Survey Report for 051779

DEPARTMENT OF HEALTH AND HUMAN SERVICES		FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES		OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION	(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER	(X2) MULTIPLE CONSTRUCTION	(X3) DATE SURVEY COMPLETED
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION	051779	A. BUILDING __________ B. WING ______________	10/18/2019
NAME OF PROVIDER OR SUPPLIER	STREET ADDRESS, CITY, STATE, ZIP
VITAS HEALTHCARE CORPORATION OF CALIFORNIA	2710 GATEWAY OAKS DRIVE, SUITE 100 SOUTH, SACRAMENTO, CA, 95833
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See reverse for further instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation
LABORATORY DIRECTOR’S OR PROVIDER/SUPPLIER REPRESENTATIVE’S SIGNATURE		TITLE	(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
(X4) ID PREFIX TAG	SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY SHOULD BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)
L0653
L0653	38834 Based on interview and record review, the agency failed to provide services during non-business hours for one of three patients (Patient 1) when Patient 1's wound on his right hand finger was not assessed and dressing was not changed in a timely manner. This failure resulted in the delay of service for Patient 1 and resulted a change in Patient 1's condition which resulted in pain, suffering, and amputation of his right hand finger. Findings: Patient 1 had a start of care date of 7/12/19 for hospice care for dementia (impaired memory) and diabetes (high blood sugar). Patient 1 resided in a memory care facility with 24 hour caregivers. Review of the clinical record for Patient 1 included an Interdisciplinary Plan of Care (POC), dated 7/24/19 which was provided by agency to the memory care facility staff. The POC contained an emergency phone number and directed the facility staff to call the agency if there were any changes in Patient 1's condition. Review of the Updated Comprehensive Assessment dated 8/5/19, indicated Patient 1 had an open area to his right middle finger. According to the physician order dated 8/5/19, the physician instructed agency to perform right finger wound treatment on each nurse's visit, and to change the dressing more often, if dressing was loosened or soiled. The POC target goal for Patient 1 was to prevent and/or minimize complications from the wound. The 8/5/19 care plan indicated nurses were to instruct Patient 1's caregivers (memory facility staff) to call the agency if the wound's condition worsened. Review of Patient 1's Telecare Call log, the agency's non-business hours' program for triaging (a process of assessment of patient needs), dated 8/1 included the documentation of the multiple telephone calls from the facility's staff to the agency with reports of a change of condition in Patient 1's right finger wound and requested the nurse visit. 1. 8/11/19 at 10:09 a.m.: The initial call from Patient 1's caregiver, "Pt's [patient's] middle finger is extremely swollen, dressing needs to be changed ...Advised to elevate the hand ...keep it dry and clean ...Agreed except states she is not allowed to remove the soiled dressing and apply a new one ...Will send a nurse to evaluate." The nurse who took the call classified the visit as priority 2 and documented Patient 1's issues, "swollen finger/dressing change/pain ...P2 [priority 2]. 2. 8/11/19 at 1:14 p.m.: "Received call from [facility] ...She called earlier to report about pt's middle finger ...now she's calling to inquire about ETA [Estimated Time of Arrival] and to also report that the back of pt's hand is swelling as well. Offered apology regarding delay. Informed ...pt is scheduled for visit today ...Per [facility], the pt's finger is throbbing and it hurts ...Advised to monitor pt. Advised to keep skin clean and dry." 3. 8/11/19 at 1:59 p.m.: "MOC [Manager on Call] called and discussed visit traffic and current staffing status." 4. 8/11/19 at 5:45 p.m.: "Called to ...apologize for delay in nurse visit ...Pt [patient] c/o [complains of] discomfort and tightness in finger ...Staff unable to remove drsg [dressing] ...Needs drsg change. Advised will send next available nurse." 5. 8/12/19 at 00:05 a.m.: "Called [facility] to ...apologize for delay in nurse visit. Pt has odor from dressing, unable to remove dressing. Hand and finger swollen and getting worse since last night...Med tech stated facility will send pt to ER [emergency room] if nurse does note come by tomorrow ...will send nurse when available." Review of Patient 1's clinical record indicated the licensed nurse (LN 1) made a visit on 8/12/19 at 3:55 a.m., 18 hours after the facility's initial call to the agency about Patient 1's change of his wound condition. Review of LN 1's visit note indicated Patient 1's right finger "dressing was brown and stained...the tip of his middle finger was open, finger nail partially obliterated [destroyed] ...exposed bone." The LN 1 documented the wound was red, inflamed, and had a yellow-tan drainage with foul odor. LN 1 documented he informed Patient 1's physician about wound condition and obtained an order for the treatment and dressing changes. Further review of LN 1's note indicated the nurse called the agency and asked for another nurse to come and re-assess the wound and to perform a treatment to Patient 1's wound. The LN 1 informed the agency staff he was not able to provide the treatment per physician's order because he did not have a specific solution for wound treatment and about the antibiotic (a medication to treat infection) treatment ordered by the physician. Review of the clinical records