Enhabit Hospice

“Based on record review and interviews the agency failed to ensure that care and services provided to each patient were completely and accurately documented for 1 of 3 patients sampled (Patient #1) in that RN- A failed to document the time medications were administered, the medication dosage, as well as the effectiveness after administration of the medications.Failure to document the time and dosage narcotic medications were administered placed Patient #1 at risk of overmedication due to an inability to determine the amount of medication needed to alleviate the patient’s respiratory and agitation symptoms. Findings Included:Review of the clinical record for Patient #1 revealed a start of care date of 06/21/2025 with a terminal diagnosis of Liver Failure and Alcoholic Cirrhosis of the liver with ascites. (Cirrhosis causes hardening and scarring of the liver. Ascites occurs when fluid builds up in the abdominal area because the liver cannot absorb the fluid). Review of the plan of care for the period 06/21/2025- 07/20/2025 revealed medication orders included: Haloperidol 1mg tablet every 6 hours as needed for agitation, Lorazepam 1mg tablet every 4 hours as needed for anxiety, Morphine concentrate 100mg/5ML (20mg/ml) oral solution, 0.25ml- 1ml hourly/as needed for pain/SOB (shortness of breath), Oxycodone 5mg tablet 1 tablet 2 times per day, Oxycodone 5mg tablet every 4 hours as needed for pain. Review of a physician order dated 07/20/2025 at 11:14 AM read: Discontinue Morphine concentrate 20mg/ml PO (by mouth) or SL (sublingual) – Q (every)1hr prn pain. Add Morphine concentrate 20mg/ml, administer po or SL- 0.25 ml for mild pain 1-3, 0.5ml for moderate pain 4-6, and 1ml for severe pain 7-10.Review of a SN visit noted dated 07/20/2025 revealed Patient #1 was transported from her residence to ALF- A for respite care. RN- A met the ambulance to assist with transfer, deliver the patient’s medications, give report to ALF staff and complete an assessment of the patient. Review of the visit note revealed RN-A arrived at 10:52 AM. RN documented vital signs on arrival were temperature: 96.5, pulse 78 bpm (beats per minute) (normal), respirations 16 (normal)at 12:13 PM then increased to 40 bpm at 12:17 PM, blood pressure 82/49, oxygen saturation was 67% on room air at 12:13 PM 96% at 12:17 PM on Oxygen 2L, pain level 5/10 (moderate). Review of the assessment findings included patient presented with an episode agitation. Signs and symptoms described patient as anxious/agitated, restless, and displayed aggressive behavior. Narrative: On exam patient agitated, disoriented, repetitive behavior observed. Pt was trying to get out of bed 10 times. Facial grimace, polypnea (panting). During an assessment the peritoneal (abdominal) dressing was covered with cloth tape and gauze. The drainage tube area was exposed to air. This nurse observed that peritoneal catheter (tube) was dislodged. (ALF) LVN was present during the finding. RN A administered Morphine, Lorazepam and Haloperidol. Pt tolerated well. Administered oxygen 2LPM via nasal cannula. At the end of this writing Pt left resting comfortable(y). Oxygen saturation 92%. RN- A failed to document the dosages or times when medications were administered and failed to document an assessment of the effectiveness of the medications.An interview was conducted on 07/24/2028 at 9:25 AM with AA/SN. Surveyor asked if there had been any issues regarding the care provided by RN- A or RN- B. AA/SN denied any concerns. Surveyor reviewed the medical record for Pt #1 for the SNV on 07/20/2025. Surveyor asked if Morphine, Lorazepam and Haldol could safely be given all at the same time. AA/SN stated, “Yes. In hospice we can give all of those medications to treat whatever symptoms the patient is having.” AA/SN reviewed the nurse narrative note and acknowledged there was no documentation of the dosage of each medication and the time the medications were administered. An interview was conducted on 07/24/2025 at 2:10 PM with Hospice Medical Director- MD #1. The medical record for Pt #1 was reviewed. Medications administered on 07/20/2025 were reviewed. It was noted the length of the SN visit was conducted over 2.5 hours. The times of Morphine, Haldol and Lorazepam were administered and were not documented. Surveyor asked if these medications were administered together would that be within the orders. MD stated, “Yes. In hospice we address all of a patient’s symptoms especially when they are in a pain crisis. We medicate and monitor for effectiveness until the symptoms have improved and patients are at an acceptable comfort level for the patient. If a patient were agitated and in pain at the same time it would be appropriate to give more than one medication. Surveyor reviewed a skilled nurse visit note by RN- B dated 07/20/2025 at 5:15 PM which indicated EMS was called by ALF staff because Pt #1 was unresponsive. Pt #1 was given Narcan by EMS prior to her arrival to the hospital. The time was not documented when EMS administered Narcan. Narcan is a medication that reverses the effects of opioid medications. If EMS gave Narcan and it was not effective, then her unresponsiveness would more than likely not be related to narcotic medications.” A telephone interview was conducted on 07/24/2025 at 4:21 PM with RN- A regarding the SN visit on 07/20/2025. RN- A stated he went to ALF- A to assist with the transfer to respite care. Patient #1 settled in her bed. RN- A stated when Pt #1 arrived she was agitated, screaming and yelling. RN- A stated the ambulance attendants advised him that Patient #1had been that way the entire transport. RN- A stated she appeared to be having terminal agitation. Terminal agitation can occur when an individual is nearing the end of life. Symptoms include restlessness, confusion ana emotional distress. RN- A stated she began tearing up the bed and fighting him. RN- A stated he was concerned about her falling out of bed, so he got 2 fall mats by the bed. RN- A stated. Pt #1 continued rolling around in the bed, yelling, screaming and combative. RN- stated he contacted AA/SN and reported the change in condition with possible terminal agitation. RN- A stated AA/SN advised him to utilize the comfort kit medications. RN- A stated SNF LVN #1 was not ready to manage her and refused to give any medications. RN- A stated he began giving Pt #1 0.25 mg Morphine every 15 minutes for over 2 hours as ordered. During that time RN- A stated he administered Lorazepam 1mg orally. RN- A stated after 30 minutes patient was still agitated and yelling. RN- A stated he then gave Haldol 1mg orally. Surveyor asked what time the medications were given. RN- A stated he did not know the times the medications were administered. Surveyor asked why the dosages and times each medication was not documented. RN- A did not have a reply. RN- A stated he contacted FM #1 and updated him on the events that were occurring. RN- A stated FM #1 reported Pt #1 had been agitated and screaming since the night before.A telephone interview was conducted on 07/25/2025 at 5:18 PM with RN- B. RN- B stated he was advised by AA/SN Pt #1 had been taken to the hospital to have her abdominal drain tube replaced and requested he follow up with FM #1. RN- B stated he contacted FM #1 and was told the patient passed away. RN- B stated he went to the hospital to provide comfort and support to FM #1. On 07/29/2025 a request for hospital medical records for Patient #1 was faxed to Hospital- B.Review of the agency’s online policies and procedures revealed a policy titled “Medications, S07, Revised date: 03-31-2025” which read “Staff promptly documents the administration, assistance and/or set-up medications in the clinical record.””

“Based on record review and interview, the agency failed to enforce its written policy to immediately (within 24 hours) report knowledge of an allegation of neglect for 1 of 20 patients (Pt #19) for which records were reviewed in that;The agency failed to report an allegation of neglect within 24 hours to HHSC. The agency learned of the allegation on 10/02/2024.This failure placed the agency’s patients at risk of further abuse, neglect and/or exploitation, and prevents HHSC from conducting timely investigations. Findings:Review of the agency’s online policies and procedures revealed policy, “Patient abuse, neglect & exploitation, S17_TX (no revision date). The agency reports all suspected cases of abuse, neglect and/or exploitation of patients (clients) in compliance with relevant state statutes. Any clinician who discovers, within the course of rendering care, any suspected abuse, neglect or exploitation or receives an allegation regarding abuse, neglect or exploitation will immediately (within 24 hours) report such occurrences.” Review of the agency’s Complaint Reports for 2023 – 2024 included a complaint submitted on 10/02/2024 by FM #2 which read, “When it was critical to send a nurse to check on Pt #19’s status, I was told the nurse would not go see or check on him but would rely on communication with the director of the facility when I specifically asked for a visual/personal ck(check). By the time I could get to him I realized their neglect caused it to be too late to get Pt #19 the care he needed to survive. They told me he had a cold when he had actually aspirated on their watch.” A search in TULIP (a database utilized by the state to maintain licensing, demographic information, complaints and self-reported incidents on Home Health and Hospice agencies for the State of Texas), revealed no self- reported incident by the agency of an allegation of neglect of Pt #19.Review of the clinical record for Pt #19 revealed a start of care date of 04/25/2024 with a terminal diagnosis of Unspecified Sequelae of Cerebral Infarction. This condition causes loss of muscle movement, difficulty swallowing and memory loss. Pt #19 was discharged on 06/26/2024 due to death.06/10/2025 at 2:10 PM- An interview was conducted with A/ASN and AA/SN. the clinical record for Pt # 19 and complaint log were reviewed. Surveyor advised the administrators that after a search of intakes in TULIP, surveyor was not able to locate a self-report for an allegation of neglect regarding Pt #19. Surveyor requested to review documentation of a self-report for the allegation. AA/SN stated “We didn’t do one. We thought it was a complaint regarding the facility. I read it to mean she was complaining about the SNF.” A/ASN agreed that a self-report should have been submitted to HHSC. 06/11/2025 at 9:45 AM- telephone interview was conducted with FM #2 regarding the care and services provided by the agency for Pt #19. FM #2 stated Client #19 began to spike a fever on 06/21/2024. ALF- B advised he may have been getting a cold and began giving over the counter pain reliever and fever reducer as well as cough medicine. On 06/22/2024 pt’s temp was even higher. FM #2 stated she asked FM #3, “Are we sure he didn’t aspirate? He had done that several times in the past and we have taken him to the hospital. I was told I could take him off hospice whenever I wanted to take him to the hospital. If I had known sooner, I would have revoked and called EMS.””