Community Loving Care Hospice

“Based on policy review, record review, and interview, the hospice provider failed to obtain measurements of a pressure injury (skin injury caused by unrelieved pressure) on admission in one of five full records reviewed (Record/Patient #3). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the providers policy titled, “;Initial & Comprehensive Admission Assessment & Plan of Care,” dated 04/01/2022, showed in part: - The purpose of the initial assessment visit will be to evaluate the patients physical, psychosocial, and emotional states related to the terminal illness and related conditions and to determine the patients immediate care and support needs; and - The comprehensive assessment will include a thorough assessment of the patients physical, psychosocial, emotional, and spiritual status related to the terminal illness and related conditions. Review of the providers policy titled, “;Wound Assessment, Documentation and Photography,” dated 03/01/2021, showed in part: - Purpose is to ensure the accurate and consistent assessment and documentation of wounds; - Upon initial visit and subsequently as applicable, all wounds will be assessed with appropriate documentation within the medical record; and - Wound measurements, including length, depth, and width of the wound in centimeters (cm) will be documented in the medical record (weekly). RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to hospice services on 04/09/2024 with a terminal diagnosis of sepsis (a life threating infection in the blood stream). He/she had pressure injuries on the coccyx (tailbone area) and the right and left heels. He/she was bed-bound and lived in an assisted living facility (ALF). Hospice provided all wound care. Review of the initial assessment, dated 04/09/2024, showed in part: - A stage one pressure injury (intact skin, persistent redness that does not blanch) on the coccyx that measured 2-centimeter (cm) long by 0.3-cm wide by 0.1-cm deep; - A stage two pressure injury (partial-thickness loss of the dermis) on the left heel that measured 2-cm long by 2.2-cm wide by 0.1-cm deep; and - A suspected deep tissue injury (SDTI; pressure injury of purple or maroon discolored intact skin or a blood-filled blister with unknown underlying damage) on the right heel that was noted to be red and “;bogey” (boggy; tissue that feels spongy to the touch). The skin was intact with no drainage noted; - The wound care provided by the registered nurse (RN) was “;clean wound with wound cleanser, pat dry, apply skin prep around outer aspect of wound, cover with foam island heel dressing”; and - The RN failed to obtain measurements of the right heel SDTI. Review of the skilled nurse (SN) visit note, dated 04/11/2024, showed in part: - The right heel SDTI was noted to have a small amount of purulent (containing pus) drainage and the wound care was “;Clense (cleanse) with wound cleaner, allow to dry, apply skin prep, and cover heel with Mepilex (a type of foam dressing)”; - The RN documented a narrative note that showed “;Right heel oozing white liquid, clensed (cleansed), absorbent dressing applied”; and - The RN failed to obtain measurements of the SDTI. Review of the SN visit note, dated 04/16/2024, showed in part, the right heel SDTI had no drainage noted and the wound measured 0.6-cm long by 0.6-cm wide by 0.1-cm deep (this was the first time the wound was measured, seven days after admission). During an interview on 4/16/2024 at 10:45 AM, the RN Coordinator stated that the ALF does not do the patients wound care, the hospice does the wound care and dressing changes. During an interview on 04/17/2024, at 9:40 AM, the administrator stated that the wound should have been measured on admission.”

