Horizon Hospice West

“Based on medical record review, observation, website review, and staff interview, it was determined the agency failed to ensure patient plans of care included interventions and changes based on ongoing assessments for 3 of 14 patients (Patients #4, #6 and #10) whose records were reviewed. This had the potential for identified needs to go unaddressed. Findings include: 2. Patient #10 was a 56 year old male admitted to the agency on 12/13/23 with a terminal diagnosis of alcohol induced dementia. Additional diagnoses included seizures, history of falls, and atrial fibrillation. He received SN, SW, aide, and chaplain services. His record for the certification period 12/13/23 to 2/10/24 was reviewed. Patient #10’s record included an SN SOC note dated 12/13/23 which stated the following: - Fall documentation stated, “AT RISK FOR FALLING,” and “UNSTEADY ON HIS FEET.” - The nursing narrative stated, “HE IS A RE-ADMIT FROM A 12/9/23 REVOKE. HE HAS TWO FALLS THAT DAY CAUSING A SEVERE NOSEBLEED. POA/WIFE [name] DECIDED IT WOULD BE BEST TO HAVE HIM EVALUATED AT A HOSPITAL ... NO FRACTURES NOTED.” - Head/neck assessment stated, “LEFT EYE CONTINUES TO HEAL FROM A FALL A WEEK PRIOR. EYE LID IS PURPLE.” - Integumentary assessment stated, “HAS AN EXTENSIVE HISTORY OF FALLS. CURRENTLY NO OPEN WOUNDS NOTED, BILATERAL HANDS HAVE HEALING BRUISES, FACIAL BRUISING IS HEALING.” Patient #10’s POC was reviewed. There were no fall interventions or goals for Patient #10. The DCS was interviewed on 12/04/24 beginning at 9:15 AM and Patient #10’s record was reviewed in her presence. She confirmed there were no fall interventions on Patient #10’s POC. She confirmed fall interventions would have benefitted Patient #10. 1. Patient 4 was a 59 year old male admitted to the agency on 11/14/24 with a terminal diagnosis of Protein Calorie Malnutrition. He received SN, MSW, and aide services. His record for the certification period 11/14/24 to 2/11/25 was reviewed.Patient #2’s POC included, “INSTRUCT BOWEL PROTOCAL AS NEEDED.” Additionally Patient #4s POC stated “;PATIENT WILL HAVE AN EFFECTIVE BOWEL PROGRAM.”Patient #2’s medical record included an RN start of care visit note dated 11/14/24. The note included that Patient #2s last bowel movement was on 11/11/24 3 days prior to the start of care. It also included that Patient #2 was started on a “;bowel regimen.” Patient #2’s medication list included 2 medications for constipation, MiraLAX, and Senna. Patient #2s medical record included a SN visit note dated 11/15/24. The note included that Patient #2s las bowel movement was on 11/12/24. Patient #2s medical record include a SN visit note dated 11/21/24. Under the assessment section titled “;GASTROINTESTINAL”, the nurse documented “;NO CHANGES SINCE LAST VISIT.” Additionally, under the section titled “;INTERVENTIONS PERFORMED” the record included “;INSTRUCTED PATIENT TO MONITOR DAILY BOWEL MOVEMENT AND TO CALL NURSE I NO BOWEL MOVEMENT IN 3 DAYS.” There was no documentation on when Patient #2s last bowel movement was. Patient #2s medical record included a communication note dated 11/25/24 that stated, “;RECEIVED MESSAGE FROM ON CALL NURSE... CAREGIVER CHRISSIE STATES THAT PT HAD A VERY LARGE WHITE BM [BOWEL MOVEMENT]. HADNT [sic] HAD A BM IN 7 DAYS BEFORE THIS. THEY DENY ANY NEEDS TONIGHT AS PT IS EXHAUSTED AN SLEEPING BUT WOULD LIKE A VISIT TOMORROW. Patient #2s medical record included a SN visit note dated 11/26/24. The note included, “;SPOKE TO CAREGIVER ABOUT BM LAST NIGHT. CAREGIVER STATED THAT THEY DO NOT HAVE BOWEL MEDICATION AND HAVE NOT BEEN GIVING ANYTHING TO PATIENT.” A home visit was conducted at Patient #2’s home on 12/3/24 with an RN. During the discussion with the RN, Patient #2’s caregiver was discussing Patient #2’s constipation and stated that Patient #2 was crying when he was attempting to have a bowel movement. Additionally, the caregiver stated that she had not received the MiraLAX until Friday 11/29/24. The caregiver stated he was on a scheduled medication for diarrhea Loperamide. The nurse than stated she would change the Loperamide to as needed. Drugs.com (https://www.drugs.com/tips/loperamide-patient-tips) stated that Constipation is a side effect of too much loperamide. There was no documented follow up on why Patient #2s caregivers were not giving the prescribed bowel regimen. Additionally, there was no documentation patient #2’s POC was updated to reflect his severe constipation. The DCS was interviewed on 12/4/24 beginning at 10:00 AM, and Patient #2s medical record was reviewed in her presence. She confirmed that Patient #2’s Loperamide was discontinued as scheduled medication and changed to as needed. She confirmed there was no documentation on follow up with caregivers on why medications for constipation were not given. Additionally, she confirmed Patient’s 2 POC was not updated with any changes prior to the home visit with the surveyor on 12/3/24.”

