Bitterroot Health - Hospice

“. Due to the manner and degree of the deficient practice, the facility failed to meet the Condition of Participation for Organization and administration of services. Based on interview and record review, the facility failed to provide nursing services in a manner that is consistent with accepted standards of practice (See L0652). - failed to have an RN assess and pronounce time of death at the place of residence of the deceased. -failed to coordinate with the funeral home to complete accurate information on the person who pronounced the time of death for death certificates. -failed to ensure an LPN was practicing within their scope of practice in the state of Montana.”

“Based on interview and record review, the agency failed to include bereavement in patients’ plan of care for 10 of 19 sampled patients. Findings include: Review of patient #9’s EHR plan of care, dated 1/13/25, reflected no bereavement plan of care. Review of patient #10’s EHR plan of care, dated 1/3/25, reflected no bereavement plan of care. Review of patient #11’s EHR plan of care, dated 1/13/25, reflected no bereavement plan of care. Review of patient #12’s EHR plan of care, dated 12/9/24, reflected no bereavement plan of care. Review of patient #13’s EHR plan of care, dated 11/18/24, reflected no bereavement plan of care. Review of patient #14’s EHR plan of care, dated 12/4/24, reflected no bereavement plan of care. During an interview on 1/13/25 at 2:01 p.m., staff member B stated bereavement was not added to the plan of care until after death. Staff member B stated none of the active patients would have a bereavement plan of care because they were still alive. Staff member B stated patients and families were receiving education on death, what to expect, and preparations but these items were not care-planned for bereavement. Review of the agency’s policy, “Bereavement Policy”, revised 12/10/09, reflected: -“...2.0 Information gathered from the initial Bereavement assessment must be incorporated into the plan of care and considered in the Bereavement plan of care. ...” Review of patient #1’s EHR plan of care, dated 12/5/24, did not show information for bereavement. Review of patient #2’s EHR plan of care, dated 1/13/25, did not show information for bereavement. Review of patient #3’s EHR plan of care, dated 1/12/25, did not show information for bereavement. Review of patient #4’s EHR plan of care, dated 1/9/25, did not show information for bereavement. Review of patient #5’s EHR plan of care, dated 12/31/24, did not show information for bereavement. Review of patient #7’s EHR plan of care, dated 12/24/24, did not show information for bereavement. Review of patient #8’s EHR plan of care, dated 12/19/24, did not show information for bereavement.”

“Based on interview and record review, the agency failed to ensure the plan of care was individualized for 3 (#s 7, 12, and 14) of 19 sampled patients. Findings include: Review of patient #12’s EHR RN visit note, dated 12/12/24, reflected patient #12 had a history of falls, aspiration risks, risk for skin breakdown, and tremors. Review of patient #12’s plan of call did not reflect falls, aspiration, skin breakdown, an emergency preparedness plan, or tremors. 2. Review of patient #14’s EHR initial visit note, dated 11/12/24, reflected pain was an active problem. Review of patient #14’s plan of care reflected no interventions or goals related to pain or emergency preparedness. Review of the agency’s policy, “Plan of Care Interdisciplinary Group”, revised 12/1/24, reflected: -“... 3. The plan of care will include all services necessary for the palliation and management of the terminal illness and related conditions, including: -A. Interventions to manage pain and symptoms relating to physical, psychosocial, emotional, and spiritual needs. ...” During an interview on 1/14/25 at 10:01 a.m., staff member A stated with her background she would reference the last three visit notes to know what was happening with patients. Staff member A stated the agency staff wrote very thorough notes to show what was changing with their patients. Staff member A stated the patient would not have pain care planned if they were not reporting pain or assessed as not having any pain. Review of patient #7s plan of care dated 12/24/24, showed an order for morphine but no individual plan for ongoing pain management.”

