Atlas Hospice

“Based on interviews and record review, it was determined that the hospice agency did not immediately investigate all alleged violations of patients rights and immediately take action to prevent further potential violations while the alleged violation was being verified. Specifically, the agency did not do its own investigation into 2 out of 2 incidents and did not immediately take action to prevent further violations. (Patient identifiers: 20 and 21) Findings include: 1. It was documented on an incident report dated 3/4/2024 that patient 21s bottle of morphine went missing. The follow-up regarding the incident report stated the assisted living facility notified the police and opened an investigation, but there was not enough evidence, so the incident was closed. No further documented evidence of an investigation/follow-up was provided. 2. An incident report dated 7/10/2024 regarding patient 20 was reviewed and revealed the following: The incident report was filed by an aide (staff 1) of the hospice agency who observed the incident. Staff 1 stated she was having difficulty convincing patient 20 to shower, so she requested the assistance of two aides from the assisted living where patient 20 resides. Staff 1 documented the two aides from the assisted living “;forced patient out of her bed by grabbing her by her arms and hands forcing her against her will. Patient was screaming/yelling to stop youre hurting me.” Staff 1 documented that she noticed new bruises from where the aides grabbed patient 20. Staff 1 submitted pictures with the incident report that showed bruising around patient 20s arm and wrist. The follow-up section of the incident report documented that the hospice agency met with the administrator of the assisted living facility to discuss the incident. The administrator stated they would check the camera footage and talk to the patient about the incident. In a follow-up communication note dated 7/12/2024, the assisted living administrator assured the hospice case manager that the cameras were reviewed, and no foul play was witnessed. The note further stated that education was provided to the assisted living staff and that patient 20 was safe at that time. On 12/19/2024 at 3:34 PM, an interview was conducted with the hospice director of nursing (staff 2). Staff 2 stated they do not do their own investigation if the incident does not involve their own staff. Staff 2 stated the incident investigation was left up to the assisted living facility. Staff 2 was asked if they do not investigate an incident on their own, how would they determine if a patient was safe or not. Staff 2 stated that the patient and family both felt that patient 20 was safe and that they did not want to report the incident. Staff 2 stated she was not sure if the aides from the incident continued to provide care to patient 20 after the incident but stated those aides no longer work at the assisted living facility. On 12/23/2024 at 1:53 PM, an interview was conducted with patient 20s emergency contact (patient 20s sister). The emergency contact stated she was never told of any incident involving staff being forceful with patient 20, causing bruising, or regarding the patient being forced to shower. The emergency contact was asked if patient 20 was cognitive enough to express whether she felt safe or not. Patient 20s sister replied, “;no, she does not know what is going on.” Patient 20 resided in the memory care unit of the assisted living facility. There was no documented evidence that the hospice agency took immediate action to prevent further incidents. Patient 20 was discharged from the hospice agency on 7/16/2024.”

“Based on interview and record review, it was determined the hospice agency did not ensure that violations were reported to State and local bodies having jurisdiction (including the state survey and certification agency) within 5 working days of becoming aware of the violation. Specifically, the agency did not report 2 out of 2 incidents reviewed. Findings include: Two incidents were selected from the incident log to review. One involved an observation of mistreatment/abuse, the other involved a patients bottle of morphine going missing. On 12/19/2024 at 3:34 PM, an interview was conducted with the agencys Director of Nursing (staff 2). Staff 2 stated they did not report either incident to the Department of Health, police, or Adult Protective Services. When asked why the incidents were not reported, she stated they did not want to hurt their relationship with assisted living and only reported confirmed cases. (Note: The abuse allegation incident was directly observed by hospice staff.) During the survey, on 12/19/2024, the hospice agency notified the Department of Health of both incidents, as well as notified Adult Protective Services and the police of the abuse allegation.”