University of TN Medical Center Home Care Services

“Based on agency policy review, medical record review, and interview, the agency failed to complete a thorough comprehensive assessment to include the bowel elimination for 4 Patients (#1, #4, #6, #9) of 20 patients reviewed. The findings include: Review of the agency policy titled, “Comprehensive Assessment & Plan of Care,” reviewed 2024 revealed “...The registered nurse (RN) will conduct an...assessment to determine the patient’s immediate care needs...including identification of goals and interventions, will include the assessment of...bowel...elimination...” Review of the agency policy titled, “Patient Assessments,” revised 7/1/2012, revealed “...The nurse...will assess the patient on each visit...assessment...include...Bowel...elimination...” Medical record review revealed Patient #1 was admitted to the agency on 12/5/2024 with diagnoses including Alzheimers Disease, Altered Mental Status, and Insomnia. Medical record review of Patient #1s nursing clinical notes revealed on 12/5,2024, 12/10/2024, 12/17/2024, 12/24/2024, 12/31/2024, 1/6/2025, 1/20/2025, and 2/14/2025 no documentation of bowel elimination. Medical record review of Patient #4 was admitted to the agency on 12/17/2024 with diagnoses including Hemiplegia, Dysphagia, and Chronic Obstructive Pulmonary Disease. Medical record review of Patient #4s nursing clinical notes revealed on 12/19/2024, 12/24/2024, 12/26/2024, 1/9/2025, and 1/20/2025 no documentation of bowel elimination. During an interview on 2/21/2025 at 8:30 AM the Executive Director (ED) confirmed Patient #1s bowel elimination was not assessed on 12/5,2024, 12/10/2024, 12/17/2024, 12/24/2024, 12/31/2024, 1/6/2025, 1/20/2025, and 2/14/2025. The ED also confirmed Patient #4s bowel elimination was not assessed on 12/19/2024, 12/24/2024, 12/26/2024, 1/9/2025, and 1/20/2025. Medical record review revealed Patient #6 was admitted to the agency on 11/23/2024 with diagnoses including Chronic Obstructive Pulmonary Disease and Congestive Heart Failure. Medical record review of Patient #6s nursing clinical notes revealed on 11/24/2024 no documentation of bowel elimination. Medical record review of Patient #9 was admitted to the agency on 12/19/2024 with diagnoses including Hemiplegia and Chronic Obstructive Pulmonary Disease. Medical record review of Patient #9s nursing clinical notes revealed on 12/20/2024, 12/23/2024, and 12/27/2024 no documentation of bowel elimination. During an interview on 2/21/2025 at 9:32 AM the Executive Director (ED) confirmed Patient #6s bowel elimination was not assessed on 11/24/2024. The ED also confirmed Patient #9s bowel elimination was not assessed on 12/20/2024, 12/23/2024, and 12/27/2024. The findings include: Review of the agency policy titled, “Comprehensive Assessment & Plan of Care,” reviewed 2024 revealed “...The registered nurse (RN) will conduct an...assessment to determine the patient’s immediate care needs...including identification of goals and interventions, will include the assessment of...bowel...elimination...” Review of the agency policy titled, “Patient Assessments,” revised 7/1/2012, revealed “...The nurse...will assess the patient on each visit...assessment...include...Bowel...elimination...” Medical record review revealed Patient #1 was admitted to the agency on 12/5/2024 with diagnoses including Alzheimers Disease, Altered Mental Status, and Insomnia. Medical record review of Patient #1s nursing clinical notes revealed on 12/5,2024, 12/10/2024, 12/17/2024, 12/24/2024, 12/31/2024, 1/6/2025, 1/20/2025, and 2/14/2025 no documentation of bowel elimination. Medical record review of Patient #4 was admitted to the agency on 12/17/2024 with diagnoses including Hemiplegia, Dysphagia, and Chronic Obstructive Pulmonary Disease. Medical record review of Patient #4s nursing clinical notes revealed on 12/19/2024, 12/24/2024, 12/26/2024, 1/9/2025, and 1/20/2025 no documentation of bowel elimination. During an interview on 2/21/2025 at 8:30 AM the Executive Director (ED) confirmed Patient #1s bowel elimination was not assessed on 12/5,2024, 12/10/2024, 12/17/2024, 12/24/2024, 12/31/2024, 1/6/2025, 1/20/2025, and 2/14/2025. The ED also confirmed Patient #4s bowel elimination was not assessed on 12/19/2024, 12/24/2024, 12/26/2024, 1/9/2025, and 1/20/2025. Medical record review revealed Patient #6 was admitted to the agency on 11/23/2024 with diagnoses including Chronic Obstructive Pulmonary Disease and Congestive Heart Failure. Medical record review of Patient #6s nursing clinical notes revealed on 11/24/2024 no documentation of bowel elimination. Medical record review of Patient #9 was admitted to the agency on 12/19/2024 with diagnoses including Hemiplegia and Chronic Obstructive Pulmonary Disease. Medical record review of Patient #9s nursing clinical notes revealed on 12/20/2024, 12/23/2024, and 12/27/2024 no documentation of bowel elimination. During an interview on 2/21/2025 at 9:32 AM the Executive Director (ED) confirmed Patient #6s bowel elimination was not assessed on 11/24/2024. The ED also confirmed Patient #9s bowel elimination was not assessed on 12/20/2024, 12/23/2024, and 12/27/2024.”

