Mesilla Valley Hospice, Inc.

“Based on policy review, record review, document review, and interviews, the Hospice Agency failed to ensure all medications for symptom management were available for one of four sampled patients (Patient (P) 16) observed for medication management. This deficient practice had the potential to affect all 57 patients receiving services from the Hospice Agency. Review of the agency’s policy updated on 07/2024 titled, “Medications – Labeling, Disposing and Storing of Drugs and Biologicals,” revealed, “...6. The hospice nurse counts and reconciles medications during every visit to ensure that proper quantities are available. ...” Review of P16’s “Patient Face Sheet,” found in P16’s Electronic Medical Record (EMR) under the “Face Sheet” tab, indicated that P16 was admitted to the Hospice Agency on 08/20/22 with a primary diagnosis of cerebral atherosclerosis (hardening of the arteries in the brain). Review of P16’s “Medication Profile,” found in P16’s EMR under the “Medication” tab, indicated that P16 was prescribed lorazepam (agitation and anxiety medication) on 08/29/23. Review of P16’s undated handwritten “Medication Sheet” located in the Assistant Living Facility (ALF) where the patient resided, indicated that lorazepam was not listed as an active medication on the medication sheet. Review of a document signed by the ALF’s contracted pharmacist dated 05/20/23 titled, “Note to Attending Physician/Prescriber,” revealed, “This resident is currently on PRN [as needed] Lorazepam NOT BEING USED. Please evaluate current diagnosis, behaviors and usage patterns and evaluate continued need ...Please consider discontinuing.” During an interview on 07/16/24 at 9:30 AM, the ALF’s Administrator stated, “The pharmacist came in to do an audit and said the medication needs to be discontinued due to the expiration date and the patient not using it.” The ALF’s Administrator confirmed that the lorazepam was discontinued. During an interview on 07/16/24 at 9:45 AM, the Hospice Agency’s Clinical Manager (CM) stated, “The ALF should not have discontinued the lorazepam.” The CM confirmed that the Hospice Agency’s Registered Nurse (RN) should have performed a medication reconciliation at each nursing visit to ensure that comfort medications including lorazepam were available at the ALF for patient use.”

“Based on policy review, record review, and interview, the Hospice Agency failed to ensure care plans included measurable data elements to assess progress towards expected outcomes and goals for two of 10 sampled patients (Patients (P) 8 and P10) reviewed for care plans. This deficient practice had the potential to affect all 57 patients receiving services from the Hospice Agency. Review of the agency’s policy updated on 01/2024 titled, “Plan of Care – Content” revealed, “...2. The plan of care includes but is not limited to ...b. a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs; c. measurable outcomes anticipated from implementing and coordinating the plan of care. ...” 1. Review of P8’s “Skilled Nursing Care Plan,” found in P8’s Electronic Medical Record (EMR) under the “Nursing Care Plan” tab, indicated the following: a. A respiratory care plan was started on 07/06/24 by a Licensed Practical Nurse (LPN). The care plan did not include measurable data elements to assess outcomes. b. A pain management care plan was started on 07/06/24 by a Registered Nurse (RN). The care plan did not include measurable data elements to assess outcomes. c. A cardiovascular care plan was started on 07/06/24 by an RN. The care plan did not include measurable data elements to assess outcomes. 2. Review of P10’s “Skilled Nursing Care Plan,” found in P10’s EMR under the “Nursing Care Plan” tab, indicated the following: a. A care plan was started for nausea and vomiting on 07/11/24 by an RN. The care plan did not include measurable data elements to assess outcomes. b. A pain management care plan was started on 07/11/24 by an RN. The care plan did not include measurable data elements to assess outcomes. c. A care plan for cancer – cholangiocarcinoma [gall bladder cancer] was started on 06/26/24 by an LPN. The care plan did not include measurable data elements to assess outcomes. During an interview on 07/17/24 at 2:45 PM, the Inpatient Unit (IPU) Clinical Manager confirmed that P8 and P10’s care plans did not include measurable data elements per agency policy.”

“Based on policy review, record review, and interview, the Hospice Agency failed to ensure the Registered Nurse (RN) and the Attending Physician collaborated to revise the patient’s care plan to include seizure-like activity and code status (no cardiac resuscitation) for one of 10 sampled patients (Patient (P) 8) reviewed for care plans. This deficient practice had the potential to affect all 57 patients receiving services from the Hospice Agency. Review of the agency’s policy updated on 07/2024 titled, “Coordination of Services” revealed, “...2. The RN Case Manager coordinates the patient’s plan of care and facilitates the ongoing sharing of information with the attending licensed practitioner, contracted facilities, vendors, other members of the IDT [Interdisciplinary Team] and non-hospice healthcare providers furnishing services unrelated to the terminal illness.” Review of P8’s “Skilled Nursing Visit Note,” dated 07/06/24, found in P8’s Electronic Medical Record (EMR) under the “Comprehensive Skilled Nursing Assessment” tab, indicated P8 had an internal cardiac defibrillator (a surgically placed implanted device into the chest to deliver an electric shock to stop an abnormal heart rhythm or to restart the heart). Review of the “Skilled Nursing Visit Note,” located in the EMR indicated P8 did not want cardiopulmonary resuscitation should his/her heart stop beating. There were no communication notes found that the Skilled Nurse (SN) contacted the Medical Director to obtain an order to deactivate P8’s cardiac defibrillator. Review of P8’s “Skilled Nursing Care Plan,” found in P8’s EMR under the “Nursing Care Plan” tab, revealed the RN started a cardiovascular care plan on 07/06/24. The care plan did not include the desired outcomes for the cardiac defibrillator. Review of P8’s “Skilled Nursing Visit,” dated 07/09/24 found in P8’s EMR under the “Skilled Nursing Visit” tab, indicated, “[P8] has had 2 ‘episodes’ lasting about 5-10 seconds that appear to be seizure like, [P8] appears to lose consciousness, [his/her] body begins to stiffen, [his/her] eyes roll upward, both episodes occurred while sitting. [P8] shares that this has happened in the past after ambulating, however that the episodes are becoming more frequent. [P8] shares that [he/she] begins to feel hot and dizzy, requires reorientation after episodes occur.” Review of P8’s “Interdisciplinary Group (IDT) Meeting” note, dated 07/10/24 found in P8’s EMR under the “Interdisciplinary Meeting” tab, revealed there was a discussion regarding the patient’s seizure-like episodes. There was no documentation the Attending Physician was part of the IDT meeting and no documentation the seizure-like activity was included in the patient’s care plan. There was no documentation that a discussion occurred regarding the deactivation of P8’s cardiac defibrillator during the Interdisciplinary Group Meeting, and there was no documentation indicating that P8’s cardiac care plan was updated to include the deactivation of P8’s cardiac defibrillator. Review of P8’s “Skilled Nursing (SN) Visit,” dated 07/11/24 found in P8’s EMR revealed, “This SN received phone call from [company representative monitoring the patient’s defibrillator activity], shares that [P8’s] defibrillator has activated twice within the month of July ... most recent activity July 8 & 9, [company representative] shares that [he/she] spoke with [P8 and family] and patient and family would like to discontinue defibrillator therapies at this time.” During an interview on 07/17/24 at 11:00 AM, the Chief Compliance Officer (CCO) confirmed the Hospice RN should have contacted the Attending Physician to advise him/her of P8’s seizure-like episodes, and P8’s cardiac care plan should have been completed to include the deactivation of the cardiac defibrillator.”