Survey Report for 101528

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	101528	A. BUILDING __________ B. WING ______________	12/22/2020
NAME OF PROVIDER OR SUPPLIER	STREET ADDRESS, CITY, STATE, ZIP
AVOW HOSPICE INC	1095 WHIPPOORWILL LANE, NAPLES, FL, 34105
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)
L0591
L0591	21322 Based on record review and interview the hospice failed to provide nursing care and services to meet the needs for administration of intravenous solution for 1 (Patient #2) of 1 patient receiving total parenteral nutrition. The hospice failed to collaborate with the physician to obtain the necessary treatment to prevent the development and worsening of a pressure ulcer for 1 (Patient #1) of 3 patients sampled for wound care. The hospice also failed to have documentation of effective coordination to ensure timely assessment and to ensure appropriate treatment of a pressure ulcer for 1 (Patient #3) of 3 patients reviewed for wound care. The findings included: The hospice policy #291(revised 8/5/19) documented to prevent skin impairments/pressure injuries and provide early treatment, licensed nursing personnel ...1) Perform a skin assessment, include inspection of boney prominences ...2) Identify patients at risk of developing pressure injuries and risk factors/symptoms of skin care problems ...3) Provide care according to a physician order ...4) Update the plan of care with patient specific interventions and measurable goals. Clinical record review showed Patient #1 was admitted to hospice services to the hospice house on 10/30/20 with a diagnosis of cerebral atherosclerosis (thickening/hardening of the walls of arteries in the brain) and vascular dementia with behavioral disturbance. Patient #1 was transferred to an Assisted Living Facility on 11/4/20. A nursing narrative note dated 11/5/20 showed Registered Nurse (RN) Staff A documented initial visit made to develop a plan of care for Patient #1. Skin is pale, dry, and intact with scattered bruising. On 11/11/20 at 8:45 a.m., Licensed Practical Nurse (LPN) Staff C documented Patient #1's physical assessment completed, skin is dry and intact with Mepilex bandage seen to coccyx area. On 11/12/20 at 3:00 p.m., LPN Staff D documented Patient #1's skin was pale, "there is a red, blistered area on the outside of the right foot near the baby toe." Elevated the foot off the bed on a pillow to relieve pressure on that area. In a Visit Note report on 11/13/20 at 9:00 a.m., LPN Staff F documented Patient #1's skin was intact. On 11/13/20 at 6:20 p.m., LPN Staff F documented barrier cream applied to dark purple skin to the left coccyx. A Visit Note Report on 11/18/20 showed RN Staff A documented at 1:00 p.m., Patient #1's skin is pale, dusky with multiple areas of redness over bony prominences and on both ears. Blisters developing on her heels. Pressure Ulcer to coccyx. Barrier cream being used and sacral dressing intact. A Client Coordination Note Report dated 11/13/20 at 5:00 p.m., documented RN Staff E called Patient #1's family regarding complaints of care. "RN would make sure a hospital bed was ordered for patient." On 12/22/20 at 9:00 a.m., during an interview the Registered Nurse Chief Clinical Officer (CCO), said the process for wound care is the nurse would care plan the wound and obtain a Physician order for wound care. The hospice nurse would document and collaborate with the facility nurse if the patient was in a facility. The CCO said, hospice would supply different products like barrier cream, briefs and wound care supplies and special mattress if ordered. The CCO said the care plan would be very specific and include the location of the wound, treatment, and who would be providing the wound care. The RN said the hospice would provide a hospital bed for the patient. The RN said once admitted to services we provide a hospital bed, even if the patient is in an assisted living facility. The CCO confirmed there was no documentation Resident #1 received a hospital bed or special mattress to prevent skin breakdown. On 12/22/20 at 10:22 a.m., in an interview The CCO confirmed there was no physicians order for wound care and no documentation of a care plan for Patient #1 to address the resident's skin care needs. On 12/22/20 at 11:30 a.m., during a phone interview RN Staff A said Patient #1, was at end of life and she was visiting the patient almost daily. RN Staff A said, the patient was turned every 2 hours and as need. The RN Staff A confirmed Patient #1 did not have a hospital bed or special mattress to prevent skin breakdown. RN Staff A said she obtained a physician order for the dressings but did not document the wound care orders. Review of the clinical record revealed Patient #3 resided in an ALF and was admitted to hospice services on 12/11/20 with a diagnosis of vascular dementia. On 12/13/20 LPN Staff G documented "wound noted to lower mid-back above coccyx, ~3.00 cm X5.00 cm [centimeter] in size. No depth noted in wound. No redness on skin surrounding wound. White/creamy slough noted on wound. Advanced Registered Nurse Practitioner called, and orders received for wound care. This nurse performed wound care on wound and applied dressing. Facility