“Based on agency policy review, medical record review, Long Term Facility (LTC) and Assisted Living Facility (ACLF) record review, and interviews the agency failed to reconcile the medication profile for 2 patients (#4 and #1) of 4 patients reviewed with home visits. The findings include: Review of the agency’s policy titled, “Monitoring Medications,” revised 11/21/2017, revealed “...PURPOSE...To provide a process to ensure continuous monitoring of medications in patients home...A drug regimen review will be performed on all patients in conjunction with all comprehensive assessments...all nurses will participate in medication review and reconciliation...” Medical record review revealed Patient #4 was admitted to the agency on 12/17/2024 with diagnoses including Dysphagia, Dementia, and Chronic Obstructive Pulmonary Disease. Review of Patient #4s agency hospice Physician Orders revealed “...HALOPERIDOL [medication used to treat mental disorders] 1 MG [Milligram] EVERY 6 HOURS...HYDROCODONE [[medication used to treat pain] 5 MG...2 TIMES DAILY...HYOSCYAMINE [medication used to relax muscles in the digestive tract and bladder] 0.125 MG...EVERY 4 HOURS...LORAZEPAM [medication used to treat anxiety] 0.5 MG...EVERY 6 HOURS...MORPHINE [medication used to treat pain]...100 MG/5ML [milliliter]...ORAL SOLUTION...0.25 ML EVERY 3 HOURS...SENNA PLUS [medication used to treat constipation] 8.6 MG-50 MG CAPSULE 2 TIMES DAILY...” Review of Patient #4s LTC Order Summary Report dated 2/19/2025, revealed no documentation the patient had a Physicians Order for Haloperidol, Hydrocodone, Hyoscyamine, Lorazepam, Morphine, and Senna. During an interview on 2/19/2024 at 9:45 AM, the LTC Director of Nursing (DON) confirmed Patient #4 did not have a Physicians Order for Haloperidol, Hydrocodone, Hyoscyamine, Lorazepam, Morphine, and Senna. Medical record review revealed Patient #1 was admitted to the agency on 12/5/2024 with diagnoses including Alzheimers Disease, Altered Mental Status, and Insomnia. Review of Patient #1s ACLF Physician Orders revealed “;...MILK OF MAGNESIA SUSP [suspension]...30 ML...GIVE 30 ML BY MOUTH EVERY 12 HOURS AS NEEDED...For constipation...” The medication was ordered 10/21/2024. Review of Patient #1s agency hospice Physician Orders revealed the patient did not have an order for Milk of Magnesia. During an interview on 2/19/2024 at 11:20 AM, the ACLF DON stated Patient #1s primary care physician ordered Milk of Magnesia on 10/21/2024. During an interview on 2/21/2025 at 10:20 AM, the Executive Director (ED) confirmed Patient #4s medication profile had not been reconciled with the LTC facilitys medication profile. The ED also confirmed Patient #1s medication profile had not been reconciled with the ACLF medication profile. The findings include: Review of the agency’s policy titled, “Monitoring Medications,” revised 11/21/2017, revealed “...PURPOSE...To provide a process to ensure continuous monitoring of medications in patients home...A drug regimen review will be performed on all patients in conjunction with all comprehensive assessments...all nurses will participate in medication review and reconciliation...” Medical record review revealed Patient #4 was admitted to the agency on 12/17/2024 with diagnoses including Dysphagia, Dementia, and Chronic Obstructive Pulmonary Disease. Review of Patient #4s agency hospice Physician Orders revealed “...HALOPERIDOL [medication used to treat mental disorders] 1 MG [Milligram] EVERY 6 HOURS...HYDROCODONE [[medication used to treat pain] 5 MG...2 TIMES DAILY...HYOSCYAMINE [medication used to relax muscles in the digestive tract