Providence Hospice

“Observed in Record Review. In 1 out of 24 patient records reviewed, the plan of care did not include all services needed for the palliation and management of the terminal illness and related conditions, including the following: a statement of the scope and frequency of the services necessary to meet the patient’s and family’s needs. In the chart for RRNHV#20, there was no visit frequency for the Spiritual Care Counselor on the current plan of care. This was discussed with the Quality Manager. Observed in Record Review. In 2 out of 24 patient records reviewed, the plan of care did not include all services needed for the palliation and management of the terminal illness and related conditions, including the following: a statement of the scope and frequency of the services necessary to meet the patient’s and family’s needs. In the chart for RRHV#3, there was no visit frequency for nursing on the current plan of care other than prn visits. There was no visit frequency for the Spiritual Care Counselor on the current plan of care. In the chart for RRHV#6, there was no current visit frequency on the chart for the Spiritual Care Counselor nor the Volunteer. This was discussed with the Quality Manager”

“Observed in Record Review. In 2 out of 24 patient records reviewed, the plan of care did not include clear and complete orders for medications. In the chart for RRHV#3, there were multiple and duplicative medications ordered for constipation including three separate orders for Miralax - Take daily prn for constipation; Twice daily as needed for constipation; Give second dose in the evening on day 2 of no bowel movement. Also an order for Fleet enema - daily as needed for constipation. Lastly Dulcolax 10mg give one per rectum if no BM for 3 days. In the chart for RRNHV#17, the patient was identified with no BM for one week upon admission. There were no interventions on the plan of care related to bowel program other than medications despite assessment and education about the bowel program being documented by the nursing staff in the visits. This was discussed with the Quality Manager. Observed in Record Review. In 1 out of 24 patient records reviewed, the plan of care did not include clear and complete orders. In the chart for RRNHV#20, the order for the dressing change to the patient’s abdominal pleurex site did not include any details of the dressing change such as cleansing agent, cover dressing, securement device and frequency. This was discussed with the Quality Manager.”

“Based on interview and medical record review, it was determined the hospice agency failed to administer the correct pain medication for 1 of 4 patient records reviewed (Patient #2). Review of the medical record of Patient #2’s “Hospice Plan of Care 07/06/23” revealed Patient #2’s first day of election to hospice was 7/6/2023 with the principal diagnosis of Adenocarcinoma of prostate (HCC). Other pertinent diagnoses were listed as: secondary malignant neoplasm of bone (HCC), neuropathic pain of both feet, and generalized weakness. Review of the document titled “Encounter Notes” entered by an RN filed on 7/6/23 at 1933 revealed, “Assessment: At admit, patient is alert and oriented but has bouts of forgetfulness. He c/o bilateral neuropathic pain not being relieved by MS Contin [used to help relieve severe ongoing pain] and Oxycodone [used to help relieve moderate to severe pain]. Toes are blue. Patient is requesting further help with neuro pain. Dr. [name] initiated methadone [used to treat moderate to severe pain when around-the-clock pain relief is needed for an extended period of time] during visit. Patient to stop MS Contin on 3rd day.” Review of an undated document titled “Improving the Culture of Safety & Teamwork” revealed, “Patient [#2] had 2 nursing visits after Methadone started. On the first visit 7/7, the nurse documented that the dose was verified, pain level at an 8. The next visit was on 7/10 at 9:30 AM by the same nurse, documentation reflected dose was verified. Later that day around 5:15 PM, the wife called to inform us patient was very agitated and confused. The patient received a second nursing visit that day (by a different nurse) around 7:20 PM. The nurse asked to see the medication log and the spouse noted on medication log that the patient had received methylphenidate [a central nervous system stimulant used to treat attention deficit hyperactivity disorder (ADHD), and narcolepsy]. When RN asked why, spouse reported morphine had been discontinued and this ordered. RN asked to see medication bottle. Bottle labeled as methylphenidate 5mg tabs with sig: give one tab by mouth every 12 hours for pain. Medication list indicates that patient should be on Methadone 5mg tabs. The visiting nurse confirmed the name of the medication on the bottle, and it said Methylphenidate. Review of the order written dose show that