All Saints Hospice

“Based on record review and interview, the agency failed to ensure a patient’s rights were exercised and respected for 2 (#1 and #2) of 3 sampled patients. The agency failed to allow the patients’ caregivers to make decisions about the patients’ care. The agency failed to:Respect the family’s rights to refuse medication administration for Patient #1; andBe respectful to Patient #2’s family and their rights to get Patient #2 out of bed.Findings: On 02/19/2026, a review of the agency’s undated employee handbook on section titled, “Code of Ethics and Business Conduct” revealed in part…the important thing to remember is, to be honest, fair, respectful, and responsible with each other and those with whom we come into contact.On 02/19/2026, a review of the agency’s undated policy titled, “Patient Rights and Responsibilities” revealed in part…3. The notice of the patient’s rights and responsibilities includes, but not limited to, the patient’s right…..to exercise his or her rights as a patient of the hospice without being subjected to discrimination or reprisal for exercising these rights, …to voice grievances regarding treatment or care that is or fails to be furnished,…to refuse care or treatment…5. If the patient is incapacitated or adjudged incompetent, the patient’s representative may exercise the patient’s rights in accordance with and to the extent allowed by State laws.Patient #1Review of Patient #1’s Hospice Certification and Plan of Care for certification period 01/02/2026 to 04/01/2026 revealed diagnoses that included Malignant Neoplasm of Unspecified Kidney, Secondary Malignant Neoplasm of Unspecified Lung, Secondary Malignant Neoplasm of Liver and Bile Duct, and Secondary Malignant Neoplasm of Bone. Review of the POC revealed Patient #1 received Skilled Nursing services, Hospice Aide services, Chaplain Services, and services with a Medical Social Worker. Review of a Skilled Nurse visit dated 01/08/2026 revealed Patient #1 was visited by S2 DON. S2 DON’s narrative for 01/08/2026 revealed she administered Morphine 0.25ml at 10:50 a.m. S2 DON further documented the following... (Patient’s son) “looked at this nurse, pointed finger, demanding to be asked his permission as “POA” to give Morphine again. I explained that I did not have to ask his permission and I was using my nursing judgement, which he did not have, and following Hospice MD orders. I will give meds as needed.” and “He asked for another nurse to visit, S3 RN, and I explained that I was helping her and I am just as capable of to take care of his mother.”Review of Patient #1’s orders revealed the following order:01/02/2026: Morphine Concentrate 100mg/5ml (20mg/ml) oral solution dose 0.25ml every 2 hours by mouth under the tongue prn for air hunger (give 0.25ml sublingual every 2 hours prn for air hunger).During a telephone interview on 02/18/2026 at 10:39 a.m., the Nursing Home Director of Nurses, for the nursing facility where Patient #1 resided, revealed she became aware of the incident on 01/08/2026 between S2 DON and Patient #1’s son shortly after it occurred. She stated Patient #1’s son is the POA and asked S2DON not to give his mother Morphine because he didn’t think Patient #1 needed it, and asked S2DON to get a facility nurse’s opinion before giving it. NH Director of Nurses said Patient #1’s son told her that S2DON stated to him she didn’t need to check with another nurse and gave the medication anyway. NH Director of Nurses said she and the Facility Administrator went to Patient #1’s room after the incident. She said Patient #1’s son requested S2DON not come back to see his mother. NH Director of Nurses explained to Patient #1’s son that S2DON may have to come back if S2DON was on call and his mother passed away or had an emergency. NH Director of Nurses said the son agreed that S2DON would only come back in those circumstances.In a telephone interview on 02/18/2026 at 12:33 p.m., S3RN stated she was the case manager for Patient #1. S3RN said she had a good working relationship with the patient’s son/POA. She said she respected his wishes and did not give the Morphine if he didn’t want her to. S3RN said the patient’s son had allowed her to give it to the patient on a prior day, shortly before S2DON gave it on 01/08/2026. S3RN revealed on the day she gave it, a few days prior to 01/08/2026, Patient #1 had received wound care, was turned a lot, breathing fast, and was moaning some. S3RN said the son gave her the okay to give Morphine. S3RN said Patient #1’s son was very fearful of morphine and wanted her to get a second opinion for some reassurance. S3RN said she educated him, but the decision was ultimately his to make and it was his right to say no. S3RN said the patient could not speak for herself, and he was the POA to speak for the patient. In an interview on 02/18/2026 at 2:39 p.m., S2DON stated on 01/08/2026 she gave Patient #1 Morphine because the patient was having tachypnea and no one objected to her giving it until after it was given. S2DON stated afterward giving the medication, Patient #1’s son began lashing out at her and telling her, “You don’t need to give her any more medicine.” S2DON stated she explained to the family that she was actively dying and needed to be comfortable. S2DON stated, “Yes, she did get loud” when she offered to call the doctor to discuss it but did not curse or anything inappropriate. S2DON denied Patient #1’s son asked her to get another nurse for a second opinion. S2DON confirmed the son told her he wanted S3RN to be her nurse. S2DON stated she and the Nursing Home Administrator and Nursing Home Director of Nurses agreed it would be best if S2DON didn’t come back. S2DON stated she had no proof the son was the POA. S2DON confirmed no grievance was completed on the incident.In a telephone interview on 02/19/2026 at 9:00 a.m., Patient #1’s son stated he had no problems with anyone at the hospice agency except for S2DON. He said he had S2DON removed from coming to the nursing home to see his mother, Patient #1. He said he was trying to honor his mother’s wishes. He said his mother