Patient Care Hospice

“Based on review of facility policies and procedures, and medical record review, it was determined that the facility failed to provide education and training for pain management to the patient and caregiver in one of 15 (Patient (P)2) medical records reviewed. Findings include: The medical record of P2 was reviewed on 4/18/24 at 9:13 AM. P2 started hospice care on 4/13/24 with a primary diagnosis of unspecified severe protein-calorie malnutrition. P2 was prescribed Tramadol (a controlled pain medication) 50 mg (milligrams) and Alprazolam (a controlled anti-anxiety medication) 0.5 mg. Nursing visits were conducted on 4/14/24 and 4/15/24. The medical record lacked documented evidence of medication education provided to the patient and/or the patient family. On 4/18/24 at 12:11 PM, a staff interview was conducted with Staff (S)1, Administrator, regarding pain medication education. S1 stated, “Education is provided at the time of ordering the medication and is continued throughout the patient’s visits. Education should be documented in the note.” The policy titled, “Patient/Family Education,” revised 8/1/12, stated, “... The patient/representative receive ongoing information specific to the patient/family member needs including...g. Pain: Roles in management of pain and the potential limitations and side effects of pain medication treatments...” The facility was unable to provide evidence that P2 or his/her family, received pain management education.”

“Based on one of four (Patient (P) 1) observations of patients during home visits, staff interview, and review of facility policy, it was determined the facility failed to communicate and share information to facilitate a patients request for medical supply equipment for patient comfort. Findings include: On 4/17/24 at 1:05 PM, the survey team arrived at P1s home to observe care being delivered by S7, a Registered Nurse (RN), and S8, a Home Health Aide (HHA). At 1:53 PM, S7 confirmed that all patient care for P1 was completed. S7 and S8 were preparing to leave the home. P1 asked S7 and S8 if the facility had been able to order him/her a wedge pillow for comfort. P1 stated that he/she would buy one at a store if necessary. S7 responded that they were trying and were waiting on approval of the order from supervisors. On 4/18/24 at 9:05 AM, an observation of the IDG (Interdisciplinary Group) Meeting was conducted. At 10:05 AM, S7 presented on P1 to the IDG. S7 stated, “;P1 is complaining of pain and using morphine for long-acting pain relief and oxycodone for breakthrough pain. The caregiver is giving P1 the oxycodone more frequently. The pain is in the lower back and related to cancer that metastasized to the bones. On 4/17/24, P1s pain was a 5/10. P1 has not been sleeping well.” S7 did not discuss P1s request for a wedge pillow during IDG. On 4/18/24 at 3:10 PM, an interview was conducted with S1, the Administrator. S1 was asked about P1 and the request for a wedge pillow. S1 stated that she was not aware that a request had been made for a wedge pillow. S1 was unable to locate any nursing documentation requesting a wedge pillow for P1. S1 stated that S7 was probably unaware of how to order a wedge pillow for P1. Facility policy titled, “;Interdisciplinary Group (IDG) Membership and Responsibilities,” reviewed 11/01/21, stated, “;... Purpose: To define the roles and responsibilities of the Interdisciplinary Group. Procedure ... 2. The IDG responsibilities include but are not limited to: ... f. Providing for and ensuring the ongoing sharing of information between all disciplines providing care and services in all settings, whether the care services are provided directly or under arrangement ...” N.J.A.C. 8:42C – 7.3(b)(2)”

“Based on one of four (Patient (P) 1) observations of patients during home visits, staff interview, and a review of facility policy and procedure, it was determined the facility failed to ensure acceptable standards of practice for cleaning and disinfecting reusable equipment are implemented. Findings include: During a home visit for P1, on 4/17/24 at 1:05 PM, the following was observed as S7, a registered nurse (RN), provided care for P1: At 1:11 PM, S7 removed vital signs equipment from a nursing bag. S7 had all of the equipment (sphygmomanometer to measure blood pressure, pulse oxygen meter, stethoscope, and thermometer) contained within a clear plastic bag inside the nursing bag. S7 removed the clear plastic bag with all the equipment in it from the nursing bag and placed the clear bag with the equipment on left side of a clean barrier that was set on top of tray table at end of P1s bed. At 1:12 PM, S7 began assessing P1s vital signs: blood pressure, heart rate, temperature, and pulse oxygen percentage. At 1:15 PM, S7 finished assessing P1’s vital signs and began disinfecting the vital signs equipment with MagiCare 75% Alcohol Wipes. After wiping the equipment with disinfectant, S7 placed each piece of equipment on the right side of the barrier to dry. At 1:50 PM, S7 placed the equipment back in the plastic Ziploc bag on the barrier and placed the clear plastic bag with the vital signs equipment back in his/her nursing bag. S7 failed to clean the clear plastic bag prior to placing it in the nursing bag. During a home visit for P1, on 4/17/24 at 1:05 PM, the following was observed as S8, a Home Health Aide (HHA), provided care for P1: At 1:11 PM, S8 was preparing to give P1 a bed bath while S7 assessed vital signs. S8 placed a wash basin on a tray table adjacent to and touching the clean barrier that had S7s cleaned vital signs equipment on it. At 1:16 PM, S8 removed the washcloth from the water basin and shook water out of it causing water droplets from the washcloth to visibly land on the edge and side of the water basin that was touching the barrier with the clean equipment. S7 and S8 failed to prevent the potential transmission of infectious agents to the clean reusable equipment. Facility policy titled, “Infection Control Plan”, last reviewed on 11/01/21, states, “;... Purpose: To enhance the safety and quality of patient care being provided by the agency. To decrease the risk of infections and transmission of communicable diseases. ... Policy: ... Infection Transmission Prevention Practices: ... 3. Medical Equipment, Device and Supplies Cleaning Compliance: The agency will prevent the transmission of infection through the proper sanitation of medical equipment, devices, and supplies such as: stethoscopes, blood pressure cuffs, pulse oximeters, and thermometers ...” NJAC 8:42C - 10.2(b)”