“Based on policy review, record review, observation, and interview, the hospice provider failed to ensure a complete and accurate list of all the medications that the patient was currently using in one of four home visit observations, (Record/Patient #4). This deficient practice has the potential to affect the hospice provider’s ability to ensure safe and effective use of medications for all patients served by the provider. Findings included: Review of the provider’s policy titled, “Monitoring Medications,” dated revised 11/01/2017, showed in part: - A Comprehensive Medication Review will be completed on admit and at every Interdisciplinary Group (IDG) meeting, in conjunction with all comprehensive assessments; - Compare medication list to actual medications the patient is taking. If the patient resides in a facility, compare medication list to the facility’s medication administration record (MAR) rather than reviewing actual medications; - Review over the counter (OTC) medications, vitamins, herbs and herbal products, and creams and topical ointments and medical marijuana (in states where legalized) to identify issues such as: * potential adverse effects and drug reactions * ineffective drug therapy * significant side effects * significant drug interactions * duplicate drug therapy * noncompliance with drug therapy * dosage erros * drug omissions - Notify physician of any of the above identified issues/discrepancies; and - All nurses participating in the patient’s care are responsible to assist in maintenance of accurate patient medication information throughout the tenure of care. RECORD/PATIENT #4:Review of the clinical record showed the patient was admitted to hospice services on 04/13/2024 with a terminal diagnosis of Alzheimers disease (a disease marked by progressive loss of mental capacity) with late onset. Additional diagnoses included: dysphagia (difficulty swallowing), chronic respiratory failure (a long-term condition in which lungs have a hard time loading oxygen into the blood stream) with hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions), and severe edema (swelling). The patient resided in a long-term care facility (LTCF). Review of the hospital discharge orders, the hospice providers medication list, and the LTCFs medication orders, showed the following discrepancies:- The hospital discharge orders, dated 04/12/2024, showed “;stop taking” acetaminophen (analgesic/fever reducer) 500 milligram (mg) tablet, give two tabs oral every six hours as needed for pain. The hospice providers medication list, dated 04/13/2024, showed acetaminophen 500 mg tablet, give two tabs oral every six hours as needed for pain;- The hospital discharge orders, dated 04/12/2024, and the LTCFs medication orders, dated 04/13/2024, showed nystatin (antifungal) topical 100,000 unit/gram (gm), apply one application topically twice daily as needed to areas of excoriation (layer of skin abraded, usually red in color). The hospice providers medication list failed to contain this order; and- The hospice providers medication list, dated 04/13/2024, showed oxygen two liters continuous via nasal cannula. The LTCFs medication orders failed to contain this order. During an interview on 04/17/2024 at 9:50 AM, the administrator stated that the LTCFs medication order and the hospice medication list should match and if not, then would expect to see the physician being notified regarding the discrepancy.”

“Based on policy review, record review, and interview, the hospice provider failed to develop an individualized plan of care (POC) that reflected the patients goals and interventions in, two of five full records reviewed (Records/Patients #2 and #4). This deficient practice has the potential to affect all patients served by the provider. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted on 04/13/2024 with Alzheimers disease (a disease marked by progressive loss of mental capacity) with late onset, dysphagia (difficulty swallowing), chronic respiratory failure (a long-term condition in which lungs have a hard time loading oxygen into the blood stream) with hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions), and severe edema (swelling). The patient resided in a long-term care facility (LTCF). Review of the initial comprehensive assessment, dated 04/13/2024, showed in part: - The patient had occasional hemorrhoid pain; - The patient denied pain at the time of the assessment; - The patient’s identified pain goal was “4” on a scale of zero to ten, with zero being no pain and ten being the worst pain; and - The narrative showed the patient had a feeding tube up until 04/12/2024 for difficulty swallowing. The spouse said the physician in the hospital told him/her that the patient’s swallowing was not good and that the patient would/could choke on food or liquids. The LTCF nurse informed the hospice nurse that the patient had a nutritional shake the night before, but did not eat breakfast or lunch that day. The hospice nurse educated the LTCF nurse on allowing the patient to eat as he/she desired. Review of the plan of care (POC), dated 04/13/2024 through 07/11/2024, showed in part: - Education to the caregiver related to impaired swallowing; - Safety measures for aspiration precautions and choking/swallowing; - Nutritional requirements of regular diet as tolerated with honey thickened liquids; - The POC failed to be individualized to include the patient’s goal for pain, goals and interventions for hemorrhoids, goals and interventions for aspiration precautions, choking and swallowing, and nutritional supplement. During an interview on 04/17/2024 at 9:50 AM, the administrator stated that the patient’s plan of care should have included all the above and been individualized. Findings included: Review of the agency’s policy, titled, “Plan of Care,” revised 11/01/2021, showed, in part, the plan of care must include all services necessary for the palliation and management of the terminal illness and relating conditions, including, interventions to manage pain and symptoms. Review of the agency’s policy, titled, “Initial and Comprehensive Admission Assessment and Plan of Care,” revised 04/01/2022, showed, in part, all treatments, medications, and services provided must be on the initial plan of care. RECORD/PATIENT #2: Review of the clinical record showed, in part: - The patient was admitted to hospice services on 02/27/2024 with a primary diagnosis of degenerative diseases of basal ganglia (a neurodegenerative disease that causes problems controlling speech, movement, and posture) and a secondary diagnosis of obstructive sleep apnea (intermittent air flow blockage during sleep). The patient resided in the home with his/her spouse; - A client coordination note report, dated, 02/27/2024 showed, in part, during the admission visit, the patient’s “;spouse gave patient a cup of water, forgetting to put thickener in the water, and patient choked on the water for a few moments;” and - The POC failed to include orders and/or interventions for the patient to receive liquids in a thickened consistency. During an interview, on 04/17/2024, beginning at 9:30 AM, the administrator stated that: - He/she could not find any orders for the patient to be on thickened liquids; and - He/she would expect thickened liquids to be on the POC.”

