Lewis County General Hospital Hospice

“Based on a review of 10 patient records and interviews with the Administrator, Director of Patient Services, and Registered Nurse, it was determined in 1 of 10 records (patient #3), the plan of care failed to address the complications and risk factors that affect care planning. Home visit Patient #3 was admitted to the agency on 07/12/24 with a terminal diagnosis of lung cancer and additional diagnoses that included chronic obstructive pulmonary disease, chronic respiratory failure, and heart failure. On 07/01/24, the social worker visited the patient to review hospice services prior to admission and documented that the patient continued to smoke. On 07/12/24, the Registered Nurse (RN) visited to complete the start of care assessment and documented the patient was using oxygen 2 liters via nasal canula and had been for years. The RN also documented oxygen safety was reviewed with the patient and family, including proper ventilation, storage, no open flames, no smoking with oxygen, and smoke detectors were present in the home. There was no evidence RN assessed specifically how oxygen safety was maintained while the patient was smoking. The 07/23/24 IDT meeting did not address oxygen safety. The 10/29/24 IDT meeting reported “;patient has been educated on use of oxygen while smoking. Instructed to turn off and remove from area before smoking, [caregiver] reported the patient was now compliant with this after some teaching.” On 02/19/25, the surveyor requested a copy of the agencys oxygen therapy policy, and this was provided by the Director of Patient Services at 11:15 a. m. The October 2024 policy titled “;Oxygen Therapy in the Home” stated: - “;as there is always the danger of fire when oxygen is in use, all patients on oxygen will be assessed for safety risks associated with home oxygen therapy use including home fires and evidence of observation of patient smoking tobacco products, electronic cigarettes, vaporizers at each home visit.” - “;physician will be notified of any changes from baseline assess in the patients condition - “;physician will be notified of any patient/caregiver non-compliance with oxygen use. Specifics of non-compliance will be documented in the medical record.” - “;observe positioning of equipment to allow free airflow around equipment, to be away from heat source or flame, and for standing oxygen cylinders to be in stands or otherwise secured.” - “;identify, report and document any potential safety risks associated with oxygen therapy including home fires (especially related to smoking tobacco products, electronic cigarettes).” - “;if patient is known to have been smoking without removing oxygen, the following should be notified subsequent to each reported occurrence: agency supervisor, caregiver, MD, DME provider.” - “;if a safety risk is identified, education and patient/caregiver response should be documented at every visit.” On 02/20/24, the surveyor made a supervised home visit with the licensed practical nurse who assisted the patient with personal care. During the visit, the patient reported their memory was not good, did not remember if they took their meds that morning, and seemed to forget that the morphine and nebulizer were beside the chair and could have been self-administered prior to or during the visit. At the conclusion of the visit, when reminded that morphine was prepared next to the patients chair, the patient administered a dose of morphine. Throughout the visit, the surveyor observed the patient to be short of breath that worsened with activity and frequent moaning/vocalization with exhalation. The surveyor also observed multiple oxygen canisters laying on the couch approximately 3 feet from the patient. Additionally, the surveyor observed the oxygen concentrator was placed very close to patient with multiple blankets between patient and the concentrator, appearing to obstruct the airflow around the concentrator. After the visit, the surveyor interviewed the patient and caregiver. The caregiver reported the patient continued to smoke in the home, the RN provided oxygen safety a couple of months ago and resulted in the oxygen concentrator being moved closer to the patient’s chair, which allowed the patient to turn off the concentrator prior to smoking. The caregiver reported that the patient was supposed to turn off the concentrator, place oxygen nasal canula at their feet, smoke the cigarette, then re-apply the canula, and turn the oxygen back on. However, the caregiver reported an occurrence the previous week in which the patient forgot to reapply the oxygen after smoking. The caregiver was unsure if the patient ever forgot to turn off the oxygen prior to smoking. On 01/20/24 at 1:20 p.m., the findings were reviewed with the Administrator and Director of Patient Services. The Administrator and Director of Patient Services reported that these findings were not consistent with their oxygen policy and follow-up would be necessary. On 01/21/25 at 9:20 a.m., the surveyor interviewed the RN who had been covering for the case manager. The RN reported that they identified patient safety concerns related to smoking with oxygen a couple of months prior and implemented teaching with patient and caregiver. The RN reported that the patient was rarely left home alone and would not be home alone for more than 2 hours. The RN also reported that the patient had been making decisions about what they wanted until recently when they had become more forgetful, causing the RN to question if patient no longer had the capacity to make decisions, including whether to take medication when experiencing pain or dyspnea. When the surveyor asked the RN about the impact the recent change in condition might have on the oxygen safety, the clinician expressed concern the patient would not remember to turn the oxygen off prior to smoking. The RN reported that the patients change in condition had been addressed with the physician and at the IDT meetings, the potential impact of the change in cognitive status on oxygen safety had not been addressed. At 11:20 a.m., the surveyor interviewed the Administrator and asked if any actions had been taken since yesterday to address the concerns about the patient smoking with oxygen. The Administrator was unsure if any actions were taken, and they would check. The surveyor informed the Administrator that the RN reported that the patient has had decline in their cognitive status that could place patient at risk for smoking with oxygen and that this had not been addressed with patient, caregiver, physician, durable medical equipment provider, or IDT. At 12:30, the Administrator informed the surveyor that an RN was en route to the patients home to assess and educate patient and caregiver on oxygen safety. Failure to factor complications and risk factors that affect care planning has the potential for unsafe patient situations and/or unmet patient needs.”

