American Star Home Health Care Inc.

“Based on interview and record review, the hospice failed to ensure the ongoing sharing of information between all disciplines providing care and services for 1 of 14 (Patient #1) patients reviewed in that the hospice failed to communicate among all persons involved in the patient’s care to ensure relevant patient information was reported to and followed up on by the appropriate individual/discipline. This failure resulted in a report of symptoms of a UTI (an infection of the urinary tract) and possible need for an antibiotic (a medication to treat infections) failing to be reported to the hospice Medical Director (a physician who oversees the medical component of hospice care) when first identified by a hospice employee and could result in harm to patients including pain, discomfort, and development of systemic or serious infections. The findings included: Record review of the hospice’s complaint documentation, for the year of 2025, included a “Complaint/Grievance Form,” dated 08/01/25, signed by the Supervising Nurse, which indicated the Supervising Nurse received a phone call from Patient #1’s Family Member #1 who reported the patient no longer wanted to receive services from the Alternate Supervising Nurse. The form indicated Family Member #1 reported LVN J had seen the patient and requested an order for an antibiotic as the patient’s urine had sediment (solid particles found in urine which can indicate a UTI is present) and a foul odor (a bad smell to the urine which can indicate a UTI is present) to the Alternate Supervising Nurse and the Alternate Supervising Nurse failed to report the information to the physician (the hospice Medical Director). Record review of the clinical record for Patient #1 included a recertification plan of care order, for the certification period of 06/29/25 – 08/27/25, which indicated the patient had a diagnosis of CHF (a medical condition in which the heart cannot pump effectively which can result in buildup of fluid in the body’s tissues) and indicated the patient was to receive skilled nurse visits once a week for nine weeks and hospice aide visits twice a week for eight weeks, then once a week for one week. Record review of a plan of care order, dated 06/29/25, indicated the patient had a urinary catheter (a medical tube inserted into the bladder to drain urine). Record review of an initial plan of care order, dated 12/31/24, indicated the patient had a start of care date of 12/31/24. Record review of the clinical record included a hospice aide visit note, dated 07/21/25, signed by LVN J, which indicated, “Rn notified of foul smelling urine and increased sediment.” Record review of the clinical record included a hospice aide visit note, dated 07/30/25, signed by LVN J, which indicated, “Joint visit completed with RN. Patient not feeling well … Patient having foul smelling urine and bleeding around catheter.” Record review of the clinical record included a skilled nurse’s note, dated 07/30/25 (10 days after LVN J noted the sediment and foul odor to the urine on 07/21/25), signed by the Alternate Supervising Nurse, which indicated the patient was not feeling well. The note indicated the physician was notified and ordered Bactrim (an antibiotic) for a UTI. Record review of the clinical record included a plan of care update form, dated 07/31/25, which indicated the patient was weak and sleeping most of the time during the visit (on 07/30/25). The form indicated the patient’s urine was cloudy, a milky color, and indicated the patient had light bleeding in the area between her rectum and genitalia. The note indicated the physician was notified of the symptoms at the time of the skilled nurse visit (on 07/30/25) and ordered Bactrim. Record review of the clinical record did not include documentation to indicate the hospice Medical Director was notified of the sediment and foul odor to Patient #1’s urine observed by LVN J on 07/21/25 prior to 07/30/25. Record review of the clinical record for Patient #1 included a coordination note, dated 08/01/25, signed by the Alternate Supervising Nurse, which indicated, “[Name of the Supervising Nurse] … contacted me stating pt’s [Name of Patient #1’s Family Member #1] called her stating he does not want me to care for [Name of Patient #1] again and to send another nurse. His complaint was that LVN has contacted me serval times due to sediment in urinary catheter and I did not contact the MD for antibiotics until pt got worse and she became very tired.” Record review of the clinical record for Patient #1 included a coordination note, dated 08/01/25, signed by the Supervising Nurse, which indicated, “Recd call that [Name of Family Member #1] … is upset and wants to fire [Name of the Alternate Supervising Nurse]. Spoke to [Name of Family Member #1] who … explains that [LVN J] can [sic] to visit … and texted [Name of the Alternate Supervising Nurse] that … an antibiotic needed to be ordered as the pt’s urine is a bad color and odor. [Name of Family Member #1] states he knows [LVN J] told her and nothing was done.” During an interview conducted on 09/04/25 at 12:12 p.m., the Medical Director said he did not remember if he was informed of the foul odor to Patient #1’s urine on 07/21/25 (when LVN J made a hospice aide visit and first noted the foul odor to the patient’s urine) or 07/22/25 (when LVN J reported she notified the Alternate Supervising Nurse of the foul odor in the hospice’s group message system) and said he had so many patients and