St Croix Hospice

“Based on interview and document review, the hospice agency failed to ensure the Condition of Participation for Patient’s Rights was met when the agency failed to protect a patient from neglect following a suicide attempt, failed to ensure the alleged neglect was investigated in accordance with established procedures, and failed to ensure a verified violation involving neglect was accurately and completely reported to the appropriate State authority.The agency’s failure to protect a patient from neglect resulted in immediate jeopardy when hospice staff failed to activate emergency medical services (EMS) and failed to ensure the hospice physician received complete and accurate information necessary to direct the patient’s care after staff became aware the patient intentionally ingested approximately 28 milliliters (mL), or 560 milligrams (mg), of morphine in a suicide attempt. The patient subsequently became comatose and unresponsive and developed severe respiratory depression, prolonged periods of apnea, cyanosis, and oxygen saturation as low as 35%. The patient died on 2/11/26 from the toxic effects of morphine and oxycodone.The cumulative effect of these deficient practices resulted in the hospice agency’s failure to ensure patients’ rights were protected and demonstrated the agency’s inability to provide care and services in compliance with the Condition of Participation at 42 CFR §418.52. Findings include: See L509: Based on interview and document review, the hospice agency failed to provide evidence that an alleged violation involving neglect was investigated in accordance with the agency’s established procedures for 1 of 1 patient (P1) reviewed who ingested a bottle of morphine sulfate solution during a reported suicide attempt and subsequently died. The agency reported an investigation was completed and identified a hospice clinical leader failed to follow the agency’s established emergency response policy; however, the agency did not provide the investigative documentation necessary to verify the investigation was conducted in accordance with its established procedures. See L511: Based on interview and document review, the hospice agency failed to ensure a verified violation involving neglect was accurately and completely reported to the appropriate State and local authorities for 1 of 1 patient (P1) reviewed for neglect. The agency submitted an initial report to the Minnesota Adult Abuse Reporting Center (MAARC) that inaccurately identified the amount of morphine P1 ingested and did not include P1’s documented significant clinical decline following the intentional overdose or that emergency medical services (EMS) were not activated despite the known suicide attempt. The agency subsequently verified through its internal investigation that a clinical leader failed to follow the agency’s established emergency-response policy; however, the agency did not report the verified violation to the appropriate State or local authorities. See L517: Based on interview and document review, the hospice agency failed to protect 1 of 3 patients (P1) from neglect when staff failed to obtain emergency medical intervention and failed to ensure a hospice physician was provided complete and accurate information necessary to direct P1’s care after staff became aware P1 intentionally ingested approximately 28 milliliters (mL), or 560 milligrams (mg), of morphine in a suicide attempt. Staff did not activate emergency medical services (EMS) despite the agency’s policy requiring staff to immediately call 911 following a suicide attempt. In addition, the hospice physician was not informed P1 intentionally ingested the morphine in a suicide attempt, the amount of morphine ingested, or P1’s subsequent significant change in condition. P1 became comatose and unresponsive and developed severe respiratory depression, prolonged periods of apnea, cyanosis, and oxygen saturation as low as 35%. P1 died on 2/11/26 from the toxic effects of morphine and oxycodone.The immediate jeopardy began on 2/11/26 when hospice staff failed to activate EMS after becoming aware P1 intentionally ingested approximately 28 mL, or 560 mg, of morphine in a suicide attempt and failed to ensure the hospice physician received complete and accurate information regarding P1’s suicide attempt and subsequent significant change in condition. P1 became comatose and unresponsive and developed severe respiratory depression, prolonged periods of apnea, cyanosis, and oxygen saturation as low as 35%. P1 died on 2/11/26 from the toxic effects of morphine and oxycodone. The hospice agency was notified of the immediate jeopardy on 8/7/26 at 1:55 p.m. The immediate jeopardy was removed on 8/10/26 after onsite verification that the approved removal plan was implemented and the likelihood of serious injury, serious harm, serious impairment, or death no longer existed.”

