Moments Hospice of Des Moines LLC

“Based on observations, interviews, record reviews, and agency policy review, the agency failed to ensure the required Interdisciplinary group (IDG) team members had collaborated to develop and/or revise the plan of care (POC) for three of three patients (Patients (P) 5, P6, P7) observed during home visits out of a total sample of 14. The agency failed to revise the POC for P5 and P7 related the oxygen usage and failed to develop a POC for P6’s move from one facility to another and the subsequent physical and emotional decline. This deficient practice placed all 32 patients who receive services from the Hospice agency at risk for unmet care needs and a diminished quality of life. Findings include: Review of the agency policy titled, “The Plan of Care,” dated 08/25/22, revealed, “. . . A written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program and the patient’s family in collaboration with the primary/attending physician . . . The plan of care will be based on the initial, comprehensive and ongoing comprehensive assessments performed by members of the interdisciplinary group and will be reviewed on a regular basis but no less than every fifteen (15) days . . . This plan will focus on identified problems, goals, and interventions. The patient and family/caregiver will be encouraged to participate in the development of and continued updating of the plan of care . . . Any changes in the patient’s condition must result in a change in the plan of care, prior to implementation of the new service . . .” 1. Review of P5’s “Hospice IDG Comprehensive and Plan of Care Update,” located in the “IDG” tab of the electronic medical record (EMR), revealed P5 was admitted to the hospice agency with a start of care date on 01/07/25 with a terminal diagnosis of hypertensive heart disease without heart failure. Review of P5’s “Aide Care Plan Report,” dated 01/07/25 and provided by the Executive Director (ED) and confirmed on-site with CNA (Certified Nurse Aide)1, “. . . PRN [as needed] oxygen in place at 2 liters [L] via nasal cannula, practice oxygen safety, oxygen to be left on with all ADL [activities of daily living] cares; notify RNCM [Registered Nurse Case Manager] with any questions . . .” Review of P5’s “Hospice POC Report,” located in the “Clinical Entries” tab of the EMR and dated 01/07/25, revealed, “. . . Problem: Instruct on reason for oxygen and appropriate liter flow per minute as per physician order . . . Interventions: Instruct on safety issues related to oxygen use (how to connect and turn on oxygen, how to use either mask or nasal cannula, no smoking, need for no smoking signs, how to operate equipment and who and when/what number to call with any problems related to oxygen or oxygen equipment) . . . Goal: Patient/Caregiver(s) verbalizes understanding of indications of oxygen use and proper liter flow per minute . . .” During a home visit on 02/04/25 at 11:00 AM, P5 was observed in his/her recliner with oxygen being delivered via a nasal cannula. The oxygen concentrator was behind him/her with the liter setting at 3L/minute. P5 was asked if he/she knew why the liter setting on the oxygen concentrator was set at 3L instead of 2L, as per the “POC.” P5 stated, “My [family member] changes the setting when [he/she] feels it’s necessary for my breathing.” During an interview on 02/05/24 at 1:30 PM, RNCM 1 was asked about the changes in P5’s oxygen settings. The RNCM stated, “Yes, I am aware [the family member] changes the oxygen settings. [P5] had recently started using oxygen and I have educated the [family member] on oxygen settings and to call me first before changing them as I need to know if [P5] is having increased breathing problems. I will call the doctor and get the order changed to 2-4L/ min.” The RNCM was asked why the Respiratory “POC” was not updated with individualized interventions related to the family member changing the settings and when to call prior to changing the oxygen settings. The RNCM stated, “I will do it today.” 2. Review of P6’s “Hospice IDG Comprehensive and Plan of Care Update,” located in the “IDG” tab of the EMR, revealed P6 was admitted to the hospice agency with a start of care date on 02/20/24 with a diagnosis of hypertensive heart disease without heart failure. During a skilled nursing facility visit on 02/04/25 at 9:00 AM with RNCM 1, P6 was observed moaning and restless. His/her eyes were closed, and he/she refused to answer questions posed by the RNCM. The RNCM stated, “[He/she] was moved from another facility to this skilled nursing facility last week and [he/she] has not taken to the move easily. I was here on Friday, and [he/she] was having increased signs/symptoms of depression and anxiety with crying. [He/she] is 101 years old, and it now appears that [he/she] has declined as [he/she] is not eating or taking [his/her] medications.” Review of P6’s “Comprehensive POC” did not show an individualized problem, measurable goal or interventions related to moving P6 into a skilled nursing facility and the subsequent decline. 3. Review of P7’s “Hospice IDG Comprehensive and Plan of Care Update,” located in the “IDG” tab of the EMR, revealed P7 was admitted to the hospice agency with a start of care date on 07/24/24 with a diagnosis of chronic obstructive pulmonary disease (COPD). During a home visit on 02/04/25 at 1:00 PM, P7 was observed in his/her recliner and was receiving oxygen via a nasal cannula. Review of the “Comprehensive POC,” dated 07/25/24 and located in the “Clinical Entries” tab of the EMR, revealed, “Problem . . . Need for skilled teaching and monitoring use of oxygen-hospice . . . Intervention . . . Instruct on proper use of oxygen for comfort in terminal patient . . .” Further review of the “POC” revealed that on 08/13/24, the interventions to “Instruct on reason for oxygen and appropriate liter per minute as per physician order and to instruct on safety issues related to oxygen use (how to connect and turn on oxygen, how to apply either nasal cannula or face mask, no smoking, need for not smoking signs, how to operate equipment and who/when/what to call with any problems related to oxygen or oxygen equipment)” were removed from the “POC” by RNCM2. During an interview on 02/04/25 at 2:00 PM, the Administrator and Executive Director were asked why the oxygen interventions were removed from the “POC” as P7 was utilizing oxygen for his/her terminal diagnosis. The Administrator stated, “The nurse who removed it was a PRN nurse and when you look at the care plan [on the nurses’ laptop], there is a red button and if you click it, it will remove the intervention. He must have clicked on the wrong button.” During an interview on 02/06/25 at 6:00 PM, the Executive Director was asked about the IDG meeting that was just held, and the many issues that were discussed regarding the above patients and if POC was developed or updated at that time. The Executive Director stated, “Yes, I agree there were many issues discussed. Our POCs are computer generated, and it is not an easy system to work with. They can be individualized, but there needs to be education on how to do it.”