Three Rivers Hospice

“Based on policy review, clinical record review, home visit 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, but not limited to, three of five home visit observations, (Records/Patients #2, #3, and #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 “MEDICATION,” updated 2018, showed in part: - A medication list shall be maintained for each client; - Medication orders shall include the medication name, dose, frequency, and route of administration. Orders with variable doses or frequencies shall specify a maximum dose or frequency and the reason for administration; - The hospice ensures the safe and accurate dispensing of medications by Registered Nurse (RN) review of each written prescription or order for medication; and - The Medical Director will review complete medication profile upon admission and every 14 days, and as new medications are added or patients condition changes, to ensure medication effectiveness, actual or potential medication related effects, duplicate drug therapy and untoward interactions. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to the hospice provider on 02/15/2023 with senile degeneration of the brain, dementia (decline in mental capacity), anorexia (lack of appetite for food), and feeding difficulties. The patient was orientated times one (towards person). The patient lived at a skilled nursing facility (SNF). Observation on 03/12/2024 at 11:20 AM, during the patient’s home visit, showed the following medication discrepancies: - The providers skilled nurse asked the facility skilled nurse if there had been any medication changes. The facility skilled nurse verbalized there had been “no changes”; - The provider’s medication profile showed an order for morphine concentrate (opioid analgesic) 20 milligrams (mg)/milliliter (ml) give 0.25-1ml sublingual (SL) every hour as needed for shortness of air (SOA)/pain. The facilitys order summary showed: * Morphine concentrate 20 mg/ml give 0.25 ml SL every hour as needed for pain and SOA; * Morphine concentrate 20 mg/ml give 0.5 ml SL every hour as needed for pain and SOA; * Morphine concentrate 20 mg/ml give 0.75 ml SL every hour as needed for pain and SOA; * Morphine concentrate 20 mg/ml give 1 ml SL every hour as needed for pain and SOA. The provider failed to clarify what dosage for the pain level or SOA and the maximum dose in an hour; - The provider’s medication profile showed an order for lorazepam (sedative) 2 mg/ml give 0.25- ml SL every hour as needed for SOA/anxiety. The facilitys order summary showed: * Lorazepam 2 mg/ml give 0.25- ml SL every one hour as needed for anxiety and air hunger per the named hospice; * Lorazepam 2 mg/ml give 0.5 ml SL every one hour as needed for anxiety and air hunger; * Lorazepam 2 mg/ml give 0.75 ml SL every one hour as needed for anxiety and air hunger; * Lorazepam 2 mg/ml give 1ml SL every one hour as needed for anxiety and air hunger. The provider failed to clarify what dosage for SOA or anxiety level and the maximum dose in an hour; - The provider’s medication profile showed an order for senna (laxative) 8.6 mg one tablet by mouth two times a day for constipation. The facility order summary showed senna 8.6 mg give by mouth every 12 hours as needed for constipation; and - The provider’s medication profile showed an order for quetiapine (antipsychotic) ER (extended release) 150 mg tablet by mouth daily for behaviors. The facility order summary showed quetiapine tablet 150 mg give 75 mg by mouth one time a day for psychosis/delusions/agitation/irritability/safety. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to the hospice provider on 09/17/2023 with thrombocytopenia (a condition in which you have a low blood platelet count), dementia, feeding difficulties, localized edema (swelling), and urinary incontinence. The patient was orientated times two (towards person and place). The patient lived with his/her adult child in his/her adult childs home. Observation and interview on 03/12/2024 at 9:00 AM, during the patient’s home visit, showed the following medication discrepancies: - The providers medication profile showed an order for cholecalciferol vitamin D3 125 micrograms (mcg) /vitamin K2 90 mcg capsule take two capsules daily by mouth for supplement. The caregiver stated the patient had been taking one capsule daily for three years; and - The patients caregiver showed a bottle of ferrous sulfate (iron supplement) 325 mg take one tablet daily. The caregiver stated that the patient had taken one tablet twice a week since 02/14/2023 due to constipation. The medication failed to be on the provider’s medication profile. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to hospice services on 12/21/2023 with a primary diagnosis of hypertensive heart disease with heart failure, congestive heart failure (serious condition in which the heart doesnt pump blood as efficiently as it should), and chronic atrial fibrillation (abnormal heart rhythm characterized by rapid and irregular heartbeat). The patient lived at home with his/her spouse. Observation and interview on 03/12/2024 at 1:25 PM, during the patients home visit, showed the following medication discrepancies, the providers medication profile showed an order for Namenda (cognition-enhancing medication) 5 mg take one tablet daily. The caregiver stated that the patient had been taking one tablet twice a day since 12/18/2023. During an interview on 03/14/2024, at 1:55 PM, the regional RN coordinator (Governing body designee- A) stated medications should be verified and checked on each visit.”