got so many calls he could not recall specifically but usually the nursing staff was good about calling him with changes and concerns. The Medical Director said he did not think it would have changed his approach to how he treated her as he does not usually treat hospice patients until the patient begins to experience symptoms that cause them discomfort especially if they have a urinary catheter in place as it is difficult to prevent infections. The Medical Director said once the patient began to complain of pain or discomfort or obvious signs of a UTI he would order antibiotics. The Medical Director said he did prescribe the patient Bactrim on 07/30/25 when the patient began to complain of not feeling well. During an interview conducted on 09/04/25 at 12:34 p.m., the Alternate Supervising Nurse said she made a visit to Patient #1 on 07/30/25 and found the patient to be “kind of sick.” The Alternate Supervising Nurse said the hospice was using LVN J as a hospice aide for Patient #1 at the time. The Alternate Supervising Nurse said Patient #1 was sleepy, more tired than other days, during the visit on 07/30/25. The Alternate Supervising Nurse said during the visit on 07/30/25 LVN J bathed the patient, and the Alternate Supervising Nurse assisted, and they noted some brownish discharge around the urinary catheter site. The Alternate Supervising Nurse said the next day or the day after Family Member #1 complained and said the Alternate Supervising Nurse had been told several times to order antibiotics and did not. The Alternate Supervising Nurse said the only time she was notified of an issue was when she was notified of the patient having cloudy urine and sediment (on 07/15/25) and she notified the Medical Director during the IDG meeting on 07/17/25 of those findings. The Alternate Supervising Nurse said after that time no one called to tell her there were further issues. When asked regarding LVN J’s documentation on the hospice aide visit note, dated 07/21/25, regarding the foul odor to the urine and the documentation that the RN was notified, the Alternate Supervising Nurse said LVN J probably sent a message on the hospice’s secure messaging system, and she (the Alternate Supervising Nurse) did not see it. The Alternate Supervising Nurse said she usually responded to messages within thirty minutes and if she did not respond within thirty minutes, she would have expected LVN J to call her to follow-up and LVN J did not call. When asked if the Medical Director was notified of the foul odor to the urine on 07/21/25 or 07/22/25, the Alternate Supervising Nurse said she personally never smelled a foul odor to the urine. The Alternate Supervising Nurse said that she was responsible for coordinating with the physician as she did not want to overwhelm the physician with multiple clinicians calling or multiple calls regarding the same issue once it had been addressed so she liked to filter the communication through herself. Record review of the clinical record for Patient #1 included an IDG meeting note and a plan of care update order, dated 07/17/25, which indicated the Medical Director was notified of the sediment in the urine and that the urine was cloudy. The documentation indicated the urine was light yellow and did not indicate a foul odor was observed or reported and did not indicate the Medical Director was notified of a foul odor to the urine. The record did not indicate the physician ordered antibiotics to treat a UTI on 07/17/25. During an interview conducted on 09/04/25 at 12:57 p.m., LVN J said she was previously working as the hospice aide for Patient #1 and completed visits to the patient twice a week to provide hospice aide services. LVN J said Patient #1 usually had sediment in her urine but when she was getting a UTI the amount of sediment would increase, and the urine would take on a “milky” appearance. LVN J said she sent the Alternate Supervising Nurse a message over the hospice’s secure group message system and asked her to double check and determine if the Alternate Supervising Nurse felt the patient needed antibiotics. LVN J said when she went with the Alternate Supervising Nurse to conduct a joint visit (on 07/30/25) she was “horrified.” LVN J said during the visit on 07/30/25 the patient was minimally responsive and yelling help me over and over. LVN J said the patient never had any cognitive issues (issues with thinking, judgement, or memory) prior to that date and said the patient was also pale, her lips and fingertips were blue, and she looked “horrible.” LVN J said she asked the Alternate Supervising Nurse if she had gotten an order for antibiotics for the patient and advised the Alternate Supervising Nurse that she had messaged her regarding the possible need for antibiotics previously. LVN J said she proceeded to bathe the patient and noted “a ton” of discharge and bright frank red blood, to the area between the patient’s rectum and genitalia which she had never seen before. LVN J said she notified the Alternate Supervising Nurse, and the Medical Director was notified of the findings on that date (07/30/25). LVN J said the patient had UTIs in the past, but she had never noted the patient to experience a change in condition and bleeding with a UTI prior to that date. LVN J said the infection may have gone systemic based on the change in condition. LVN J said after leaving the patient’s home (on 07/30/25) she noted the physician had ordered antibiotics for the patient and on her next visit the patient appeared “a million