“Based on policy review, record review, and interview, the hospice provider failed to include all of the patients medical equipment on the plan of care (POC) in, one of five full records reviewed (Record/Patient #2). This deficient practice has the potential to adversely affect the care provided to all the provider’s patients. Findings included: Review of the provider’s policy, titled, “Plan of Care,” revised 11/01/2021, showed in part, the plan of care must include all services necessary for the palliation and management of the terminal illness and relating conditions, including, medical supplies and appliances necessary to meet the needs of the patient. RECORD/PATIENT #2: Review of the clinical record, showed in part: - The patient was admitted to hospice services on 02/27/2024 with a terminal diagnosis of degenerative diseases of basal ganglia (a neurodegenerative disease that causes problems controlling speech, movement, and posture) and a secondary diagnosis of obstructive sleep apnea (intermittent air flow blockage during sleep). The patient resided in the home with his/her spouse; - The patients disaster plan document, showed in part, DME (durable medical equipment) that included C-Pap machine (continuous positive airway pressure- a machine that uses mild air pressure to keep breathing airways open while sleeping); and - The POC failed to list the C-Pap machine as DME used by the patient. The POC failed to include orders and/or interventions for the C-Pap machine. During an interview, on 04/17/2024, beginning at 9:30 AM, the administrator stated that: - The C-Pap machine was not listed on the POC; - There were no orders for the C-Pap machine; and - He/she would expect to have orders for the C-Pap machine and for the C-Pap machine to be listed on the POC.”

“Based on policy review, record review, and interview, the hospice provider failed to ensure ongoing sharing of information between all disciplines providing care and services in all settings, whether the care and services were provided directly or under arrangement in, two of twelve records reviewed (Records/Patients #4 and #6). This deficient practice has the potential to affect the care provided to all patients on service with the hospice provider. Findings included: Review of the policy titled, “;Hospice Care In The Nursing Home/Skilled Nursing Facility Setting,” revised on 06/01/2018, showed, in part, that the Hospice Agency and Nursing Home/Skilled Nursing Facility must define the manner in which the Nursing Home/Skilled Nursing Facility and the Hospice will communicate with each other and document such communications to ensure that the needs of the patients are addressed and met 24 hours a day. Review of the respite contract, dated, March 6th, 2020, showed, in part, that the Hospice and facility shall communicate with one another regularly and as needed for each particular Hospice patient. Each party is responsible for documenting such communications in its respective clinical records to ensure that the needs of the Hospice patients are met 24 hours a day. RECORD/PATIENT #6: Review of the clinical record showed, in part: - The patient was admitted to hospice services on 03/16/2023 with a primary diagnosis of Parkinsons disease and resided in the home with his/her spouse; - The patient received respite care from 01/29/2024 to 02/01/2024; - A skilled nurse visit note, dated 02/01/2024, showed in part: * Spouse arrived to the respite facility to take the patient home * The respite facility nurse reported that the patient had fallen earlier that day and had small abrasions to the right elbow and left flank * The patient had been having some dizziness * The spouse called the hospice nurse after returning home with the patient from respite and reported that the dizziness. The spouse reported that the patient only had 2 (two) tablets of Quetiapine left and “;shouldve had 12 tablets” and expressed concerns about the patient being given too much Quetiapine at the respite facility * The nurse “;advised spouse to speak with facility administrator Rachel regarding her concerns;” and - The clinical record failed to show documentation of coordination of care regarding the patient falling, follow-up regarding the report of medication concerns, and hospice coordinating with the respite facility regarding the dizziness, fall, and medication issues prior to the patient being discharged. During an interview, on 04/17/2024, beginning at 9:30 AM, the administrator stated that: - He/she could not find any documentation of coordination of care with the respite facility during the patients stay and prior to discharge; - He/she was unable to find documentation of the falls or dizziness being reported to the IDG (interdisciplinary group) team; - He/she was unable to find documentation of the nurse following up with the respite facility and the spouse regarding the concerns of missing medications; and - He/she would expect the nurse to coordinate care and follow-up with the facility and patient regarding the issues. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted on 04/13/2024 with Alzheimers disease (a disease marked by progressive loss of mental capacity) with late onset, dysphagia (difficulty swallowing), chronic respiratory failure (a long-term condition in which lungs have a hard time loading oxygen into the blood stream) with hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions), and severe edema (swelling). The patient resided in a long-term care facility (LTCF). Review of the initial comprehensive assessment, dated 04/13/2024, showed the patient had a feeding tube up until 04/12/2024 for difficulty swallowing. The spouse said the physician in the hospital told him/her that the patient’s swallowing was not good and that the patient would/could choke on food or liquids. The LTCF nurse informed the hospice nurse that the patient had a nutritional shake the night before, but did not eat breakfast or lunch that day. The hospice nurse educated the LTCF nurse on allowing the patient to eat as he/she desired. Review of the plan of care (POC), dated 04/13/2024 through 07/11/2024, showed in part: - Education to the caregiver related to impaired swallowing; - Safety measures for aspiration precautions and choking/swallowing; and - Nutritional requirements of regular diet as tolerated with honey thickened liquids. Review of the LTCF physician’s orders, printed 04/16/2024, showed an order for regular diet with low concentrated sweets and to send a sandwich at bedtime with snack tray. Observation and interview on 04/16/2024 starting at 9:30 AM with the provider’s social worker, showed the patient sitting in bed with the head of the bed up. The patient had a tall handled cup with ice water, a coffee cup with a dark brown liquid in it, and a small cup with a little bit of milk product. SA (state agency) saw no evidence of thickened liquids. The patient stated he/she would like a nutritional shake with each meal, as he/she felt he/she could swallow that without choking. The patient also stated that he/she wanted a small glass of water as the large one was too heavy and he/she was unable to lift. Review of the social worker’s note, dated 04/16/2024, showed: - Care coordination with facility staff and patient; - The note failed to show documentation of the patient’s above request or observation of unthickened liquids and failed to show coordination with the hospice’s IDG regarding the patient’s request.”