indicated there was no nursing visit to re-assess the wound on Patient 1's finger and apply the specifically ordered wound treatment for another 10 hours since the initial LN 1's visit. There was no documented evidence the agency started Patient 1's antibiotic to treat the wound and prevent the worsening of the condition of his wound. Review of the LN 2's note, dated 8/12/19 at 6:20 p.m., indicated LN 2 received a call from the facility staff informing Patient 1 had been sent to the emergency room due to the wound infection. In an interview with LN 1 on 9/24/19 at 9:50 a.m., LN 1 stated when he unwrapped the dressing on Patient 1's hand during his visit on 8/12/19 at 4 a.m., the wound looked "red, inflamed, exposed bone ...draining foul smell purulent [pussy] drainage." LN 1 stated the wound looked bad and he expected the physician the send patient to emergency room "with that type of wound." LN 1 stated he informed the agency staff to send someone to start the antibiotic treatment and to bring a solution for wound dressing change. In an interview with the facility's staff 1 (FS 1) on 9/24/19, FS 1 stated she called and informed the agency's nurse that Patient 1's dressing was "soiled and had really bad smell ...I kept asking them to come out, he [Patient 1] was complaining of tightness, pain, said it was itchy and bothered him ...They [agency nurses] were asking me if he [Patient 1] was going to be okay if they send a nurse tomorrow." FS 1 stated, "I couldn't make that decision, I'm not a nurse, I don't have an expertise in that ...I had to agree to what [agency's name] nurse was telling me." The FS 1 stated she was frustrated that the agency's nurses were teaching the facility staff to call the agency if they encountered any issues with patient's wounds, but did not come when she and other facility staff called them several times. In an interview with the FS 2 on 9/25/19 at 11:20 a.m., the FS 2 stated she called the agency to report that Patient 1's entire hand was swollen and the dressing was wet and brown. The FS 2 stated the nurses instructed her to keep patient's dressing dry. FS 2 further added, "How was I supposed to keep it dry if it was already wet ...Told them repeatedly ...we are not allowed to change the dressing ...I don't think they heard me." The FS 2 stated the agency staff told her the "nurse will come to do dressing change today. It didn't happen." Review of Patient 1's hospital records dated 8/12/19 at 3:58 p.m., indicated Patient 1 arrived to the emergency room with elevated temperature, his right hand was swollen, and right middle finger was noted with "redness, warmth ...some necrotic tissue [death of tissue, usually from infection], a foul smell ...Infection has spread to include the finger and hand." Further review of Patient 1's hospital discharge summary dated 8/16/19, indicated his finger wound infection had spread to the bone and he had to undergo the amputation of his entire finger. Review of the Patient 1's record included a Medical Social Worker's (MSW) note, dated 8/13/19. The MSW documented, "Spoke with ...daughter about possible revocation [canceling] ...Daughter told ...that they blame [agency] for pt's [patient's] amputation ...Daughter wants to change hospice ASAP." Review of the agency's policy titled, "[name of the agency] Management Standard, last updated on 3/9/19, indicated, "Nursing services, physician services, drugs and biologicals ...must be made routinely available on a 24-hour basis 7 days a week...when necessary to meet the needs of the patient." The policy indicated Telecare was responsible for triaging patient needs and dispatching on-call staff for 'Non-Business hours,' including Saturday and Sunday. The policy further indicated, "The Team Manager needs to triage and prioritize patient calls throughout the day to ensure patient needs are met in a timely manner and not delayed for non-business hours ...Visit priority on hospice care is primarily dictated by the caller ...Section 3. Visit Priority," indicated a priority one was "dispatch the visit within one hour of completing the phone assessment" and for priority two "dispatch a visit today ...A 911 threat that ...continues to persist after the RN phone assessment, a visit is sent and is considered a priority one." In a interview on 8/30/19 at 1:12 p.m., the Patient Care Administrator (PCA) explained the priority 1 level were the reports with the urgent patient needs, which included pain, shortness of breath, and change of patient's condition. The PCA stated the facility staff and agency's nurse who took the call agreed that the call regarding Patient 1's finger swelling was categorized as priority level 2 and that was why the agency did not dispatch the nurse right away. In a concurrent record review and interview with the PCA on 9/19/19 at 2:40 p.m., she emphasized that the purpose of the hospice care was to keep patients comfortable, and pain free if possible. Upon review of the Telecare call log documentation, dated 8/11/19, the PCA acknowledged the facility staff's reported of Patient 1's increased hand and finger swelling, his complaints about throbbing, tightness, discomfort, and pain. The PCA stated that the agency standard was to dispatch the nurse to visit the patient within one hour if the caller was threatening to call 911. The PCA was not able to provide any explanation why the nurse was not sent to assess Patient 1's change of condition and wound for 18 hours, even after the facility repeatedly called the agency and threatened to send Patient 1 to the emergency room. The PCA acknowledged that Patient 1 was no longer receiving hospice services with the agency.