“Based on interview and record review, the agency failed to ensure the plan of care included medical appliances to meet the needs of 2 (#’s 8 and 14) of 19 sampled patients. Findings include: Review of patient #14’s EHR initial visit, dated 11/12/24, reflected patient #14 had an intrathecal pump in lower left quadrant that is managing her baclofen medication. Review of patient #14’s EHR plan of care, dated 12/4/24, did not reflect a plan of care for the baclofen pump or symptoms being assessed for the condition being treated with the baclofen pump. During an interview on 1/13/25 at 2:01 p.m., staff member B stated the plan of care should have contained the baclofen pump and stated she would be adding the pump to the plan of care. Review of the agency’s policy, “Plan of Care Interdisciplinary Group”, revised 12/1/24, reflected: -“... 3. The plan of care will include all services necessary for the palliation and management of the terminal illness and related conditions, including: -...E. Medical supplies and DME. ...” During an interview on 1/14/25 at 3:30 p.m., staff member B stated patient’s start of care orders were received from the physician to admit the patient and the agency had standing orders from the medical director to utilize when needed. Staff member B stated if used, the agency nurse would have to let the physician know a standing order was added to the patients care. Review of patient #8s visit notes from 9/20/24 to 1/16/25 showed notes from multiple clinicians showing patient #8 had been progressively using more supplemental oxygen: 9/27/24, “;...utilizing supplemental oxygen.” 12/16/24, “;...she uses supplemental oxygen almost continuously.” 1/15/25, “;...using supplemental oxygen, which she is using the majority of the time.” There was no notification to the physician for oxygen use being implemented from the standing orders. Review of patient #8s physician standing orders signed 9/19/24, showed under Implementation, “;...5. Hospice RN/LPN will notify the MD within 24 hours of initiation on any new standing orders.” Under dyspnea, “;Oxygen 1-10 liters per minute PRN. Titrate to symptoms or sat 90-95%.” Review of patient #8s current plan of care from 12/19/24, showed the word oxygen was under supplies and safety precautions. No orders for oxygen use or individual needs was listed in the plan of care for oxygen use.”

“Based on observations, interviews and record review, the agency failed to ensure standard precautions were followed by clinical staff in the field for 3 (#s 11,12, and 14) of 19 sampled patients. Findings include: . During an observation on 1/14/25 at 9:31 a.m., staff member E entered the room of patient #11 and completed hand hygiene. Staff member E began a physical assessment of patient #11 and changed her gloves four times during the assessment. Staff member E did not complete hand hygiene between any glove changes. 2. During an observation on 1/14/25 at 10:07 a.m., staff member E entered the residence of patient #12. While assessing patient #12, staff member E changed her gloves one time, and did not complete hand hygiene before applying the next set of gloves. During an interview on 1/14/25 at 11:00 a.m., staff member E stated she was not aware she should complete hand hygiene between glove changes. 3. During an observation on 1/14/25 at 1:00 p.m., staff member D was completing vitals on patient #14. Staff member D completed the oxygen saturation check, placed the blood pressure cuff, and did not have his stethoscope out. Staff member D entered his clean bag with dirty gloves to pull out the stethoscope. During an interview on 1/14/25 at 1:45 p.m., staff member D stated he normally keeps and clean gallon Ziplock bag and a dirty gallon Ziplock bag in his nursing bag. Staff member D stated he changed the bags each morning. Staff member D stated he pulls clean equipment from the clean bag, used the items, and then placed the items in the dirty side until he cleaned them at the end of the visit. Staff member D stated the then would clean the equipment and place back in the clean bag before the next visit. Staff member D stated he did not realize he had entered the clean bag with dirty gloves until this interview. Review of the agency’s policy, “Hand Hygiene”, revised 7/7/15, reflected: -“2.0 The WHO Five Moments are: -... 2.5 After removing gloves” During a request for a policy regarding cleaning of equipment in travel nurse bags, staff member E stated the agency did not have a policy specific to the bag technique of cleaning equipment. Staff member E stated all clinical staff watch the bag technique video. Review of the agency’s video synopsis provided, “Nursing Bag Technique: Step-by-Step Guide”, no date, reflected no specific instruction on maintaining a clean side and dirty side of the bag.”

