Heartland Hospice Milwaukee

“Upon observation, there was no evidence the hospice is in compliance with accepted professional standards and principles for all core services which includes nursing services, medical social services and counseling services. The agency failed to provide nursing services that meet the needs of the patient as identified in an email communication to agency leaders from the on call nurses that reported activities and communications with patient #2 and families/etc. for the weekend of 2/21/26. However, there was no documentation in the patient chart by clinicians involved regarding the communication with patient or caregiver, the symptoms patient was having, or any assessment of the patient’s condition. There is no documentation or evidence that the on-call nurse made a visit to address needs of patient or notified the hospice physician. The documentation revealed nurse stated that the Mobile X-ray would not be available until Monday. There was no further documentation of communication to the hospice physician for timely follow-up related to obtaining an X-ray. Pain meds were not readily available to the patient to offer pain relief.”

“Upon observation, there was no evidence the patient has the right to voice grievances/complaints regarding treatment or care that is (or fails to be) furnished and lack of respect of property by anyone who is furnishing care/service on behalf of the hospice failed to complete investigation Patient#2: There is a complaint form concerning the families complaint; however, it is noted to be incomplete. The form documents that the agency is meeting with the leadership at the assisted living to determine why the medications were not available to the patient; however, there is no information on the complaint form as to the findings and no plan of correction documented. The agency states that they did education on 4/3/26 regarding findings from this complaint. There was an education sign sheet and information on the education at the agency. It also does not appear that the complainant was contacted for follow up after the investigation.”

“Upon observation, there was no evidence that all alleged violations involving mistreatment, neglect, or verbal, mental, sexual and physical abuse, including injuries of unknown source, and misappropriation of patient property by anyone furnishing services on behalf of the hospice, are reported immediately to the Administrator or appropriate designee. Patient#1: During review of record it was documented by the nurse on admission that the spouse expressed concern about patient being neglected by the assisted living staff. Spouse has hired a private caregiver due to these concerns. There is no evidence of any follow up to this concern by agency.”

“Upon patient record review, 2 of 6 (Patient #2,#3) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient#2: The medication profile indicates patient was ordered 3 medications PRN for constipation: milk of magnesia, senna, and polyethylene glycol. There is no evidence of instruction on when to take each medication or if patient was suppose to take them together. Patient#3: The medication profile indicates there are two active orders for guaifenesin 100mg/5ml three times a day PRN for cough.”

“Upon patient record review, 2 of 6 (Patient #1,#2) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family’s needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient#1: The record indicates the patient had a wound when admitted to hospice services. The order for wound care is dated 2/27/26. There is no evidence of wound measurements the week of 2/27/26. Patient#2: The agency has an email the on call nurses sent to report activities and communications with patients/families/etc. for the weekend of 2/21/26. However, there was no documentation in the patient chart regarding the the communication with patient or caregiver, the symptoms patient was having, or any assessment of the patient condition. There is no documentation or evidence that the on call nurse made a visit.”

“Upon patient record review, 4 of 6 (Patient #3,#4,#5,#6) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient#3: The record notes nurse has documented in multiple visits that patient has to wear an eye patch daily. There is no evidence of problems, goals, or interventions related to patient using eye patch daily, vision issues, or safety regarding vision or eye. Patient#4: The record indicates patient was admitted to hospice services for a terminal diagnosis of Alzheimer’s. There is no evidence of neurological problems goals or interventions on the plan of care. Patient#5: The record indicates patient was admitted to hospice services for a terminal diagnosis of atherosclerosis. There is no evidence of cardiac problems, goals, or interventions on the plan of care. The record indicates patient has a secondary diagnosis of vascular dementia. The nurse documents on admit that patient has increased confusion, is in memory care, and has dementia with intermittent behaviors. There is no evidence of problems, goals, or interventions related to dementia or neurological needs. Patient#6: The record indicates patient was admitted to hospice services for a terminal diagnosis of Alzheimer’s. There is no evidence of neurological problems goals or interventions on the plan of care.”