“Based on standards of practice, policy review, clinical record review, and interview the hospice provider failed to ensure skin/wound assessments were completed and services were provided in accordance with the written plan of care in, but not limited to, one of five full records reviewed (Record/Patient #1). This deficient practice has the potential to affect all patients with wound care ordered served by the provider. Findings included: Review of the article by Karen S. Clay, RN, BSN, CWCN Copyright 2008 titled, “Evidence-Based Pressure Ulcer Prevention: A Study Guide for Nurses,” showed the following: “The standard of practice requires at least weekly measurement of the wound. In addition, every time you change the dressing, assess peri-wound skin, wound margins, wound tissue, drainage, odor, pain, and any other relevant issues. On a weekly basis, assess those macroscopic (i.e., visible to the naked eye) indices, measure the wound, assess the effectiveness of the treatment, and determine any treatment plan changes.” (http://www.hcpro.com/content/76944.pdf Chapter 9-Wound Healing-Page 95) Review of the provider’s policy titled “Skilled nursing services” updated 2019, showed in part that:-Skilled nursing treatments which may be provided in the clients home wound dressings and weekly skin assessments; and-Regularly re-evaluating the clients nursing needs. Review of the provider’s policy titled “Physician Orders” updated 2018, showed in part that “The plan of treatment services shall include the specific procedures and modalities to be used and the amount, frequency, and duration of the treatments.” RECORD/PATIENT #1: Review of the clinical record showed that the patient was admitted to hospice services on 12/14/2023, with an admitting terminal diagnosis of hypertensive heart disease without heart failure (a chronic condition in which the heart doesn’t pump blood as well as it should). He/she lived in a long-term care facility (LTCF). Review of the physician orders showed: -An admission order dated 12/14/2023 for Dakins solution (a prescription medicated solution for wound care), apply to wound bed with moist gauze, cover with ABD Pad and tape, change daily and PRN (as needed); -An admission order dated 12/14/2023 for Flagyl (a prescription antibiotic tablet) 250 mg, crushed and applied to wound bed daily; -An admission order dated 12/14/2023 for Bilateral great toe wound treatment of cleanse with normal saline, apply xeroform (medicated gauze), cover with foam filler and dry dressing; -An admission order dated 12/14/2023 for right lower leg, cleanse with normal saline, apply xeroform, apply ABD pad, and wrap with kerlix daily; and-An admission order dated 12/14/2023 for Right inner heel wound treatment, “;cleanse with normal saline, apply xeroform gauze, and (the order stopped here and failed to show anything further).” Review of the clinical record skilled nurse visits (SNV) showed:-On 01/29/2024 documentation of the skin showed “;Pale, warm, dry, pressure ulcers (skin injury caused by unrelieved pressure)”, and the skin assessment sheet documentation showed the coccyx as a stasis ulcer (a wound that occurs due to poor blood flow), bilateral toes as stasis ulcers, and right heel as unstageable (a pressure injury to the skin that can not be staged due to tissue obstructing the wound bed). “;See TAR (treatment administration record) for wound care.” The documentation failed to show wound measurements; -On 02/01/2024 documentation of the skin showed “;Pale, warm, dry, pressure ulcers”, and the skin assessment sheet documentation showed the coccyx as a stasis ulcer, bilateral heels as stasis ulcers. See TAR for wound instructions”. The documentation failed to identify the bilateral great toe wounds and show any wound measurements;-On 02/06/2024 documentation of the skin showed “;Pale, cool, warm, dry, pressure ulcers”, and the skin assessment sheet documentation showed the coccyx as a Decubitus ulcer measurements 7cm x 5 cm x 2 cm, inner bilateral thighs identified as other “;Pink, treated with barrier cream”, and right lower shin identified as a “;scab, OTA” (open to air) bilateral heels not identified. Narrative note stated “;PT (patient) tolerated wound care well”. The documentation failed to identify the bilateral heel wounds and the bilateral great toe wounds;-On 02/08/2024 documentation of the skin showed “;Pale, warm, dry, pressure ulcers”, and the skin assessment sheet documentation showed the coccyx as a stasis ulcer, bilateral heels as stasis ulcer, and a skin tear to the left front shin treated with skin prep. “;See TAR for wound care instructions” The documentation failed to identify the bilateral great toe wounds and wound measurements; -On 02/12/2024 documentation of the skin showed “;Pale, warm, dry”, and the skin assessment sheet documentation showed the coccyx as a stasis ulcer, right heel as decubitus ulcer, and failed to identify the bilateral great toes as wounds. “;See TAR for wound care”. The documentation failed to show wound measurements;-On 02/16/2024 documentation of the skin showed “;Pale, warm, dry”, and the skin assessment sheet documentation showed the coccyx as a stasis ulcer, right heel as decubitus ulcer, the left shin as a skin tear treated with an island dressing. “;See TAR for wound instructions.” The documentation failed to identify the bilateral great toe wounds and wound measurements; -On 02/19/2024 documentation of the skin showed “;Pale, warm, dry see TAR for wound instructions.” The documentation failed to show any skin assessment sheet or any wound documentation; -On 02/20/2024 documentation of the skin showed “;Pale, cool, dry”, and the skin assessment sheet documentation showed the coccyx as a stasis ulcer “;TAR”. The documentation failed to show wound measurements;-On 02/23/2024 documentation of the skin showed “;Pale, warm, dry, Pt has opens areas to buttocks and right heel.” The documentation failed to show any skin assessment sheet or any wound documentation; -On 02/26/2024 documentation of the skin showed “;Pale, warm, dry”, and the skin assessment sheet documentation showed the coccyx as a decubitus ulcer, right heel as “;other”, the right shin as a skin tear treated with an island dressing. “;See TAR for treatment orders.” The documentation failed to show wound measurements;-On 03/01/2024 documentation of the skin showed “;Pale, cool, warm, dry Skin is warm and pale, bilateral hand and feet are cool to the touch.” The documentation failed to show any skin assessment sheet or any wound documentation; -On 03/04/2024 documentation of the skin showed “;Pale, warm, dry”, and the skin assessment sheet documentation showed the coccyx as a decubitus ulcer, right heel as “;other”, the right shin as a skin tear treated with an island dressing. “;See TAR for treatment orders.” The documentation failed to show wound measurements; and-On 03/08/2024 documentation of the skin showed “;Pale, cool, warm, dry Skin is warm and pale, bilateral lower extremities are cool to the touch.” The documentation failed to show any skin assessment sheet or any wound documentation. Review of the LTCF clinical record on 03/11/2024 showed in part that: -A coordinated task plan dated 02/07/2024, skilled nurse visits schedule for Mondays and Thursdays; and-The LTC nurse was responsible for wound care daily; and -The hospice nurse failed to select a day for wound care to be completed by the hospice provider. During an interview on 03/11/2024 during the SNF observation visit beginning at 2:00 PM, the LTCF staff nurse stated that the LTCF staff was completing the wound care daily and as needed. If the hospice nurse completed wound care when he/she came in, then the hospice nurse would tell the LTCF charge nurse that the wound care had been completed. He/she stated that the patient often required multiple dressing changes per day due to the wound location and the patient’s bed mobility. During an interview on 03/14/2024 at 11:15 AM, the regional registered nurse coordinator (Governing body designee- A) stated that the policy stated that there needed to be a head to toe weekly assessment for non-wound patients and if a wound was present then the wounds needed to be addressed at each visit. The director of operations (Governing body designee- B) stated that the wound assessment was not a policy, but an expectation for the hospice staff.”