“Based on interviews and record review, the agency failed to provide nursing services in a manner that is consistent with accepted standards of practice for 7 (#s 17,18, 20, 22, 23, 25, and 26) of 26 sampled patients. Findings include: During a phone interview on 1/16/25 at 10:23 a.m., NF1 stated normally they would be called by a hospice nurse and told to pick up the deceased patient. The hospice would relay information about the patients name and time of death, their primary physician, next of kin and if they would be present, and the address and logistics of the home. NF1 stated they used the time of death given by the hospice nurse as they do not bring a stethoscope or pronounce time of death and assume that was the time of death hospice provided the patient physician. NF1 stated they assumed the time of death was called by the hospice nurse as part of their process. NF1 stated they never asked how time of death was called when told a hospice visit was refused because they figured hospice had a process they followed. NF1 stated there had been times in the past where different hospices’ had called them out to perform their duties and the patient was still alive when they arrived. NF1 stated they would let the hospice medical director know to stop by their office and sign the death certificates for his patients. Review of patient #17’s RN Time of Death visit note, dated 12/14/24, reflected the RN did not visit the home and assess the patient to determine time of death. The narrative note reflected the family reported the death and the time given by the family was listed as the time of death of 4:55 p.m. Review of patient #17’s death certificate reflected the time of death was pronounced by staff member K on 1/17/24 at 4:55 p.m. 2. Review of patient #18’s RN Time of Death visit note, dated 12/14/24, reflected the RN did not visit the home and assess the patient to determine time of death. The narrative note reflected the family reported the death and the time given by the family was listed as the time of death of 7:58 p.m. Review of patient #18’s death certificate reflected the time of death was pronounced by staff member L on 12/14/24 at 7:58 p.m. 3. Review of patient #20’s RN Time of Death visit note, dated 6/24/24, reflected the RN did not visit the home and assess the patient to determine time of death. The narrative note reflected the family reported the death and the time given by the family was listed as the time of death of 2:05 a.m. Review of patient #20’s death certificate reflected the time of death was pronounced by staff member H on 6/24/24 with no time of death listed. 4.Review of patient #22’s RN Time of Death visit note, dated 5/15/24, reflected the RN visited the home and assess the patient to determine time of death five hours after death. The narrative note reflected the family reported the death and the time given by the family was listed as the time of death of 4:30 a.m. Review of patient #22’s death certificate reflected the time of death was pronounced by staff member J on 5/15/24/24 at 4:50 a.m. 5. Review of patient #23’s RN Time of Death visit note, dated 1/11/25, reflected the RN did not visit the home and assess the patient to determine time of death. The narrative note reflected the family reported the death and the time given by the family was listed as the time of death of 4:56 p.m. Review of patient #23’s death certificate reflected the time of death was pronounced by staff member I on 1/11/25 at 4:56 p.m. 6. Review of patient #25’s RN Time of Death visit note, dated 8/23/24, reflected the RN did not visit the home and assess the patient to determine time of death. The narrative note reflected the family reported the death and the time given by the family was listed as the time of death of 4:00 a.m. Review of patient #25’s death certificate reflected the time of death was pronounced by staff member C on 8/23/24 at 4:30 a.m. 7. Review of patient #26’s RN Time of Death visit note, dated 1/6/24, reflected the RN did not visit the home and assess the patient to determine time of death. The narrative note reflected the family reported the death and the time given by the family was listed as the time of death of 11:55 a.m. Review of patient #26’s death certificate reflected the time of death was pronounced by staff member H on 1/6/24 at 11:55 a.m. During an interview on 1/16/25 at 8:20 a.m., with staff members A and B, staff member A stated they completed an audit overnight on how many deaths were not completed with a nursing visit. Staff member A stated she and staff member B determined 35% of deaths did not have a visit from clinical staff. Staff member B stated the physicians did not ever pronounce the time of death. Staff member B stated the family stated they did not need a nursing visit, and the nurses use the date and time provided by the family at the bedside. Staff member B stated the family members were not clinically trained to assess and pronounce the time of death. During an interview on 1/16/25 at 11:19 a.m., staff member K stated she and staff member H did not pronounce time of death unless the patient was in the hospital. Staff member K stated she was not aware the death certificate reflected she or staff member H pronounced the time of death. Staff member K stated the physician’s role was only to put a diagnosis on the death certificate and certify the death certificate with their signature. Staff member K stated she expected the nurses to go to the home and assess for the time of death. Staff member K stated, “ ...they need to improve on assessing, as this should be done.” During an interview on 1/16/25 at 11:27 a.m., staff member C stated he was not aware the nurses were not going out to assess and pronounce the time of death. Staff member C stated it should be part of the nurses’ jobs. Staff member C stated he was not aware the death certificate reflected he had pronounced the time of death 30 minutes after the family stated the patient died and no visit was done to determine the time of death. During an interview on 1/16/25 at 12:24 p.m., staff member L stated he never called time of death on hospice patients, and he was not aware his name was listed on the death certificate as the person pronouncing time of death. Staff member L stated he did not know an RN was not going to the home to assess and pronounce the time of death. Staff member L stated, “Best practice would be to go out on a visit and better business practice too. The RN should be providing support as well.” Review of the agency’s policy, “Pronouncement of Death”, revised 10/2024, reflected: -“2.0 A physician or a registered nurse may make the pronouncement of death. The nurse assesses the patient for the absence of an apical pulse and respiration. The patient’s death is pronounced, documented and communicated in accordance with MT state laws. ...” Review of the Administrative Rules of Montana statute 24.159.1625 General Nursing Functions and Tasks That May Not Be Delegated reflected: -“(1) The following nursing tasks require nursing knowledge, judgement, and skill and may not be delegated: (a) the nursing assessment ...(e) evaluation of the patient’s progress, or lack of progress, toward goal achievement. ...” Review of the agency’s policy, “Post-Mortem Procedures Policy, revised 4/27/07, reflected: -“...1. A registered nurse, or physician, must pronounce the patient as deceased. Observations will be made and documented by the registered nurse or physician to ensure the patient has no observable signs of life. ...””

