Family Hospice Ltd DBA Gentiva

“Based on record review and interview the agency failed to identify and treat a new onset injury for 1 (P [Patient]1) of 11 (P1-P11) patients reviewed for care received by the agency. This deficient practice can lead to increased suffering and pain for the patient that is on hospice and has unrelated medical concerns. The findings are: A. Record review of the agencys policy titled, “;Physician Service – Medical Director/Hospice Physician” dated 10/11/2023 included a table that lists hospice physicians duties and responsibilities, the third box stated, “;Acting as primary physician for patients whose referring/attending physicians desire to relinquish that care and/or if the referring/attending physicians are not available for further contact.” B. Record review the agencys policy titled, “;Patient Bill of Rights” dated 01/12/2023 stated, “;Each patient will be an active, informed participant in his/her plan of care. To ensure this process, the patient will be empowered with certain rights as described. The rights contained within this policy include the basic rights of the patient. A patient may designate someone to act as his/her representative. This representative, on behalf of the patient, may exercise any of the rights provided by the policies and procedures established by the hospice. . .” C. Record review of P1s medical record revealed the following: 1. Patient information under “;Physician Info” revealed the hospice doctor was listed as the patients primary physician. 2. Provider Note dated 01/11/2023 stated “;This [patient] has a terminal hospice diagnosis of dysphagia [trouble swallowing], related to CVA [cerebrovascular accident, stroke] in 2019. . . Related diagnoses include pneumonia [infection in the lungs] and respiratory failure [condition that makes it difficult to breathe] with possible aspiration [when something is swallowed and enters the lungs]. . .” 3. Legal document of guardianship dated 11/15/2023 titled, “;Order appointing full guardian” revealed that P1 is incapacitated and requires a full guardian to provide continuing care and supervision. 4. Nursing note dated 11/30/2023 under assessment of orientation status stated, “;Patient unable to understand and participate in care.” 5. Nursing note dated, 12/03/2023, stated “;PRN [as needed] visit due to change in pt [patient] condition. CG [caregiver] . . . called and reported pts left upper arm was swollen. Pt in bed, arms assessed bilaterally [both sides]; left upper arm is swollen, hard on lateral aspect [outer side], no signs of pain noted upon palpation [feel]; temp and color to both arms are the same, radial [wrist] pulses equal bilaterally. No s/s [signs or symptoms] of a DVT [clot] or cellulitis [infection] noted. . .” 6. Nursing note dated, 12/06/2023, stated “;Routine RN [Registered Nurse] visit. Was called to go over to see pt as her arm is getting worse. Health aides with pt. Tried to call guardian but no answer. Health aides stated her [bruising] is getting worse adn [sic] seems like pain is worsening. Pt grimaces and gets tense when arm is moved. Bruising noted to left [upper] inner arm down to the midle [sic] of her hand. [swelling] noted and is hard to touch. All VITLS [vital signs] obtained. . . . Called guardian. Spoke with her she requested [name of doctor] come see pt and if she thinks her arm is broken they will take her off hospice for further care. Spoke with [name of doctor] she stated she will come look at it after IDG [interdisciplinary group] meeting is over. Informed her guardian is wanting an Xray [digital image of internal body parts in this case bone]. . . .” 7. Provider note dated, 12/6/2023, stated under history, “;. . . She initially came on to hospice services November of 2020 but revoked in January of 2021 as she chose aggressive care for abdominal distention. She was readmitted to hospice related to further decline in January of 2023. About 3 days [ago] hospice was contacted related to [what] would appear to be a scratch in the left arm at the elbow medially [middle]. Initially there was no visible bruising noted, however over the next 3 days bruising began to appear in the left upper and lower arm.” Under assessment it stated, “;L [left] arm bruising likely related to soft tissue injuries during recent transfer for outings and nutritionist appointment yesterday. No clinical evidence of fractures.” Under plan stated, “;Spoke with new guardian. . . Explained that in view of these recent injuries it is time to stop transferring the patient and allow her to stay in bed 24/7. . .” 8. Nursing note dated, 12/18/2023, stated “;Routine RN visit. Recived [sic] a call from CG stating pts arm was popping when moved. Pt laying in bed with eyes half opened. [Caregiver] stated pt is doing well other than her arm. She stated pt appeared to be in pain whne [sic] left [arm] was moved. All vitals obtained. . . .mild edema [swelling] noted to left upper arm. [Bruising] noted to left arm but is getting better. CG raised pts arm and moved it in different poositions [sic] this RN held her arm. No popping [noises] heard or felt upon palpation. Gaurdian [sic] requested pt be taken for xrays. Spoke with [name of hospice doctor] [and] she stated she did not [suggest] pt be taken for xrays when no obvious injuries were noted upon assessment. . .” a. Nurses assessment dated 12/18/2023 revealed that patient was prescribed an opioid medication (medication class used to treat pain). The medications documented are hydrocodone (pain medication) and oxycodone (pain medication). It was documented “;Has patient required this medication for PRN [as needed] breakthrough pain? No” 9. Nursing note dated, 12/20/2023, stated “;. . . Swelling and bruising in arm is getting better. . . CG stated they did not need anything at time of visit. . .” a. Nurses assessment dated 12/20/2023 revealed that patient was prescribed an opioid medication (medication class used to treat pain). The medications documented are hydrocodone. It was documented “;Has patient required this medication for PRN [as needed] breakthrough pain? No” 10. Nursing note dated, 12/26/2023, stated “;. . . CG stated pt is still but lethargic. [sic]. CG [name] said pt is sleeping 20 hours a day. . . Pts left arm is in a sling due to pathological fracture. . .” a. Nurses assessment dated 12/26/2023 revealed that patient was prescribed an opioid medication (medication class used to treat pain). The medications documented are Norco (hydrocodone-acetaminophen, pain medication) and Roxanol (morphine, pain medication). It was documented “;Has patient required this medication for PRN [as needed] breakthrough pain? No” 11. Nursing noted dated, 01/02/2024, stated “;. . . CG stated she went [for an xray] Friday before last and was found her left was brokend [sic] and she has it casted now. . .” 12. Nursing note dated, 01/04/2024 stated, “;Routine RN visit. Pt laying in bed awake and alert. CG state she has been in a god [sic] mood today. Stated she ha s [sic] been laughing all day. Pt laughed all through visit. . .” D. During an interview on 05/01/2024 at 9:35 AM with S (Staff)9, P1s personal caregiver, it was confirmed that it took several weeks and more than one request to get patient an X-ray. S9 stated they (the guardian and caregiver) decided to take her to get an X-ray on 12/21/2023 because the patients arm swelling and bruising had gotten worse. E. During an interview with on 05/01/2024 at 1:00 PM with S12, Medical Doctor, it was confirmed that she did not advise the patient to get an X-ray or present to the hospital for new bruising and swelling of the left arm because she felt the transfer to the hospital would have been cruel. When asked why she would not treat a fracture, S12 stated a cast would be uncomfortable and “;maybe she (P1) should not be on hospice if the caregivers want everything done [for assessing the reason for patients arm swelling and bruising]”.”

