Hospice of Mercy

“Based on clinical record review, hospice policy review and staff interview, the hospice failed to ensure the hospice interdisciplinary Group reviewed the patient’s plan of care based on the updated comprehensive assessment and include the patient’s progress towards outcomes and goals specified in the plan of care for 1 of 6 sampled patients (Patients #6) requiring a start of care and an updated comprehensive assessment and Interdisciplinary Group meeting review. Failure of the hospice to ensure the Interdisciplinary Group (IDG) reviewed the patient’s plan of care based on the updated comprehensive assessment and include patient’s progress towards outcomes and goals placed patients at risk to not receive care and services based on their current assessed needs. According to the policy, titled Wound Care, dated 10/23/23, wound assessment will occur with the comprehensive assessment and as part of the update to the comprehensive assessment when a wound is present and includes the Type of wound, location, measurements, drainage, and assessment of the wound bed. The wound assessment will also include orders for the current treatment. During an interview with the Clinical Manager, Staff B, on 9/4/24, at 4:00 pm stated that the expectation is when there is a wound present, an assessment will be done for the wound, as part of the comprehensive assessment and updated care plan. During an interview on 9/5/24 at 11:50 AM, Staff A, Administrator, reported the hospice would need to look at the wound policy and process for monitoring wounds and make changes to improve the process for monitoring wounds. Hospice will provide education to all staff, including Staff D, RN. Patient #6 had a start of care date of 11/14/23, date of death of 4/20/24 and received hospice services in the home. Review of the clinical record revealed the following: a. The Plans of Care (POC) dated 11/14/23 to 2/11/24 and 2/12/24 to 5/11/24, included the physician orders for skilled nursing to complete a wound assessment every visit. b. The comprehensive start of care assessment completed by Staff D, Registered Nurse (RN), dated 11/14/23, identified documentation of a pressure ulcer on the patient’s coccyx, covered with a dressing, and Staff D, RN documented she was unable to assess. The documentation lacked assessment of the wound. The patient’s spouse does the wound cares. c. The 2 IDG notes, dated 11/15/23 and 11/23/23, identified patient required wound care supplies, but lacked documentation of the coccyx wound. d. The recertification comprehensive assessment, dated 1/29/24, completed by Staff D, RN, included coccyx wound assessment with measurements 0.5 centimeters (cm) by 0.5 cm and indicated the wound was a stage two pressure ulcer ( open area over a pressure area with partial thickness). e. IDG note, dated 1/31/24, included orders, effective 1/29/24, to cover the coccyx with a dressing every three days and as needed if the dressing became soiled or came off, but lacked wound assessment. f. The 4 IDG notes, dated 2/28/24, 3/14/24, 3/28/24, and 4/10/24, lacked assessment of the coccyx wound. g. The recertification comprehensive assessment dated 4/15/24, completed by Staff D, RN, included documentation the wound was not assessed, but the caregiver reported coccyx wound was not open. The 7 IDG notes, prior to the coccyx wound being reported as not open, failed to include documentation of a wound assessment every 15 days. The findings were reviewed with the Administrator.”

“Based on hospice clinical record review, hospice policy review, patient/representative interview and hospice staff interview, the hospice failed to ensure the patient received information about the level of care services covered under the hospice benefit for 1 of 5 sampled patients (Patient #5). Failure of the hospice to ensure the patient received information about the level of care services covered under the hospice benefit increased the risk that patients did not receive appropriate services to meet assessed needs. Findings include: Review of the undated policy titled, Rights and Responsibilities Hospice, dated 10/13/23, The patient’s rights include, but are not limited to: a. to receive information about the services covered under the Medicare hospice benefit or by other payer sources, the services the hospice will provide and any specific limitation(s) on those/services services, and to be informed of the charges not covered by insurance. b. To make decisions regarding care, including pallative care and the right to refuse care, treatment or services. Patient #5 had a hospice admission date of 7/12/23, a death date of 12/20/23 and received hospice services while residing in a private home from 7/12/23 to 10/25/23, in Hospice House from 10/26/23 to 12/3/23, and in a nursing home from 12/4/23 to 12/20/23. Clinical record review revealed the following: a. Interim physician order, dated 11/1/23, level of care changed from hospice routine care to hospice general inpatient care. b. Social work visit note, dated 11/1/23, included documentation the level of care was changed to general inpatient care. The level of care consents were left in patient #5’s room for caregiver to sign when he/she arrived at Hospice House later that day on 11/1/23. The clinical record lacked documentation of patient or caregiver consent to level of care change from hospice routine care to hospice general inpatient care. During an interview on 3/6/24 at 3:15 PM, the Administrator reported the inability to locate a signed consent for the level of care change on 11/1/23 from hospice routine care to hospice general inpatient care. The above findings with the Administrator, Clinical Manager and Quality Coordinator. Hospice staff provided no further information prior to the end of the survey.”

