Lutheran Hospice

“Based on review of the hospice’s Emergency Preparedness Program and interview, the hospice failed to ensure that the entire patient population was included in the hospice’s Emergency Preparedness Plan (EP) for 1 of 15 patient charts reviewed for an EP plan, Patient #15 was not assigned a risk level on the hospice admission documents. Patient #15 with a diagnosis of Alzheimer was admitted 6/24/2020. Review of the hospice documents revealed the patient was not assigned a Risk Level per the hospice’s Emergency Preparedness Plan. The finding was confirmed in an interview with the Clinical Operations Manager on 12/7/23 at 10:00 AM.”

“This standard is NOT MET as evidenced by: Based on review of 3 of 4 patient medical records (Patient #1, #2, and #4) and interviews, it was determined physician orders were not followed for medications, wounds, and diet. Home visit on 12/04/2023 at 1:05 PM reveals, Patient #2 reports taking Flomax 0.4 mg tablet by mouth once a day and Reglan 5 mg one tablet by mouth three times a day. These medications are not on the agency medication list. On 12/04/2023 at 1:30 PM, Skilled Nurse (SN) #1 confirms the finding. The findings include: Patient #1 is in a local facility with a diagnosis of Failure to Thrive. The current physician orders per the residential facility are a ground diet but the hospice orders are for a regular diet, which is delivered to the patient on the 12/4/23 11:00 AM during the patient visit. The patient, having no teeth, has been losing weight since she is unable to chew. The meal was immediately changed out to a ground diet. In an interview with the hospice Patient Care Coordinator on 12/4/2023 at 2:00 PM, it was verified that the hospice failed to ensure the patient was receiving the proper diet. Patient #4 with a diagnosis of Alzheimer’s is in a residential facility, admitted 10/17/23. During the patient visit on 12/4/23 at 10:00 AM, it is noted that the facility medicine administration record (MAR) does not match with the hospice’s MAR. Specifically, the hospice MAR lists Prozac 10 milligram capsule every day while the residential facility lists 2.5 milliliter Fluoxetine (Prozac) 20mg/5ml solution. Further the residential facility lists MediHoney 80% topical gel to wounds. This alerted us to the fact that the patient had wounds. There are no wounds listed on the hospice care plan, or hospice Interdisciplinary Discipline Team (IDT) notes for this patient. The hospice’s admitting diagnosis section lists “Pressure ulcer of right buttock, unstageable, pressure ulcer of other site, stage 2, pressure ulcer of other site, stage 3”. In an interview on 12/4/23 at 2:00 PM, the Patient Care Coordinator explains that an outside wound care agency cares for the wounds, but there is no coordination between that agency and the hospice. This leaves open the question of the medications/services the patient is receiving versus what the hospice holds claim to. Facility policy# PC.M50 reads: “A Medication profile is maintained for every patient and includes a listing of the current medication orders for each patient and specifies whether the medication is or is not related to the patient’s terminal illness....includes all prescription medications, over the counter drugs, vitamins and herbal and alternative supplements.””

“Based on record reviews, interviews, and the hospice policy, entitled, “;CLINICAL RECORDS”, the hospice failed to provide in the initial Plan of Care (POC) a data system to measure patient outcomes for 17 of 19 patient records reviewed. (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #17, and #19) The Findings include: On 12/05/2023 and 12/06/2023, review of the plan of care for patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #17, and #19 revealed none of the patient plan of cares had goals in the initial assessments to measure performance or quality. On 12/06/2023 at 11:00 AM, the Administrator and Patient Care Coordinator verified the findings and reported “;issues with our computer system.” Hospice policy, entitled, “;CLINICAL RECORDS”, revealed “;Each patients clinical record includes, at a minimum, the following: g. outcome measure data elements”.”

