Infinity Hospice Care

“Based on record review, interview, and policy review, the Hospice agency failed to ensure effective symptom management for one of 27 patients (Patient (P)1. This failure had the potential to result in a patient’s death and cause additional distress for the family.Findings include: Review of an undated agency policy titled, “Plan of Care,” revealed, “Hospice care and services provided to patients and their families are in accordance with an individualized, written plan of care established by the hospice IDG [Interdisciplinary Group] in collaboration with the patient’s attending physician (if any), and, if appropriate, the patient or representative and the primary caregiver.”Review of the undated agency policy titled, “Content of the Plan of Care,” revealed, “The plan of care reflects patient and family goals and interventions that are based on problems identified . . . The plan of care includes but is not limited to: interventions to manage pain and symptoms . . . drugs and treatment necessary to meet the needs of the patient.”Review of P1’s “Initial Assessment,” dated 04/01/2025 and located in the electronic medical record (EMR) under the “Nursing” tab, revealed an admitting diagnosis of heart disease, unspecified dementia, secondary hypertension, and atherosclerotic heart disease. The assessment revealed P1 had been hospitalized for atrial fibrillation and was noted to have a urinary tract infection and possible pneumonia. P1 was transferred to a skilled nursing facility with hospice services. Documentation showed P1 had a family member who was the designated health care power of attorney.Review of a “Progress Note,” dated 04/02/2025 at 11:30 AM and located in the EMR under the “Nursing” tab, revealed, “Patient did not open eyes during entire assessment. Patient did withdraw from pain but did not follow any commands . . . mouth is dry . . . has been sleeping since yesterday and unable to arouse enough to be able to give medications or food. No PO [by mouth] intake for 2 days.”Review of a “Patient Communication,” dated 04/04/2025 at 8:04 PM and located under the “Communication” tab, revealed, “Family is requesting IV [intravenous] fluids be administered to patient.”Review of a “Physician order,” dated 04/04/2025 at 9:44 PM and located in the EMR under the “Orders” tab, revealed, “Start IV fluids. Run at 1 liter IV over 24 hrs. IV access to be placed as appropriate.”Review of a “Patient Communication,” dated 04/05/2025 at 2:04 PM and located under the “Communication” tab, revealed, “Caller [nursing home staff] states no orders received for IV fluids … states pt is semi-responsive, unable to give medications, not eating and is only taking small amounts of fluid by mouth. Caller also states fax machines at facility have been unreliable. [hospice nurse] given visit due to failure to start of [sic] IV fluids. Also [hospice nurse] is advised that [he/she] will need to print order or write the orders directly in facility chart.”Review of a “Subseq Nur Fac/High,” dated 04/05/2025 at 3:20 PM and located under the “Physician” tab written by Nurse Practitioner Lead (APN1), revealed the visit was conducted via two-way audio-video telecommunications and showed, “83 yo [year old] [gender withheld] admitted with the primary hospice diagnosis of end stage cardiac with senile degeneration of the brain . . . Patient is unable to make his own decisions and prognosis is poor. POA [power of attorney] agrees to hospice philosophy. 4/5-The patient was found to be semi-responsive and unreactive to painful stimuli during the assessment. RN [Registered Nurse] reported that the patient had not been eating or drinking, and all attempts to administer oral nutrition were unsuccessful, fluids pool in the cheeks. HR 109 bpm [beats per minute], other vitals WNL [within normal limits]. Given the patient’s poor oral intake, altered mental status, and aspiration risk, a face-to-face evaluation was conducted . . . Change level of status to imminent. Discontinue PO and all medications except liquid and sublingual.”Review of a “Progress Note,” dated 04/05/2025 at 3:50 PM and located under the “Nursing” tab, revealed, “Given the patient’s poor intake, lack of responsiveness, and risk of aspiration, a face-to-face evaluation was conducted by the nurse practitioner determined that the patient is in an eminent decline due to their overall condition. Due to the patient’s inability to tolerate oral medications and fluids, oral medications were discharged. Due to patient states [sic] order for IV Fluid was discharged too. The [family member] was updated regarding the patient’s condition and plan of care.”Review of a “Patient Communication” note, dated 04/05/2025 at 6:05 PM and located in the “Communication” tab, revealed, “[F1] has had pt taken to ER [emergency room] via ambulance.”Review of a “Revocation Statement” dated 04/06/2025 (no time indicated) located under the “Nursing” tab revealed, “Patient admitted to [hospital] 4/6/25, revoked from [hospice agency] to receive aggressive treatment.”Review of a “Patient Communication,” dated 04/06/2025 at 10:59 AM and located under the “Communication” tab, revealed, “[F1] calling to update on patient. Caller is unhappy with level of service. Caller is unhappy also with approach of OCRN [on-call Registered Nurse], felt that there was compassion lacking and the nurse failed to provide basic comfort measures such as oxygen. States patient was never offered oxygen by OCRN. Facility offered oxygen, pt was reported to have labored breathing. EMS [emergency services] found abnormal