“Based on interview and document review, the hospice agency failed to provide evidence that an alleged violation involving neglect was investigated in accordance with the agency’s established procedures for 1 of 1 patient (P1) reviewed who ingested a bottle of morphine sulfate solution during a reported suicide attempt and subsequently died. The agency reported an investigation was completed and identified a hospice clinical leader failed to follow the agency’s established emergency response policy; however, the agency did not provide the investigative documentation necessary to verify the investigation was conducted in accordance with its established procedures. Findings include:Review of the Post-Incident Internal Report: P1 Suicide indicated the hospice received a report on 2/12/26 that P1 attempted suicide and died on 2/11/26. The report indicated an internal investigation led by external counsel and in-house counsel was initiated on 2/12/26.The Post-Incident Internal Report indicated P1 consumed a bottle of morphine sulfate solution at approximately 9:00 a.m. on 2/11/26. P1’s spouse subsequently contacted the hospice and reported the event. The report indicated the Regional Director of Clinical Operations (RDCO) assessed P1’s condition through P1’s spouse and advised the spouse to call 911 for emergency medical services (EMS) and transport to a hospital emergency department. The report indicated P1’s spouse declined EMS transport and additional emergency intervention and P1 also stated he did not want 911 called or transportation to the hospital.The Post-Incident Internal Report indicated the agency’s investigation included witness interviews, review of P1’s medical record, and evaluation of applicable organizational policies. The report identified the agency’s policy required employees to immediately contact 911 when a suspected suicide attempt was identified. According to the report, during an interview the RDCO acknowledged awareness of the policy but stated she did not contact 911 because she questioned whether the circumstances clearly constituted a suicide attempt.The Post-Incident Internal Report concluded the RDCO’s failure to follow the agency’s established emergency response policy was unacceptable because the policy was known but was not followed without adequate justification. The report further identified inconsistent understanding among clinical leaders regarding the required response to suspected suicide attempts. The agency indicated policies were subsequently revised and company-wide education and training were implemented.Review of the agency’s Assessment of Possible Abuse, Neglect, or Exploitation policy, revised 7/21/26, identified neglect as the failure of a caregiver to provide necessary medical care, supervision, or other services necessary to maintain a patient’s health and safety. The policy directed the Clinical Director or designee to review reports for completeness and objectivity, coordinate additional investigation as necessary, and forward findings to the Administrator or designee. The policy further directed all reports, investigations, and related documentation be maintained confidentially in accordance with privacy and record-retention requirements.The agency did not provide documentation supporting the investigation described in the Post-Incident Internal Report, including documentation of witness interviews, investigative notes, or other evidence reviewed. Therefore, the documentation available for review did not establish what information was obtained during the investigation, whether conflicting information was identified and reconciled, or what evidence supported the agency’s investigative conclusions.During an interview on 8/7/26 at approximately 9:00 a.m., an attorney representing the hospice agency stated an outside organization completed the internal investigation at the advice of legal counsel. The attorney stated the details of the investigation were “privileged.” The agency did not provide the State Agency with the underlying investigative documentation described in its Post-Incident Internal Report.At survey exit on 8/10/26, the hospice agency had not provided documentation sufficient to verify the investigation of the alleged violation was conducted in accordance with the agency’s established procedures.”