times better.” LVN J said she felt Family Member #1 had every right to make a complaint about the situation and said the patient was very sick. LVN J said 07/21/25 was the first time she noted the foul odor to the urine and said she notified the group message in the hospice’s secure group message system which went to all the nurses, the Alternate Supervising Nurse, the Supervising Nurse, and the Alternate Administrator. LVN J said on 07/22/25 she reported the patient’s urine had a foul odor and sediment. LVN J said no response was received but the message was marked as “seen.” LVN J said it did not indicate who had seen the message. LVN J said she did not think the Medical Director was a member of that group message. LVN J said on 08/01/25 she called the Supervising Nurse to report the complaint from Family Member #1. LVN J reviewed her messages from the hospice’s secure group message system and said she sent the group message on 07/22/25 regarding the patient’s urine being foul and milky. LVN J said the patient did not have an elevated temperature or burning upon urination at the time, but the appearance of the urine was not good. LVN J said she always received some response when she sent a message, but in that case, the only response was that the message was seen, and it did not indicate by whom. LVN J said there was no system in place for what to do if a nurse did not get a response to a report of a concern with a patient of which she was aware. LVN J said she did not call the physician herself for patients and said contacting the physician was completed by the RN and that was what she was trained to do by the hospice. When asked what steps she took after the initial message, LVN J said she made the mistake of assuming the Alternate Supervising Nurse would follow up. LVN J said as a nurse it was within her scope of practice to report to a physician but when she was acting in the role of a hospice aide, she tried to restrict her activities to those of a hospice aide and respect those boundaries. During an interview conducted on 09/04/25 at 1:28 p.m., the Supervising Nurse said she received a phone call from Patient #1’s Family Member #1 who was very angry and no longer wanted the Alternate Supervising Nurse to provide care to the patient. The Supervising Nurse said LVN J was working as a hospice aide for Patient #1 at the time the phone call was received and LVN J was trying not to step over the bounds of the role of hospice aide during those visits. The Supervising Nurse said LVN J advised the Alternate Supervising Nurse the patient might require antibiotics. The Supervising Nurse said when LVN J next made a visit the patient was worse. The Supervising Nurse said she was not sure if the foul odor to the urine was reported to the Medical Director on 07/21/25 (when LVN J conducted the visit with Patient #1 and first noted the foul odor to the urine) or 07/22/25 (when LVN J reported she sent a message to the hospice’s group message regarding the foul odor to the urine and need for antibiotics) and reviewed her documentation of the hospice’s secure group messaging system. The Supervising Nurse said the hospice had two group messages, one which included the hospice Medical Director, and one which did not include the hospice Medical Director. The Supervising Nurse said the group message which included the Medical Director did not include a message regarding the foul odor to Patient #1’s urine observed by LVN J on 07/21/25. The Supervising Nurse said the Medical Director was not included in the other hospice group message because it was too “busy” with too many messages. The Supervising Nurse said there was a message from LVN J on 07/22/25 in the group message which did not include the Medical Director which indicated LVN J thought it was time for another round of antibiotics (needed to have antibiotics ordered) for Patient #1 as the urine was foul and milky. The Supervising Nurse said the Alternate Supervising Nurse did not respond to that message. The Supervising Nurse said sometimes she would just call to respond to a message and not message back so that did not necessarily mean the Alternate Supervising Nurse did not respond. The Supervising Nurse said based on the information reported by LVN J in the message on 07/22/25 she (the Supervising Nurse) would have notified the physician. The Supervising Nurse said the Alternate Supervising Nurse was usually good about notifying the physician and she did not know if the Alternate Supervising Nurse had notified the physician of the foul, milky urine on 07/22/25. Record review of a group message, dated 07/22/25, from LVN J, indicated, “@ [Name of the Alternate Supervising Nurse] I saw [Name of Patient #1] late last night, I think she’s ready for another round of abx. Urine is foul and is milky with sediment …” There was no documentation to indicate a response was received from the Alternate Supervising Nurse or other administrative staff of the hospice, including the Administrator, Alternate Administrator, or Supervising Nurse. There was no documentation to indicate the Medical Director was notified of the findings. During an interview conducted on 09/04/25 at 4:32 p.m., with the Administrator, when asked what the hospice’s process was regarding what a clinician should do if they sent a message about a patient concern and did not receive a response, the Administrator said the hospice had a policy in place for the on-call for what to do if a patient or caregiver called after hours which would