“Based on medical record review and staff interview, it was determined the agency failed to ensure care and services were provided in accordance with the plan of care for 3 of 14 patients (Patients #4, #9, and #11) whose records were reviewed. This had the potential to interfere with patient safety and coordination of patient care. Findings include: Patient #11 was a 89 year old male admitted to the Hospice on 11/07/24 with the primary terminal diagnosis of “;stroke” and additional comorbidities including but not limited to “;nontraumatic intracerebral hemorrhage, cerebral infarction, chronic systolic (congestive) heart failure, presence of xenogeneic heart valve, presence of other cardiac implants, non-rheumatic aortic (valve) stenosis, unspecified atrial fibrillation primary hypertension, atherosclerosis heart disease of native coronary artery without angina, inflammatory disease of prostate, peptic ulcer”. Patient #11 received SN, MSW, Chaplain and HHA. An updated terminal illness was recorded at the 11/13/24 IDG meeting as “;unspecified severe protein-calorie malnutrition” and the POC was updated to include “;Hospice nurse to provide instructions related to nutrition and hydration status.” Patient #11s medical record included a visit note dated 11/14/24, post change in diagnosis and POC, and included a nutritional assessment which stated “;No change since last visit.” Visits dated 11/08/24, 11/11/24, 11/18/24, 11/19/24, 11/21/24, 11/25/24, and 12/2/24 all documented a nutritional assessment which stated “;No change since last visit.” Vital signed documented in the medical record from the above mentioned visit dates did not include a weight. Additionally, narratives from these eight visits did not reference details of a nutritional assessment or education on nutrition. The DCS was interviewed on 12/03/24 at 2:35 PM and Patient #11s medical chart was reviewed. The DCS confirmed that POC and terminal diagnosis were changed and updated 11/13.24. The DCS further confirmed notes on 11/08/24, 11/11/24, 11/14/24, 11/18/24, 11/19/24, 11/21/24, 11/25/24, and 12/2/24 included documentation of “;No change since last visit” and no nutritional assessment or education on nutrition were documented. The agency failed to ensure Patient #11s POC was followed which could result in harm to the patient. 2. Patient #9 was an 88 year old female admitted to the agency on 12/14/23 with a terminal diagnosis of unspecified alzheimer’s disease. Additional diagnoses included dementia and depression. She received SN, SW, chaplain, and aide services. Her record for the certification period 9/09/24 to 11/07/24 was reviewed. Patient #9’s POC was reviewed and included nursing visits to be scheduled 1 time weekly. There were no nursing visits between 9/13/24 to 10/04/24. There was a missed visit note completed on 9/27/24, but there was no missed visit note for the week of 9/15/24. It was unclear why the SN visit was missed. The DCS was interviewed on 12/04/24 beginning at 9:15 AM and Patient #9’s medical record was reviewed in her presence. She confirmed there was no reason documented for the missed visit the week of 9/15/24. She stated the nurse should have completed a missed visit note. The agency failed to ensure all patients received services in accordance with the POC. 1. Patient 4 was a 59 year old male admitted to the agency on 11/14/24 with a terminal diagnosis of Protein Calorie Malnutrition. He received SN, MSW, and aide services. His record for the certification period 11/14/24 to 2/11/25 was reviewed.Patient #2’s POC included, “INSTRUCT BOWEL PROTOCAL AS NEEDED.” Additionally Patient #4s POC stated “;PATIENT WILL HAVE AN EFFECTIVE BOWEL PROGRAM.”Patient #2’s medical record included an RN start of care visit note dated 11/14/24. The note included that Patient #2s last bowel movement was on 11/11/24 3 days prior to the start of care. It also included that Patient #2 was started on a “;bowel