at least five excruciatingly painful electrical shocks from his defibrillator as it attempted to restart his heart over a 4-hour period preceding his death. Review of patient #1s medical record revealed Registered Nurse (RN) B documented seven comprehensive assessments during the month he received hospice services. The RN Hospice Visit assessments done on 3/13/23, 3/16/23, 3/22/23, 3/28/23, 4/04/23, 4/07/23, and 4/10/23 showed no narrative documentation under Comments in section designated for Cardiovascular findings regarding the presence of an ICD or plans to deactivate the device. However, the RN Hospice Visit notes dated 3/16/23, 4/04/23, and 4/10/23 showed patient #1 had a permanent pacemaker/ICD checked off as a device. On 1/29/24 at 2:19 PM, RN B stated she was never aware patient #1 had a defibrillator and therefore would not have discussed deactivation of the device with the patient or his wife. RN B recalled she discovered the patient had a defibrillator the morning after he died. She explained the previous medical record software used by the hospice agency prominently displayed an alert in the system for an ICD, but “;now I have to look in the admission notes or cardiac notes.” RN B was informed the patients admission notes and some of her Hospice Visit notes showed patient #1 had an ICD. She reviewed the medical record and explained the presence of the ICD was pre-populated as it was carried forward from the initial assessment. She expressed disbelief and emphasized she never noticed it. RN B showed an email to her supervisor dated 4/12/23 at 7:45 AM that read, “;[Name of patient] died (how did I not know he had a defibrillator?!).” On 1/30/24 at 10:54 AM, in a telephone interview, patient #1s wife was informed the Nurse Case Manager, RN B, was not aware her husband had an ICD. The wife explained the device was clearly visible as it protruded from his chest and there was a noticeable scar over the device at the insertion site. Patient #1s wife stated her husband was usually in bed without a shirt when hospice staff visited, and he kept only his lower body covered with a sheet for dignity. The wife recalled RN B contacted her on the morning after her husband died when she learned he was shocked by his defibrillator. Patient #1s wife said, “;She took no responsibility for what happened.” On 1/29/24 at 3:21 PM, Director of Clinical Services (DCS) J verified when a new hospice patient was admitted, the Admission Nurse would communicate basic information about the patient in an email to members of the clinical and management teams in an Explanation of Visit report. DCS J confirmed the assigned RN Case Manager would receive that email. DCS J was informed that review of an email dated 3/10/23 at 2:35 PM, sent by the Admission Nurse after patient #1 was admitted, revealed his pacemaker/ICD was not listed. DCS J explained the admission note indicated the patient had an ICD and her expectation was the RN Case Manager would review all prior notes and not rely on the Explanation of Visit report. She acknowledged patient #1 ultimately experienced a negative outcome due to the RN Bs inaction. On 1/30/24 at 10:15 AM, Nurse Mentor RN C confirmed data such as the presence of a pacemaker/ICD pulled forward from previous visits, but each nurse must read and verify all information in an assessment note. She stated a head-to-toe assessment involved a thorough review of each body system and was required at least once every week. She explained a comprehensive head-to-toe assessment included listening to the patients lungs and heart sounds, preferably underneath clothing, and evaluating the skin on all surfaces of the body. Nurse Mentor RN C stated an ICD was typically easily visible in the left upper chest area and she could not explain how RN B could have completed several head-to-toe assessments for patient #1 and missed the presence of an ICD. She stated the hospice agency did not assess RN Case Managers for competency in assessments as they hired experienced nurses and assumed this basic skill was present. Review of the job description for Case Manager, revised in May 2020, revealed he/she would provide professional nursing care in the coordination of patients plans of care. The Case Managers duties and responsibilities included providing skilled nursing services, conducting patient assessments, and utilizing clinical nursing skills. Required knowledge and skills included knowledge of the electronic medical record and knowledge of nursing skills in the performance of duties.”

“Based on interview and record review, the hospice agency failed to effectively organize and manage its resources and implement its processes to optimize comfort, peace, and dignity during the dying process for 2 of 4 patients reviewed for implanted cardiac devices, (#1 & #2), and failed to develop systems that prioritized interventions to meet the needs of all patients admitted with life-sustaining treatments. Findings: Review of the Hospice Caregiver Guide (undated) revealed the hospice agency’s goal to help patients be as comfortable as possible and provide necessary support on their end-of-life journey. The guide indicated the hospice care team would assess patients’ needs and provide visits and equipment as indicated. Review of the hospice agency’s Implantable Cardiac Defibrillators (ICDs) Deactivation and Disabling Process, updated 7/30/20, revealed the electrical shock from a defibrillator implanted in the chest may feel like a kick in the chest. The document read, “Such discharges may not be consistent with the patient/caregiver goals of care as well as a source of pain and distress to the patient/caregiver.” The process indicated an ICD would attempt to resuscitate the patient at the end of life, which was inconsistent with the goal of comfort care for a dying patient. The document revealed the hospice agency would provide education, and if requested by the patient or caregiver, temporarily disable the device with a magnet, and then facilitate permanent deactivation of the ICD. On 1/29/24 at 1:00 PM, Director of Clinical Service (DCS) J confirmed recently there was an allegation regarding a patient being shocked by his pacemaker/defibrillator at the end of life although hospice staff were previously aware of the patients wish to deactivate the device. She stated patient #1s wife posted a negative review on a social media site on 1/17/24 and it was brought to her attention via an email from their Marketing department. DCS J explained she was not aware of the event that occurred in April 2023 until she was notified approximately ten days ago, and therefore the agencys Administration had not yet fully investigated or addressed it with all staff to prevent reoccurrences. She verified the hospice agencys goal was to promote a peaceful dying process which would not be