“Based on record review and interview, the hospice staff failed to follow physician orders and Interdisciplinary Team (IDT) Plans of Care for 9 out of 19 patients regarding visit schedules, wound care, medications and diet (Patient #1, #2, #3, #4, #5, #9, #14, #15, and #19). Chart review on 12/06/2023 at 2:00 PM for Patient #1 reveals the home health aide (HA) orders for the HA are for 1-3 visits per week yet the HA visited the patient 4 times in week one of this episode. This information was verified in an interview with the Patient Care Coordinator on 12/6/23 at 2:45 PM. Chart review on 12/06/2023 at 2:00 PM for Patient #4 reveals the Home Health Aide (HA) is to visit 3-5 times per week, yet only visited twice in weeks 1 and 4 with no missed visit notes. This information was verified in an interview with the Patient Care Coordinator on 12/6/23 at 2:45 PM. Chart review on 12/06/2023 at 2:00 PM for Patient #5 reveals the home health aide (HA) is to visit the patient 3 times per week, yet visited only once in week 1, with no missed visit notes to explain the 2 absences. Likewise, in week 4 the HA visited twice, with no missed visit note to explain the missed third visit. This information was verified in an interview with the Patient Care Coordinator on 12/6/23 at 2:45 PM. Chart review on 12/06/2023 at 2:00 PM for Patient #15 reveals initial physician orders are for the registered nurse (RN) to visit twice per week and the home health aide (HA) is to visit twice per week. The RN made no visits in week 2 with no missed visit notes. The HA visited only once in week 1, with no missed visit note. The social worker visited twice in week 2 without any orders to visit. This information was verified in an interview with the Patient Care Coordinator on 12/6/23 at 2:45 PM. The Findings include: Chart review on 12/05/2023 at 9 AM for Patient #2 reveals, wound care orders for hepatic drain of Right Upper Quadrant, “;Cleanse with : Cleaner, Dress with: split gauze dressing, Cover with: Medipore tape Start effective date: 07/19/2023”. Nursing Assessment notes dated 11/03/2023 and 11/07/2023 reports”; Wound Care provided, Cleansed with Betadine & wound cleanser”. This is not the care ordered. Hospice Nursing Clinical Note dated 11/15/2023 reveals Patient #2 fell and experienced a skin tear of right forearm. SN reports “;Wound Care Provided, Neosporin and bandage”. There is no documentation of the physician being notified of the fall and no orders for wound care to the skin tear. Interview on 12/06/2023 at 12:23 PM, Administrator verifies the finding. Chart review on 12/05/2023 at 12:30 PM for Patient #3 reveals, frequencies for HHA 1 visit per week for 9 weeks starting 11/18/2023 and RN 1 visit per week for 9 weeks starting 11/18/2023. There are no visits by the Registered Nurse (RN) or Certified Nurse Assistant (CNA) for the week of 11/18/2023. Interview on 12/06/2023 at 12:50 PM, Administrator verifies the finding. Chart review on 12/05/2023 at 2:35 PM for Patient #9 reveals, frequencies for RN 1 visit per week for 9 weeks starting 09/20/2023. There are no visits documented by the RN for the week of 09/20/2023. Interview on 12/06/2023 at 12:52 PM, Administrator verifies the finding. Chart review on 12/06/2023 at 9:08 AM for Patient #14 reveals, frequencies for CNA 2 visit per week for 13 weeks starting 11/22/2023. There are no visits documented by the CNA for the week of 11/22/2023. Skilled Nurse (SN) note dated 12/02/2023 reports “;BP 90/64. Dtr stated pt os taking Coreg 3.25mg twice daily. Lasix increased yesterday r/t ascites and SOB. T/c to Dr Orick, orders received to stop coreg, continue Lasix for now, dtr stated she will take the Coreg out of the pts pill box.” Physician orders from Dr Orick dated 12/03/2023 report “;Increase Lasix to 60 mg by mouth twice a day x 3 days”. Verbal order read back and verified. There are no documentation for physician orders to hold the Coreg. Interview on 12/06/2023 at 1:35 PM, Administrator verifies the finding. Chart review on 12/06/2023 at 10:13 AM for Patient #19 reveals, frequencies for RN 2 x week for 13 weeks starting 03/28/2023. There is documentation for SN visit on 03/30/2023, 04/6/2023, 04/13/2023 and 04/20/2023. This is once a week for 4 weeks. There is no documentation for a second visit the first 4 weeks of the episode. Interview on 12/06/2023 at 1:44 PM, Administrator verifies the finding.”

“Based on patient record review, interview, and hospice policy, entitled, “;COORDINATION OF SERVICES”, the Interdisciplinary Team (IDT) failed to provide a means to identify and measure goals in the ongoing Plan of Care (POC) for 17 of 19 patient charts reviewed. (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #17, and #19). The Findings include: Patient chart review on 12/05/2023 and 12/06/2023 revealed 17 patient POCs that had no goals in the POC’s assessments to coordinate the patient care. Interview on 12/06/2023 at 11:00 AM, the Administrator and Patient Care Coordinator verified the findings. Hospice policy, entitled, “;COORDINATION OF SERVICES”, revealed, “All members of the IDG participate in care planning and document problems, interventions, goals, observations, and outcomes based on the assessed and reassessed needs of the patient/caregiver”.”