regimen.” Patient #2s medical record included a SN visit note dated 11/15/24. The note included that Patient #2s las bowel movement was on 11/12/24. Patient #2s medical record include a SN visit note dated 11/21/24. Under the assessment section titled “;GASTROINTESTINAL”, the nurse documented “;NO CHANGES SINCE LAST VISIT.” Additionally, under the section titled “;INTERVENTIONS PERFORMED” the record included “;INSTRUCTED PATIENT TO MONITOR DAILY BOWEL MOVEMENT AND TO CALL NURSE I NO BOWEL MOVEMENT IN 3 DAYS.” There was no documentation on when Patient #2s las bowel movement was. Patient #2s medical record included a communication note dated 11/25/24 that stated, “;RECEIVED MESSAGE FROM ON CALL NURSE... CAREGIVER CHRISSIE STATES THAT PT HAD A VERY LARGE WHITE BM [BOWEL MOVEMENT]. HADNT HAD A BM IN 7 DAYS BEFORE THIS. THEY DENY ANY NEEDS TONIGHT AS PT IS EXHAUSTED AN SLEEPING BUT WOULD LIKE A VISIT TOMORROW. Patient #2s medical record included a SN visit note dated 11/26/24. The note included, “;SPOKE TO CAREGIVER ABOUT BM LAST NIGHT. CAREGIVER STATED THAT THEY DO NOT HAVE BOWEL MEDICATION AND HAVE NOT BEEN GIVING ANYTHING TO PATIENT.” There was no documented follow up on why Patient #2s caregivers were not giving the prescribed bowel regimen. Patient #2 did not have his bowel movements monitored from 11/15/24 to 11/25/24, and did not have a bowel movement from 11/12/24 to 11/25/24. The DCS was interviewed on 12/4/24 beginning at 10:00 AM, and Patient #2s medical record was reviewed in her presence. When asked if Patient #2 required more frequent bowel monitoring, she stated “;Absolutely”. Additionally, she stated the follow up to the prescribed bowel regimen should have been followed up on by the case manager. The agency failed to ensure services outlined on Patient #2s POC were done.”

“Based on medical record review and staff interview, it was determined the agency failed to ensure care was provided based on a current assessment of the patients needs for 1 of 14 patients (Patient #8) whose medical records were reviewed. Failure to ensure care and documentation were based on current assessment and status of the patient had the potential to cause patient needs to go unmet. Findings include: Patient #8 was a 78 year old female admitted to the agency on 1/15/24 with a terminal diagnosis of congestive heart failure. Additional diagnoses included chronic pain and depression. She received SN, SW, chaplain, and aide services. Her record for the certification period 1/15/24 to 4/13/24 was reviewed. 1. Patient #8’s medical record included an SN note from 2/08/24 which stated, “PATIENT STATED THAT SHE FELL LAST NIGHT FROM HER CHAIR.” Under the safety assessment, the same note stated, “PATIENT DENIES FALLS.” It was unclear if Patient #8 fell the night before her 2/08/24 visit. There was no fall incident recorded for the 2/08/24 visit. Patient #8’s medical record included another SN note from 2/15/24 which stated, “PATIENT STATED THAT SHE FELL LAST NIGHT FROM HER CHAIR.” Under the safety assessment, the same note stated, “PATIENT DENIES FALLS.” It was unclear if Patient #8 fell the night before her 2/15/24 visit. There was no fall incident recorded for the 2/25/24 visit. The DCS was interviewed on 12/04/24 beginning at 9:15 AM. She confirmed the fall documentation for Patient #8 was not clear. She confirmed there were no fall incidents documented for 2/08/24 or 2/15/24. 2. Patient #8’s medical record included an SN note from 1/23/24 which included supervisory functions of the hospice aide, who was identified by name. It stated the patient was satisfied with the aide’s cares, the aide followed the care plan, complied with infection control standards, and created a successful interpersonal relationship with the patient and family. Patient #8’s medical record included the first aide visit was completed on 1/30/24, a week after the RN supervisory visit. There were no aide visits provided to Patient #8 prior to 1/30/24. It was unclear how the RN supervised the aide if no aide visits had been provided. The DCS was interviewed on 12/04/24 beginning at 9:15 AM and Patient #8’s record was reviewed with her. She confirmed there were no aide visits provided prior to 1/30/24. She confirmed the nurse could not have provided aide supervision without the aide having completed any visits for Patient #8. The agency failed to ensure care and documentation were based on current assessment of Patient #8.”