had told him she didn’t want to take Morphine. He stated he asked S2DON to get a second opinion on 01/08/2026 before giving Morphine to her and S2DON refused. He confirmed he told S2DON that he didn’t want her to administer Morphine before S2DON gave it to his mother, and S2DON gave it to Patient #1 anyway. He stated S2DON told him she didn’t need a second opinion and that S2DON stated she could give it anytime she wanted. He stated S2DON told him she could give it again in 15 minutes if she thought Patient #1 needed it. Patient #1’s son stated he told S2DON he was the POA and S2DON stated to him she didn’t care if he was the POA.During an interview on 02/19/2026 at 1:00 p.m., S1ED reviewed S2DON’s visit note for 01/08/2026 with this surveyor and the narrative where S2DON documented telling the son that she “did not have to ask his permission and I was using my nursing judgement, which he did not have, and following Hospice MD orders. I will give meds as needed.” S1ED confirmed this documented behavior was not appropriate behavior by S2DON. S1ED further stated if family does not want the patient to have Morphine, it should not be given. S1ED confirmed it didn’t matter if the son was POA or not, that nurses should have followed his wishes.During a telephone interview on 02/19/2026 at 1:37 p.m., S4 Former ED reviewed S2DON’s narrative on 01/08/2026 for Patient #1, where S2DON documented she told the patient’s son she would give Morphine to Patient #1 if she wanted to, which was against their wishes. S4Former ED confirmed the documented behavior was not appropriate and violated the resident/family’s rights to refuse medications. Patient #2Review of Patient #2’s Hospice Certification and Plan of Care for certification period 09/07/2025 to 11/05/2025 revealed diagnoses that included Alzheimer’s disease and Vascular Dementia. Review of the POC revealed Patient #2 was received Skilled Nursing services, Hospice Aide services, Chaplain Services, and services with a Medical Social Worker. Review of Complaint Report dated 10/07/2025 for Patient #2 reported by her Husband revealed When DCO (DON) called to the family’s home to provide assistance x 3 persons to move patient from chair to bed, education was provided on patient safety and do’s and don’ts for further care. Husband began threatening DCO, stating “I will find a better hospice, Y’all are not the best, I’m going to get the best.” Interventions included: Clarified expectations with patient and/or caregiver; Apologized to complainant; Escalated concern to manager.In an interview on 02/19/2026 at 9:30 a.m., S5CNA recalled the day S2DON and Patient #2’s husband had a disagreement and confirmed she was present. S5CNA said she and S3RN were having problems transferring the patient and had called S2DON to come help. S5CNA stated the Patient #2’s husband got upset and lashed out at S2DON. S5CNA said S2DON defended her points about safety, transferring, and him not being able to change her and confirmed S2DON did get loud. S5CNA said S2DON was calm at first but her voice became raised trying to respond to Patient #2’s husband. S5CNA said S2DON told him hospice staff find the patient soaked in the mornings and that they could report that, but they don’t. During a telephone interview on 02/19/2026 at 10:42 a.m., S6SW said the incident on 10/07/2025 was “not a great situation at all.” S6SW stated when she arrived at the home for her regularly scheduled visit, S2DON and the patient’s husband were having a “sit down” about concerns. S6SW said S3RN and S5CNA were present. S6SW stated she was upset with how S2DON was talking to Patient #2’s husband. S6SW stated she heard S2DON say it’s getting hard for you to take care of her and “when we come, she is covered in piss.” S6SW stated S2DON told the patient’s husband that when the CNA comes, Patient #2 had to be in the bed. S6SW said the patient’s husband was upset and stated he did not want to keep Patient #2 in the bed. S6SW said Patient #2’s husband was upset and said “if you all can’t take care of her, I may need to look for another hospice.” S6SW stated S2DON told him, “We are the best.” S6SW said she could tell this aggravated him and he said, “Really y’all are the best?” S6SW said S2DON replied to the husband and said, “Yes.” S6SW said everyone began to leave the home and Patient #2’s husband was still very upset. S6SW said she told S2DON she was going to stay at the Patient’s home. S6SW said Patient #2’s husband told her he couldn’t believe the things S2DON had said to him and he felt like S2DON was bullying him. S6SW acknowledged Patient #2’s husband’s feelings and stated it was not a good conversation between him and S2DON. S6SW confirmed S2DON was loud when S2DON and Patient #2’s husband were bantering back and forth about if it was the best hospice, and S2DON told him the patient had to be in bed when the CNA came. S6SW confirmed that S2DON’s conversation with Patient #2’s husband was loud, argumentative, and inappropriate. In a telephone interview on 02/19/2026 at 11:07 a.m., S3RN stated on the day of Patient #2’s incident, staff were unable to transfer the patient and called the office for assistance. S3RN said S2DON came and the conversation became heated between S2DON and the patient’s husband. S3RN said their two personalities clashed and S2DON was “stern” with him. S3RN stated the husband and S2DON went back and forth about her needing to stay in bed, transferring, and needing extra help from a sitter. S3RN acknowledged S2DON told Patient #2’s husband that hospice staff find her “sitting in piss” and that Patient #2 needed to be in the bed when hospice arrived. S3RN confirmed the conversation between S2DON the patient’s husband was not appropriate. During a telephone interview at 1:37 p.m. on 02/19/2026, S4Former ED stated she was not aware S2DON had told Patient #2’s husband that staff find Patient #2 “Sitting in piss.” S4Former ED confirmed this statement was not appropriate, getting loud with family was not appropriate, and acknowledged these comments made by S2DON were disrespectful to the Patient’s family.”