“Based on policy review, record review, and interview, the hospice provider failed to assess a newly identified pressure injury (skin injury caused by unrelieved pressure) and failed to notify the physician of the pressure injury in one of five full records reviewed (Record/Patient #5). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the providers policy titled, “;Patient Reassessments,” dated 07/01/2012, showed in part: - The nurse will complete and assessment of the patient on each visit according to the patients plan of care (POC); - This assessment may include skin integrity; - Reassessments should focus on changes in patients condition; and - The hospice medical director and attending physician will be notified regarding any treatment/interventions that require physician approval. Review of the providers policy titled, “;Wound Assessment, Documentation and Photography,” dated 03/01/2021, showed in part: - Upon initial visit and subsequently as applicable, all wounds will be assessed with appropriate documentation within the medical record; and - Document the treatment and condition of the wound each visit, the appearance of the wound bed, wound measurements weekly, depth and location of undermining, surrounding tissue appearance, color, odor, amount of drainage and stage the wound weekly. RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to hospice with the terminal diagnosis of small cell B lymphoma (a type of cancer) of the right parietal lobe of the brain. The patient had a history of right breast cancer with a mastectomy (surgical removal of the breast) and uterine cancer with a hysterectomy (surgical removal of the uterus and possibly the fallopian tubes and ovaries) additional diagnoses were obstructive sleep apnea (a sleep disorder that affects breathing), atrial fibrillation (abnormal heart rhythm characterized by rapid and irregular heartbeat) and morbid obesity. The patient was chair-fast, required a mechanical lift for transfers and lived in a long-term care facility (LTCF). Review of the skilled nursing (SN) note, dated 04/11/2024, showed in part: - The registered nurse (RN) documented “;two small new stage 2 (two) pressure injuries to the sacral area noted. Facility staff are using Triad (a medicated paste) paste for this area”; - The RN failed to document an assessment and measurements of the new pressure injuries; and - The RN failed to notify the physician of the new pressure injuries. Review of the SN note, dated 04/15/2024, showed the RN assessed and measured the sacral pressure injuries to be 1-centimeter (cm) by 0.5-cm by 0.1-cm deep and obtained physician orders to cleanse area with skin cleanser, pat dry, apply thin layer of Triad paste daily and with incontinence episodes (measurements and physician notification occurred four days after the initial discovery of the wounds). During an interview on 04/17/2024 at 9:40 AM, the administrator stated that he/she would expect the nurse to assess the site, obtain measurements and notify the physician when a new wound is discovered.”

