Huron Regional Medical Center

“Based on record review, interview, and policy review the provider failed to ensure drug regimen and medication reviews were completed, and the physician was notified of a severe drug interaction for four of four sampled patients (1, 2, 3, and 4) records reviewed with a severity level two severe drug interaction. Findings include: 1. Review of patient 1’s electronic medical record (EMR) revealed: *He was admitted to hospice on 9/7/23. *He had omeprazole 20 milligrams (mg) twice daily and phenytoin sodium extended 200 mg daily dated 9/7/23 on his medication profile. *There was a severity level 2 severe drug interaction [potentially harmful and unsafe combinations of prescription medications] alert between the omeprazole and the phenytoin highlighted in red on his medication profile. *There was no documentation of the severe drug interaction being addressed or that the physician was notified. 2. Review of patient 2’s EMR revealed: *He was admitted to hospice on 1/11/23. *He had gabapentin 300 (mg) twice daily dated 1/11/23, promethazine 6.25 mg-codeine 10 mg/5 milliliters (ml) every four hours, and lorazepam 0.25 to 1 ml every four hours as needed dated 4/26/23 on his medication profile. *There were two severity level 2 severe drug interaction alerts between the gabapentin, promethazine, and lorazepam highlighted in red on his medication profile. *There was no documentation of the severe drug interaction being addressed or that the physician was notified. 3. Review of patient 3’s EMR revealed: *He was admitted to hospice on 10/16/23. *He had citalopram 20 mg daily and ondansetron 4 mg twice daily dated 10/16/23 on his medication profile. *There was a severity level 2 severe drug interaction alert between the citalopram and the ondansetron highlighted in red on this medication profile. *There was no documentation of the severe drug interaction being addressed or that the physician was notified. 4. Review of patient 4’s EMR revealed: *She was admitted to hospice on 3/17/23. *She had escitalopram 10 mg daily and ondansetron 8 mg twice daily dated 3/17/23 on her medication profile. *There was a severity level 2 severe drug interaction alert between the escitalopram and the ondansetron highlighted in red on her medication profile. *There was no documentation of the severe drug interaction being addressed or that the physician was notified. 5. Interview on 5/1/24 at 3 p.m. with director A, and registered nurse (RN) case manager and resource nurse B revealed: *A drug regimen and medication review were completed at admission and with new medications. *Severity level 1 and 2 drug interactions were faxed to the physician. *They had no process to track if the physician was sent or received the fax. *They had no process to follow up with the physician for orders regarding the severity level 1 and 2 drug interactions. *They felt the process had been overlooked for the hospice program. *They confirmed no evidence existed to support that the reviews were completed, or the physician was notified for the above patients. 6. Review of the provider’s 5/2024 Medication Control in Home Care [hospice] policy revealed: *”The home care computer system checks for drug interactions. When level 1 or 2 interactions are found they are faxed to the prescribing physician by the home care staff.” *”Documentation is made in the nurse’s notes and/or care plan of patient education in the safe and appropriate use of the drugs.””

“Based on record review, interview, and policy review, the provider failed to ensure there was documentation of education related to the continuation of hospice services versus revocation of hospice benefits for a planned out-of-state trip that occurred for one of one closed patient (14) records reviewed for revocation. The provider had three total patients who had been discharged due to the revocation of their hospice benefits during the period of 3/30/23 through 4/30/24. Findings include: 1. Review of patient 14s closed electronic medical records (EMR) revealed:*He elected hospice services on 8/18/23 with a primary diagnosis of pleural effusion. -His initial certification period was from 8/18/23 through 11/15/23. *His 8/18/23 hospice certification of terminal illness form included a physician’s note of: -“;Patient has end stage CHF [congestive heart failure], pleural effusion and pneumonia. I am advising against any further treatment as patient is refusing any further treatment.”*His 8/18/23 Plan of Care included the following: -He was going to have skilled nursing visits twice weekly for 12 weeks and then weekly for 1 week. -Skilled nursing staff would monitor his respiratory status, pain management, nutrition, anxiety, and skin integrity. -He was to receive hospice care in his own home with assistance from his family through the certification period for end-of-life cares. *A 9/21/23 hospice routine visit note by the registered nurse (RN) stated: -“;...Pt [patient] talks of going to Branson Missouri in the next couple weeks, upon speaking to daughter she thinks it is Oct 1st. Daughter [name] agrees with pt revoking hospice for now as he is traveling out of the area. She will explain to him the revocation and forms will be taken to him next visit.” -There was no documentation to support the patient or daughter were educated on potential options of potential continuation of hospice care versus revocation of his hospice benefits during the planned trip.*A 9/25/23 hospice routine visit note by the RN stated: -“;Pt signed revocation form d/t [due to] traveling out of the HRMC [ provider abbreviation] hospice area, daughter aware, meds ordered at Lewis Drug by Dr. [name]. Pt understands that he gives up current certification period but may apply to hospice again upon return...” *A Hospice Benefit Revocation form included the following: -His 8/18/23 election date. -A 9/25/23 revocation date. -A statement indicating he understood he was revoking his hospice benefits for the remainder of the current benefit period and could elect hospice in the future. -Another statement indicated he was no longer covered by hospice but may resume regular insurance benefits that were previously waived. -It was signed by the patient and an RN on 9/25/23. *There was no further evidence to support what had been done to educate the patient regarding the potential risks or options of continuing his hospice services for his planned trip out of state versus revocation of his hospice benefits. *He was later readmitted to hospice from 10/16/23 through his death on 10/24/23. Interview and record review on 5/1/24 at 1:15 p.m. with RN/case manager B regarding patient 14 revealed:*She confirmed the notes above and the rationale for the revocation of his hospice benefits was related to his planned trip out of the state and their service area. -The notes indicate the plan was for him to revoke the benefits while out of state and then re-elect hospice after he returned home. *She was unsure if there was any additional documentation related to this patients revocation. Interview and record review on 5/1/24 at 2:05 p.m. with director A regarding patient 14s revocation revealed: *She confirmed the clinical notes indicated a plan for the patient to revoke his hospice benefits when he traveled out of state and then re-elect hospice upon his return home. *The patient revoked his benefits on 9/25/23 and then re-elected hospice on 10/16/23 through his death on 10/24/23. *She had discussed the options related to revocation with his daughter but had not documented that in his EMR. *There was no evidence to support they had attempted continuation of his hospice benefits during his planned out-of-state trip. Review of the providers revised May 2023 Discharge from Hospice Policy revealed: *”The election of the hospice benefit is the beneficiarys choice rather than the hospices choice, and thus, the hospice cannot revoke the beneficiarys elections. Therefore, when a hospice agency admits a beneficiary to hospice, it may not automatically or routinely discharge the beneficiary at its discretion, even if the care promises to be costly or inconvenient.”*Circumstances for discharge included: -“;A. The beneficiary decides to revoke the benefit to seek treatment or no longer desires the service; -B. The beneficiary moves out of the service area or into a nursing home with which the hospice has no agreement to provide care; -C. The beneficiary transfers to another hospice; -D. The hospice is unable to recertify the patient because the beneficiarys condition improves and he/she is no longer terminal; or -E. The beneficiary dies.” --There was no category related to traveling out of the service area.”