“Upon patient record review, 1 of 6 (Patient #2) did not have evidence that the plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions which including interventions to manage pain and symptoms. Patient#2: The agency has an email the on call nurses sent to report activities and communications with patients/families/etc. for the weekend of 2/21/26. However, there was no documentation in the patient chart regarding the the communication with patient or caregiver, the symptoms patient was having, or any assessment of the patient condition. There is no documentation the patient’s plan of care was updated to include services necessary to manage pain and symptoms reported to hospice.”

“Upon patient record review, 2 of 6 (Patient #2,#3) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient#2: The medication profile indicates there are three medications ordered as PRN for constipation. However, there are no instruction on any of these medications indicating when to take each of these medications or if they are all taken together. Patient#3: The medication profile shows there are 2 active orders for guaifenesin 100mg/5ml take 10ml 3 times a day PRN for cough.”

“Upon patient record review, 4 of 6 (Patient #1,#2,#3,#5) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient#1: The nurse documents patient uses two wheeled walker; however, there is no evidence of a walker listed for DME order on plan of care. Patient#2: The nurse documents on 2/18/26 patient requires use of wheeled walker. There is no evidence of a walker on the DME order on the plan of care. Patient#3:The NP documents on F2F on 2/18/26 that patient requires use of wheelchair. There is no evidence of a wheelchair on the DME order on the plan of care. Patient#5: The nurse documents a hospital bed being ordered for patient. There is no evidence of hospital bed on the DME order on the plan of care.”

“Upon patient record review, 2 of 6 (Patient #1,#3) did not have evidence that a revised plan of care includes information from the patient’s updated comprehensive assessment and must note the patient’s progress towards outcome/goals from the plan of care. Patient#1: The current plan of care indicates wound care interventions dated 2/27/26. There is no evidence of the interventions being updated on plan of care with new orders from 3/14/26, 4/3/26, or 5/9/26. Patient#3: The nurse documents patient had falls on 3/13/26 and 4/27/26. Nurse also documents that patient has a call button that patient wears around his neck to call for help when transferring. Nurse documents educating patient regarding using the button. There is no evidence plan of care was updated to reflect these patients needs.”

“Upon observation, there was no evidence that the following services are made routinely available on a 24-hour basis 7 days a week. • Nursing services • Physician services • Drugs and biologicals • Other covered services must be available on a 24-hour basis when reasonable and necessary to meet the needs of the patient and family. Patient#2: The patient caregiver contacted an on call nurse on Sunday 2/22/26 more than once; however, there is no evidence that the nurse offered services including an over the phone or in person assessment in order to meet the needs of the patient.”

“Upon patient client record review, 2 of 6 (Patient #1,#2) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient#1: The MSW documents in all IDG’s 3/4/26 - 5/13/26 that the patient is not a full code; however, the nurse documents that patient is a full code. It is also noted in the chart on IDG status as full code. There was evidence of a DNR form in chart. Patient#2: The discharge summary states revocation; however, it also states discharged for out of service area.”

“Upon patient record review, 4 of 19 (Patient #1,2,5,10) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient 1: Plavix 75mg daily and Finasteride 5mg daily listed on the current MAR twice with 2 different order dates, 10/11/2024 and 11/19/2024. Corrected on site. Patient 2: Dulcolax 5mg and 10mg daily PRN for constipation, Miralax daily PRN for constipation. No evidence that instructions were given on which medication for constipation to take first. RN documentation on 12/02/2024 stated that the patient had a fall and started taking Motrin PRN for pain relief. RN documentation also shows that the patient takes cod liver oil PRN for constipation. During home visit the patient identified motrin tablets and cod liver pill in his medication planner. No evidence that an order for Motrin or Cod liver oil pill was placed on the active medication list. Corrected on site. Patient 5: Dulcolax 10mg PRN daily, Fleet enema rectally PRN daily, and Milk of Magnesium 400mg/5ml PRN daily. No evidence that instructions were given on which medication for constipation to take first. Corrected on site. Patient 10: Sienna 8.6 tab PRN daily and Milk of Mag PRN daily for constipation listed on the active medication list. No evidence that instructions were given on which medication for constipation to take first. Corrected on site.”