the correct prescription was faxed to the pharmacy and the pharmacy filled the order wrong. The error was reported to the pharmacy for them to complete their investigation and follow up.” During an interview with Employee #1 and Employee #2 on 3/20/24 at 1:58 PM, Employee #2 confirmed that a medication error has occurred. Instead of Methadone 5 mg every 12 hours, Patient #2 was taking methylphenidate 5 mg every 12 hours from 7/6/23 to 7/10/23. Employee #2 stated the hospice doctor ordered the correct medication, but pharmacy delivered the wrong medication to Patient #2. Employee #2 further stated that an investigation and “Safety Story” was done, where the medication error was reviewed, an opportunity for learning was identified, look alike and sound alike medication list shared, process of medication reconciliation reviewed, and safety tools were reminded to staff. Employee #1 and #2 stated that the nurse who was assigned to Patient #2 visualized the medication bottle to verify the dose and name of the medication but read what the nurse expected to read instead of what was written on the bottle. Review of a document dated May 2023 and titled “Methadone Administration/Nurse Monitoring Guidelines,” revealed “Monitoring a patient starting methadone or titrating doses will consist of daily contact for at least 5 days after dose initiation or titration. Contact may be either virtual/phone or in-person. Method of contact is up to the clinical judgement of the team.” Review of a document titled “7/7/2023 SN REPEAT VISIT HOSPICE” under “Communication Notes” revealed “Communication details: Protocol Day: 1 of 5 - Nurse is to provide methadone education to patient and appropriate caregivers using the Patient Methadone Information Sheet. Nurse instructs patient/caregivers on correct administration and ensures the patient/caregiver can give the correct dose. Spoke with: [name of spouse]. Methadone dose ordered: 5mg 1 tab q12hr. Methadone strength visually verified with caregiver: 5 mg tablet. Reported dose start date: 7/6 at 9pm. How is your pain today? 8/10, unchanged. How many doses of breakthrough pain medication have you used in the last 24 hours? oxycodone 70mg.” Review of a document titled “7/8/2023 TELEPHONE ENCOUNTER HOSPICE” under “Communication Notes” revealed “Communication details: Protocol Day: 2 of 5”, when Patient #2 was asked “How is your pain today?” Patient #2 answered “8-9/10, unchanged.” Patient #2 further stated [they] used 0xycodone 10mg x2 for breakthrough pain in the last 24 hours. When the nurse asked Patient #2 “Do you have any concerns about new medications?” The nurse wrote, “Patient had concerns that it’s [Methadone] not helping (spouse felt like it was helping). [The nurse on the call] Reviewed that methadone would take approximately 72 hours to know the true effects. Patient only taking for 1 & 1/2 days. Encouraged use of oxycodone PRN if painful.” Even though Patient #2 stated the pain was “8/10 and 8-9/10, unchanged,” the agency failed to understand why the pain was not under control nor find out why Patient #2 used Oxycodone 10mg only twice for breakthrough pain when pain was rated high. Review of the document titled “7/9/2023 TELEPHONE ENCOUNTER HOSPICE” under “Communication Notes” revealed “Communication details: Protocol Day: 3 of 5 ... Methadone strength visually verified with caregiver: 5 mg tablet ... How is your pain today? 8-9/10, unchanged. How many does of breakthrough pain medication have you used in the last 24 hours? oxycodone 10mg x2 yesterday, none yet today but plans to take some now d/t pain ... Do you have any concerns about new medications? Patient had concerns that it’s not helping (spouse felt like it was helping). Reviewed that methadone would take approximately 72 hours to know the true effects which would be this evening. Encouraged use of oxycodone PRN if painful.” Patient #2 repeatedly stated Methadone was not helping, however the agency failed to investigate why the new medication was not helping Patient #2. During a phone interview with Employee #1 on 3/27/2024 at 11:31 AM, Employee #1 stated “It is concerning to me that we didn’t make a visit on the 9th, but they [staff] were trying to do their best.” Review of a document titled “7/10/2023 SN REPEAT VISIT HOSPICE” from 9:26 AM - 10:30 AM under “Communication Notes” revealed “Communication details: Protocol Day: 4 of 5 - Reinforced education: (ie dosing instructions, side effects, calling hospice) continue oxycodone. Spoke with: [name of spouse] ... Methadone strength visually verified with caregiver: 5 mg tablet ... How is your pain today? 