require escalating the matter up the ladder to the Supervising Nurse, Alternate Administrator, or himself, if there was no response received in the required amount of time. When asked if the hospice had a system in place for what to do if a clinician reported a concern and did not receive a response, the Administrator confirmed the hospice did not. During an interview conducted on 09/05/25 at 11:30 a.m., with Patient #1 and Patient #1’s Family Member #1, when asked if they had been satisfied with the hospice’s services, Family Member #1 said one of the hospice’s nurses, the Alternate Supervising Nurse, was not allowed to complete visits with the patient any longer. Family Member #1 said the family had requested antibiotics for a possible UTI and the Alternate Supervising Nurse had not followed-up on the request with the Medical Director and by the time the Medical Director was notified of the request the patient was very ill. Family Member #1 said the patient was pale as a sheet and Patient #1 said she just felt “ugh.” Family Member #1 said the patient was not engaging as usual and was just staring into space. Family Member #1 said the patient was “really bad” by the time the antibiotics were ordered. Family Member #1 said on 07/21/25 LVN J made a visit and told the family about a smell to the urine and reported the urine was cloudy and the patient might need antibiotics. Family Member #1 said he knew that LVN J had reported this to the Alternate Supervising Nurse. Family Member #1 said when LVN J came with the Alternate Supervising Nurse on 07/30/25 LVN J immediately noted something was wrong and told the Alternate Supervising Nurse that the patient had signs and symptoms of a UTI, and the symptoms were reported to the Medical Director that day (07/30/25) and the patient received the antibiotics the next day (07/31/25). Family Member #1 said the signs and symptoms of the UTI cleared up and the patient began feeling better right away after she began the antibiotics. During an interview conducted on 09/08/25 at 8:48 a.m., the Supervising Nurse said the other hospice administrative staff were also on the hospice’s secure group message and usually if the employee who was tagged in a message or was the individual who would usually address the issue did not respond someone else, usually herself or the Alternate Administrator, would send another message to the person tagged or responsible to let them know there was a message to make sure they had seen it and if no response was received after that they would send a text or call. When asked if this process was followed for Patient #1, the Supervising Nurse said she did not recall. The Supervising Nurse said in her opinion if no response was received from the person who would usually address the situation within twenty minutes, she would expect someone to follow up, but she believed that they had two hours to respond based on the policies at other agencies she had previously worked at. The Supervising Nurse said this was her opinion that it should be within twenty minutes and not a written policy. When asked if the hospice had a written policy on what to do if no response was received and within what time frame the follow-up should occur, the Supervising Nurse said she did not know. The Supervising Nurse said she did not believe there were any adverse outcomes to Patient #1 and said there was a potential outcome if the patient did have an infection and coordination of care between the disciplines did not effectively occur to communicate that information and said the patient could experience pain, discomfort and the infection could potentially become more serious or systemic. During an interview conducted on 09/08/25 at 10:30 a.m., with the Alternate Administrator, when asked the agency’s process for what to do if a clinician reported a concern with a patient and did not receive a response, the Alternate Administrator said the hospice’s responses systems were very fast and if no answer was received on the group messaging system the clinician should call the person who would be responsible for following up directly. The Alternate Administrator said he, the Supervising Nurse, and the Administrator were all included in the secure group message and with the whole team included in the message it was hard to miss messages. The Alternate Administrator said if no response were received within a few minutes of the first message the clinician should then contact the person who would usually respond directly either by text or phone. The Alternate Administrator said he did not know the specific reason the process was not followed for Patient #1. When asked if there could be any potential outcomes related to the failure, the Alternate Administrator said, “I believe the potential outcome would be to make sure learn from it and act promptly.” When asked if the failure could result in a failure to notify the physician of something or to address a patient need, the Alternate Administrator said, “Chances of missing are almost zero.” Record review of a hospice policy titled, “Interdisciplinary Group Roles and Responsibilities,” dated 09/01/24, indicated, “The Hospice will develop a system to communicate among all persons involved in the patient’s care, which includes an opportunity to ask and respond to questions (e.g. – reporting, updating and/or handing off communications) … Additionally, the IDG/IDT will … Provide for and ensure the ongoing sharing of information between all disciplines providing care and services …””