Mercy Hospice

“Based on policy review, record review, home visit observation, and interview, the hospice provider failed to maintain an accurate, updated medication profile in two of four home visit observations conducted (Records/Patients #1 and #3). This deficient practice has the potential to affect all the patients served by the provider. Findings included:Review of the provider’s undated policy titled, “Medication Administration Policy,” showed in part “a medication regime review will occur at the time of the initial comprehensive assessment on admission. The medication profile will include all prescribed and over-the-counter (OTC) medications.”Review of the provider’s undated policy titled, “ Comprehensive Assessment,” showed in part the patient’s drug profile is a review of all the patient’s prescription and over-the-counter drugs, herbal remedies and other alternative treatments that could affect drug therapy. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice services on 06/16/2025 with a terminal diagnosis of senile degeneration (cognitive decline in older adults, often associated with dementia) of the brain. The patient resided in a skilled nursing facility (SNF). Observation on 07/07/2025 at 3:00 PM, showed the following discrepancies between the provider’s medication profile and the SNF’s medication list:- The provider’s profile showed the patient took amlodipine (used to treat high blood pressure) 5 milligrams (mg) by mouth daily. The SNF medication list failed to contain this medication; - The provider’s profile showed the patient took olanzapine (used to treat schizophrenia and bipolar disorder) 10 mg injected intramuscularly one time for aggressive behavior. The SNF medication list failed to contain this medication; - The provider’s profile showed the patient took rosuvastatin (used to treat high cholesterol) 10 mg by mouth daily. The SNF medication list failed to contain this medication; - The provider’s profile showed the patient took risperidone (used to treat schizophrenia and bipolar disorder) 0.5 mg by mouth two times daily. The SNF medication list showed the patient took risperidone 0.5 mg by mouth daily in the morning and 1 mg by mouth daily in the evening; - The SNF medication list showed the patient took sodium phosphate, mono-dibasic (saline laxative used to treat constipation) give one enema rectally daily as needed. The provider’s profile failed to contain this medication; and- The SNF medication list showed the patient took acetaminophen (used to treat mild pain) 650 mg by mouth daily as needed. The provider’s profile failed to contain this medication. During an interview on 07/09/2025 at 10:30 AM, the registered nurse coordinator stated that he/she would expect the medications to match between the SNF and the hospice provider. RECORD/PATIENT #3:Review of the clinical record showed the patient was admitted to hospice services on July 21, 2022 with Alzheimer’s disease (a disease marked by progressive loss of mental capacity). The patient resided in a SNF.Observation on 07/08/2025 at 4:45 PM, showed the following discrepancies between the provider’s medication profile and the SNF’s medication list:The provider’s profile showed the patient took famotidine (for stomach upset) two times daily. The SNF medication profile showed the patient took famotidine one time a day;The provider’s profile showed the patient took Lasix (swelling lower extremities) 40 milligram(mg) daily. The SNF medication profile showed the patient took Lasix 40 mg two times a day;The provider’s profile failed to show Morphine Sulfate oral every two hours for pain, Remeron 15 mg at bedtime to increase appetite, and Zofran as needed for nausea, every eight hours. These medications were on the SNF medication profile.During an interview on 07/09/2025 at 10:45 AM, the registered nurse coordinator (RNC) stated that the skilled nurse (SN) was to compare the provider’s medication list to the SNF’s medication list during each SNF visit.”

“Based on record review and interview, the hospice provider failed to ensure all visits were completed as ordered by the physician in three of five full records reviewed (Records/Patients #1, #2, and #4). This deficient practice has the potential to affect all the patients served by the provider. RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice services on 06/16/2025 with a terminal diagnosis of senile degeneration (cognitive decline in older adults, often associated with dementia) of the brain. The patient resided in a skilled nursing facility (SNF).Review of the Hospice Plan of Care Update, dated 06/26/2025 – 07/10/2025, showed a hospice aide visit schedule of two visits every week for 12 weeks beginning 06/22/2025.Review of the clinician visit notes failed to show a second visit for the week of 06/29/2025 – 07/05/2025.Review of the Hospice Plan of Care Update, dated 07/10/2025 – 07/24/2025, failed to show physician notification of the missed aide visit.RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice services on 06/10/2025 with a terminal diagnosis of malignant neoplasm (a disease in which abnormal cells divide uncontrollably and destroy body tissue) of the colon. The patient resided at home alone.Review of the Hospice Plan of Care Update, dated 06/10/2025 – 06/19/2025, showed a hospice aide visit schedule of one visit every week for 12 weeks beginning 06/15/2025.Review of the clinician visit notes failed to show:- A visit for the week of 06/15/2025 – 06/21/2025; and- A visit for the week of 06/22/2025 – 06/28/2025.Review of the Hospice Plan of Care Update, dated 07/03/2025 - 07/17/2025, failed to show physician notification of the missed aide visits.During an interview on 07/09/2025 at 10:30 AM, the registered nurse coordinator stated that he/she would expect documentation as to why the aide visits were missed and the physician to be notified of the missed visits. RECORD/PATIENT #4:Review of the clinical record showed the patient was admitted to hospice services on 12/28/2024 with a terminal diagnosis of Congestive Heart Failure (CHF; - a decrease in the ability of the heart to pump blood),and secondary diagnosis which included chronic kidney disease,(a condition where the kidneys gradually lose the ability to filter waste products from the blood).The patient resided in a skilled nursing facility.Review of the POC, dated 07/03/2025 to 07/17/2025, showed the physician’s order for pastoral care, two visits each month, for 12 weeks.Review of pastoral care visit notes showed:-The provider staff documented one missed pastoral visit on 04/11/2025, for the month of April 2025, due to schedule change; -The provider failed to reschedule the visit for another day in the month of April 2025; and-The staff failed notify the physician, and supervisory staff of the missed pastoral visit on 04/11/2025.Review of the Hospice Plan of Care Update, dated 07/03/2025 to 07/17/2025, failed to show physician notification of the missed pastoral visit.During an interview on 07/09/2025 beginning at 9:20 AM, the Registered Nurse Coordinator (RNC) stated that the visit was missed and was not re-scheduled. The RNC stated that there was no documentation that the physician, or supervisory staff were notified. The RNC also stated that there was not a policy regarding the issue of missed visits.”

“Based on policy review, record review, and interview, the hospice provider failed to ensure the ongoing sharing of information between all disciplines providing care and services in one of five full records reviewed (Record/Patient #5). This deficient practice has the potential to affect all the patients served by the provider. Findings included:Review of the provider’s policy, titled, “CAPE HOSPICE Hospice Interdisciplinary Group Policy,” dated 07/08/2025,howed in part, the hospice will provide for and ensure the ongoing sharing of information between all disciplines providing care and services in all settings, where the care and services are provided directly or under arrangement. RECORD/PATIENT #5:Review of the clinical record showed the patient was admitted to hospice services on 06/17/2025 with a primary diagnosis of cancer of the right lung. Patient resided at home with family support. Review of the skilled nurse (SN) visit note, dated 06/30/2025, showed that the patient stated that he/she was not pleased with the medicine that he/she started taking on Friday. The patient stated that he/she felt weak ever since he/she started on the medication and that he/she could not even make it to the bathroom.Review of the record failed to show communication to the physician, nurse practitioner, and/or other patient care providers. During an interview on 07/09/2025 at 10:30 AM, the registered nurse coordinator (RNC) stated that he/she would expect the nurse to notify the physician related to the medication complaints. Showed”