DBA Hawai’i Care Choices

“Based on interview and record review, the Hospice Provider failed to implement their own policies and procedures regarding complaint resolution, thereby limiting the patient/family from exercising their rights. Findings include: Patient (P)1 was an 80-year-old male admitted to the Hospice Provider (HP) on 06/04/24 while he was a resident at a skilled nursing facility. On 06/25/24, P1 was discharged home where he continued to receive Hospice services and then passed on 07/16/24. On 11/27/24 the state agency (SA) received a complaint from the family of P1 regarding the care he received while receiving Hospice services at home. The familys concerns and complaints were expressed to multiple staff members of the HP, both in person and over the phone. Part of their complaint to the SA is that their concerns were not addressed by the HP. On 01/02/25, the SA entered the HP to conduct an abbreviated survey investigation into the familys complaint(s). A copy of the Grievance/Complaint Log for the last 12 months was requested. Review of the Hospice Provider policy and procedure, Complaint Resolution, last revised 02/2019, revealed the following: “;... [the facility/Hospice Provider] has a complaint resolution process that is implemented whenever a complaint is received.” “;Complaints/concerns brought to the direct attention of any employee or volunteer are addressed immediately whenever possible...” “;All complaints are documented in a complaint log...” “;Appropriate personnel conduct and document an investigation of all written or verbal complaints received.” Review of the 2024 Concern/Complaint Summary, which the Hospice Provider identified as their Complaint Log, noted documentation of five total complaints for the 2024 calendar year, none of which were from P1 or his family. On 01/02/25 at 12:00 PM, an interview was done with the RN [Registered Nurse] Quality & Compliance Auditor (QCA) in the conference room. QCA verified that the complaint(s) from P1s family were not documented on the log. QCA also confirmed that the HP was aware that the family was upset and had concerns, and that a complaint had been initiated by HP staff. QCA explained at this time that the HP believed an IT [information technology] disruption had occurred and that was why the complaint was not showing as being logged. In addition, QCA confirmed that without documentation of the familys complaint(s), they would not have been investigated or fully addressed. On 01/02/25 at 01:14 PM, an interview was done with P1s primary caregiver (PCG) and P1s second daughter (D2) in their home. PCG shared that on the day P1 passed away, they were visited by the Director of Clinical Services (DCS) to whom they expressed several concerns and issues. DCS told her/them she would “;look into” the concerns and “;get back” to her/them, but never did. A review of DCSs Nurse Progress Note Routine Visit, dated 07/16/24, documented that the family “;voiced concern about various medications used and how they impacted patients [sic] response.” Documentation did not indicate any action to be taken (such as investigation into the concerns expressed) or how the concerns would be addressed.”

“Based on interview and record review, the Hospice Provider failed to involve the patient/family in the development of Patient (P)1s plan of care. As a result of this deficient practice, the family (and primary caregiver) were unaware of what the Hospice Aide plan of care was. Findings include: Patient (P)1 was an 80-year-old male admitted to the Hospice Provider (HP) on 06/04/24 while he was a resident at a skilled nursing facility. On 06/25/24, P1 was discharged home where he continued to receive Hospice services and then passed on 07/16/24. On 11/27/24 the state agency (SA) received a complaint from the family of P1 regarding the care he received while receiving Hospice services at home. The familys concerns and complaints were expressed to multiple staff members of the HP, both in person and over the phone. Part of their complaint to the SA is that they were never invited to a care plan meeting, aware of P1s plan of care, or involved in developing his plan of care. Specifically, the family stated they had no idea what the Hospice Aide was responsible for doing or even was able to do when she visited. On 01/02/25, the SA entered the HP to conduct an abbreviated survey investigation into the familys complaint(s). On 01/02/25 at 01:14 PM, an interview was done with P1s primary caregiver (PCG) and P1s second daughter (D2) in their home. PCG shared that on the day P1 passed away, they were visited by the Director of Clinical Services (DCS) who they expressed several concerns and issues to, including that they had not received a copy of the plan of care despite requesting it multiple times, and as a result, they had no idea what the Hospice Aide should be doing when she visited. PCG and D2 stated that DCS did discuss the Hospice Aide plan of care with them, told them she would revise it, and they still never got a copy of it. A review of DCSs Nurse Progress Note Routine Visit, dated 07/16/24, verified that a discussion did take place regarding the plan of care, as the family indicated. During the same interview, PCG stated (and later provided screen shot documentation) that on 07/14/24 she had communicated by text message with Medical Social Worker (MSW)1 and had indicated that she had previously requested a copy of the plan of care and had not received it. Review of the screen shot text messages noted the following: PCG: “;I have not received the Care Plan. I was hoping to receive it Friday [07/12/24].” MSW1: “;Sincere apologies. I will follow up with the team and request they contact you.” Review of the HPs policy and procedure titled Plan of Care, created and last reviewed on 03/2013, revealed the following: “;The care and services provided to patients and their families are in accordance with an individualized, written plan of care...” “;Each patient and his or her primary caregiver(s) receive education and training from the hospice as appropriate to their responsibilities for the care and services provided in the plan of care.” Review of the HPs policy titled Hospice Aide Services, last revised 10/2021, revealed the following: “;The hospice aides services are ordered by the IDT [interdisciplinary team], included in the patients plan of care and are consistent with the hospice aides training.” Review of the HPs policy and procedure titled Coordination of Services, created and last reviewed on 03/2013, revealed the following: “;All members of the IDT, volunteers, and contracted personnel have access to the patients plan of care and are expected to provide care in accordance with it.””