and bladder] 0.125 MG...EVERY 4 HOURS...LORAZEPAM [medication used to treat anxiety] 0.5 MG...EVERY 6 HOURS...MORPHINE [medication used to treat pain]...100 MG/5ML [milliliter]...ORAL SOLUTION...0.25 ML EVERY 3 HOURS...SENNA PLUS [medication used to treat constipation] 8.6 MG-50 MG CAPSULE 2 TIMES DAILY...” Review of Patient #4s LTC Order Summary Report dated 2/19/2025, revealed no documentation the patient had a Physicians Order for Haloperidol, Hydrocodone, Hyoscyamine, Lorazepam, Morphine, and Senna. During an interview on 2/19/2024 at 9:45 AM, the LTC Director of Nursing (DON) confirmed Patient #4 did not have a Physicians Order for Haloperidol, Hydrocodone, Hyoscyamine, Lorazepam, Morphine, and Senna. Medical record review revealed Patient #1 was admitted to the agency on 12/5/2024 with diagnoses including Alzheimers Disease, Altered Mental Status, and Insomnia. Review of Patient #1s ACLF Physician Orders revealed “;...MILK OF MAGNESIA SUSP [suspension]...30 ML...GIVE 30 ML BY MOUTH EVERY 12 HOURS AS NEEDED...For constipation...” The medication was ordered 10/21/2024. Review of Patient #1s agency hospice Physician Orders revealed the patient did not have an order for Milk of Magnesia. During an interview on 2/19/2024 at 11:20 AM, the ACLF DON stated Patient #1s primary care physician ordered Milk of Magnesia on 10/21/2024. During an interview on 2/21/2025 at 10:20 AM, the Executive Director (ED) confirmed Patient #4s medication profile had not been reconciled with the LTC facilitys medication profile. The ED also confirmed Patient #1s medication profile had not been reconciled with the ACLF medication profile.”

“Based on agency policy review, medical record review and interview, the agency failed to implement a bowel regimen for 2 Patients (#5 and #16) of 20 patients reviewed for opioid medications. The findings include: Review of the agency policy, “;Comprehensive Assessment,” reviewed 2024 revealed “;...An assessment of the need for a bowel regimen when the patient has been prescribed opioids...” Review of the agency policy, “;Pain and Symptom Management,” reviewed 2024 revealed “;...The interdisciplinary team ensures that patients receive effective pain management and symptom control from the hospice...including constipation...The patients pain and other symptoms...are thoroughly assessed during the comprehensive assessment of the patient by the RN Case Manager...” Medical record review revealed Patient #5 was admitted to the agency on 1/28/2025 with diagnoses including Malignant Neoplasm of Rectum. Medical record review of a Physician Order dated 1/28/2025, showed Patient #5 had been ordered Morphine Concentrate (an opioid used to treat pain) 20 milligrams/5 milliliters (MG/ML) oral syringe every 4 hours as needed for pain and Oxycodone (an opioid used to treat pain) 30 mg tablet every 4 hours for pain. Medical record review of the medication profile summary showed Patient #5 had not been ordered medications for constipation. Medical record review revealed Patient #16 was admitted to the agency on 1/24/2025 with diagnoses including Chronic Obstructive Pulmonary Disease. Medical record review of a Physician Order dated 1/24/2025, showed Patient #16 had been ordered Dilaudid (an opioid used to treat pain) 2mg/ml oral liquid every 6 hours as needed for pain. Medical record review of the medication profile summary showed Patient #16 had not been ordered medications for constipation. During an interview on 2/21/2025 at 10:30 AM the Executive Director (ED) confirmed the agency failed implement a bowel regimen for Patient #5 and Patient #16 who received opioids.”