“Based on policy review, observation, record review, and interview, the hospice provider failed to ensure the hospice plan of care reflected which entity (hospice or the long-term care facility (LTCF)) was managing one patient’s foley catheter (a sterile tube inserted in to the bladder to drain urine), in one of two facility records reviewed (Record/Patient #1). This deficient practice has the potential to affect the coordination of care for all of the providers patients living in nursing facilities. Findings included: Review of the provider’s policy titled “Physician Orders” updated 2018, showed in part that “The plan of treatment services shall include the specific procedures and modalities to be used and the amount, frequency, and duration of the treatments.” Review of the provider’s policy titled, “Coordinated task plan- Instructions,” updated 2018, showed in part that: -Circle the days of the week the hospice nurse plans to visit. Update any on-going schedule changes on the next line; -List frequency of foley catheter care under each party responsible; -List each treatment planned and document frequency under each party responsible; and -Document a start date for each new or changed intervention and an end date for each discontinued intervention. RECORD/PATIENT #1: Review of the clinical record showed that the patient was admitted to hospice services on 12/14/2023, with an admitting terminal diagnosis of hypertensive heart disease without heart failure (a chronic condition in which the heart doesn’t pump blood as well as it should). He/she lived in a LTCF. Review of the admission physician orders, dated 12/14/2023 showed in part an order for a foley catheter, 16 French with 30 millimeter bulb for wound healing. Review of the LTCF clinical record on 03/11/2024 showed in part that: -A coordinated task plan dated 02/07/2024, skilled nurse visits schedule for Mondays and Thursdays; and -The treatment section failed to include documentation of the catheter management to include the date of the change and if the provider or the LTCF was responsible for management of the catheter. Review of the clinical record skilled nurse visits (SNV) showed: -On 01/29/2024 clear urine with foley catheter in place; -On 02/01/2024 clear urine with foley catheter in place; -On 02/06/2024 clear, cloudy with sediment visible in foley tubing with foley catheter in place; -On 02/08/2024 clear urine with foley catheter in place; -On 02/12/2024 clear urine with foley catheter in place; -On 02/16/2024 clear urine with foley catheter in place; -On 02/19/2024 clear urine with foley catheter in place; -On 02/20/2024 cloudy, concentrated, foley catheter in place, no genitourinary concerns; -On 02/23/24 concentrated urine with foley catheter in place; -On 02/26/2024 cloudy concentrated urine with foley catheter in place, catheter remains patent to DD (dependent drainage) dark yellow urine observed in drainage bag with mild amounts of sediment; -On 03/01/2024 pale urine with foley catheter in place; -On 03/04/2024 clear urine with foley catheter in place, patient wears briefs; and -On 03/08/2024 pale urine with foley catheter in place. The clinical record failed to show documentation that the foley catheter had been changed from 01/29/2024 to 03/08/2024, if any coordination had occurred with the LTCF staff regarding the catheter condition (cloudy, concentrated urine), or if the LTCF staff had changed the foley catheter and if so when the catheter was last changed. Observation beginning on 03/11/2024 at 2:00 PM, with a Medical Social Worker (MSW) showed: -The patient was resting in a private care room at the LTCF, -A foley catheter drainage bag was visible at his/her bedside with clear urine present in the collection bag; and -He/she denied any concerns with the catheter at the time of the observation visit. During an interview on 03/14/2024 at 11:15 AM, the regional registered nurse coordinator (Governing body designee- A) stated the LTCF was responsible for the catheter changes. The catheter was last changed on 02/15/2024 and was due to be changed again that week by the LTCF. He/she would have expected there to been an order to clarify who was responsible for the catheter changes.”