“Upon patient record review, 2 of 19 (Patient #3,5) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient’s family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient 3: No evidence the initial bereavement risk assessment was completed within 5 days of admit. Admitted on 06/17/2024, assessment completed on 06/24/2024. Patient 5: No evidence the initial bereavement risk assessment was completed within 5 days of admit. Admitted on 03/29/2024, assessment completed on 04/05/2024.”

“Upon patient record review, 4 of 19 (Patient #2,8,12,13) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. conditions. Patient 2: Medical record indicates active problem for constipation. Currently prescribed three different medications for constipation. No evidence of goals and interventions related to constipation listed on the current plan of care. Corrected on site. Patient 8: Medical record indicates active problem for depression and diabetes. Patient currently takes three medications for depression. Diabetes is listed as being related to the patients prognosis. No evidence of goals and interventions related to depression or diabetes listed on the current plan of care. Corrected on site. Patient 12: The record indicates that patient is currently prescribed Eliquis 5mg daily as a blood thinner. No evidence that goals and interventions related to risk for bleeding on current plan of care. Corrected on site. Patient 13: Medical record indicates active problem with depression. Patient currently takes two medications for depression. No evidence of goals and interventions related to depression listed on the current plan of care. Corrected on site.”

“Upon patient record review 4 of 19 (Patient #1,8,9,10) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient 1: Plan of care had aide frequency ordered as twice weekly. No evidence that the patient was seen 2 times during the week of November 4th. Aide plan of care has orders to change linens once a week. Aide documentation shows that the linen changes are being done at every visit. Patient 8: Aide plan of care has orders to weigh patient weekly. Aide documentation shows that the patient is not being weighed weekly, no weighs noted on the patients chart. Aide documenting that the weights are not due on all visit notes. Patient 9: Aide task on current plan of care ordered for shampoo and nail care to be performed at first visit of the week. Aide documentation shows that the task were being completed at every visit. Aide plan of care has orders to weigh patient on the first visit of the week. Aide documentation shows that the patient is not being weighed on the first visit weekly, only 2 weights noted on the chart. Those weights occurred on 10/17/2024 and 11/21/2024. Aide documenting that the weights are not due on all other visit notes. Patient 10: Order placed on 11/15/2024 to start the aide services at 2 visits a week, effective date 11/10/2024. No evidence that the patient was seen 2 times during the week of November 10th. Aide documentation shows a missed visit for one visit that stated that the visits were not suppose to start until the following week. No evidence that a new order was to reflect a new start date or that the delay was at the request of the patient/family.”

“Upon patient record review 1 of 19 (Patient #2) did not have evidence in the patient record that the hospice aides report: • Changes in the patient’s medical, nursing, rehabilitative, and social needs to a registered nurse, as the changes relate to the plan of care and quality assessment and improvement activities • Hospice aides must also complete appropriate records in compliance with the hospice’s policies and procedures Patient 2: Aide plan of care has orders to weigh patient at the first visit of the month. No evidence that the weights are being obtained since time of admission due to patient’s refusal. No evidence that the aide is notifying the RNCM of the patients refusal.”

“Upon patient record review, 2 of 19 (Patient #7,10) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. unauthorized access to the patient records. Patient 7: Aide missed visit note entered on 11/01/2024 and 11/29/2024 not completed, had no evidence of which physician/RN was notified that the visit was missed or why the visit was missed included in the note. RN entered a missed visit on 10/26 not completed, did not include why the visit was missed in the note. Patient 10: Aide missed visit note entered on 12/04/2024 not completed, had no evidence of which physician/RN was notified that the visit was missed included in the note.”