“Based on interview and record review, the Hospice Provider (HP) failed to revise and document an individualized plan of care for Patient (P)1 once he was discharged from Hospice services in the skilled nursing facility (SNF) to receiving Hospice services in the home. As a result of this deficient practice, P1s plan of care did not accurately reflect his increased needs. Findings include: Patient (P)1 was an 80-year-old male admitted to the Hospice Provider (HP) on 06/04/24 while he was a resident at a skilled nursing facility (SNF). On 06/25/24, P1 was discharged home where he continued to receive Hospice services and then passed on 07/16/24. On 11/27/24 the state agency (SA) received a complaint from the family of P1 regarding the care he received while receiving Hospice services at home. Part of their complaint to the SA is that they were never made aware, or received a copy of, P1s plan of care, despite multiple requests for it. On 01/02/25, the SA entered the HP to conduct an abbreviated survey investigation into the familys complaint(s). Review of P1s plan of care at the time of his passing, Combined Disciplinary Plan of Care, dated 07/11/24, revealed that although the Level of Care indicated “;Routine Home Care,” the Goal Description and Intervention listed for most of the goals in the plan of care included “;facility nursing staff” and “;facility staff.” On 01/03/25 at 11:26 AM, an interview was done with the RN [Registered Nurse] Quality & Compliance Auditor (QCA) in the conference room. During a concurrent review of P1s plan of care with QCA, she confirmed that the plan of care should have been revised on 06/25/24 when P1 began receiving Hospice services in the home but was not. QCA agreed that P1 had different needs in the home and that the interventions planned while in the SNF would not be applicable once in the home setting. Review of the HPs policy and procedure titled Plan of Care, created and last reviewed on 03/2013, revealed the following: “;The care and services provided to patients and their families are in accordance with an individualized, written plan of care...” “;The plan of care is reviewed and updated by the IDT [interdisciplinary team] every 15 days or more frequently if needed.” “;Revisions to the plan of care are based on information from the patients updated comprehensive assessment...””

“Based on interview and record review, the Hospice Provider failed to provide hospice care that optimized comfort and dignity for Patient (P)1 and was consistent with family needs and goals. Findings include: Patient (P)1 was an 80-year-old male admitted to the Hospice Provider (HP) on 06/04/24 while he was a resident at a skilled nursing facility (SNF). On 06/25/24, P1 was discharged home where he continued to receive Hospice services and then passed on 07/16/24. On 11/27/24 the state agency (SA) received a complaint from the family of P1 regarding the care he received while receiving Hospice services at home. Part of their complaint to the SA is that while he was actively declining and death was “;imminent,” a Registered Nurse (RN)1 administered a laxative suppository to P1 despite him appearing comfortable with no indications of pain, and against the primary caregivers wishes. A review of RN1s Nurse Progress Note Routine Visit, dated 07/12/24 08:00 AM, revealed she assessed P1 as “;imminent [meaning his passing was close]”, having a pain score of zero, his emotional condition as “;Peaceful,” his blood pressure as normal, with “;dry membranes”, and a “;dry mouth [indicating dehydration],” his abdomen as “;Soft – nontender, nondistended,” and his last documented bowel movement as 07/05/24. RN1 also documented P1 as having three pressure ulcers in the area of his disposable brief, one on each gluteal fold and one on his tailbone [which would be aggravated with watery stools]. On 01/02/25 at 01:14 PM, an interview was done with P1s primary caregiver (PCG) and P1s second daughter (D2) in their home. PCG shared that on 07/12/24, RN1 administered a laxative suppository to P1 even though he was “;comfortable” and “;peaceful,” and against her very strongly expressed wishes and belief that he did not need it as he had just had a bowel movement the day before. PCG stated she just wanted P1 to rest and not be bothered with the movement required to change his disposable brief, as his pain increased with movement. She also did not want P1 to become more dehydrated, having watery stools, when he was unable to take in as much fluid volume as he was putting out. PCG expressed frustration and deep distress that although she was the primary caregiver for P1, she was not being listened to. When informed that RN1s progress note indicated that she had received consent prior to administering the laxative, documenting “;PCG [primary caregiver] is agreeable,” PCG stated that was absolutely not true and she never gave consent. PCG explained that she had to leave the room in anger and frustration because she was not feeling heard, and while she was gone, RN1 “;pressured” D2 into giving consent. When asked, D2 stated that RN1 told her P1 “;had a blockage” and even though PCG was against it, she did feel pressured by RN1 to listen to her because she was the educated and trained nurse. D2 explained that she reluctantly gave her consent after much discussion, but she regretted it instantly. Both daughters agreed that they believed the suppository caused P1 unnecessary pain and discomfort and may have hastened his death. On 01/07/25 at 08:15 AM, a phone interview was done with the RN [Registered Nurse] Quality & Compliance Auditor (QCA). QCA was asked what the standard of care is for a patient that has no indications of discomfort as long as he is not being moved, a soft and nondistended abdomen, whose death is imminent but has not had a bowel movement in 7 days. Would the administration of a laxative suppository be clinically necessary or appropriate from a Hospice point-of-view? Although agreed that constipation without signs of discomfort when death is imminent is not a priority, QCA responded that it depends on the patient, and she would ask the family. If the family did not agree, she would not administer it.”

