Hospice and Palliative Care of St Lawrence Valley

“Based on a review of clinical records and interviews with the Administrator, and Director of Patient Services, it was determined in 2 of 19 records (patients #3 and 11), the comprehensive assessment was incomplete and failed to identify all of the patient’s needs. Evidence was as follows: 1. Patient #3 was admitted to the hospice on 12/21/23 with a terminal diagnosis of cerebral infarction and additional diagnoses of atrial fibrillation, type 2 diabetes, osteoarthritis, and hypertension. On 12/21/23, the hospice nurse visited the patient for the initial comprehensive assessment and documented the patient had dysphagia (swallowing difficulties) and was on a pureed diet with thickened liquids following a swallow evaluation. There was no evidence the hospice nurse determined the level of thickened liquids the caregiver was providing and assessed the caregivers knowledge and ability to correctly thicken liquids. On 12/23/23, the on-call registered nurse documented a call was received from the social worker in the patient’s home “requesting a visit for increased congestion.” The registered nurse contacted a licensed practical nurse who visited the patient’s home and documented the family stated the patient “may have aspirated last evening.” “;Fluids may have been too thin, or the patient took them in too fast.” The licensed practical nurse reported “;abnormal sounds in the lungs on the right side, left side is clear” to the on-call registered nurse via phone, who notified the physician. Orders were received for an antibiotic and a bronchodilator inhaler. On 12/26/23, 3 days after aforementioned event, the registered nurse case manager performed a “quick visit” to check in with the patient after the holiday weekend. There was no documented follow-up assessment of the aspiration event including auscultation of the lungs, or evidence the thickened fluids were addressed at the visit. The registered nurse failed to visit timely, and failed to perform a complete assessment of the patient’s respiratory system, after a possible aspiration was reported. As identified in New York Education Law, section 6902 of Article 139, Licensed Practical Nurses in New York State do not have assessment privileges; they may not interpret patient clinical data or act independently on such data; they may not triage; they may not create, initiate, or alter nursing care goals or establish nursing care plans. Licensed Practical Nurses function by law in a dependent role at the direction of the registered nurse or other select authorized health care providers. Performing nursing assessments and corresponding progress notes are non-permissible tasks. On 01/04/24, the surveyor conducted an observational home visit and interviewed the caregiver afterward. The caregiver stated the thickening products were purchased independently. They developed a trial-and-error method; the patient would indicate if the liquid was too thick or thin until it was a “good consistency.” She stated she had received no instruction on thickening liquids at the hospital, rehabilitation center, or from the hospice. On 01/08/24 at 11:30 a.m. the surveyor reviewed the record with the Administrator, Director of Patient Services, and Director of Quality Compliance. They acknowledged the findings, and no additional information was provided. 2. Patient #11 was admitted to the agency on 12/08/23 with a terminal diagnosis of chronic obstructive pulmonary disease and additional diagnoses of atherosclerotic heart disease of native coronary artery, hyperlipidemia, essential hypertension, and benign prostate hyperplasia. On 12/08/23 the hospice nurse visited with the patient and the patients caregivers to establish the patients plan of care which included a medication profile review as well as medication administration and management. The 12/08/23 plan of care included morphine (20 mg/mL) 0.5 mL-1 mL every 2 hours as needed for dyspnea (shortness of breath. On 12/12/23, 12/19/23, and 12/26/23 the hospice nurse documented the patients breathing was labored at rest and the patient was “;visibly SOB” (short of breath) “;that increases with exertion”. There was no evidence that the hospice nurse assessed the use of the morphine, including the frequency, effectiveness, and ability to administer, in relation to the patients shortness of breath. On 01/08/24 at 11:30 a.m. the surveyor reviewed the record with the Administrator, Director of Patient Services, and Director of Quality Compliance. They acknowledged the findings, and no additional information was provided. Failure to conduct a comprehensive assessment of the patient has the potential for the development of an incomplete plan of care and unmet patient needs.”

