Amedisys Hospice

“Based on record review and interview, the agency failed to include physician orders in the clinical record for 2 (#1, #3) of 3 patient records reviewed of patients on service for less than 3 weeks. The failure placed the agency’s clients at risk of the omission of care or inappropriate care which could result in a negative outcome. Client #1: Record review of Client #1’s record revealed a Plan of Care dated 8/2/2023 to 10/30/2023. The Plan of Care indicated that Client #1 started on the agency’s services on 8/2/2023. The Plan of Care listed Malignant Neoplasm (cancerous tumor) of Unspecified Kidney, Except Renal Pelvis as the terminal diagnosis. The Plan of Care listed Secondary Malignant Neoplasm of Bone and Secondary Malignant Neoplasm of Brain as secondary diagnoses. Registered Nurse C conducted a skilled nurse visit on 8/10/2023. Registered Nurse C documented “Received a call from patient’s spouse that patient was gasping for air and that oxygen was started on 2 liters for comfort. Registered Nurse C conducted a skilled nurse visit on 8/17/2023. Registered Nurse C documented that Client #1 was on oxygen at 2 liters. Registered Nurse D conducted an as needed skilled nurse visit on 8/17/2024 due to Client #1’s pain. Registered Nurse D documented that that Client #1 was on oxygen at 2 liters per nasal cannula. Client #1s record did not contain an order for oxygen. Client #3: Record review of Client #3’s record revealed a Plan of Care dated 12/18/2023 to 3/16/2024. The Plan of Care indicated that Client #3 started on the agency’s services on 12/18/2023. The Plan of Care listed Bacteremia (presence of bacteria in the bloodstream) as the terminal diagnosis. Registered Nurse C conducted a start of care comprehensive assessment skilled nurse visit on 12/18/2023. Registered Nurse C documented that Client #3 was alert, oriented to person, place and time. Registered Nurse C documented that Client #3 reported a pain level of 8 on a pain scale of 0-10, that the pain was to the back and lower extremities, and described the pain as aching, sore, and tingling. Client #3’s record contained an order, dated 12/18/2023, for Lyrica (medication used to treat pain caused by nerve damage) 50 milligrams by mouth three times a day. Registered Nurse C conducted a skilled nurse visit on 12/19/2023. Registered Nurse C documented that Client #3 had severe pain that was described as aching, sore, and tender and that the pain was intermittent. Registered Nurse C documented that Client #3 refused pain medication at that time. Registered Nurse C documented that comfort medications were ordered. Registered Nurse C documented that controlled substances were counted and listed Ativan (Lorazepam - used for anxiety), Fentanyl Transdermal (used for pain), Hydromorphone (used for pain), and Morphine (used for pain). Client #3’s clinical record did not contain a physician order for medications on 12/19/2023. Registered Nurse C conducted a skilled nurse visit on 12/26/2023. Registered Nurse C documented for Client #3 was unable to swallow pills. Client #3 complained of pain when repositioned. Client #3’s family requested an increase in dosage of Fentanyl patch due to inability to swallow tablets. Client #3’s family were instructed to give morphine for pain and shortness of breath as needed. Registered Nurse C documented that controlled substances were counted and listed Ativan (Lorazepam), Fentanyl Transdermal, and Morphine. Registered Nurse C conducted an as needed skilled nurse visit on 12/27/2023. Registered Nurse C documented instructions to Client #3’s family to give Client #3 Morphine as needed for pain. Registered Nurse C documented that controlled substances were counted and listed Ativan (Lorazepam), Fentanyl Transdermal, and Morphine. Registered Nurse C conducted a skilled nurse visit on 12/28/2023. Registered Nurse C documented instructions to Client #3’s family to give Morphine as needed. Registered Nurse C documented that controlled substances were counted and listed Ativan (Lorazepam), Fentanyl Transdermal, and Morphine. Registered Nurse C conducted a skilled nurse visit on 12/29/2023. Registered Nurse C documented instructions to Client #3’s family to give Morphine as needed. Registered Nurse C documented that controlled substances were counted and listed Ativan (Lorazepam), Fentanyl Transdermal, and Morphine. Registered Nurse E conducted a skilled nurse visit on 12/30/2023. Registered Nurse E documented that Client #3’s family reported that the family were giving Client #3 Lorazepam and Morphine. Registered Nurse E documented that controlled substances were counted and listed Ativan (Lorazepam) and Morphine. Registered Nurse C conducted a hospice death at home visit on 12/31/2023. Client #3’s client record did not contain orders for Morphine or Lorazepam. During an interview on 2/7/2024 at 12:42 with the Administrator/Alternate Supervising Nurse, the surveyor discussed that orders for medications were not in the client records. The Administrator/Alternate Supervising Nurse was to review the records. The Administrator informed the surveyor that Registered Nurse D was no longer employed at the agency. During an interview on 2/7/2024 at 2:16 p.m. with the Administrator/Alternate Supervising Nurse, the Administrator/Alternate Supervising Nurse informed the surveyor that the Administrator/Alternate Supervising Nurse was not able to reach Registered Nurse C. Registered Nurse C was on sick leave. The surveyor was not able to speak with Registered Nurse C. During an interview on 2/7/2024 at 4:19 p.m. with the Administrator/Alternate Supervising Nurse, the Administrator/Alternate Supervising Nurse informed the surveyor that the nurses were to follow the agency’s policy regarding receipt of physician orders, the nurses were to put the order in the client record when the order was received. The Administrator responded “No,” when asked if the medication orders were in the client records. The agency had a policy titled “Physician Verbal Orders,” labeled TX-002, that was last reviewed on 10/16/2023. The policy read in part; “Policy Verbal or telephone orders may only be taken by appropriately licensed staff members, acting within the scope of their licenses, and shall be immediately recorded, signed and dated by the licensed staff member receiving such an order...Operational Guidelines: 1. The licensed staff member receives the verbal order from the physician either in person or on the phone, verifies the order by ‘reading back’ the full order then records the verbal order electronically via the PointCare device or directly into the HCHB [Home Care Home Base - electronic medical record].”