“Based on medical record review and staff interview, it was determined the agency failed to ensure ongoing assessment of spiritual needs for 2 of 14 patients (Patients #8 and #9) whose records were reviewed. Failure to ensure a spiritual assessment was completed on an ongoing basis had the potential to result in unmet spiritual needs. Findings include: 1. Patient #8 was a 78 year old female admitted to the agency on 1/15/24 with a terminal diagnosis of congestive heart failure. Additional diagnoses included chronic pain and depression. She received SN, SW, chaplain, and aide services. Her record for the certification period 1/15/24 to 4/13/24 was reviewed. Patient #8’s medical record included a note by the chaplain on 3/10/24 and was titled, “CHAPLAIN HOSPICE PHONE VISIT.” The note included a narrative which stated, “THE CHAPLAIN LEFT A DETAILED MESSAGE OF SPIRITUAL AND EMOTIONAL SUPPORT. A MESSAGE WAS LEFT AS THE POA DID NOT ANSWER THE PHONE FOR VOICE TO VOICE SUPPORT.” The note also included a wellness screening which required assessment of the patient. It was unclear how Patient #8’s spiritual needs were assessed if there was no contact with the Patient #8 or her representative. There was no documentation of an attempt made to see Patient #8 in person. 2. Patient #9 was a 78 year old female admitted to the agency on 1/15/24 with a terminal diagnosis of congestive heart failure. Additional diagnoses included chronic pain and depression. She received SN, SW, chaplain, and aide services. Her record for the certification period 1/15/24 to 4/13/24 was reviewed. a. Patient #9’s record included a note by the chaplain on 10/18/24 and was titled, “CHAPLAIN HOSPICE PHONE VISIT.” The note included a narrative which stated, “VOICE MESSAGE OF SUPPORT LEFT AFTER MULTIPLE ATTEMPTS AT A CALL.” The note also included a wellness screening which required assessment of the patient. It was unclear how Patient #9’s spiritual needs were assessed if there was no contact with the Patient #9 There was no documentation of an attempt made to see Patient #9 in person. b. Patient #9’s record included a note by the chaplain on 10/22/24 and was titled, “CHAPLAIN HOSPICE PHONE VISIT.” The note included a narrative which stated, “THE CHAPLAIN LEFT A DETAILED MESSAGE OF SPIRITUAL SUPPORT AFTER MULTIPLE FAILED ATTEMPS AT CONTACT.” The note also included a wellness screening which required assessment of the patient. It was unclear how Patient #9’s spiritual needs were assessed if there was no contact with the Patient #9 There was no documentation of an attempt made to see Patient #9 in person. The DCS was interviewed on 12/04/24 beginning at 9:15 AM and Patients #8 and #9’s medical record were reviewed with her. She confirmed no contact was made with either patient in the above three visits. She confirmed if no contact was made it should have been documented as a missed visit. She confirmed no spiritual assessment was made for the above 3 visits. The agency failed to ensure spiritual needs were assessed on an ongoing basis.”