vitals, but caller states that OCRN stated VS were normal and also noted that pt did not have a fever. However pt was noted by EMS to have a fever. Taken to ER. Pt improved at ER, with saline and electrolytes. Pt status has significantly improved since minimal intervention at the hospital. Caller is very unhappy with entire hospice experience. Caller states he is appalled by entire situation.”During a telephone interview on 07/30/2025 at 2:07 PM, Family Member (F) 1 stated, “My [patient] was dehydrated and the nursing home agreed to give the IV fluids if the hospice provided the order. The hospice said the order was faxed but the facility said they didn’t receive it because all their fax machines weren’t working.” F1 tried to call the hospice on the night the IV fluids should have been administered per the order, but did not get an answer and a staff person later told F1 that their phone was turned off at night and F1 should have called the 24-hour phone number. F1 stated they had not received a 24-hour phone number. F1 stated a nurse did not come out to the nursing home until 3:00 PM the next day and the nurse said there was nothing more they could do. F1 said the hospice had not started oxygen so the family member asked the nursing home staff who agreed to oxygen via nasal canula. F1 called an ambulance and P1 was transported to the hospital. F1 relayed that the emergency department (ED) gave IV fluids and P1 immediately responded and was able to take medications to treat P1’s atrial fibrillation at that time. P1 was currently living at the Veterans’ home.During an interview on 07/31/2025 at 8:15 AM, the Executive Director (ED) confirmed the hospice’s complaint procedure was not followed and there was no complaint documentation to show that F1’s concerns were investigated or followed up per the agency’s normal complaint procedures. The ED stated there was documentation in the communication section of the medical record and the agency had a phone call tracking system which showed that on 04/04/2025 when the order was given for IV fluids (F1) turned down a nurse visit and stated, “just send the order for the IV.” The ED did agree that it may have been better if a nurse had gone out to do a visit a little earlier than 3:00 PM on 04/05/2025. During an interview on 07/31/2025 at 10:35 AM, the Registered Nurse Case Manager (RNCM) confirmed being informed to bring the IV order on 04/05/2025. RNCM stated the NP was contacted on the phone for a face-to-face evaluation and the NP discontinued the IV order and felt the patient was at the point of imminent death.”

“Based on record review, interview, and policy review, the Hospice agency failed to ensure a thorough comprehensive assessment was completed that included identification of drug allergies for one of 27 patients (Patient (P) 1). The failure to identify an allergy to morphine had the potential to cause harm to the patient.Findings include: Review of the undated Hospice policy titled, “Hospice Medication Management. Medication Reconciliation: Patient Admission,” revealed, “A drug regimen review will be performed minimally at the start of care, recertification, and resumption of care to identify any actual or potential clinically significant medication issues … Medication reconciliation is the process of: comparing the medication that the patient took prior to admission with the medication that the patient will receive while under the organization’s care … and identifying any potential or actual clinically significant medication issues.”Review of P1’s “History and Physical,” dated 03/28/2025 and located in the “Misc” section of the electronic medical record (EMR), revealed an admission to the hospital for atrial fibrillation (a heart condition where the heart’s upper chambers beat irregularly and faster than normal.) Past medical history included dementia, hypertension, coronary artery disease, stroke, and deep vein thrombosis.Review of P1’s “Medication Administration Record,” dated 03/28/2025 and included in the hospital discharge information and located in the “Misc” section of the EMR, revealed an allergy to morphine, hydrocodone, and ketorolac. Review of P1’s “RN Initial Assessment,” dated 04/01/2025, revealed, “Allergies: NKDA [No known drug allergy]” was documented. The “RN Initial Assessment” revealed Morphine 4 milligrams (mg) as needed was initiated at start of care. The RN documented a medication review utilizing the hospital discharge summary was completed.Review P1’s hospice medication profile, dated 04/01/2025 and located in the “Orders” section of the EMR, revealed an order for “Morphine Sulfate concentrate oral solution 20 mg/ml [milligrams per milliliter] give 0.25 ml (5 mg [milligrams]) po [by mouth] or SL [under tongue] every 4 hours as needed for SOB [shortness of breath] or pain.”Review of P1’s “Progress Note,” dated 04/05/2025 at 3:00 PM and located in the “Nursing” section of the EMR, revealed, “POA [power of attorney] informed the team that the patient has a known allergy to morphine. As a result, the medication order was promptly revised, and morphine was replaced with Hydromorphone 2 mg to manage the patient’s symptoms safely.”Review of P1’s EMR did not show the patient experienced an allergic reaction to morphine.During an interview on 07/30/2025 at 2:15 PM, the Chief Compliance Officer (CCO) stated the nurse who completed the initial assessment visit should have reviewed the hospital discharge medication during medication reconciliation and noted the allergy to morphine. The CCO stated the nurse no longer worked for the agency.”