VNA Hospice

“Based on policy review, clinical record review, and interview, the hospice provider failed to ensure the plan of care (POC) included pain assessment and interventions (pharmacological and non-pharmacological) to manage one patient’s pain in a review of five full records (Record/Patient #3). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the hospice providers policy titled, “;Hospice Initial and Comprehensive Assessment,” dated 04/2017 showed, in part, the following: - The hospice will conduct and document a comprehensive assessment that is patient-specific; - The patients need for physical, psychosocial, emotional, and spiritual care will be assessed and documented; - This assessment includes all areas of hospice care related to the palliation and management of the terminal illness and related conditions; and - Based on the initial assessment, the interdisciplinary team establishes and reviews the POC. Review of the hospice providers policy titled, “;Physician Orders and Plans of Care,” dated 08/2005, showed the contents of the orders /POC will include the following: - The patients diagnosis; - A comprehensive assessment of the patients needs; - Management of discomfort and symptom relief; and - A description of any medical, physical, psychosocial, or environmental precautions or limitations that affect the implementation of the POC. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to hospice services on 09/23/2023 with a terminal diagnosis of prostate cancer. The patient had a recent functional status decline and chose to decline further curative treatment. He/she lived in a long-term care facility (LTCF), is widowed and his/her adult children visit regularly. Review of the initial comprehensive assessment, dated 09/23/2023, showed, in part, the following: - The patients primary hospice diagnosis was cancer; - The patient had distant metastasis of the cancer (tumor cells that have broken away from the primary tumor and have traveled to other parts of the body); - The patient rated his/her current pain as a three on a numeric pain scale of zero to 10 (zero indicated no pain and 10 indicated the worst imaginable pain); - The location of the pain that interfered with the patients activity was the “;back” and “;head”; - The frequency of pain that interfered with the patients activity was “;daily, but not constantly”; - Repositioning was identified as an intervention that relieved pain; - “;Certain positions” was listed as something that made pain worse; - The portion of the assessment that stated, “;Indicate effects of the pain on quality-of-life indicators,” was answered “;Emotions”; and - The question, “;Is pain an active problem for the patient?” was answered “;Yes”. Review of the POC, dated 09/23/2023, showed, in part, the following: - The patients primary diagnosis was malignant neoplasm of the prostate (prostate cancer with metastasis); - The patient had an order for hydrocodone 10 milligram (mg) /acetaminophen 325 mg (an opioid pain medication used for moderate to severe pain) one tablet every four hours as needed (PRN) for pain; - The POC failed to contain interventions for the assessment of cancer-related pain or its effect on the patients emotional status (as identified in the initial comprehensive assessment); and - The POC failed to contain interventions for managing the patients cancer-related pain. Review of the patients medication profile showed, in part, the following: - The patients hydrocodone/acetaminophen 10mg/325mg was discontinued on 10/04/2023; - Morphine concentrate (a liquid opioid pain medication used for severe pain) 20 mg/milliliter (mL) give 2 mg sublingually (SL – under the tongue) every four hours PRN for pain was started on 10/04/2023; - A one time order for an additional “;now” dose of morphine 2mg SL was ordered on 12/01/2023; and - The morphine dose was changed from 2 mg to 5 mg every four hours PRN for pain on 12/01/2023. Review of the client coordination note report, dated 12/01/2023, showed the registered nurse documented that the nurse from the long-term care facility (LTCF) called “;to report pt (patient) having a pain level of 10/10 and it has been only 3 (three) hours since medicated last” and the physician gave orders for an additional dose of morphine 2 mg to be given now and a new order to increase the dosage to 5 mg every four hours as needed for pain. Review of the interdisciplinary group (IDG) meeting notes, dated 12/05/2023, showed the new orders for morphine but failed to update the POC with any interventions for pain assessment or non-pharmacological pain-relieving interventions (such as repositioning as identified as a pain-relieving measure during the initial comprehensive assessment). During an interview on 01/04/2024, the administrator stated that, if pain was identified as a problem during the initial assessment, he/she would expect a pain assessment and interventions to manage the patients pain to be on the POC.”