nurse was spoke to regarding new orders and informed that wound was changed by this nurse." The clinical record lacked documentation of the physician's orders on 12/13/20. On 12/18/20 at 10:47 a.m., RN Staff H documented an order with a verbal date of 12/13/20 that read "Wound care to lower mid-back above coccyx: Clean with normal saline, apply medihoney and place dressing once daily and as needed if dressing is soiled or if there is any drainage." The clinical record lacked documentation of coordination with the ALF to determine who would perform the daily wound care. The next hospice nursing visit was completed on 12/18/20. The RN documented "Order to clean with normal saline , apply medihoney and place dressing once daily and as needed if dressing is soiled or if there is any drainage. Wound not visualized. Stage 3 wound not visualized above coccyx. Facility nurse completed care. Wound with slough. No depth measured". The clinical record lacked documentation of a Registered Nurse assessment to ensure Patient #3 received the appropriate treatment for prevention of worsening of the wound. On 12/22/20 at 2:50 p.m., during an interview The CCO said the nurse can collaborate with the facility. The hospice RN is referring to the assessment done by the facility nurse. She said if hospice was doing the wound care there would be wound notes, but they only make weekly visits. She said ideally the nurse should schedule her visits to observe the wound with the facility nurse at least weekly. She said the order should have been clarified to specify who was doing the daily wound care since they are only visiting the patient once a week. Review of the clinical record revealed Patient #2 was admitted to hospice services at home on 11/5/20 with a diagnosis of Pancreatic Cancer. The medications included Clinimix 4.25% in 10% dextrose sulfite solution (total parenteral nutrition) to be administered intravenously at 30 milliliters (ml) per hour. The instruction for use of the 2 chambers Clinimix solution specified to "Place the bag flat on a table with the label facing you. The top (hanger end) should be nearest you with the ports pointing away from you. Grasp the bag firmly on each side of the hanger end. Using some pressure, firmly roll the bag to open the seal between the chambers. If only half of the seal separates, flip the bag over and roll it again. The entire seal from top to bottom must be separated. Do not pull or rip the seal apart; roll to open. Mix solutions thoroughly; discard if there are any leaks." Review of the skilled nurse's communication note dated 11/7/20 revealed the family had called with concern related to the infusion of the Clinimix solution. RN Staff I noted one side of the solution bag was empty and one side full. She explained the solution was not mixed and demonstrated how to break center seal to mix solution on current bag. She took a new solution bag from the refrigerator and had the patient's son break the seal. She educated the family on how to set up the new bag with a return demonstration. On 12/21/20 at 3:24 p.m., during a telephone interview RN Staff I said on 11/7/20 when she visited the patient with RN Staff I the seal separating the 2 chambers was not broken. She did not know who hung the previous bag but one of the chambers was empty and the other one was full. She said she wasn't sure which side had infused or the content of each chamber. She said they notified the physician who increased the rate of the solution to 60 ml per hour. On 12/21/20 at 4:00 p.m., during an interview RN Staff J said on 11/7/20 she informed the supervisor Patient #2 only received the saline solution but not the additives. She said she had to read the instructions to hang the new bag of fluids. She said she could easily see where the nurse who hung the previous bag got confused. She said she was comfortable accessing a port (port implanted to administer intravenous medications) but she would need a refresher on the TPN (total parenteral nutrition). On 12/22/20 at 9:30 a.m., during an interview RN Staff K said she visited Patient #2 in November but could not remember the exact date. She was told it was either the 4th or the 5th. She said on 11/5/20 she watched a video on the tubing used but not on the Clinimix. This was the only time she had administered Clinimix. She was called to assist the nurse who was going to hang the solution, but she did not remember who the nurse was or the exact date. She verified she failed to document her visit and the care she provided to the patient. On 11/10/20 hospice documented a medication error report that read :" TPN infusion bag did not have seal in center of IV [intravenous] bag broken; contents were not mixed per instructions. Unknown which side of the IV bag was infused." On 12/22/20 at 9:10 a.m., during an interview the CCO said hospice did not investigate the incident, did not implement corrective actions or provide education specific to the Clinimix to the nurses. She said they just determined education was needed from that incident based on the assumption the bag did not get reconstituted. She said last night they assigned the training on the use of Clinimix to all the nurses.