“Based on interview and document review, the hospice agency failed to ensure a verified violation involving neglect was accurately and completely reported to the appropriate State and local authorities for 1 of 1 patient (P1) reviewed for neglect. The agency submitted an initial report to the Minnesota Adult Abuse Reporting Center (MAARC) that inaccurately identified the amount of morphine P1 ingested and did not include P1’s documented significant clinical decline following the intentional overdose or that emergency medical services (EMS) were not activated despite the known suicide attempt. The agency subsequently verified through its internal investigation that a clinical leader failed to follow the agency’s established emergency-response policy; however, the agency did not report the verified violation to the appropriate State or local authorities. Findings include:P1’s hospice certification and plan of care, dated 2/5/26, indicated P1 was admitted to hospice services on 2/5/26 with a primary diagnosis of congestive heart failure.P1’s Client Medication Report, dated 2/5/26, identified an order for morphine concentrate 20 milligrams per milliliter (mg/mL) oral solution, 5 mg (0.25 mL) by mouth every four hours as needed for pain or shortness of breath.P1’s Registered Nurse Case Manager (RNCM) visit note, dated 2/11/26, indicated P1’s spouse reported, “I knew he wanted to die, I didn’t think he would try to kill himself.” The RNCM inspected P1’s morphine bottle, noted the bottle was nearly empty, and estimated P1 consumed approximately 28 milliliters (mL) of morphine. At 10:40 a.m., P1 was arousable but drowsy with slurred speech and reported he consumed the morphine at approximately 9:00 a.m. P1 declined activation of EMS and stated, “I just want to die.” The note indicated P1’s spouse also declined EMS activation after the RNCM discussed that EMS activation would most likely result in administration of Narcan, hospitalization, and a psychiatric hold for the suicide attempt.The RNCM documented P1’s continued clinical decline throughout the day. At 11:15 a.m., P1 had irregular respirations and audible gasping. At 12:00 p.m., P1 was comatose and unresponsive to verbal stimuli, had a respiratory rate (RR) of 7, periods of apnea lasting 15 to 20 seconds, and oxygen saturation of 68%. At 1:00 p.m., P1’s RR was 5 with 30-second periods of apnea and oxygen saturation of 72%. At 2:00 p.m., P1’s RR remained 5, oxygen saturation decreased to 50%, and cyanosis was noted to P1’s lips and nose. At 4:00 p.m., P1’s oxygen saturation was 35% with periods of apnea lasting 50 seconds.Review of P1’s hospice RN Death Visit, dated 2/11/26, indicated P1’s death was confirmed at 8:50 p.m. The record identified notifications completed by the agency following P1’s death, including the interdisciplinary group (IDG) team, emergency contact/next of kin, physician, coroner, durable medical equipment supplier, and pharmacy. Under other relationship notified of P1’s death, the record identified, “911 due to suicide.”P1’s Cause of Death Worksheet identified P1’s date of death as 2/11/26 and the time of death as 7:32 p.m. The worksheet identified the manner of death as suicide and described the injury as intentional overdose ingestion of prescription medication. The immediate cause of death was identified as toxic effects of morphine and oxycodone.Review of the MAARC report submitted by the hospice agency on 2/13/26 indicated the reporter became aware of the incident from an internal report submitted by the Clinical Director. The MAARC report indicated that on 2/11/26 at 9:00 a.m., P1 overdosed on oral morphine. The report indicated P1 was supposed to take 5 mg every four hours as needed but informed his spouse he had taken 20 mg. The report further indicated P1 died later that night at an unknown time and stated, “Reporter has no concern that VA overdosing on Morphine caused VA to pass away but the actual cause is unknown.” The report indicated the on-call registered nurse contacted the Anoka County Sheriff’s Office and made a report to a detective.The MAARC report did not accurately or completely reflect the circumstances documented in P1’s clinical record. The report identified P1 ingested 20 mg of morphine rather than the approximately 28 mL of morphine concentrate 20 mg/mL documented in P1’s clinical record, which equaled approximately 560 mg. The report did not identify P1’s documented significant clinical deterioration following the overdose or that EMS was not activated despite the known suicide attempt. In addition, the report stated there was “no concern” P1’s morphine overdose caused his death while also indicating the actual cause of death was unknown.During an interview on 8/7/26 at approximately 10:15 a.m., the county intake worker stated the county received a MAARC report regarding P1 on 2/13/26. The county intake worker confirmed the information documented in the MAARC report reflected the information reported to the county. The county intake worker stated the report was closed with no further action because P1 had died and there was no longer a vulnerable adult to protect. The