3-4/10. How many doses of breakthrough pain medication have you used in the last 24 hours? oxycodone 70mg ... Do you have any concerns about new medications? no.” Under “Encounter Notes,” the document revealed “Evidence of Decline noted today (specifics): [the nurse answered] increased confusion, hallucinations.” During a phone interview with Employee #1 on 3/27/2024 at 11:31 AM, when asked about why all the nurses who conducted the Methadone protocol follow-up calls and in-person visits answered, “5 mg tablet” to the question, “Methadone strength visually verified with caregiver?” Employee #1 stated it may have to do with Epic SmartPhrase but will find out and let me know. Review of a document titled “Confidential Investigation Report” and dated 7/11/23 revealed “The Methadone SmartPhrase staff utilize per Methadone protocol includes a template with wildcards (***) that must be filled out, as well as drop down for selecting mg tablets or mg/mL liquids. Interviews with nurses involved revealed that there is differing interpretation of what ‘visually verified’ means when completing methadone follow-up calls. These interpretations included: clarifying with the caregiver or patient on the phone that they are administering the correct strength or expecting the caregiver or patient on the phone to be reading either from the pill bottle or a written medication list.” Review of a document titled “7/10/2023 TELEPHONE ENCOUNTER HOSPICE” under “Communication Notes” revealed Patient #2’s spouse called at 1647 and stated “pt remains agitated and would like a visit to help with meds. Advised she give lorazepam now and will request a visit for tonight.” Review of a document titled “7/10/2023 TELEPHONE ENCOUNTER HOSPICE” under “Communication Notes” revealed Patient #2’s spouse called again at 1715 and stated “pt agitated and confused x2 days, today worse. Difficult time redirecting pt. Gave 1 tab lorazepam at 1430 and Haldol 0.25ml at 1515 ... [the nurse] advised [spouse] to give [Patient #2] 10mg oxycodone and 0.5ml Haldol now and if remains agitated to call back in an hour and we can send a nurse to assess if desired.” Review of a document titled “7/10/2023 SN REPEAT VISIT HOSPICE” visit time 7:20 PM - 9:15 PM revealed, “Brief visit summary: Pt appears agitated Reviewed medications provided today. Note that spouse has indicated pt received methylphenidate. When reviewed why taking methylphenidate, she indicated that it is because morphine was d/c’d. This RN unable to sync pt. TC to triage and methylphenidate not on med list. Requested spouse get medication out of cupboard. Medication is methylphenidate. Reviewed pt’s symptoms with symptom management provider [name] and received new orders for lorazepam and Haldol scheduled.” During an interview on 4/4/2024 with Employee #1, Employee #2, Employee #3, Employee #4, and Employee #5 at 10:00 AM, Employee #1 reviewed the investigation summary for the medication error. Employee #1 read the summery of the investigation that “it was assessed that medication reconciliation procedure was followed. No deviations from expected practice for medication reconciliation procedure. It was human error. Medication error was taken to core event review committee (multidisciplinary committee trained in high reliability classification) to be reviewed and classified. The event was classified as PSE2 - minimal temporary harm, which does not require a root cause analysis but rather an action plan and follow up ... Findings: pharmacy made dispensing error. The error was reported to the pharmacy for them to complete their investigation and follow up. The pharmacy agreed that it was pharmacy dispensing error and as a result they filled out a Continuous Quality Improvement report that includes the error occurred on 7/6/23 ... Nurse did complete medication reconciliation but read the medication as methadone. Methylphenidate is listed as a ‘Look Alike or Sound Alike’ medication to Methadone. An in-person visit was not indicated since patient still had PRN medication available that was not being utilized fully ... Patient/family were instructed on utilizing their PRN medications & were agreeable to that plan. The source of the patient’s agitation during this time is unclear. Although patient was agitated on 7/10, agitation is expected at end of life & a common side effect of dexamethasone that was started on 7/9. When patient had increased agitation reported during hospice stay, RN visits occurred & patient had new medications ordered to help with managing agitation. The methadone protocol does not require daily in-person visits, but it was noted the methadone SmartPhrase language uses ‘visually verified with caregiver’ and there are differing interpretations of what ‘visually verified’ means when completing methadone follow-up calls. Appropriate practice would be to visually or verbally verify what is written on the pill bottle with either the hospice RN or patient/caregiver visualizing the bottle while actively verifying the medication name, dose, strength, and frequency.” Employee #1 further stated that we need to be clearer to what you need to know when you ask through a phone call.”