“Based on a review of 10 patient records and interviews with the Administrator and Director of Patient Services, it was determined in 4 records (patients #6, 7, 8, and 9), the plan of care failed to address all of the patient’s needs. Home Visit1. Patient #1 was admitted to the hospice on 09/19/23 with a terminal diagnosis of rectal cancer and additional diagnoses of diabetes type 2, hypertension, and benign prostatic hyperplasia (BPH). Diabetes The 01/11/25-03/11/25 Plan of Care included a diagnosis of diabetes type 2. The following was documented by the registered nurse (RN), during visits, regarding blood glucose (BG):01/13/25 and 01/17/25: no documentation01/24/25: patient has not checked today but checked yesterday and it was 155 01/27/25: patient has not checked today01/31/25: patient has been testing BG in the morning with a range of 145-175 for the past week02/03/25: patient reports BG of 188 this morning02/06/25: patient reports BG of 144 this morning and states it has been in the 140s this week02/11/25: patient has not checked today02/13/25 and 02/17/25 (as needed visit): no documentation On 02/18/25 at 2:00 p.m. the surveyor conducted an observational home visit with the RN. During the visit, the patient told the RN they did not check their BG today but it was checked yesterday. The RN responded “;okay” and told the patient it was their decision if they wanted to check it or not. After the RN left, the surveyor asked the patient how often they checked their BG. The patient stated they usually check it every morning. The patient also stated the physician discontinued their diabetic medications. The Plan of Care failed to include an order for the patient to test their BG daily including when to notify the agency and/or physician if they obtained a high or low reading. Treatment OrderOn 11/18/24 the RN saw the patient for a routine visit and documented the patient had two perirectal abscesses that had ruptured and started draining. On 11/18/24 the RN obtained the following treatment order for the abscesses: cleanse perirectal abscess areas with mild soapy water and pat dry. Apply over the counter triple antibiotic ointment and cover with 4 X 4 gauze twice a day and as needed. On 11/21/24 the RN saw the patient for a routine visit and documented the patients rectal abscesses had resolved. The 11/26/24 IDT (interdisciplinary team) meeting notes included the patients rectal abscesses had resolved. On 01/09/25 the RN visited the patient. Documentation within the “;Integument” (skin) system only included the patient had some scratches to the right arm. The 01/11/25-03/11/205 Plan of Care continued to include the 11/18/24 treatment order for the patients rectal abscesses, which had since resolved. The RN failed to update the Plan of Care by discontinuing treatment orders no longer being used. On 02/20/25 at 1:20 p.m. the record was reviewed and the Administrator and Director of Patient Services were interviewed. The findings were acknowledged. The Director of Patient Services stated the treatment order should have been discontinued. 2. Patient #2 was admitted to the hospice on 02/05/25 with a terminal diagnosis of bladder cancer and additional diagnoses of diabetes type 2, atrial fibrillation, and chronic kidney disease. The 02/05/25-05/05/25 Plan of Care included:- diagnosis: diabetes type 2- diabetic medication: metformin 1,000 mg twice a day with meals On 02/05/25 the registered nurse (RN) saw the patient for an initial visit and documented the patient does not check their blood glucose (BG). The Plan of Care failed to include an order that the patient did not need to check their BG and/or interventions for signs and symptoms of hypo/hyperglycemia if the patient was not using a monitoring system for their BG. On 02/20/25 at 1:20 p.m. the record was reviewed and the Administrator and Director of Patient Services were interviewed. The findings were acknowledged. Neither the Administrator nor Director could provide any additional information. 3. Patient #8 was admitted to the hospice with a terminal diagnosis of Parkinsons disease and additional diagnoses of dementia, hypertensive heart disease with heart failure, and atrial fibrillation. SwallowingThe 02/14/24-05/13/24 Plan of Care included:- aspiration precautions- pureed diet On 02/14/24 the registered nurse (RN) visited the patient for an initial visit and documented the patient had choking/difficulty swallowing. The Plan of Care failed to include an order on how liquids should/could be consumed due to swallowing difficulties (i.e. thin vs thickened). Fluid RetentionThe 02/14/24-05/13/24 Plan of Care included:- diagnosis: hypertensive heart disease with heart failure- medication: Lasix (diuretic) 40 mg daily At the following visits the RN documented the patient had edema: - 02/14/24: + 1 edema bilateral lower extremities (BLE)- 02/21/24: + 2 pitting edema- 02/28/24: + 2 pitting edema to BLE The Plan of Care failed to include an order for monitoring fluid retention (i.e. weight monitoring, edema measurements) and/or interventions for signs and symptoms of fluid retention if the patient was not going to be monitored through weights and edema measurements. On 02/20/25 at 1:20 p.m. the record was reviewed and the Administrator and Director of Patient Services were interviewed. The findings were acknowledged. Neither the Administrator nor Director could provide any additional information. 