“Based on record review and interview, agency staff failed to investigate a complaint thoroughly and failed to ensure corrective actions were completed and documented according to agency policy and procedure in 1 of 10 records reviewed (patient #1). FINDINGS INCLUDE: Review of agency policy and procedure titled “;Complaint/Grievance Process Policy No. 2-006” dated 4/13/2022 reveals in part, “Procedure 1. The supervisor will investigate the grievance...and will make every effort to resolve the grievance to the patients satisfaction. Response to the complaint will occur within 10 days of receipt.....3. Complaints and any action taken will be documented in the QI Report section of the electronic medical record or on a complaint form...... 4. Corrective action will be specific and related to the complaint.” Review of patient #1’s medical record revealed that patient #1 was admitted to hospice on 02/22/2024 when treatment for Multiple Myeloma was stopped due to poor response. Patient #1 resided at home and received Home Hospice services. Complainant A is patient #1s wife and primary caregiver. Patient #1 expired on 3/26/2024 at 7:20 AM. Review of the agency’s “;Complaint Report” dated 4/22/24 revealed that Administrator G received a mailed-in complaint letter from complainant A dated 4/17/2024. The complaint letter revealed, “;...At 1 AM Tuesday, March 26, I called hospice and said that (patient #1) was laboring greatly and I needed help...(RN B) called back about 1:22 AM and said hed called the Dr (doctor) on call...At 1:45 AM he called and said the Dr. on call was not answering his page...At 2:18 AM he called and finally gave an order to increase lorazepam to 3...I gave 2 doses of the 3 lorazepam...and then had only 2 lorazepam left to give with the next dose and none for the final dose...He (Patient #1) did not die a comfortable death as we had been assured it would be...” On the facility “Complaint Report” under the section “Actions Taken,” Administrator G “spoke with complainant A (unknown date), listened to the concerns outlined in the attached letter. Expressed condolences and apologized for not bringing more comfort and support to her during the last days/hours. She (complainant A) appreciated the call, but stated, that I could not change the past. She was very unhappy with (RN B) and hoped her feedback would assist us to re-educate him......Reviewed chart.” Further review of the Complaint report indicated, “;Follow-up with RN B (no date) regarding concerns and the perception of his demeanor by the family of being uncaring.” During a phone interview with complainant A on 5/23/2024 at 12:05 PM, when asked if and how the agency had rectified the problem, complainant A responded, “they called initially and said it would be discussed with the team, no there was no resolution.” During a phone interview on 6/12/24 at 1:15 PM, Administrator G stated, “;given what she focused on for the call, his demeanor (referencing RN B),” that was the focus of the investigation. When asked about the lack of medication, Administrator G stated, “;I thought [Complainant A] had medication the whole time.” The facility investigation and Complaint Report failed to address all the allegations listed within the complaint letter dated 4/17/2024. The report also failed to contain a Corrective Action plan, specific and related to all of the complaint allegations per the agency’s policy and procedure and there was no evidence of follow-up with the complainant regarding the resolution of the issues related to medications and symptom management at end of life.”