“Based on record review and interview, the facility failed to ensure the initial bereavement assessment for 3 of 19 patients (Patients 2, 15, and 17) sampled appropriately identified and documented the needs and coping ability of the patients families, and/or were accurately reflected in the bereavement risk level. Findings include: 1) Patient (P)2 is a 71-year-old female with an election of hospice care (EOC) date of 04/03/24. Since spiritual counseling services were declined by P2, the Bereavement Assessment, done on 04/04/24, was completed by Medical Social Worker (MSW)1 as part of her initial assessment. Review of the Social Worker Progress Note Initial Assessment revealed the following under the section Family Adaptation – Social Worker: “;Patient and family/caregiver interaction: Appropriate.” “;Family/Caregiver emotional status: Calm.” “;Comments: Patient reports she lives with 1 daughter... Patient reports PCG [primary care giver] works and is a good caregiver.” Under the section Bereavement – Social Worker: “;Risk Level: Low Risk.” Under the section Summary: “;Per patient request, MSW conducted telephonic initial visit with patient.” Nowhere in the assessment was there any indication that the daughter P2 lived with, her PCG, was either present or spoken to by MSW1. An interview was done with the RN [registered nurse] Quality and Compliance Auditor (RQCA) in the conference room on 05/23/24 at 10:04 AM. Upon concurrent record review of MSW1s initial assessment, RQCA agreed that it was unclear how caregiver interactions, emotional status, and bereavement readiness could have been assessed by telephone, and agreed that it was not reflected in the documentation. 2) Patient (P)15 was a female with an EOC date of 09/29/23, who passed on 10/10/23. Since spiritual counseling services were declined by P15, the Bereavement Assessment, done on 10/02/23, was completed by MSW1 as part of her initial assessment. Review of the Social Worker Progress Note Initial Assessment revealed the following under the section Family Adaptation - Issues: “;Issue: Family/CG [caregiver] not coping effectively.” “;Issue Description: Patients daughter and 2 grandchildren are not coping effectively.” Under the section Bereavement – Social Worker: “;Risk Level: Low Risk” An interview was done with the RQCA in the conference room on 05/23/24 at 12:39 PM. Upon concurrent record review of MSW1s initial assessment, RQCA agreed that when family coping issues are identified and documented, a bereavement determination of Moderate Risk Level might be more appropriate. The RQCA also agreed that a higher risk determination could only be beneficial as it would mean a greater degree of planning and interventions implemented to address the issues identified. 3) Patient (P)17 was a female with an EOC date of 02/02/24, who passed on 02/07/24. Since spiritual counseling services were declined by P17, the Bereavement Assessment, done on 02/05/24, was completed by MSW2 as part of her initial assessment. Review of the Social Worker Progress Note Initial Assessment revealed the following under the section Family Adaptation – Social Worker: “;Family/Caregiver emotional status: Overwhelmed.” “;Comments: ... Family expressed some difficulties, surrounding patients somewhat rapid decline and was not ready for patient to go so quickly.” Under the section Bereavement – Social Worker: “;Risk Level: Low Risk” “;Coping challenges: None...” An interview was done with the RQCA in the conference room on 05/23/24 at 12:37 PM. Upon concurrent record review of MSW2s initial assessment, RQCA agreed that when family adaptation concerns are identified and documented, a bereavement determination of a Moderate Risk Level might be more appropriate. The RQCA also agreed that a higher risk determination could only be beneficial as it would mean a greater degree of planning and interventions implemented to address the concerns identified.”