“Based on a review of clinical records and interviews with the Administrator, Director of Patient Services, and Director of Quality Compliance, it was determined in 3 of 19 records (patients #1, 3 and 12), the plans of care were incomplete and failed to reflect all of the patients’ needs. Patient #3 was admitted on 12/21/23 with a terminal diagnosis of cerebral infarction and additional diagnoses of atrial fibrillation, type 2 diabetes, osteoarthritis, and hypertension. The hospice failed to ensure the interdisciplinary plan of care included the specific consistency of thickened liquids. The 11/08/23 hospital discharge summary as part of the referral to hospice included “;diet: pureed diet; nectar thick.” The 12/21/23 Hospice Certification and Plan of Care (POC) included “;Nutrition” as follows: - Ensure - Pureed diet - Diet as tolerated The POC heading “;Orders/treatments, additional services” included: - “;pureed diet; thickened fluids, as tolerated.” The POC failed to include the ordered level of thickening which was “;nectar thick” to all liquids. On 01/03/24, the interdisciplinary group met and discussed the patient. The surveyor was present at the meeting. The social worker reviewed the spouses report of the patient choking the evening prior to the 12/23/23 visit when the on-call RN was notified, and the LPN visit was made. The social worker mentioned the patient was taking a pureed diet and drinking water, however, no discussion of the aspiration event or ordered level of thickening occurred. On 01/08/24 at 11:30 a.m. the surveyor reviewed the record with the Administrator, Director of Patient Services, and Director of Quality Compliance. They acknowledged the findings, and no additional information was provided. Patient #12 was admitted to the ospice on 11/15/23 with a terminal diagnosis of senile degeneration of the brain and additional diagnoses of mitral insufficiency, congesrtive heart failure and type 2 diabetes. The 11/15/23-02/12/24 Hospice Certification and Plan of Care included Hospice Aide service 2 days a week to assist with personal care. The aide visit note dated 12/23/23 included a narrative note written by the licensed practical nurse (LPN) performing aide services. The LPN documented the patient donning clean clothing including compression stockings on both legs. The 11/15/23 Hosppice Certification and Plan of Care failed to include compression stockings. On 01/08/24 at 11:30 a.m. the surveyor reviewed the record with the Administrator, Director of Patient Services, and Director of Quality Compliance. They acknowledged the findings, and no additional information was provided. Home Visit Patient #1 was admitted to the hospice on 09/23/23 with diagnoses of heart failure and oxygen dependent. On 11/17/23 the physician had ordered wound care as follows, stage 2 pressure sore of the coccyx, clean with normal saline pat dry, apply skin prep to peri wound, medihoney to wound bed and cover with mepliex, change every 4 days, and as needed for loosening or soiled. On 11/22/23 the intradisciplinary team notes had documented stage 2 pressure sore to coccyx resolved today, family will start using 50/50 creams after incontinent care. The 12/25/23 plan of care included interventions for wound care, stage 2 pressure sore of the coccyx, clean with normal saline pat dry, apply skin prep to peri wound, medihoney to wound bed and cover with mepliex, change every 4 days, and as needed for loosening or soiled. On 01/04/24 the surveyor conducted an observational home visit with hospice nurse present. After the nurse conducted the visit and left the home, the surveyor interviewed the patient and care giver. The patient and caregiver confirmed that the wounds to the coccyx area had healed, and no further treatments were necessary other than the cream they apply. On 01/04/24 the hospice nurse had documented in the narrative note, no wounds. The hospice nurse failed to update the plan of care. On 01/08/24 at 11:30 a.m. the surveyor reviewed the record with the Administrator, Director of Patient Services, and Director of Quality Compliance. They acknowledged the findings, and no additional information was provided. Failure of the agency to develop a plan of care that accurately reflexes patients current health status.”

