Freda H Gordon Hospice

“Based on review of the agency’s admission packet, clinical records, and an interview, it was determined the agency failed to provide effective pain management and symptom control related to the terminal illness. Specifically, the agency failed to provide Tylenol for two (2) of five (5) patients reviewed in the survey sample (Clinical Record for Patients #1 and #4). Findings: The agency’s admission packet was reviewed on July 23, 2024 at 12:47 PM. Specifically, the admission packet included a list titled “Comfort Kit Medications” which included (Tylenol) Acetaminophen for mild pain or fever. The clinical record for Patient #1 was reviewed for the period of July 18, 2023 through August 14, 2023. The Plan of Care for Patient #1 indicated the patient may have general comfort kit to assist with uncontrolled fevers. The clinical record revealed Patient #1 had a temperature of 101.1 degrees Fahrenheit on August 14, 2023 and (Tylenol) Acetaminophen was not provided upon admission on July 18, 2023 through the duration of services ending August 14, 2023. The clinical record for Patient #4 was reviewed for the period of October 19, 2023 through January 16, 2024. The clinical record for Patient #4 revealed (Tylenol) Acetaminophen was not provided upon admission on October 19, 2023 through the duration of services ending January 16, 2024. An interview with Staff Member #4 revealed (Tylenol) Acetaminophen was not provided for Patients #1 and #4, however Staff Member #4 was unable to indicate why the medication was not provided to either patient. The hospice staff failed to include (Tylenol) Acetaminophen in the “Comfort Kit Medications” for Patients #1 and #4.”

“Based on clinical records, an interview, and the agency’s clinical record policy and procedure review, it was determined the agency failed to fully document the clinical records as outlined per procedure. Specifically, the agency’s Skilled Nurse did not follow the agency’s procedure for documenting the medication specifics during a death visit for two (2) of five (5) patients reviewed in the survey sample (Clinical record for Patients #s 1 and 4). Findings: The clinical record for Patient #1 was reviewed for the period of July 18, 2024 to August 14, 2024. The clinical record indicated a death visit on August 14, 2024. The death visit note of August 14, 2024, by Staff Member #7, revealed the patient’s comfort kit was present, intact, and education was provided regarding safe medication disposal per organizational protocol. The clinical record for Patient #4 was reviewed for the period of October 19, 2023 to November 30, 2023. The clinical record indicated a death visit on November 30, 2023. The death visit note of November 30, 2023, by Staff Member #7, revealed the patient’s comfort kit was present, intact, and education was provided regarding safe medication disposal per organizational protocol. Review of Agency Policy: “Medication Disposal” dated November 01, 2021; Policy Number 12.007 read in part as follows: The hospice nurse will document in the patient’s medical record the medication name, dosage, route, quantity, method of disposal, date and time of disposal, who disposed of the controlled substance(s), and who witnessed the disposal. On July 24, 2024 at 10 AM the Medical Facilities Inspector requested an interview with Staff Member #7. Staff Member #4 revealed Staff Member #7 was no longer employed with the agency. Personnel File Review: The personnel file for Staff Member #7 was reviewed on July 24, 2024. Staff Member #7s resignation letter was signed on February 02, 2023. Staff Interview: On July 24, 2024 at 2 PM, an interview with Staff Member #4 revealed it is the agency’s policy and procedure to document all the specifics of what medications are destroyed along with the dosages, quantity left, how it was disposed and who witnessed it when a skilled nurse is in the home with a caregiver. In addition, Staff Member #4 revealed that Staff Member #7 did not fill out the death visits per agency procedure. The hospice staff failed to document the medication specifics at the death visit on August 14, 2024, and November 30, 2023 for Patients #1 and #4.”