Constellation Hospice Pa, LLC

“Based on review of policies and procedures, Clinical records (CR), and an interview with the agency’s director of nursing, the agency failed to ensure the patients received effective pain management and symptom control in one (1) of three (3) files reviewed. (CR#1). Findings Include: Review of agency’s policies and procedures on 11/29/23 at approximately 1:00PM revealed the following: Policy titled, “Pain Assessment” states, “ All patients will receive pain assessments. When pain is identified a more comprehensive pain assessment will be completed when warranted by the patient’s condition. Pain Assessments will be appropriate to the patient’s age/capacities and will be documented to facilitate regular reassessments and follow-up by the clinicians... Pain Management: The patient’s preferences for pain management will be reflected in the pain control measures selected...” Documentation titled, “Hospice Patient’s Bill of Rights/Responsibilities” states, “Patients have the right to be free from mistreatment and mental, physical, sexual and verbal abuse, neglect and exploitation...receive effective pain management and symptom control for conditions related to terminal illness...” Clinical records were reviewed on 11/29/23 at approximately 10:30 AM and revealed the following: CR #1: Start of Care (SOC): 11/15/23. Patient date of death: 11/19/23. Patient resided in a skilled nursing facility. A review of certification period 11/15/23-2/12/24 revealed order for Skilled nursing once weekly for one week, two times weekly for twelve weeks and six as needed, Home Health Aides for one-two visits weekly for one week then four-five times weekly for twelve weeks then once weekly for one-week, Social Worker starting on 11/17/23 for once monthly for one month and Chaplain evaluation only. Patient did not receive pain medication (morphine) until sometime between the evening on 11/17/23 and the morning of 11/18/23. (2-3 days post admission). Prior to receiving pain medication patient was assessed by the nurse and the patients family to be visually in pain (patient nonverbal). See documentation below. The initial RN assessment for pain stated patient is not comfortable with current pain treatment and stated a medication regimen change was implemented. RN assessed the patient through non-verbal means as a 3/10 (10 being the highest pain). Medication profile included Morphine 20mg/ml solution: take 5mg orally or under the tongue every three hours as needed for shortness of breath or moderate to severe pain that was listed with a start date of 11/15/23. Nursing visit on 11/16/23 conducted and the narrative stated, “;Visit made to assess pts status. Pt (patient) received in bed at the facility. Pt was nonverbal and sleeping continuously since her daughter left per supervisor...Supervisor could not confirm whether pts meds arrived from their pharmacy since pts charge nurse was on break. Supervisor promised to follow up since pt needs the medicine to control her symptoms especially pain management. Spoke to daughter after the visit. She stated she was with pt all day but was worried about medication not arriving on time since she saw patient grimacing in pain.” In addition, the RN assessed the patients pain during visit to be 5/10 (10 being the highest pain). Service Comment Report Form stated 11/17/23 at 2:00 PM states patients family member called stating, “;pain meds still not arrived at facility...I spoke with (Facility staff nurse) who stated meds were due to arrive that evening. Recommendation made to remove IV line since arm was swollen. (Facility staff nurse) noted pt was comfortable...updated (patients family member) at 8:30 PM. F/U (follow-up) next morning 11/18/23, meds arrived.” Skilled nursing visit conducted on 11/18/23 stated, “;FSN (facility staff nurse) also reported the pt has been getting the Morphine and Ativan as ordered. Pt was totally unresponsive with a flat affect. The pt was peaceful and not showing s/s (signs and symptoms) of distress or pain...I discussed the pts status with the family and the pts death was probably imminent. The family stated they understood and just wanted (patients name) to be comfortable...” An interview with the director of nursing was conducted on 11/29/23 at approximately 10:15 AM and stated that the facility where CR#1 resided at would only allow their specific pharmacy to order and deliver the medications. The hospice failed to follow-up on the delivery on the medication in a timely matter. Medications were delivered sometime between the evening on 11/17/23 and the morning of 11/18/23. (2-3 days post admission). In addition, the director of nursing stated the RN made an additional visit to the patient on 11/16/23 due to the patient’s family “calling about pain meds.” After a review of the nursing visit conducted on 11/16/23 the RN failed to effectively follow-up on the delivery of the patient’s medication during their visit and that the RN spoke to the family after this visit, and they stated they were “worried about medication not arriving on time since she saw patient grimacing in pain.” An additional interview conducted with agency’s director of nursing on 11/29/23 at approximately 2:30 PM confirmed the above findings.”

“Based on review of agency policy, clinical records (CR) interview with the Director of Nursing, the hospice failed to follow the Hospice Plan of Care and/or Physician orders for one (1) of three (3) clinical records (CR #1). Findings include: A review of the agency policy occurred on 11/29/23 at approximately 1:00 PM and revealed the following: Policy titled “Wound Assessment, Documentation, Treatment, and Clinical Oversight” stated, “All patients with wounds will receive a comprehensive wound assessment at time of admission or upon first report of wound. Wounds will be documented in detail. Wound assessments will allow through documentation and will prompt and facilitate regular reassessment and follow-up of wounds by clinicians...The Registered Nurse performs the initial assessment for open wounds and surgical incisions upon admission and as ordered by the physician...Assessment of wound should include the following: location, wound condition, condition of surrounding skin, pain...Wound measurement techniques: stage...size...” A review of Clinical Records was conducted on 11/29/23 at approximately 10:30 am and revealed the following: CR #1: Start of Care (SOC): 11/15/23. Date of Death: 11/19/23. Patient resided in a skilled nursing facility. A review of certification period 11/15/23-2/12/24 revealed order for Skilled nursing once weekly for one week, two times weekly for twelve weeks and six as needed, Home Health Aides for one-two visits weekly for one week then four-five times weekly for twelve weeks then once weekly for one-week, Social Worker starting on 11/17/23 for once monthly for one month and Chaplain evaluation only. The Hospice Plan of Care listed pressure ulcer on sacral region, stage 4 on patient when they were admitted to services on 11/15/23. The wound treatment listed stated Cleanse Sacrum with Normal Saline Solution, pack with 4X4 gauze soaked with 1/4 Dakins Solution (germicidal/bacteriostatic topical agent used in wound cleansing) and cover with foam border gauze two times a week.” The file did not contain any documentation of wound measurements or assessment. In addition, initial RN assessment and Hospice plan of care did provide any assessment on the patient’s IV lines but did state, “She is currently on two IV antibiotics Vancomycin and Zosyn...daughter prefers to allow it to finish. (Hospice Medical Director) agreed to allow it complete.” An interview with the agency’s director of nursing on 11/29/23 at approximately 2:00 pm confirmed the above findings. ***This is a repeat deficiency (wound assessment). It was also cited during a re-licensure survey conducted on 7/21/23”