Accentcare Hospice & Palliative Care of Texas

“It is required that each patient’s individualized written plan of care: reflects patient and family goals; [and] identifies planned interventions based on problems identified in the initial and updated comprehensive assessments This standard was not met as evidenced by clinical record review, observation, document review, and interview. Agency policy “Ongoing Nursing Assessment” (revised 02/15/2022) stated in part, “Based on the assessments, the care plan - including problems, needs, goals, and outcomes, shall be reviewed and updated by the interdisciplinary group members ....” In 5 of 14 (36%) clinical records reviewed and home visits observed, the agency did not ensure that the patient’s plan of care reflected the patient’s goals and identified planned interventions based on problems identified in the initial and updated comprehensive assessments. Clinical Record 1: The patient elected hospice care on 01/11/2024. The Certification of Terminal Illness (CTI) for the benefit period dated 04/01/2024 to 07/08/2024 documented, “Patient with ... hospice diagnosis of Alzheimer’s disease and comorbid conditions of dementia, depression... COPD... FAST score is 7A… Patient is having increased episodes of confusion and fatigue ...” The Registered Nurse (RN) visit note dated 05/22/2024 documented the patient was experiencing anxiety and was alert and oriented to person and place only. Additionally, the visit note documented that the patient was disoriented, forgetful, confused, restless, and had abnormal cognitive functioning. On 05/22/2024, the physician ordered the medication change “Fluoxetine from 40mg: two capsules by mouth twice a day for anxiety to one capsule daily.” The physician’s face-to-face visit dated 06/25/2024 documented, “daughter reports increased amount of confusion throughout the day and agitation at night intermittently...Patient’s sleep has been interrupted at times as well due to the agitation at night and has been compliant with Seroquel in the evening ...” On 06/26/2024, the RN visit note documented that the patient exhibited confusion, was alert and oriented to person and place only, was disoriented, forgetful, confused, had an abnormal cognitive function, and was restless. On 06/26/2024, the physician ordered: “Quetiapine 50 mg taken by mouth at bedtime for sleep” to be changed to 75 mg. The patient’s plan of care for the benefit period 04/01/2024 to 07/08/2024 did not identify planned interventions based on the patient’s problems with anxiety. Clinical Record 2: The patient elected hospice care on 03/25/2024. The Skilled Nurse (SN) Hospice pro re nata/as needed (PRN) Visit note dated 05/25/2024 documented that the patient complained of a pain score of 3 out of 10 due to burning with urination and sore bladder and urethra and that the patient’s urine had a foul odor. Additionally, the visit note documented, “16Fr catheter removed. Replacement done using sterile technique. 16 Fr foley catheter draining pink-tinged urine to bedside bag ... sediment, odor, scant blood at urethra ...” The hospice physician was notified at that time and ordered: “Levofloxacin 750 mg by mouth daily for five days.” On 06/02/2024, the SN PRN visit note documented that the patient was complaining of urinary urgency and frequency with pain and hematuria. In addition, the visit note documented, “Last week tx with 7 days of Levofloxacin… Completed Friday. UTI s/s started again yesterday... Catheter changed to larger catheter with more volume in Foley bulb yesterday per MD order. Today s/s continue and are worsening. Notified doctor... He ordered Augmentin for 7 days and to change catheter out again today ...18 Fr foley cath with 25 mls normal saline inflated into bulb...” On 06/02/2024, the physician ordered: “Augmentin 875 mg/125 mg by mouth twice daily for seven days, and on 06/12/2024, the physician ordered: “Oxybutynin 5mg tablets - two tablets daily for burning with urination.” On 06/20/2024, the SN documented that the patient had brown urine with sediment visible. The physician ordered: “Cipro 500 mg by mouth twice daily for five days” and to obtain a urinalysis with culture and sensitivity with an early catheter change. The patient’s plan of care for the benefit periods 03/25/2024 to 06/22/2024 and 06/23/2024 to 08/21/2024 did not identify planned interventions based on the patient’s problems with repeated urinary tract infections and symptoms. Clinical Record 5: The patient elected hospice care on 01/30/2024. The RN visit note dated 05/02/2024 documented, “Stage two pressure ulcer measured 2 x 2 x 0 on the left buttocks.” On 05/02/2024, the physician ordered wound care: “Clean the wound with soap and water, pat dry, apply Calazime lotion, and dress with Optifoam three times a week and as needed.” The SN visit note dated 07/11/2024 documented that the patient presented with a coccyx wound but refused measurement. On 07/11/2024, the physician ordered wound care for the coccyx “clean with soap and water, applying a barrier cream daily and “Buspirone 5 mg by mouth three times daily for anxiety.” The patient’s plan of care for the benefit period dated 04/29/2024 to 07/27/2024 did not identify planned interventions based on the patient’s problems with skin integrity/wounds or anxiety. Clinical Record 6/Home Visit 3: The patient elected hospice care on 02/27/2024. The CTI for the benefit period dated 02/27/2024 to 05/26/2024 documented, “She has worsening dysphagia for which she is on a pureed diet. She has lost more than 20lbs of weight in the last 6 months and is down to 88.3 lbs now...” On 05/09/2024, the physician ordered a pureed diet and nectar-thickened fluids. The CTI for the benefit period dated 05/27/2024 to 08/24/2024 documented, “She is unable to eat regular food and chokes on it regularly ... Patient’s anxiety has also increased at home requiring more intervention... increased dysphagia and inability to have good nutrition and declining weight ... “ The patient’s medication profile documented, “Escitalopram 10 mg by mouth daily for anxiety,” dated 04/09/2024. During the home visit with the Registered Nurse (RN) [Personnel Record 6] on 07/17/2024, the patient was so hard of hearing that the RN needed to use a whiteboard to communicate with the patient. The patient’s plans of care for the benefit periods dated 02/27/2024 to 05/26/2024 and 05/27/2024 to 08/24/2024 did not identify planned interventions based on the patient’s problems with dysphagia, aspiration, anxiety, and difficulties communicating due to severe hearing loss. Clinical Record 7: The patient elected hospice care on 06/10/2022. On 06/14/2024, the physician ordered: “Doxycycline 100 mg by mouth every twelve hours for a suspected staph infection for seven days.” The SN visit notes dated 06/12/2024 and 06/18/2024 did not document the reason for the Doxycycline order. During the Interdisciplinary Group Meeting on 06/25/2024, the SN reported no infections, and the scribe left blank the section for medication changes, new orders, and changes to the plan of care. The plan of care for the benefit period dated 05/30/2024 to 07/28/2024 ordered the Chaplain to visit the patient once every four weeks. The patient’s plan of care for the benefit period dated 05/30/2024 to 07/28/2024 did not contain an identified problem or related intervention for the Doxycycline or the Chaplain visits. The findings were confirmed during an interview and a joint record review with the Executive Director on 07/17/2024.”