“Upon patient record review, 7 of 25 (Patient #4, 6, 10, 14, 17, 19, 20) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy Patient 4: The medication list indicates lidocaine-prilocaine (EMLA) cream apply topically to affected area bid as needed. There is no specifier for the as needed indication. (corrected onsite) Patient 6: The patient’s oxygen does not appear on the medication list. (corrected onsite) Patient 10: The medication list indicates camphor menthol lotion 1 application topically bid for itching. There is no location indicated for the topical lotion. (corrected onsite) Patient 14: The medication list indicates Lumigan 0.01% 1 gtt to eye HS. There is no indication which eye(s) the eyedrops are to be used in. The medication list also indicates dorzolamide gtts inject 22.3mg to eye daily. There is no strength indicated for this eye drop, no indication which eye(s) the eyedrops are to be used in, and an error in the instructions related to injecting these topical eyedrops. (corrected onsite) Patient 17: Miralax is indicated on the medication list, with no instructions for reconstitution. (corrected onsite) Patient 19: The patient’s oxygen does not appear on the medication list. (corrected onsite) Patient 20: Miralax is indicated on the medication list, with no instructions for reconstitution. (corrected onsite)”

“Upon patient record review (and direct observation during the home visit of Patient #1), 2 of 25 (Patient #1, 19) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 1: During the home visit, it was observed the patient had a Foley catheter in place. Orders were present from the physician for the Foley catheter, including appropriate size and instructions for changing. On 11.24.2023, the hospice received a call from the SNF and a PRN SN visit was made related to the Foley being clogged. The medication list included flushes for ongoing Foley catheter care. However, no care plan was present relating to the genitourinary system/impaired continence/use of Foley catheter reflecting the patient’s problems and ongoing interventions. (corrected onsite) Patient 19: Per the initial comprehensive nursing assessment and subsequent documentation, it was noted that the patient relies on a Foley catheter. Orders were present for the Foley catheter, and the medication list included flushes for ongoing Foley catheter care. However, no care plan was present relating to the genitourinary system/impaired continence/use of Foley catheter reflecting the patient’s problems and ongoing interventions. (corrected onsite)”

“Upon patient record review, 1 of 25 (Patient #12) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 12: On admission on 10.17.2023 an order was obtained for Tylenol 650mg po 2 tabs bid for pain. On the SN visit of 12.12.2023, the SN indicated the patient was now taking the Tylenol TID (3 times daily), but there was no evidence a new order was obtained from the physician for this increased dosage.”

“Upon patient record review (and on direct observation during the home visit of Patient #5), 4 of 25 (Patient #4, 5, 11, 13) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient 4: The patient has nebulized medications ordered; however, a nebulizer does not appear on the plan of care related to equipment needs. (corrected onsite) Patient 5: The patient has nebulized medications ordered, and during the home visit the patient was observed to have a nebulizer in her room; however, a nebulizer does not appear on the plan of care related to equipment needs. (corrected onsite) Patient 11: Per the initial comprehensive nursing assessment and subsequent visit notes, the patient utilizes a Hoyer lift for transfers; however, a Hoyer lift does not appear on the plan of care related to equipment needs. (corrected onsite) Patient 13: Per the initial comprehensive nursing assessment and subsequent visit notes, the patient utilizes a walker for ambulation; however, a walker does not appear on the plan of care related to equipment needs. (corrected onsite)”

“Upon observation and patient record review, there was no evidence the hospice investigates all adverse events, incidents, accidents, variances or unusual occurrences that involve patient care and develops a plan of correction to prevent the same or similar event from occurring again. Patient 3: Per documentation in the patient record, the patient experienced 2 falls during the week of 11.19.2023. Neither fall was recorded on the hospice’s incident report log; therefore, the falls were not investigated and included in the hospice’s plan of correction to prevent similar events. Patient 5: Per documentation in the patient record, the patient experienced a fall on or about 11.16.2023. This fall was not recorded on the hospice’s incident report log; therefore, the fall was not investigated and included in the hospice’s plan of correction to prevent similar events. Patient 7: Per documentation in the patient record, the patient experienced a fall on or about 11.30.2023. This fall was not recorded on the hospice’s incident report log; therefore, the falls were not investigated and included in the hospice’s plan of correction to prevent similar events.”

“Upon patient record review, 1 of 25 (Patient #18) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient 18: The HA care plan indicates the patient’s bath may be a sponge bath or a shower. The care plan must specify which tasks are to be performed by the aide, and cannot allow for the choice of bath type. (corrected onsite)”

“Upon observation of the New Construction, there is no evidence the smoke compartmentation and control of a facility is provided consistent with the 2012 editions of the LSC of the National Fire Protection Association and NFPA 99. The provisions of the adopted edition of the Life Safety Code do not apply in a State if CMS finds that a fire and safety code imposed by State law adequately protects patients in hospices. During Life Safety Code inspection of the IPU, it was observed that a ceiling tile in the common hallway space where the piano is located had been compromised by a previous water intrusion, which would potentially allow the passage of smoke or fire. The ceiling tile had a spattering of rust, and was located directly beneath a sprinkler test drain; there was no present indication of water on the sprinkler system pipe or fitting. It was also observed that a ceiling tile in the whirlpool room, across from patient room #7, had been compromised by a previous water intrusion, which would potentially allow the passage of smoke or fire; there was no present indication of water. Additionally, one of the smoke barrier doors in the main visitor passage leading from the visitor front entrance to the patient care area does not close flush, preventing a complete seal of the smoke barrier doors and potentially allowing the passage of smoke or fire. (corrected onsite) During Life Safety Code inspection of the IPU, it was observed that soiled linen was stored in a receptacle measuring approximately 48” x 28” x 60”, or approximately 350 gallons, which was located in the tech’s utility closet, rather than in an appropriate fire rated hazardous storage area. (corrected onsite)”