“Upon patient record review, 7 of 19 (Patients #8,#9,#10,#11,#12,#13,#14) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications. Patient 8: The medical record contained an order for oxygen supplies 1/18/24. There was no evidence of oxygen on the medication profile. The profile contained Voltaren topical gel with no area defined for administration. Corrected on site. Patient 9: The medication profile contained duplicative Seroquel listings. Corrected on site. Patient 10: The medication profile contained differing albuterol nebulization PRN orders for four times daily and every two hours. Corrected on site. Patient 11: The medication profile contained duplicative scheduled Miralax listings. Corrected on site. Patient 12: The medical record contained nursing documentation upon admission identifying patient use of continuous oxygen. There was no evidence of oxygen instructions on the medication profile. The profile also contained Aspercreme topical patch with no area defined for administration. Corrected on site. Patient 13: The medication profile contained two differing docusate sodium listing for 100mg twice daily and 250 mg every other day. There was no evidence of instructions to take both as instructed together. Corrected on site. Patient 14: The medication profile contained lidocaine topical patch with no area defined for administration. Corrected on site.”

“Upon patient record review, 4 of 19 (Patients #5,#9,#12,#14) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient’s family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient 5: There was no evidence of a bereavement assessment. Patient 9: There was no evidence of a bereavement assessment. Patient 12: The medical record contained an initial bereavement assessment completed 8/8/23 with start of care 6/18/23. Patient 14: The medical record contained an initial bereavement assessment completed 2/28/24 with start of care 2/17/24.”

“Upon patient record review, 2 of 19 (Patients #10,#11) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family’s needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient 10: The medical record contained nursing documentation identifying a UA/UC was ordered 3/4/24, collected and delivered to lab 3/6/24, and results were positive for UTI 3/11/24 with antibiotics ordered. Nursing documentation on visit 3/7/24 indicates patient ongoing with symptoms. There was no evidence of assessments, communication with the lab, or communication with the physician between 3/7/24 and 3/11/24. Patient 11: The medical record contained nursing documentation identifying a UA/UC was ordered 2/21/24. There was no evidence of RN follow up on results. Corrected on site with late entry documentation.”

“Upon patient record review, 1 of 19 (Patient #14) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 14: The medical record identified patient’s primary diagnosis is heart failure and patient is insulin dependent. There was no evidence of problems, goals, and interventions related to cardiac and endocrine dysfunction included in the plan of care. Corrected on site.”

“Upon patient record review, 1 of 19 (Patient #8) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient’s plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient 8: The medical record contained evidence the patient was receiving social work services. The current frequency order inaccurately stated social work was declined and did not define anticipated patient needs requested for monthly visits.”

“Upon patient record review, 4 of 19 (Patients #8,#12,#13,#14) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 8: The medical record contained an order for oxygen supplies and an order for Voltaren topical gel with no area defined for administration. There was no evidence of an order for oxygen dose, frequency, and delivery method. Corrected on site. Patient 12: The medical record contained nursing documentation upon admission identifying patient use of continuous oxygen. There was no evidence of an order for oxygen rate, frequency and delivery method. The record also contained an order for Aspercreme topical patch with no area defined for administration. Corrected on site. Patient 13: The medical record contained two differing docusate sodium orders for 100mg twice daily and 250 mg every other day. There was no evidence of instructions to take both as instructed together. Corrected on site. Patient 14: The medical record contained an order for lidocaine topical patch with no area defined for administration. Corrected on site.”

“Upon patient record review, 2 of 19 (Patients #8,#13) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient 8: The medical record contained nursing documentation upon admission identifying patient use of a walker and nebulizer. There was no evidence of orders for the equipment included in the plan of care. Corrected on site. Patient 13: The medical record contained nursing documentation upon admission identifying patient use of a wheelchair. There was no evidence of an order for the wheelchair included in the plan of care. Corrected on site.”

“Upon patient record review, 2 of 19 (Patients #1,#14) did not have evidence in the patient record that hospice aide assignments and duties are individualized to patient needs. Patient 1: The medical record contained nursing documentation 2/3/24 identifying patient is a max assist for transfers. There was no evidence of transfer instructions included on the aide care plan. Corrected on site. Patient 14: The medical record contained nursing documentation upon admission identifying patient is wheelchair bound. There was no evidence of transfer instructions included on the aide care plan. Corrected on site.”