“Based on patient family interview, staff interview, and review of facility documents, the facility failed to ensure that the patient’s right to dignity and respect was maintained in one of four (Patient (P) 3) hospice home visits conducted. Findings include: On 4/17/24 at 9:45 AM, Staff (S) 1, Administrator, was asked to procure three home visits with hospice patients. This surveyor clarified that each home visit would have two surveyors present in the home. On 4/17/2024 at 11:00 AM, S1 stated that the facility had called P3 and the family was willing to let state surveyors observe their care scheduled for 4/17/2024 at 11:45 AM. At 11:49 AM, on 4/17/24, the survey team arrived at the home of P3 and observed S2, Nurse, speaking with the family member of P3 on the doorstep of the home. Upon approach to the home, the survey team was then met by S2 and S10, Nurse, on the sidewalk outside the home. S2 stated that he/she was supervising S10 on the visit as S10 was a new hire to the agency. S10 provided updates regarding P3’s condition stating that P3’s condition was declining, and that the family was anxious. This surveyor stated that it was very accommodating for the family to have the additional people in their home during this time, and S2 remarked that the family “knows now.” When asked what S2 meant by that statement, S2 responded that he/she had just asked the family if surveyors could conduct a home visit. This surveyor asked S2 to confirm if the family had been called ahead of time for consent, and S2 stated that he/she had just asked the family and the family had agreed. At 11:54 AM, an interview was conducted on the doorstep of the home of P3 with P3’s family. This surveyor explained the purpose of a home visit, and that the survey team had been told that the family had already consented to the visit prior to the team coming out. P3s daughter confirmed that she had not received a phone call from the facility prior to S2 and S10 arriving onsite to ensure that the family consented to having the survey team observe care for P3. When asked if P3s family was still comfortable with having the state surveyors observing care, P3’s family stated that they did not really want extra people in the home, but also did not want to “hinder anyone from doing their job.” This surveyor explained that it is their right and the patient’s right to be respected during this difficult time and after explaining to P3’s family, that they could decline observation of P3s care if they were not comfortable, P3’s family declined to participate in the survey. P3’s family stated they didn’t think they could refuse, but that given the explanation of their rights, they would prefer to just have the hospice agency staff in their home. P3’s family stated, “;four people would be too many in the house with [P3] today.” The survey team thanked P3’s family for their time, wished them well and left. At 12:00 PM, a call was placed to the remainder of the survey team to notify them of the incident at the home visit of P3 and to have them notify S1. S1 was informed that the family of P3 was not informed prior to the surveyors arriving, and P3’s family did not consent to the visit because it would be too many people in the home. S1 stated that he/she was told that the nurses had gotten consent. S1 was then asked to reconfirm that the other home visits were properly consented. S1 agreed, and prior to the survey team leaving for the remaining home visits, the consent for the visits were reconfirmed with the patients and patients’ families via the hospice agency. On 4/18/24, the hospice agency and the survey team were notified that P3 had expired. N.J.A.C. 8:42C- 5.1(b)(19)”

“Based on review of facility policy and procedure and medical record review, it was determined that the facility failed to implement their policy regarding the disposal of controlled drugs in one of 15 medical records (Patient (P) 6) reviewed. Findings include: A medical record review of P6 was conducted on 4/18/24. P6 was prescribed the medication Ativan (a controlled anti-anxiety medication) 0.5mg (milligrams) and the medication Morphine (a controlled pain medication) 100mg/5mL (milliliters). A nursing note, documented on 4/3/24, stated, “Ativan and Morphine within reach ... .” A nursing note, documented on 4/4/24 indicated that P6 had expired and stated, “Destroyed Morphine 25mL with both daughters according to patient care policy.” The facility policy titled, “Medication Disposal,” last revised 11/01/21, stated, “... When hospice medications are disposed of in the presence of a hospice nurse, the disposal must be witnessed by the nurse, the patient/caregiver, and/or another employee of the hospice or facility (for facility patients). The witnessing of the medication disposal should be documented ...” The facility was unable to provide evidence of the documented disposal of P6’s Ativan. NJ 8:42C-8.1(c)”