“Based on record review and interview, agency staff failed to ensure that patients received effective pain and symptom management in a timely manner in 1 of 10 patient records reviewed (Patient #1). Findings Include: Review of the policy “Standard Operating Procedures-On Call Response,” date revised 05/02/2024, revealed in part,”1. All calls received are required to be responded to within 15 minutes..... 3.The on-call RN (Registered Nurse) will document each patient/family interaction in a Coordination note in the specific patient record. The coordination note must minimally contain, b. Nature of the concern, c. On call staff interventions including physician notifications/orders, f. Individual response to the interventions. 5. An on-call visit is required prior to contacting the Physician for any change to the plan of care.... On Call Visit: 1. Examples of issues that may require a PRN (as needed visit) include but not limited to: b. Unusual severe or uncontrolled pain or symptoms, g. Respiratory difficulty, k. Increased anxiety/restlessness/agitation.” Review of the document titled “Patient Information Handbook” revealed in part, “Hospice care and services are available to you and your caregiver 24 hours a day, 7 days a week. The team will be working with you during the week to ensure you have adequate supplies, equipment and medications between visits including weekends. If you have a change in condition, the staff will assess your situation, advise you of alternatives, make a visit when necessary and contact your physician.” Review of patient #1’s medical record revealed patient #1 was admitted to hospice on 02/22/2024 when treatment for Multiple Myeloma was stopped due to poor response. Patient #1 resided at home and received Home Hospice services. Complainant A is patient #1s wife and primary caregiver. Review of the triage “;Client Coordination Note Report” dated 3/26/2024 1:02 AM revealed “(complainant A) [End of Life/Active Dying] concern/status: caller stated, he (patient #1) has been getting 1ml of morphine for last few hours, breathing more labored. Advice/action provided per triage protocols tools: Reviewed narrative and medication profile confirming medications; Will reach out to RN on call for 1 onsite visit as evidenced by: terminal restlessness without relief. On-Call: Triage has identified a PRN visit need.” Review of patient #1’s medical record revealed a coordination note found in patient #1’s medical record completed by RN B, was dated 03/25/2024 at 9:08 PM (the medical record indicated the 3/25/2024 9:08 PM visit note was not closed until 3/26/2024 at 6:37 AM) “Hospice RN Subsequent Billable Visit.” Review of the visit note revealed in part, “pulse 129 weak, respirations 28 labored and shallow, oxygen saturation level at 82% on 5 liters of oxygen via nasal cannula, Restlessness. Patient #1 receiving morphine 1ml every hour, last dispensed by pharmacy [on 3/26/2024], quantity 20mls. Medications assessed and 10mls remain.” Narrative section of the visit note revealed, “Second visit of the day: respirations 28, pulse 129, oxygen level 79%, Reviewed and offered increased pain medication, caregiver refused. Inspected oxygen concentrator line was not connected, patient not getting enough oxygen, secured line and set concentrator at 3 liters per minute, oxygen level increased to 92%.” According to the Visit Note Report “;were medications reviewed?” RN B answered “;Yes” “;Were any issues identified?” RN B answered “;No”. RN B documented he reviewed pain medications at this visit and Morphine 10mls remained. Patient #1 was receiving Morphine 1ml and Lorazepam 1 tablet (0.50 mg) hourly. Review of the complaint letter sent by complainant A to the facility, dated 4/17/2024, reveals