“Based on policy review, record review, and interview the hospice provider failed to ensure only medications included in the plan of care (POC) was administered to one patient in a review of five full records (Record/Patient #1). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the providers policy titled, “;Verification of Physician Orders and Licensure,” dated 03/2017 showed in part: - Hospice shall obtain physician orders when indicated by the patients condition; - The most recent patient orders are used for care, treatment, and services; and - Medications cannot be initiated by a nurse without receiving orders from the physician PRIOR to administration. RECORD/PATIENT #1: Review of the clinical record showed that the patient was admitted to hospice services on 02/09/2023 with a diagnosis of chronic lymphocytic leukemia of B-Cell type (a type of cancer of the blood and bone marrow) and resided in the home with a caregiver. Review of a client coordination note, dated 12/21/2023, showed that the provider received a call from the patients caregiver stating that the patient was having pain. The registered nurse (RN) made a visit to assess the patients pain, notified the physician of complaints of left shoulder pain, and obtained an order for Lidocaine gel (a topical pain medication). Further documentation stated that the RN “;fed patient a boost (a nutritional supplement) and administered Ibuprofen (a medication used for inflammation and pain) during visit.” Review of the client medication report, dated 01/02/2024, failed to contain a current or discontinued order for Ibuprofen. During an interview on 01/04/2024 beginning at 11:35 AM, the administrator stated that he/she would expect the nurse to use what is ordered on the POC or contact the physician for a new order.”

“Based on policy review, home visit observation, and interview, the hospice provider failed to ensure staff did not place their cellphones (used to document patient assessments and obtain patient signatures) into their scrub pockets without cleaning them after each patient contact in, but not limited to, two of four home visit observations conducted (Records/Patients #2 and #3). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the hospice providers policy titled, “;Infection Prevention and Control – Cleaning and Disinfection of Equipment and Instruments,” showed in part, wipe electronic devices with an alcohol pad/wipe to disinfect surface (preferred) or using a soft microfiber cloth, spray an approved electronics cleaner directly onto the cloth and then wipe the device. Review of the document titled, “;Mandatory Education: Clean Your Cell Phone Tablet!!,” dated 05/19/2022, and provided by the administrator as evidence of infection control education provided to the staff, showed in part: - Your cellphone boosts the production of bacteria due to the ongoing heat of its battery; - Cell phones contain approximately 25,000 germs per square inch; - 30% of the bacteria found on surfaces get on your hands; - Clean your phone on a regular basis; - Sanitize your hands prior to touching your phone to reduce the germ load it carries; - Cover your device with a plastic barrier (such as a Ziplock bag) when you have to carry it with you; - Designate a clean place in your bag (or purse/pocket when not making visits) that you wont enter until you have sanitized your hands to keep it protected; - Follow approved cleaning steps for electronic devices; and - Other high-touch electronic items that should be cleaned the same way include tablets, cell phone and tablet cases, keyboards, computer mouse, desk phones, stylus, and remote controls. RECORD/PATIENT #2: Observations on 01/02/2024 at 2:00 PM, during the patients home visit, showed social worker A (SW-A) was waiting in the driveway when this surveyor arrived at the home. SW-A handed this surveyor a surgical mask and a sanitizing wipe and stated that the patient and family have all been sick with a respiratory infection. SW-A and this surveyor entered the home and were greeted by the patients caregiver who was holding a cloth over his/her nose and mouth and stated that he/she has been sick and did not want to infect the patient. The patient was sleeping and did not wake up at SW-A’s voice or touch. SW-A visited with the caregiver and the caregiver used his/her finger to sign SW-As hand-held device at the end of the visit. SW-A placed the hand-held device into his/her pocket and exited the home with this surveyor. SW-A then removed device from his/her pocket and used sanitizing wipes to clean hands and hand-held device. SW-A then placed the cleaned device back into the same pocket. During an interview following the home visit at 4:00 PM, the administrator stated that SW-A probably did not even think about the pocket holding germs because he/she would not want to take anything home to his/her family. The administrator stated that he/she could see how this could spread infections from patient to patient. RECORD/PATIENT #3: Review of the clinical record showed, in part, the following: - A narrative nurses note, dated 12/27/2023, that showed the patient was restless, confused and difficult to redirect and “;facility has several flu cases”; and - The medication profile showed Tamiflu (used to treat influenza) 75 milligrams (mg) one capsule two times daily started on 12/27/2023 and ended on 12/31/2023. Observation on 01/03/2024 at 9:05 AM, during the patients home visit, showed Registered Nurse – B (RN-B): - Obtained vital signs, reached into their scrub pocket with soiled hands, removed a cell phone, entered findings and returned the phone to their scrub pocket; - Listened to lungs and heart rate with stethoscope, reached into their scrub pocket with soiled hands, removed a cell phone, entered findings and returned the phone to their scrub pocket; - Moved the patients blankets aside, assessed the patients abdomen and lower extremities, replaced the blankets, reached into their scrub pocket with soiled hands, removed the cell phone, entered findings and returned the phone to their scrub pocket; - Cleaned the vital signs equipment, gathered his/her bag and discarded the barrier and cleaning wipes; - Went to a common area in the long-term care facility, sat at a dining table and documented on the cell phone; and - Failed to clean his/her phone before placing it in his/her pocket and before leaving the patients room. During an interview immediately following the visit, RN-B stated that he/she usually uses his/her laptop for documentation but did not think about cleaning or wiping down the phone before putting it back into their pocket. They usually wipe down their phones or laptops in their car after the visit is over but now, will be more conscious of spreading germs. During an interview on 01/04/2024 at 11:00 AM, the administrator stated that they did an in-service about cell phones and the importance of cleaning their devices and he/she agrees that placing the contaminated devices into their pockets could re-contaminate them after they were cleaned and put back into the pocket and it could potentially spread infection from patient to patient.”