4. Patient #7 was admitted to the hospice on 11/20/23 with a terminal diagnosis of pulmonary fibrosis and additional diagnoses of asthma, diabetes type 2, and pulmonary hypertension. Diagnosis/AllergiesThe hospice referral included a physician note dated 11/02/23 documenting:- diagnosis: diabetes type 2- allergies: nitrofurantoin, cefaclor, chlorpheniramine, diphenhydramine, and aspirin. The 11/20/23-02/17/24 Plan of Care included the following:- diabetic medications: glipizide 20 mg daily, Jardiance 10 mg daily, metformin 1,000 mg twice a day, Trulicity 0.75 mg/0.5 mL injection weekly- allergies: Macrodantin (nitrofurantoin), Ceclor (cefaclor), Chlor-Trimenton (chlorpheniramine), and Benadryl (diphenhydramine). The Plan of Care failed to include:- diabetes type 2 as a pertinent diagnosis- aspirin as an allergy Medication/PrecautionsThe 11/2023-02/17/24 Plan of Care included the following medications:- lorazepam 0.5 mg every 4 hours as needed for anxiety. 1 tablet for mild to moderate anxiety or 2 tablets for moderate to severe anxiety- warfarin (anticoagulant/blood thinner) 7 mg daily The Plan of Care failed to include:- a maximum daily dose safely allowed for a 24-hour time period for the Ativan- bleeding precautions secondary to taking a anticoagulant/blood thinning medication DiabetesThe 11/20/23-02/17/24 Plan of Care included the following diabetic medications: glipizide, Jardiance, metformin, and Trulicity. On 11/20/23 the RN saw the patient for an initial visit and documented the patient would like to continue checking their blood glucose (BG) daily even though they were instructed by the physician they did not need to. The Plan of Care failed to include an order the patient could test their BG daily including when to notify the agency and/or physician if they obtained a high or low reading. On 02/20/25 at 1:20 p.m. the record was reviewed and the Administrator and Director of Patient Services were interviewed. The findings were acknowledged. Neither the Administrator nor Director could provide any additional information. X. Patient #9 was admitted to the hospice on 10/17/24 with a terminal diagnosis of protein-calorie malnutrition with additional diagnoses that included dysphagia (difficulty swallowing) and history of stroke. The 10/17/24 plan of care included the order for “;caregiver performs gastrostomy tube feeding: Nestle fiber source HN as tolerated via infinity pump daily. May hold for nausea, vomiting, diarrhea. Flush prior to a d after feedings/medications with 35 ml tap water. Elevate head of bed 30 degrees at all times while feeding is running/with flushes.” The plan of care failed to include: - rate, volume, or duration of the tube feeding infusion - order for oral intake On 10/17/24, the Registered Nurse (RN) visited the patient for the start of care visit and documented the patient “;drinks water well, is not able to take foods or other liquids orally” and that patient has not tolerated more than 2 containers of tube feeding a day. On 10/30/24, the RN visited the patient and documented the patient was “;nibbling on foods.” On 11/08/24, the RN visited the patient and documented the patient “;had not had tube feeding at all this week. Decrease in fluid intake reported. Patient is taking 1-2 20-ounce tumblers a day. [Patient] reports [they] are not thirsty but drinks some. [Spouse] reports no foods yet today, taking in maybe an ounce of food total daily for the past few days. Yesterday, had a very small bowl of Special K cereal, ½ English muffin, picked at French fries at dinner last night.” On 01/20/25 at 1:20 p.m., the record was reviewed, and the Administrator and Director of Patient Services were interviewed. The findings were acknowledged. The Director of Patient Services that the plan of care should have included complete tube feedings orders and a diet order. X. Patient #6 was admitted to the hospice on 12/20/24 with a terminal diagnosis of chronic obstructed pulmonary disease and additional diagnoses that included, chronic bronchitis, heart failure, and type 2 diabetes. The 12/20/24 Plan of Care included: - diagnoses of heart failure and type 2 diabetes - furosemide (diuretic) 20 mg orally twice a day - metformin 500 mg orally twice a day The 12/20/24 plan of care failed to include orders related to the management of heart failure or diabetes. On 01/20/25 at 1:20 p.m., the record was reviewed with the Administrator and the Director of Patient Services. The findings were acknowledged, and the Director of Patient Services reported that the plan of care should have reflected the management for diabetes and heart failure.”