“This standard is NOT MET. Based on record review of 2 of 4 patient medical records and interview, the hospice failed to ensure a system of communication and integration, in accordance with the hospice’s own policies and procedures, to ensure that the patient’s care and services were provided in accordance with the patient’s plan of care. The findings include: Patient #1is in a facility with a diagnosis of Failure to Thrive. The current physician orders per the residential facility are a ground diet, but the hospice orders are for a regular diet which was delivered to the patient on the 12/4/23 11:00 AM during the patient visit. The patient had no teeth is unable to chew. In an interview with the hospice Patient Care Coordinator on 12/4/2023 at 2:00 PM, he/she verified the hospice did not ensure the patient received the ordered diet. The meal was immediately changed to a ground diet. Patient #4 with a diagnosis of Alzheimer’s is in a residential facility. During the patient visit on 12/4/23 at 10:00 AM, review of the patient’s it facility medicine administration record (MAR) revealed the facility MAR did not match with the hospice’s MAR. The hospice MAR listed Prozac 10 milligram (mg) capsule every day while the residential facility listed 2.5 milliliter Fluoxetine (Prozac) 20mg/5ml (milliliter) solution. The residential facility listed MediHoney 80% (percent)topical gel to wounds. There were no wounds listed on the patient’s hospice care plan, or hospice Interdisciplinary Discipline Team (IDT) notes. The hospice’s admitting diagnosis section lists “Pressure ulcer of right buttock, unstageable, pressure ulcer of other site, stage 2, pressure ulcer of other site, stage 3”. In an interview on 12/4/23 at 2:00 PM, the Patient Care Coordinator revealed an outside wound care agency cares for the patient’s wounds, but there was no coordination between the wound care agency and the hospice. Hospice policy, titled,# PC.M50 reads, “A medication profile is maintained for every patient and includes a listing of the current medication orders for each patient and specifies whether the medication is or is not related to the patient’s terminal illness. The medication profile includes all prescription medications, over the counter drugs, vitamins, herbal and alternative supplements. “”

“Based on observations and interview, the hospice staff failed to follow accepted principles for potential cross transmission of infectious agents in the hospice setting for 2 of 4 applicable patients. (Patient #2 and Patient #3) The Findings include: Home observation visit on 12/04/2023 at 1:05 PM with Patient #2 revealed the Skilled Nurse (SN) #1 used bare un-sanitized hands to reach into his/her uniform pocket to remove scissors, and then cut gauze, and then placed the scissors back into his/her pocket without sanitizing the scissors or performing hand hygiene. SN #1 reached into the clean side of equipment bag to retrieve equipment without performing hand hygiene. SN #1 placed barrier on a couch, placed his/her equipment bag on the barrier, and then removed clean equipment from bag and placed the clean and used equipment on the same barrier. On 12/06/2023 at 12:23 PM, the Administrator reported “;We need to do some education.” Home observation visit on 12/04/2023 at 3:10 PM with Patient #3 reveals, SN #2 used electronic device for charting, failed to sanitize at the end of the visit, placed device under her arm then placed device into equipment device without sanitizing. This surveyor asked when equipment is sanitized, SN #2 reported “;I have a clean and dirty side in the bag...clean the equipment in the car”.”

“This standard is NOT MET. Based on record reviews and interview, the hospice failed to ensure supervisory visits of the Home Health Aides (HHA) were completed every 14 days for 1 of 15 patient charts reviewed for supervisory visits of the HHA. (Patient #6) The findings are: Patient #6 with a diagnosis of Alzheimer and contractures in the episode #32 of hospice care revealed physician orders for the Registered Nurse (RN) to visit 1-3 times per week. The Home Health Aide (HA) visits 3 times per week. There was no documentation that a registered nurse made supervisory visits for the home health aide (HA) in week 7 and week 9 of service.”

“This standard is NOT MET. Based on record reviews and interview, the hospice failed to ensure patient wounds and wound care was charted for 1 of 2 patient charts reviewed for wound care. (Patient #4) The findings are: Patient #4 with a diagnosis of Alzheimer was admitted into a residential facility 10/17/23. During the patient visit on 12/5/23 at 10:00 AM, the residential facility’s medicine administration record (MAR) listed MediHoney 80%(percent) topical gel and Anasept 0.057% topical gel to wounds. The medications were not on the hospice medicine administration profile for the patient. There were no wounds documented on the patient’s hospice care plan, or in the hospice Interdisciplinary Discipline Team (IDT) notes for the patient. The hospice’s admitting diagnosis section listed pressure ulcer of right buttock, unstageable, pressure ulcer of other site, stage 2, pressure ulcer of other site, stage 3 at the end of a long list of diagnoses. In an interview 12/6/23 at 10:15 AM, the Patient Care Coordinator reported an outside wound care agency provides care for the patient’s wounds, but there was no coordination documented between the wound care agency and the hospice. Hospice policy, titled, #PC.M50, reads,” Under 4. A medication profile is maintained for every patient and includes a listing of the current medication orders for each patient and specifies whether the medication is or is not related to the patient’s terminal illness. It must include all prescription medications, over the counter drugs, vitamins, and herbal and alternative supplements.””

“Based on record reviews, interviews, and review of the hospice policy, entitled, “;CLINICAL RECORDS”, the hospice failed to assign goals in the patient’s initial and ongoing Plan of Care (POC) for 17 of 19 patient charts required to assess patient outcomes, quality of care, and patient needs. (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #17 and #19) The Finding includes: On 12/05/2023 and 12/06/2023, review of patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #17 and #19’s charts revealed the patients’ POCs had no goals in the POC assessment for the hospice to accurately measure patient care. On 12/06/2023 at 11:00 AM, the Adminisrator and Patient Care Coordinator verified the findings. Hospice policy, entitled, “;CLINICAL RECORDS”, revealed “;Each patients clinical record includes, at a minimum, the following: g. outcome measure data elements”.”