“Based on policy review, record review, and interview the hospice provider failed to ensure that the physician was notified of changes in the patient’s condition in one of five full records reviewed (Record/Patient #1). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the providers policy titled, “;Registered Nurse (RN) Job Description,” dated 10/2022, showed in part the RN should: - Regularly evaluate the patients nursing needs; - Provide appropriate end of life care and symptom management; - Inform the physician and other agency personnel of changes in the patients condition and needs. Document changes in narrative notes; - Coordinate services, make appropriate referrals to other resources/disciplines; - Document all calls in patient chart, respond to calls in acceptable time frame as per on-call policy and make prudent judgement handling calls; - Have the ability to adequately assess and reassess pain and/or other symptoms; and - Assist in developing pain management and symptom management plan to keep the patient as comfortable as possible. Reassess pain/symptoms and notifies the primary care physician when not manageable on the current medications. Review of the providers policy titled, “;Patient and Staff Safety: Physician Reporting Guidelines,” dated 09/2022, showed in part: - Patient-specific parameters for notifying physician are outlined in the plan of care (POC) at the time of admission; - If there are no parameters provided by the physician, then follow the guidelines as outlined within this procedure; - For hospice patients, deviations in vital signs are normal. As the focus of care is not treatment but alleviation of pain and other symptoms, changes in vital signs do not need to be reported unless physician has specifically requested it; - Pain: Client reports of pain must be assessed and fully documented. Any new onset of pain or pain unrelieved by current treatment requires physician notification; - Changes in physical or mental condition: Any changes need to be reported to the attending physician; and - In the absences of client specific physician orders, the following guidelines represent reportable clinical findings: temperature of 100 degrees or more. RECORD/PATIENT #1: Review of the clinical record showed that the patient was admitted to hospice services on 02/09/2023 with a diagnosis of chronic lymphocytic leukemia of B-Cell type (a type of cancer of the blood and bone marrow) and resided in the home with a caregiver. Review of RN visit notes showed, in part: - On 11/15/2023, the patient had a temperature of 100.4 degrees via temporal artery scan (a method of scanning the forehead for body temperature, a normal adult body temperature is 98.6 degrees), eye drainage was noted, and the lung sounds were clear in all lung fields to auscultation (normal lung sounds when using a stethoscope); - On 11/21/2023, the patient had a temperature of 100.0 degrees via temporal artery scan, eye drainage was noted, and the lungs sounds were clear in all fields; - On 12/13/2023, the patient had a temperature of 99.3 degrees via temporal artery scan, no eye drainage was documented, and diminished lung sounds in all lobes were noted (diminished lung sounds can mean air or fluid is noted in or around the lungs and are abnormal); and - The provider failed to notify the physician of any changes in the patients condition. Review of a home health aide (HHA) client coordination note, dated 12/19/2023, showed that the patient complained of pain in the left arm. The HHA reported the complaint of pain to an RN and the record failed to contain any follow-up on the patients complaint of pain until 12/21/2023 when the caregiver placed a call to another RN. The provider failed to notify the physician of any changes in the patients condition and manage the patients symptom of pain. During an interview on 01/04/2024 beginning at 11:35 AM, the administrator stated that he/she would expect changes in the patients condition to be reported to the physician and that the nurse that received the original call about pain should have followed up.”