in part, “around 1:00 AM on 3/26/2024, I (complainant A) called hospice and said (patient #1) was laboring very greatly and I need help. RN B called back on 3/26/2024 at 1:22 AM and said he’d (RN B) would call the Doctor on call for permission to increase medications; At 1:45 AM he called and said the Doctor on call was not answering the page; At 2:18 AM he called and finally gave an order to increase lorazepam to 3 tablets (0.5 mg), and morphine to 2.0ml (milliliters) every hour. I gave Lorazepam 3 tablets and Morphine 2mls dose at 2:45 AM, 4:03 AM, I then only had Lorazepam 2 tablets and Morphine 2mls left to give at 5:10 AM.” During a telephone interview with Complainant A on 5/23/2024 at 12:15 PM, when asked, what was the expected outcome of the investigation, complainant A reported, the outcome she was hoping for was that “;no one else had to have the same experience” as she did with the hospice agency, specifically RN B. Complainant A went on to say, “;after he [RN B] left [3/25/24] I stayed up the entire night and I dont think we ever reached a level of comfort.” Complainant A reported medicating patient #1 with morphine and Lorazepam as recommended, but only had enough medication, for full doses left at 4:03 AM. Complainant A reported having only 2 tablets of lorazepam and morphine 2mls to give at 5:10 AM, and no more medications to give after the 5:10 AM dose, so “I increased the oxygen to 5 lpm (liters per minute), He (Patient #1) labored all night, and it was agonizing to watch.” Patient #1 expired at 7:20 AM. The next documentation found in patient #1’s medical record was dated 3/26/2024 at 9:23 AM, completed by RN B, visit type Hospice Death at Home. Review of the visit note revealed in part, “Medications-indicate if agency staff disposed of medications: NO, Indicate reasons medications were not destroyed by staff: Family wanted to dispose of medications. Indicate medications destroyed: Lorazepam 10 tablets of 0.5mgs and Morphine 10mls. Method of Disposal: coffee grounds, Disposal by caregiver and agency staff witness. Indicate time of death: 8:08 AM. Narrative note: TOD (time of death) 8:08 am, wife and son grieving “approximately” Dr. E notified, funeral home notified.” This note was signed by RN B only, caregiver refused to sign. RN B’s documentation in the 3/26/2024 visit note indicating “medications destroyed: Lorazepam 10 tablets of 0.5mgs and Morphine 10mls.” Contradicts complainant A’s report of having no more medications to give after the 5:10 AM dose. On 5/30/2024 at 9:35 AM a call was placed to complainant A to confirm “medications destroyed: Lorazepam 10 tablets of 0.5mgs and Morphine 10mls. Method of Disposal: coffee grounds”, revealed in the 3/26/2024 visit note. Complainant A stated “I only had morphine 1ml left to waste, and no Lorazepam was left. He (patient #1) never reached a level of comfort which was agonizing to watch.” On 5/30/2024 at 9:55 AM a call was placed to Walgreens pharmacy to confirm receipt of medication orders sent on 3/26/2024 at 2:32 AM. Spoke with Pharmacist F who confirmed the orders were received and processed at 2:45 AM for Morphine 100mg/5ml (30mls) and Lorazepam 0.5mg tablets (#96). Pharmacist F reported the prescriptions were never picked up and they were restocked to the shelf. Pharmacist F reported the only time those medications were picked up was on 3/15/2024 by complainant A. Review of agency documentation did not reveal a visit and/or communication with Complainant A from RN B after it was identified by the Triage on-call system. There was no documentation by RN B of Doctor Es orders refilling Morphine and Lorazepam and no documentation of RN B informing Complainant A of available medications at their chosen pharmacy.”