county intake worker confirmed the 2/13/26 MAARC report was the only report the county received regarding P1.During an interview on 8/7/26 at 11:20 a.m., the hospice agency’s attorney, who was also a registered nurse and submitted the MAARC report, stated she obtained the information used to make the report from P1’s medical record. She stated she told MAARC that P1 had consumed a “vial” of morphine and stated the MAARC reporter may have misunderstood the information. She stated she offered to provide MAARC with P1’s medical records. The attorney stated she did not recall stating, “Reporter has no concern that VA overdosing on Morphine caused VA to pass away but the actual cause is unknown.” The attorney stated she did not have P1’s death certificate when the MAARC report was submitted and stated she could not say for certain whether 560 mg of morphine was a lethal dose.Review of the agency’s investigation timeline indicated the agency continued its investigation after the MAARC report was submitted on 2/13/26. The timeline identified an interview with the Regional Director of Clinical Operations (RDCO) on 3/23/26 as the last investigative event related to the incident.Review of the agency’s Post-Incident Internal Report indicated the agency’s investigation included witness interviews, review of P1’s medical record, and evaluation of applicable organizational policies. The report identified the agency’s policy required employees to immediately contact 911 when a suspected suicide attempt was identified. According to the report, during an interview the RDCO acknowledged awareness of the policy but stated she did not contact 911 because she questioned whether the circumstances clearly constituted a suicide attempt.The Post-Incident Internal Report concluded the failure to follow the agency’s established emergency-response policy was unacceptable because the policy was known but was not followed without adequate justification. The investigation further identified inconsistent understanding among clinical leaders regarding the required response to suspected suicide attempts.At survey exit on 8/10/26, the agency was requested to provide evidence of reporting related to the incident. The agency identified the 2/13/26 MAARC report and stated it had received notification that the report would not be investigated further by the county. The agency did not provide evidence that the verified violation identified through its subsequent investigation was reported to the appropriate State or local authorities.An agency policy Assessment of Possible Abuse, Neglect, or Exploitation, revised 7/21/26, directed staff to report suspected abuse, neglect, exploitation, or other maltreatment to the appropriate State agency in accordance with applicable law. The policy directed the reporting individual to document relevant information, including the date and time of the occurrence, a description of the concern, the nature of the alleged abuse or neglect, witnesses, and actions taken or notifications made. The policy further directed the Clinical Director or designee to review reports for completeness and objectivity.”

“Based on interview and document review, the hospice agency failed to protect 1 of 3 patients (P1) from neglect when staff failed to obtain emergency medical intervention and failed to ensure the hospice physician received complete and accurate information necessary to direct P1’s care after staff became aware P1 intentionally ingested approximately 28 milliliters (mL), or 560 milligrams (mg), of morphine in a suicide attempt. Staff did not activate emergency medical services (EMS) despite the agency’s policy requiring staff to immediately call 911 following a suicide attempt. In addition, the hospice physician was not informed P1 intentionally ingested the morphine in a suicide attempt, the amount of morphine ingested, or P1’s subsequent significant change in condition. P1 became comatose and unresponsive and developed severe respiratory depression, prolonged periods of apnea, cyanosis, and oxygen saturation as low as 35%. P1 died on 2/11/26 from the toxic effects of morphine and oxycodone.The immediate jeopardy began on 2/11/26 when hospice staff failed to activate EMS after becoming aware P1 intentionally ingested approximately 28 mL, or 560 mg, of morphine in a suicide attempt and failed to ensure the hospice physician received complete and accurate information regarding P1’s suicide attempt and subsequent significant change in condition. P1 became comatose and unresponsive and developed severe respiratory depression, prolonged periods of apnea, cyanosis, and oxygen saturation as low as 35%. P1 died on 2/11/26 from the toxic effects of morphine and oxycodone. The hospice agency was notified of the immediate jeopardy on 8/7/26 at 1:55 p.m. The immediate jeopardy was removed on 8/10/26 after onsite verification that the approved removal plan was implemented and the likelihood of serious injury, serious harm, serious impairment, or death no longer existed. Findings include:P1’s hospice certification and plan of care, dated 2/5/26, indicated P1 was admitted to hospice services on 