“Based on policy review, record review, and interview, the hospice failed to ensure a discharge summary was provided to the patients attending physician upon discharge from the hospice in, one of two applicable records reviewed (Record/Patient #10). This deficient practice has the potential to adversely affect the post discharge continuity of care for all the live patients discharged by the provider. Findings included: Review of the provider’s policy titled, “;Live Discharge/Transfer of The Hospice Patient,” revised on 04/01/2022, showed in part: - Purpose: To ensure continuity of care and appropriate live discharge procedures for a non-revocation patient live discharge from Hospice services; - When a patient is discharged, transferred, or referred to another agency, relevant information for discharge is documented in the medical record; - Documentation sent to the patients physician and receiving agency may include, in part: * Reason for transfer or discharge and date of transfer or discharge * Physical and psychosocial status at the time of transfer or discharge, * Summary of the care provided and progress toward achieving goals * Copy of the current medication profile * Copy of the current plan of care * Copy of a current physician orders * Date of discharge * Patient diagnosis - The discharge plan will be discussed with the patient/representative as well as the attending physician, if any, and documented in the medical record; and - Documentation shall include the date and time of the communication, individuals involved with the communication, information discussed and the outcome of the communication. RECORD/PATIENT #6: Review of the clinical record, showed in part: - The patient was admitted to hospice services on 10/13/2019 with a terminal diagnosis of Malignant Neoplasm of Left Upper Lobe/Bronchus (lung cancer) and resided at home alone with assistance from family and caregivers; - The patient was discharge from hospice services on 12/20/2023 due to no longer meeting hospice eligibility requirements; and - The clinical record failed to include record that the discharge summary was provided to the patients attending physician after discharge from hospice services. During an interview, on 04/17/2024, beginning at 9:30 AM, the administrator stated that: - The discharge summary was provided to the hospice medical director but not the patients PCP (primary care provider); and - He/she would expect the discharge summary to be sent to the patients physician.”

“Based on review of the respite contract, record review, and interview, the hospice provider failed to ensure that a copy of the discharge summary was provided to the hospice provider from the respite facility at the time of the patients discharge from respite care in, one of two applicable records reviewed (Record/Patient #6). This deficient practice has the potential to affect the care provided to all patients on service with the hospice provider. Findings included: Review of the respite contract, dated March 6th, 2020, showed, in part, that the facility shall provide hospice with a copy of the discharge summary at the time of discharge. RECORD/PATIENT #6: Review of the clinical record, showed in part: - The patient was admitted to hospice services on 03/16/2023 with a terminal diagnosis of Parkinsons disease (a neurological disorder that causes unintended or uncontrollable movements or stiffness) and resided in the home with his/her spouse; - The patient received respite care from 01/29/2024 to 02/01/2024; and - The clinical record failed to include a discharge summary from the facility that provided the respite care to the patient. During an interview, on 04/17/2024, beginning at 9:30 AM, the administrator stated that: - The facility provided the patients spouse with a discharge summary but they (hospice provider) never received a discharge summary; and - He/she would expect the facility to provide them (hospice provider) with a copy of the discharge summary.”

“Based on policy review, observation, and interview, the hospice provider failed to provide the long-term care facility (LTCF) with a copy of the physician certification of terminal illness in, but not limited to, two of five full records reviewed (Records/Patients #1 and #4). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the providers policy titled, “;Hospice Care in the Nursing Home / Skilled Nursing Facility Setting,” dated 06/01/2018, showed the hospice will provide the nursing home/skilled nursing facility with the physician certification and re-certification of the terminal illness (CTI). RECORD/PATIENT #1: Review of the clinical record showed a physician re-certification of terminal illness for hospice on 03/28/2024. Observation on 04/15/2024 at 2:30 PM, showed the hospice binder and the patients LTCF chart failed to contain a copy of the CTI. Per an interview immediately following the home visit, the hospice nurse stated he/she also looked in the patients chart and hospice binder and did not see the CTI. RECORD/PATIENT #4: Review of the clinical record showed a physician certification of terminal illness for hospice, dated 04/13/2024. Observation on 04/16/2024 at 9:30 AM, showed the LTCF hospice binder failed to contain a copy of the CTI. Per interview conducted during observation, the LTCF charge nurse stated the patient’s LTCF chart also did not contain a copy of the CTI. During an interview on 04/17/2024, at 9:40 AM, the administrator stated that the CTI should have been in the hospice binder.”