“Based on record review and interview, facility staff failed to keep accurate and complete records related to symptom management needs when 1 of 10 (patient #1) patients reviewed experienced a change of condition. Findings Include: Review of patient #1’s medical record revealed patient #1 was admitted to hospice on 02/22/2024 when treatment for Multiple Myeloma was stopped due to poor response. Patient #1 resided at home and received Home Hospice services. Patient #1 passed away on 3/26/2024 at 7:20 AM. Review of patient #1’s medical record revealed the last coordination note found in patient #1’s medical record completed by RN B, was dated 03/25/2024 at 9:08 PM by RN B. Review of the visit note revealed in part, “pulse 129 weak, respirations 28 labored and shallow, oxygen saturation level at 82% on 5 liters of oxygen via nasal cannula, Restlessness. Patient #1 receiving morphine1ml/hour, last dispensed by pharmacy on 3/26/2024, quantity 20mls. Medications assessed and 10mls remain.” Narrative section of the visit note revealed, “Second visit of the day: respirations 28, pulse 129, oxygen level 79%, Reviewed and offered increased pain medication, caregiver refused. Inspected oxygen concentrator line was not connected, patient not getting enough oxygen, secured line and set concentrator at 3 liters a minute, oxygen level increased to 92%.” Review of the triage “;Client Coordination Note Report” for patient #1, dated 3/26/2024 1:02 AM. (complainant A) – [End of Life/Active Dying] concern/status: caller stated, “he (patient #1) has been getting 1ml of morphine for last few hours, breathing more labored. Advice/action provided per triage protocols tools: Reviewed narrative and medication profile confirming medications; Will reach out to RN on call for 1 onsite visit as evidenced by: terminal restlessness without relief. On-Call: Triage has identified a PRN visit need.” Review of the complaint letter dated 4/17/2024 and sent to the facility reveals complainant A reported receiving a phone call on 3/26/2024 at 1:22 AM from RN B indicating he (RN B) would call the Doctor on call for permission to increase medications; At 1:45 AM he called and said the Doctor on call was not answering the page; At 2:18 AM he called and instructed Complainant A to increase lorazepam to 3 tablets (1.5 milligrams), and morphine to 2.0 ml (milliliters) every hour. No documentation of late entry The visit note dated 3/25/2024 at 9:08 PM indicates that morphine was “;last dispensed by the pharmacy on 3/26/2024.” This is a future date. There is no indication that this documentation was a late entry. No documentation of change in condition There is no documentation in patient #1s medical record after the triage note of 3/26/204 at 1:02 AM (last RN coordination note was dated 3/25/2024 at 9:08 PM). There is no documentation of a phone conversation between RN B and patient #1s spouse regarding the patient change in condition. There is no assessment of patient #1s condition documented. Patient #1 passed away on 3/26/2024 at 7:20 AM (approximately 6 hours and 20 minutes after the triage call). No documentation of new medication orders Cross reference L-690. Review of the complaint reveals complainant A reported, “;...At 2:18 AM he (RN B) called and finally gave an order to increase lorazepam to 3 tablets, and morphine to 2.0 ml every hour. On 5/29/2024 at 4:05 PM in a phone interview with Doctor E to confirm communication/orders on the night of 3/25/2024; When asked about his conversation with RN B, Doctor E responded, “;I was asked for refills to be approved, I have to assume they were out of medications.” Doctor E confirmed “when I received the request for refills, I signed the script electronically and sent it via I-prescribe notes...” There was no documentation of the new doses for the medication orders in the patient #1s medical record. There is no documentation of the call with MD E regarding the dose change for the medications or the immediate need for a refill of the medications. On 5/29/2024 at 3:15 PM Senior Director C when asked about an order needed to increase pain medications, response was “;you would expect an order in the system. I looked and could not find it either.” No documentation of coordination with family on medication refill On 5/30/2024 at 9:35 AM call placed to (name of pharmacy) to confirm receipt of medication orders sent on 3/26/2024 at 2:32 AM. Spoke with Pharmacist F who confirmed the orders were received and processed at 2:45 AM for Morphine 100mg/5ml 30mls and Lorazepam 0.5mg tablets #96. Pharmacist F reported the prescriptions were never picked up and they were restocked to the shelf. There was no documentation in the medical record by RN B related to discussions with the family about medications on hand and the need for a refill. There was no documentation of notification to the family that the medications were available for pick up at the pharmacy after the medication order was processed by the pharmacy on 3/26/2024 at 2:45 AM. Documentation of medications wasted (disposed of) contains contradictory information A review of patient #1’s medical record, dated 3/26/2024 at 9:23 AM, completed by RN B, revealed, “visit type Hospice Death at Home. Medications-indicate if agency staff disposed of medications: NO, Indicate reasons medications were not destroyed by staff: Family wanted to dispose of medications. Indicate medications destroyed: Lorazepam 10 tablets of 0.5mgs and Morphine 10mls. Method of Disposal: coffee grounds, Disposal by caregiver and agency staff witness...” This note was signed by RN B only, caregiver refused to sign. RN B’s documentation in the 3/26/2024 visit note indicated “medications destroyed: Lorazepam 10 tablets of 0.5mgs and Morphine 10mls.” This documentation is contradicted by complainant A’s report of having no more Lorazepam left to give and only 1 ml of Morphine after the 5:10 AM dose. It is also contradicted by the need to call a refill to the pharmacy on 3/26/2024 at 2:32 AM and the pharmacy indicating that the medication refill was processed on 3/26/2024 at 2:45 AM and never picked up. On 5/30/2024 at 9:35 AM a call was placed to complainant A to confirm disposal of medications. Complainant A stated “I only had morphine 1ml left to waste, and no Lorazepam was left.””