2/5/26 with a primary diagnosis of congestive heart failure.P1’s Client Medication Report, dated 2/5/26, indicated an order for morphine concentrate 20 mg/mL oral solution, 5 mg (0.25 mL) by mouth every four hours as needed for pain or shortness of breath.P1’s Provider Orders for Life-Sustaining Treatment (POLST), signed by P1’s spouse on 2/5/26, indicated P1’s preference for do not attempt resuscitation (DNR) and selected selective treatment, which included possible transfer to the hospital and basic medical treatment aimed at treating new or reversible illness. The POLST was signed by the hospice physician on 2/13/26.P1’s Certification of Terminal Illness, dated 2/6/26, indicated P1 had a life expectancy of six months or less if the disease ran its normal course.P1’s RN symptom follow-up visit note, dated 2/6/26, indicated morphine had been delivered to P1’s home the previous evening. P1 denied pain, shortness of breath, or discomfort during the visit.P1’s registered nurse visit note, dated 2/9/26, indicated P1 denied pain or shortness of breath.P1’s as-needed registered nurse visit note, dated 2/10/26, indicated P1 was sitting at the counter when the nurse arrived. P1 denied pain, shortness of breath, or dizziness. P1’s respiratory rate was 16 breaths per minute and oxygen saturation was 98% on room air.P1’s RNCM visit note, dated 2/11/26, indicated the RNCM arrived at P1’s home and was greeted by P1’s spouse, who was tearful and stated, “I knew he wanted to die, I didn’t think he would try to kill himself.” The RNCM inspected P1’s morphine bottle, found the bottle nearly empty, and estimated P1 had ingested approximately 28 mL of morphine.The visit note indicated at 10:40 a.m., P1 was arousable but drowsy and slurring his words. P1 reported he drank the morphine after eating breakfast with a friend at approximately 9:00 a.m. The RNCM discussed activating EMS with P1. P1 declined EMS and stated, “I just want to die.”The visit note indicated the RNCM discussed activating EMS with P1’s spouse and explained EMS activation would most likely involve administration of Narcan, hospital admission, and a psychiatric hold related to the suicide attempt. P1’s spouse stated, “That’s not what he wants. If he survived he would be furious,” and declined activation of EMS.At 11:15 a.m., the RNCM documented P1 had irregular respirations and audible gasping and rolled his eyes in response to tactile stimulation.At 12:00 p.m., the RNCM documented P1 was comatose and unresponsive to verbal stimuli. P1’s respiratory rate was seven breaths per minute, with periods of apnea lasting 15 to 20 seconds, and his oxygen saturation was 68%.At 1:00 p.m., P1’s respiratory rate was five breaths per minute, periods of apnea lasted 30 seconds, and oxygen saturation was 72%. Rattling respirations were noted.At 2:00 p.m., P1’s respiratory rate remained five breaths per minute, oxygen saturation decreased to 50%, and cyanosis was observed around P1’s lips and nose.At 3:00 p.m., P1’s respirations remained irregular and shallow with a Cheyne-Stokes respiratory pattern.At 4:00 p.m., P1’s respiratory rate remained five breaths per minute, oxygen saturation decreased to 35%, and periods of apnea lasted approximately 50 seconds.The RNCM’s visit note indicated the RNCM remained at P1’s home until 5:00 p.m., when the RNCM was relieved by P1’s spouse. The record did not indicate EMS was activated during the visit despite P1 becoming comatose and unresponsive and developing severe respiratory depression, prolonged apnea, cyanosis, and profound hypoxemia.P1’s Medical Social Worker (MSW) visit note, dated 2/11/26, indicated the MSW was informed by the Regional Director of Clinical Operations (RDCO) and RNCM that P1 had ingested most of the bottle of morphine. The MSW obtained a controlled substance agreement and went to P1’s home. Upon arrival, P1 was lying in bed asleep and appeared calm and comfortable. The MSW discussed funeral plans with P1’s spouse and obtained a signed controlled substance agreement. The note lacked a suicide assessment and listed P1 as having no abnormal behavioral assessment findings and indicated P1’s coping mechanisms as “acceptance.”P1’s hospice RN Death Visit, dated 2/11/26, indicated P1’s death was confirmed at 8:50 p.m.P1’s Cause of Death Worksheet indicated P1 died on 2/11/26 at 7:32 p.m. The manner of death was identified as suicide and described as “intentional overdose ingestion of prescription medication.” The immediate cause of death was identified as “toxic effects of morphine and oxycodone.”During an interview on 8/6/26 at 11:34 a.m., the RNCM stated the RDCO notified him that P1’s spouse had contacted triage and reported P1 had intentionally consumed most or all of his morphine in an attempt to die by suicide. The RNCM was directed to go to P1’s home, assess the situation, verify whether P1 had consumed the morphine, and determine whether P1 wanted to go to the hospital. The RNCM stated upon arrival, P1 was awake and cognizant but had slurred speech and impaired balance and P1 admitted he intentionally drank the morphine. The RNCM stated he verified P1 had consumed nearly the