“Based on interviews and record review, the agency failed to ensure a Licensed Practical Nurse acted only within the scope of his or her State license for 1 (#21) of 26 sampled patients. Findings include: . Review of patient #21’s Hospice Time of Death visit note, dated 12/1/24, reflected staff member D completed the visit and determined time of death. Staff member D was an LPN and assessing for time of death is not in the scope of practice for a LPN. Review of the agency’s policy, “Pronouncement of Death”, revised 10/2024, reflected: -“2.0 A physician or a registered nurse may make the pronouncement of death. The nurse assesses the patient for the absence of an apical pulse and respiration. The patient’s death is pronounced, documented and communicated in accordance with MT state laws. ...” Review of the Administrative Rules of Montana statute 24.159.1625 General Nursing Functions and Tasks That May Not Be Delegated reflected: -“(1) The following nursing tasks require nursing knowledge, judgement, and skill and may not be delegated: (a) the nursing assessment ...(e) evaluation of the patient’s progress, or lack of progress, toward goal achievement. ...” Review of the agency’s policy, “Post-Mortem Procedures Policy, revised 4/27/07, reflected: -“...1. A registered nurse, or physician, must pronounce the patient as deceased. Observations will be made and documented by the registered nurse or physician to ensure the patient has no observable signs of life. ...””

“Based on interviews and record review, the agency failed to provide core service of a medical social services for a period of more than six months. This deficient practice had the potential to affect all patients requiring the services of social services. Findings include: During an interview on 10/22/24 ay 1:10 p.m., staff member B stated the agency did not have a social worker available. Staff member B stated the agency had been actively searching for a social worker for the past six months. Staff member B stated the agency hired a social worker who would be starting on 10/22/24. Staff member B stated staff member F had worked for the agency approximately six months. Staff member B stated no one was completing the social services assessments on admissions and social services was not represented in the IDG meetings. During an interview on 10/22/24 at 3:33 p.m., NF1 stated, “They (agency) eventually got a social worker, I don’t know what that was all about. I’m not sure if or how much it might have helped to have a social worker helping us in the beginning with [Name].” During an interview on 10/23/24 at 8:20 a.m., staff member E stated, “... several patients would have benefited from having social services available over the past six months, especially with family dynamics.” During an interview on 10/23/24 at 8:30 a.m., staff member B stated, “We simply avoided promoting the service (social services) because we didn’t have one (social service worker). We didn’t complete the social service assessments, and we did not have a social worker to go to IDG.” During an interview on 10/23/24 at 10:56 a.m., NF2 stated no one had discussed social service services with her from hospice. NF2 stated social services was mentioned by hospital staff before hospice was involved, but hospice had not mentioned the service. During an interview on 10/23/24 at 11:22 a.m., staff member A stated staff member H was employed with the agency from 8/29/22-1/8/23. Staff member F’s dates of employment were from 9/25/23-3/25/24. Staff member A stated there was not a social worker in place for the periods between 1/8/23-9/25/23 and 3/25/24-10/22/24. This was a period of eight months in 2023 and seven months in 2024. Review of the agency’s IDG attendance records, dated 3/19/24-10/15/24, reflected no social worker was in attendance for the IDG meetings.”