“Based on record review and interview, agency staff failed to immediately record and sign a verbal order given by the physician in 1 out of 10 records reviewed (Patient #1). This has the ability to affect all patients receiving care from this agency. Findings Include: Review of the policy “Standard Operating Procedures-On Call Response,” dated revised 05/02/2024, revealed in part,”1. All calls received are required to be responded to within 15 minutes..... 3. The on-call RN (Registered Nurse) will document each patient/family interaction in a Coordination note in the specific patient record. The coordination note must minimally contain b. Nature of the concern, c. On call staff interventions including physician notifications/orders, f. Individual response to the interventions.” Review of patient #1’s medical record revealed patient #1 was admitted to hospice on 02/22/2024 when treatment for Multiple Myeloma was stopped due to poor response. Patient #1 resided at home and received Home Hospice services. Complainant A is patient #1s wife and primary caregiver. Review of the triage “;Client Coordination Note Report” dated 3/26/2024 1:02 AM revealed complainant A-- [End of Life/Active Dying] concern/status: caller stated, “he (patient #1) has been getting 1ml of morphine for last few hours, breathing more labored. Advice/action provided per triage protocols tools: Reviewed narrative and medication profile confirming. Will reach out to RN on call for 1 onsite visit as evidenced by terminal restlessness without relief. On-Call: Triage has identified a PRN visit need.” Review of the submitted complaint letter, reveals in part, “around 1:00 AM on 3/26/2024, I (complainant A) called hospice and said [John] was laboring very greatly and I need help. RN B called back on 3/26/2024 at 1:22 AM and said he’d (RN B) would call the Doctor on call for permission to increase medications; At 1:45 AM he called and said the Doctor on call was not answering the page; At 2:18 AM he called and finally gave an order to increase lorazepam to 3 tablets (0.5 mg), and morphine to 2.0ml (milliliters) every hour. I gave Lorazepam 3 tablets and Morphine 2mls dose at 2:45 AM, 4:03 AM, I then only had Lorazepam 2 tablets and Morphine 2mls left to give at 5:10 AM.” There was no evidence of any additional calls to/from the agency after the 2:18 AM call from RN B. During an interview on 5/29/2024 at 3:15 PM with Senior Director C when asked, where the order “to increase Lorazepam to 3 tablets (0.5 mg), and morphine to 2.0ml (milliliters) every hour” obtained by RN B at 2:18 AM on 3/26/2024 would be found. Senior Director C response was “;you would expect an order in the system. I looked and could not find it either.” When asked which Doctor was on call the night of 3/25/2024, Senior Director C replied Doctor E. On 5/29/2024 at 4:05 PM a phone interview with Doctor E to confirm communication/orders on the night of 3/25/2024; When asked about his conversation with RN B, Doctor E responded, “;I was asked for refills to be approved, I have to assume they were out of medications.” Doctor E confirmed “when I received the request for refills, I signed the script electronically and sent it via I-prescribe notes to a 24-hour Walgreens and notify the requesting staff the medication has been reordered. I prefer communicating via Email as there is a paper trail of all requests.” The e-mails were not included in Patient #1s medical record. Senior Director C provided the email correspondence upon request. E-mail correspondence between RN B and Medical Doctor E on 3/26/2024 revealed: 2:03 AM Medical Doctor E relays to RN B “;Increase morphine to 1-2cc q1 h, Ativan 3mg q1h.” 2:27AM RN B to Medical Doctor E “;Please sign order.” 2:32 AM Medical Doctor E to RN B “;Done.” 2:42 AM RN B to Medical Doctor E “;Thank you. “; On 5/30/2024 at 9:55 AM a call was placed to Walgreens pharmacy to confirm receipt of medication orders sent on 3/26/2024 at 2:32 AM. Spoke with Pharmacist F who confirmed the orders were received and processed at 2:45 AM for Morphine 100mg/5ml (30mls) and Lorazepam 0.5mg tablets (#96). Pharmacist F reported the prescriptions were never picked up and they were restocked to the shelf. Pharmacist F reported the only time those medications were picked up was on 3/15/2024 by complainant A. Review of agency’s documentation failed to reveal RN B documented the verbal order received by Doctor E on 3/26/202; And failed to notify complainant A of Doctor E’s orders to refill Morphine and Lorazepam prescriptions at 2:32 AM on 3/26/2024 and that the medications were available at their chosen pharmacy.”