Enhabit Hospice of the Northshore

“Based on record review and interview, the hospice agency failed to ensure drugs and biologicals were disposed of properly, in accordance with all applicable laws and regulations, after a patients death. This deficient practice was evidenced by failure to: 1. Establish a written procedure to ensure the safe disposal of unused controlled substances by a hospice nurse at the time of a patient’s death; 2. Ensure the hospice nurse, in the presence of a witness, documented the name and remaining counts of controlled drugs in the patients death note for 4 of 4 (#3, #4, #15, and #16) sampled death records; and 3. Ensure the hospice nurse, in the presence of a witness, performed the disposal of, documented the name of the witness and disposal method of controlled drugs in the patients death note for 4 of 4 (#3, #4, #15, and #16) sampled death records. Patient #15Review of Patient #15’s Clinical Record revealed a start of care date of 12/13/2023. Further review revealed the patient expired at home on 12/25/2023. Review of Patient #15’s Plan of Care revealed the patient had current orders (prior to death) for the following medications: 12/14/2023 Hydrocodone 10mg/Acetaminophen 325mg tablet take one tablet every 6 hours for pain.12/14/2023 Lorazepam 2mg/ml oral concentrate take 0.5ml every 2 hours.12/14/2023 Morphine concentrate 100mg/5ml oral solution take 0.25ml every 2 hours for pain and/or shortness of breath. 12/14/2023 Xanax 1mg po take one tablet every six hours for anxiety. 12/14/2023 MS Contin 15mg tablet extended release take one tablet two times daily for pain. Review of Patient #15’s death note documentation, dated 12/25/2023, revealed the following, in part: 12/25/2023 at 3:35 p.m. Patient expired at home. Further review revealed no documented evidence of a final narcotic count being conducted with a witness on the above medications, no documented evidence of a witness for the disposal of the above narcotic medications, and no documented evidence of the method used for disposal. Patient #16Review of Patient #16’s Clinical Record revealed a start of care date of 12/28/2023. Further review revealed the patient expired at home on 01/17/2024. Review of Patient #16’s Plan of Care revealed the patient had current orders (prior to death) for the following medications: 12/14/2023 Hydrocodone 10mg/Acetaminophen 325mg tablet take one tablet every 6 hours for pain.12/28/2023 Lorazepam 2mg/ml oral concentrate take 0.5ml every 2 hours12/28/2023 Morphine concentrate 100mg/5ml oral solution take 0.25ml every 2 hours for pain and/or shortness of breath. Review of Patient #16s death note documentation, dated 01/17/2024, revealed the following, in part: 01/17/2024 at 10:02 a.m. Patient expired at home. Further review revealed no documented evidence of a final narcotic count being conducted with a witness on the above medications, no documented evidence of a witness for the disposal of the above narcotic medications, and no documented evidence of the method used for disposal. An interview was conducted on 05/08/2024 at 12:00 p.m. with S1ADM. S1ADM reviewed the Clinical Record for Patient #3, #4, #15 and #16. She confirmed Patient #3, #4, #15 and #16s death note documentation failed to contain a final narcotic count and disposal with a witness and the method used for disposal. S1ADM confirmed the agency was not aware of LA RS 40:2191 so their policy did not reflect those requirements. Review of the memo issued by LDH Health Standards Section, dated 06/25/2018, revealed the following, in part: In accordance with Act 23 of the 2018 Regular Legislative Session, regarding the 2018 Regular Legislative Session, the LDH Health Standards Section is issuing this notice to all licensed hospice providers. Effective 08/01/2018, Act 23 amends and reenacts LA RS 40:2191 relative to disposal of controlled substances by hospice providers; to provide for ownership; to provide for written procedures; to provide for patient records; to provide for disposal; to provide for patient notification; and to provide for related matters. Review of LA RS 40:2191 revealed the following, in part: Disposal of deceased patient’s unused controlled substances:A. Upon death of a patient receiving hospice services, ownership of the patient’s unused Schedule II, III, IV, or V controlled substances under 21 CFR 1308 may transfer to the hospice for immediate disposal pursuant to the following provisions:(1) Each hospice shall establish a written procedure to ensure safe disposal of unused controlled substances by a hospice nurse at the time of a patient’s death.(2) Upon the death of a patient receiving hospice services, in the presence of a witness, the hospice nurse shall record in the medical record the name and quantity of each unused controlled substance.(3)(a) The hospice nurse shall conduct immediate disposal of the controlled substance at the site of care ... (b) ... the hospice nurse shall perform the disposal in the presence of a witness, who shall sign a document indicating their witnessing the disposal. (5) The hospice nurse shall record the method of disposal in the medical record. Review of the agencys policy titled “;Controlled Medication Management and Disposal Policy” last reviewed 10/20/2023, revealed it did not meet the requirements established in LA RS 40:2191. Review of the agencys policy titled “7.65 Disposal of Controlled Substances”, undated, revealed it did not meet the requirements established in LA RS 40:2191. Patient #3Review of Patient #3s Clinical Record revealed a start of care date of 09/16/2022. Further review revealed the patient expired at home on 05/30/2023. Review of Resident #3s Plan of Care revealed the patient had current orders (prior to death) for the following medications: 09/18/2022 - Lorazepam 2mg/mL Oral Concentrate 0.5mL every 2 hours by mouth for anxiety. 09/18/2022 - Morphine Concentrate 100mg/5mL (20mg/mL) Oral Solution 0.25mL every 2 hours by mouth for pain. Review of Patient #3’s death note documentation, dated 05/30/2023 revealed the following, in part: 05/30/2023 at 7:00 p.m. Patient expired at home. Further review revealed no documented evidence of a final narcotic count being conducted with a witness on the above medications, no documented evidence of a witness for the disposal of the above narcotic medications, and no documented evidence of the method used for disposal. Patient #4Review of Patient #4s Clinical Record revealed a start of care date of 06/13/2023. Further review revealed the patient expired at home on 06/19/2023. Review of Resident #4s Plan of Care revealed the patient had current orders (prior to death) for the following medications:06/13/2023 - Fentanyl 25mcg/hr Transdermal Patch 1 patch transdermal every 72 hours for pain. 06/13/2023 - Hydrocodone 10mg acetaminophen 325mg tablet 1 tablet by G-tube every 6 hours for pain. 06/13/2023 - Lorazepam 2mg/mL Oral Concentrate 0.5mL every 2 hours by G-tube for agitation. 06/13/2023 - Morphine Concentrate 100mg/5mL (20mg/mL) Oral Solution 0.25mL every 2 hours by G-tube for shortness of breath. 06/13/2023 - Morphine Concentrate 100mg/5mL (20mg/mL) Oral Solution 1mL every 4 hours by G-tube for pain. 06/13/2023 - Valium 5mg tablet 1 tablet every 8 hours for anxiety. Review of Patient #4’s death note documentation, dated 06/19/2023, revealed the following, in part: 06/19/2023 at12:40 a.m. Patient expired at home. Further review revealed no documented evidence of a final narcotic count being conducted with a witness on the above medications, no documented evidence of a witness for the disposal of the above narcotic medications, and no documented evidence of the method used for disposal.”