entire bottle, approximately 28 mL, of morphine and stated P1 was aware he had consumed several hundred milligrams of morphine. The RNCM recommended hospitalization; however, P1 adamantly declined. The RNCM stated he understood the amount of morphine ingested was likely to be fatal and acknowledged P1’s ingestion was an active suicide attempt. The RNCM stated he explained to P1’s spouse what could occur if EMS were activated, including administration of Narcan, possible intubation, admission to the intensive care unit (ICU), possible death in the hospital, and placement on a 72-hour hold. The RNCM confirmed P1 subsequently fell asleep and never regained consciousness. The RNCM stated the RDCO directed him to remain in P1’s home to monitor P1 and provide support to P1’s spouse, and he remained in the home until the end of his normal shift. The RNCM stated he informed P1’s hospice physician of the situation at some point and believed the RDCO was also notifying a physician; however, the RNCM stated he did not receive medical guidance directing P1’s care. When asked whether he would respond the same way if presented with a similar situation again, the RNCM stated, “what happened happened, if it happened again, I think activation against pt wishes to 911 would be the call I would make.” The RNCM stated he was put on leave for “about a week” and that discussion happened “above his level” that he was not made aware of. The RNCM stated when he came back to work it was business as usual and he received no education, coaching or debrief on what had happened. During an interview on 8/6/26 at 11:55 a.m., the RDCO stated P1’s spouse contacted the hospice and reported P1 had consumed approximately 22 to 23 mL of morphine. The RDCO could hear P1 talking in the background and stating he did not want 911 called. The RDCO dispatched the RNCM to P1’s home and remained in communication with the RNCM throughout the day but confirmed 911 was never activated. The RDCO stated P1 was initially alert and oriented but became increasingly tired and eventually progressed to an unresponsive state. The RDCO stated the medical director directed staff to continue monitoring P1 and provide updates. When asked whether she would respond the same way if presented with a similar situation again, the RDCO stated, “I think about that a lot, I would probably lean toward calling EMS and let them decline the EMTs, and it would be on them to act or not.” The RDCO stated she was also put on leave after the incident happened, and when she came back to work was told an investigation was completed but was given no detail. The RDCO stated she received no coaching, education or debrief on the situation before working again.During an interview on 8/6/26 at 2:34 p.m., the attorney representing P1’s hospice physician stated the physician was not aware of the situation while it was occurring, and the hospice nurse practitioner was also not aware. The attorney stated that if a similar situation occurred again, the hospice’s response would be to activate 911 regardless of the patient’s stated preference when an attempted suicide had occurred.During an interview on 8/7/26 at 10:45 a.m., the Chief Medical Officer (CMO) stated he was informed that a hospice patient had ingested an unknown amount of morphine but remained alert and talking. The CMO stated he received the information through administrative staff and not directly from the RN caring for P1. The CMO stated he was not informed of the amount of morphine P1 had ingested and was not informed the ingestion was intentional or represented a suicide attempt. The CMO stated he instructed staff to monitor P1 based upon the information provided to him that P1 remained alert and talking. The CMO stated he was not subsequently notified when P1 became unconscious or experienced a change in condition. The CMO further stated had he been informed of the amount of morphine P1 ingested or that P1 had intentionally ingested the medication in a suicide attempt, he would have instructed staff to call 911 immediately.An agency policy, revised December 2018, Suicide-Patient, directed staff to immediately call 911 when a patient attempted suicide and notify the attending physician or Hospice Medical Director/Hospice Physician as soon as possible. The policy also required immediate investigation, evaluation, and intervention for identified suicide risks. Staff were required to keep the interdisciplinary team, including the attending physician, informed of the risk.An agency policy, revised 7/21/26, Assessment of Possible Abuse, Neglect, or Exploitation, defined neglect as the failure of a caregiver to provide necessary medical care, supervision, or other services necessary to maintain the patient’s health and safety.The immediate jeopardy began on 2/11/26 was removed on 8/10/26, when it was verified onsite that the hospice reviewed and provided education on the revised Suicide-Patient policy and provided education to all staff regarding the appropriate response to a suicidal patient or had a plan in place to ensure staff received the education prior to returning to work for their next shift.”