“Based on a review of the hospices Professional Advisory Committee and Quality Council meeting minutes, Performance Improvement meeting minutes, and interviews with the Administrator and Director of Quality, the hospice failed to measure, analyze, and track quality indicators. On 02/18/25 at 11 a.m., during the entrance conference, the surveyor requested the hospices QAPI Plan and minutes for the past 12 months and this information was given to the surveyors later that day at 1:20 p.m. The 03/19/24 and 10/08/24 Professional Advisory Committee meeting minutes and the 12/16/24 Quality Council meeting minutes reflected the reporting of CMS quality metrics and family experience scores. The meeting minutes did not address adverse event tracking, analysis, or preventative actions that were implemented. The undated Quality Assurance/Performance Improvement Plan included: - The hospice must measure, analyze, and track quality indicators, including adverse patient events and other aspects of performance that enable the hospice to assess processes of care, hospice services, and operations. - Performance improvement activities must track adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospice On 02/21/25 at 1:25 p.m., the surveyor interviewed the Administrator regarding the hospices quality program. The Administrator was not able to answer questions about the agencys adverse event tracking or analysis tasks. The Director of Quality was unable to attend the interview, and the Administrator reported that they would ask them to send this information to the surveyor on the next business day, 02/24/25. On 02/24/25, no information was received from the hospice via email or secure file transfer. On 02/25/25 at 10:15 a.m., the surveyor received PAC meeting minutes for 2023 and Quality Council meeting minutes for 2024. The Quality Council meeting minutes had already been provided to the surveyor and did not contain any new information on adverse event tracking. On 02/25/25 at 11:07 a.m., the surveyor interviewed the Director of Quality who reported that the hospice tracks all adverse events, including falls, medication errors, and patient safety issues. The Director of Quality reported that the hospice reviews the patient record when there is an adverse event to analyze their cases and implements preventative actions. Additionally, the agency had a performance improvement plan (PIP) for falls for the years 2023 and 2024. A PIP for diabetes was implemented in December for 2025 and included staff education regarding orders related to diabetes as this was an identified need in the certified home care agency and the PIPs are usually implemented in both agencies. When asked about how the PIP reflected the management of diabetes in the hospice patient population, the Director of Quality reported that they will need to revisit the implementation of PIPs. The surveyor requested documentation to support the tracking and analysis of adverse events and performance improvement information for 2024. On 02/25/25 at 12 p.m., the surveyor received performance improvement meeting minutes from 01/25/23 through 11/08/23 and a fall report from 2024. The fall report contained information documented by clinicians about the circumstances of a patient fall and did not include any documentation to support the record was reviewed by the hospice, causes were analyzed, or preventative actions were implemented. On 02/26/25 at 11:24 a. m., the Director of Quality reported via email that there were no performance improvement meeting minutes for 2024 and that the fall report was the only tool the hospice has at that time. The Director of Quality also reported that this is something they will need to be working back into the QAPI program. Although the Director of Quality reported that the hospice tracks, analyzes, and implements preventative measures for adverse events, the hospice failed to produce supporting documentation. Failure to implement a QAPI program that tracks, analyzes, and implements preventative measures for adverse events has the potential to place patients and the patient population at risk.”