supported by an active defibrillator, a life-sustaining device. DCS J acknowledged patient #1s defibrillator was never deactivated as requested, no magnet was left in the home, and no staff were immediately available to provide a magnet to disable the device once it began to shock him. She confirmed she would have expected all staff who were aware of the negative outcome, including the nurse who responded to patient #1s home and eventually applied the magnet, the assigned Registered Nurse (RN) Case Manager, and the Patient Services Line Triage Nurse, to communicate that information to nursing management and/or nursing administration. DCS J stated she did not know how many of the 821 current patients had ICDs, nor if any of the devices still had functioning defibrillators. She explained to her knowledge, there was no way to pull that information as a report from the medical record. When asked to provide a list of all patients who were admitted with pacemaker/defibrillator devices from April 2023 to present, DCS J sent an email to all Team Managers and asked them to reach out to their RN Case Managers to obtain names of patients with ICDs. On 1/29/24 at 2:19 PM, patient #1s Nurse Case Manager, RN B, stated she was surprised when she discovered patient #1 was shocked by his defibrillator before he died, as she did not know he had the device. She explained in the previous medical record software, there used to be an alert located on the opening screen if a patient had an ICD, but the current system did not provide easily visible access to information about devices such as ICDs. RN B provided email communication dated 4/12/23 at 7:45 AM, the morning after patient #1 died, that showed she informed her supervisor, the Yellow Team Manager, that she was not aware he had a defibrillator. She explained after the incident she had heightened awareness of ICDs and discovered other patients with devices she had not noted before. RN B stated she made a second attempt to have her concern addressed when she brought it to the attention of the Shared Governance Committee in a monthly meeting that was usually attended by either the Executive Director of Clinical Operations or DCS J. She recalled she spoke about the incident involving patient #1 shortly after it happened, as she felt it would be helpful to have a prominent alert regarding an ICD in the medical record. On 1/29/24 at 2:57 PM, the Yellow Team Manager recalled she found out RN B did not know patient #1 had a defibrillator until after he died. She did not remember an email from RN B and said, “;I somehow might have missed it. If I had known there was a traumatic ending, I would have reached out to the family. . .” The Yellow Team Manager added if she were aware, she would have discussed it with the clinical management and administrative team members or initiated the hospice agencys concern process. She stated an ICD should probably be displayed prominently in the electronic medical record and said, “;I think it was probably a process issue and lack of communication.” On 1/29/24 at 3:21 PM and 5:23 PM, DCS J stated she would have expected the Yellow Team Manager to forward RN Bs email to her and inform her of patient #1s negative outcome. DCS J was informed RN B shared her concerns regarding the unidentified ICD with the Shared Governance Committee. DCS J stated she was not present at the meeting and the concern was never relayed to her by the committee members. The hospice agency did not retain minutes of the Shared Governance meeting at the time of the incident. DCS J explained the incident was not recorded as a concern and escalated to or by the Yellow Team Manager; therefore, it was never brought to quarterly meetings when the Steering Committee, which included executive staff, reviewed concerns and incidents. On 1/30/24 at 9:24 AM, DCS J provided a list of patients admitted with defibrillators from April 2023 to January 2024. She explained the list comprised randomly selected patients from the names she retrieved via a search of email communication from the Admissions department. DCS J stated she was unable to provide a complete list as there was no way to retrieve a report with this information from the hospice agencys electronic medical records. She acknowledged she would not have known patient #1 was admitted with a defibrillator as the device was not included in the Admissions department communication. On 1/30/24 at 10:05 AM, DCS J confirmed although magnets were affordable and there was adequate stock, the hospice agency did not have a process in place to provide them to nurses or leave them in the homes of patients whose defibrillators remained active. On 1/30/24 at 4:27 PM, DCS J and the Director of Corporate Responsibility and Quality were informed a review of patient #2s medical record revealed he was also shocked by his defibrillator in April 2023 due to nurses failing to arrange deactivation of the device as requested by his son. DCS J stated she knew nothing about that incident and commented that it occurred practically the same week as patient #1s incident. She emphasized her expectation was the Nurse Case Manager, RN E, would have reported it to her Team Manager and the Triage Nurse should have reported to her Team Manager. DCS J said, “;No matter what, it should have been reported to me. I would have wanted to be aware.” She validated the occurrence of two similar incidents, approximately one week apart, related to patients with defibrillators being shocked was concerning. DCS J stated it was even more concerning that she was not aware of either incident for more than nine months afterward. On 1/31/24 at 10:20 AM, DCS K stated it would be helpful if an ICD was shown in the electronic medical record as a priority item to be addressed by hospice staff. She explained the hospice agency admitted patients with other life-sustaining treatments and measures such as dialysis, chemotherapy, and tube feeding, and it would be appropriate to highlight these issues since ideally, they should be withdrawn in the end-of-life setting. DCS K explained the hospice agency did not currently have a system in place to ensure patients with life-sustaining measures had these interventions clearly flagged in the medical record. She validated there was no method for nursing leadership to accurately retrieve information and monitor the patients who had life-sustaining treatments as they were not always noted as diagnoses in the medical record. On 1/31/24 at approximately 10:56 AM, the Director of Corporate Responsibility and Quality confirmed the hospice agency did not honor the preferences of patients #1 and #2 to have their ICDs deactivated to prevent electrical shocks at the end of their lives. He acknowledged there was evidence of communication failures at the frontline, management, and administration levels.”