“Based on review of clinical records and interviews with the Administrator and Director of Patient Services, it was determined in 1 of 11 records of patients receiving Hospice Aide Services (patient #8 ),aide written instructions were incomplete and/or inaccurate. This was evidenced by: Patient # 8 was admitted to the hospice on 10/30/23 with a terminal diagnosis of chronic obstructive pulmonary disease and additional diagnoses of lymphedema, hypertension, atrial fibrillation and benign prostatic hypertrophy. The 10/30/23-01/27/24 Hospice Certification and Plan of Care included Eliquis (blood thinner) 2.5 mg twice daily. Hospice Aide service was ordered 7 days a week for 1 hour to assist with personal care. The 10/30/23 hospice aide care plan failed to included bleeding precautions and directed the aide to shave the patient. The care plan failed to direct the aide to use an electric razor to prevent injury from a razor blade and bleeding. On 01/08/24 at 11:30 a.m. the surveyor reviewed the record with the Administrator, Director of Patient Services, and Director of Quality Compliance. They acknowledged the findings, and no additional information was provided. Patient #9 was admitted to the hospice on 07/10/23 with terminal diagnoses of heart failure, chronic obstructive pulmonary disease, and epilepsy. The 11/07/23 – 01/05/24 aide plan of care ordered home aide 4 times a week for 8 weeks. That included: skin care Recognize and report any changes in the patients skin condition. Incontinent care change adult briefs bath May apply 50/50 cream or barrier cream to patients buttocks/peri area as needed, intact skin only. The 11/07/23 – 01/05/24 plan of care orders included wound care to the left upper posterior back scapula blister that has developed into a stage 2 pressure sore, and buttocks coccyx – clean with normal saline pat dry, apply dressing. The aide plan of care failed to include: How the aide is to care for the wounds/dressing during bathing, dressing and to report with changes to wounds. Who is managing the wounds in the home. On 01/08/24 at 11:30 a.m. the surveyor reviewed the record with the Administrator, Director of Patient Services, and Director of Quality Compliance. They acknowledged the findings, and no additional information was provided. Failure of the hospice to ensure aide plans of care include specific instructions necessary to provide care has the potential for unmet patient needs and possible negative patient outcomes.”

“Based on record review and interview with the Administrator, Director of Patient Services and Director of Quality Compliance, it was determined for 1 of 1 patient residing in a skilled nursing facility (patient #5), the hospice failed to establish and maintain the hospice plan of care in consultation with facility representatives. Evidence as follows: Patient #5 was admitted to the hospice on 10/13/23 with a terminal diagnosis of chronic obstructive pulmonary disease, and additional diagnoses of anxiety, hypertension and hypothyroidism. The patient was a resident of a skilled nursing facility. On 10/13/23 the hospice nurse visited the patient for the initial assessment and documented the patient had been a resident of the facility since 2018. During the visit the hospice nurse documented providing education to the patient and caregiver, who was identified as a family member, regarding bowel regimen, prevention of skin breakdown, inhalation therapy, oxygen therapy, and review of the plan of care. There was no evidence the hospice nurse provided instruction and reviewed/developed the plan of care with facility staff. On 10/14/23 the medical social worker visited the patient and documented meeting with the patient and family member for an assessment visit. The social worker documented the patient struggled with being in the facility, the lack of help and quality of care. The patient expressed anxiety and depression primarily related to nursing home care and lack of that. There was no evidence the social worker collaborated with the facility staff and discussed a plan to relieve anxiety. The 10/25/23 Interdisciplinary Group Meeting documented the care location as the skilled nursing facility. The plan of care failed to include a plan for how the hospice was going to communicate with the skilled nursing staff to update the care plan, the responsibilities of the skilled nursing staff and the name of staff contacts. The bereavement plan identified the patients daughter as the bereaved and failed to identify staff of the nursing home as potentially needing grief support. On 01/08/24 at 11:30 a.m. the surveyor reviewed the record with the Administrator, Director of Patient Services, and Director of Quality Compliance. They acknowledged the findings, and no additional information was provided. Failure to coordinate and consult with skilled nursing facility staff has the potential for unmet needs.”