Survey Report for 101545

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	101545	A. BUILDING __________ B. WING ______________	11/27/2019
NAME OF PROVIDER OR SUPPLIER	STREET ADDRESS, CITY, STATE, ZIP
VITAS HEALTHCARE CORPORATION OF FLORIDA	4450 W EAU GALLIE BLVD STE 250, MELBOURNE, FL, 32934
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)
L0500
L0500	36489 Based on interview and record review, the hospice failed to ensure uncontrolled symptoms of respiratory distress at the end of life were treated in a prompt and effective manner for 1 of 5 sampled residents, (#1). This failure led to prolonged suffering and contributed to an uncomfortable death for patient #1 and caused psychosocial harm for patient #1's caregiver. On 10/21/19 at approximately 10:30 PM, patient #1's daughter notified the hospice her mother was experiencing respiratory distress. The after-hours nurse who responded to the home failed to identify patient #1 was actively dying, and did not obtain appropriate orders for symptom management, educate the caregiver on the dying process or attempt non-pharmacological interventions to promote comfort. The nurse left patient #1 with no medication orders or treatments in place, in her daughter's care. Patient #1 continued with respiratory distress and struggled to breathe until she died on 10/22/19 at approximately 3:30 AM. The hospice failed to provide necessary care and services to ensure comfort at the the end of life for an actively dying patient, and failed to to provide education and support for grieving family, for 1 of 5 sampled patients, (#1). These failures led to prolonged respiratory distress that contributed to an uncomfortable death for patient #1 and caused psychosocial harm for patient #1's daughter. On 10/21/19 at approximately 10:30 PM, patient #1's daughter notified the hospice her mother was experiencing respiratory distress. The after-hours nurse who responded to the home failed to identify patient #1 was actively dying, and did not obtain appropriate orders for symptom management, educate the caregiver on the dying process or attempt non-pharmacological interventions to promote comfort. The nurse left patient #1 with no medication orders or treatments in place, in her daughter's care. Patient #1 continued with respiratory distress and struggled to breathe until she died on 10/22/19 at approximately 3:30 AM. The hospice's failure to provide prompt and effective symptom management and to prevent neglect resulted in Immediate Jeopardy starting on 10/21/2019. Cross reference L512, L517
L0512
L0512	36489 Based on interview and record review, the hospice failed to ensure uncontrolled symptoms of respiratory distress at the end of life were treated in a prompt and effective manner, for 1 of 5 sampled residents, (#1). This failure led to prolonged suffering and contributed to an uncomfortable death for patient #1 and caused psychosocial harm for patient #1's caregiver. On 10/21/19 at approximately 10:30 PM, patient #1's daughter notified the hospice that her mother was experiencing respiratory distress. The after-hours nurse who responded to the home failed to identify patient #1 was actively dying, and did not obtain appropriate orders for symptom management, educate the caregiver on the dying process or attempt non-pharmacological interventions to promote comfort. The nurse left patient #1 with no medication orders or treatments in place, in her daughter's care. Patient #1 continued with respiratory distress and struggled to breathe until she died on 10/22/19 at approximately 3:30 AM. The hospice's failure to provide prompt and effective symptom management resulted in Immediate Jeopardy starting on 10/21/19. Cross Reference to L517. Findings: Patient #1 was admitted to hospice services on 9/20/19. She was 92 years old with a terminal diagnosis of Alzheimer's disease and other diagnoses including chronic kidney disease, heart disease, anxiety and pain. Patient #1 was transferred from a nursing facility to her daughter's home on 9/25/19 and continued to receive hospice services. A "Pre-Admit Evaluation" dated 9/20/19 revealed patient #1's goals of care were comfort and symptom management. The evaluation indicated she was non-verbal, dependent on her caregivers for activities of daily living care. During a telephone interview with patient #1's daughter on 11/27/19 at 8:48 AM, she explained she brought her mother home to be with family and to provide good care for her. The daughter acknowledged she was aware her mother's health was declining so she chose hospice to ensure her mother was as comfortable as possible in her last days. She referred to the hospice admission brochure and said, "The main thing they emphasized was that they would keep her comfortable." The daughter explained during the week prior to her mother's death there were changes in her breathing, increased congestion and pain when her legs were touched. She stated during the visit on 10/21/19, she asked the regular nurse, Registered Nurse (RN) A, about liquid Morphine since her mother had Tylenol tablets for pain and she was concerned about worsening swallowing issues. The daughter stated RN A told her Tylenol was adequate. She explained RN A promised to order an oxygen concentrator as they noted changes in her mother's breathing, but she never did. Patient #1's daughter explained she called the hospice after-hours service later that night at about 10:30 PM because her mother's congestion worsened, and she had difficulty breathing. She stated after-hours staff instructed her to administer one Levsin tablet from the supply in her home, which was effective. The daughter said, "It was a big effort to catch her breath. Her stomach was moving up and down. She was opening her mouth to get more air. By the time [RN B] got there the breathing was much faster and got even worse while she was there." Patient #1's daughter stated she wanted to call 911 to get her mother to the hospital emergency room, but RN B informed her she would have an oxygen concentrator delivered to the home as soon as possible, within 2 to 4 hours. The daughter stated RN B shone a flashlight in her mother's eyes, then checked her hands and feet which she noted were cold. Patient #1's daughter said, "I thought she would give her something for pain or breathing. I asked if she was dying." She stated RN B did not respond to her questions about Morphine or her mother's status and she even asked if RN B was a regular hospice nurse or from another company. The daughter stated neither RN A nor RN B explained her mother's throat congestion was indicative that she was actively dying. She said, "They know more about dying than I do. They said they would keep her comfortable. That was what I had seen in the past with hospices." Patient #1's daughter stated she was surprised when RN B left her home after ordering the oxygen and not giving any medication. She explained her mother struggled to breathe for 3 hours after RN B left, and the oxygen concentrator never arrived. The daughter said, "When she couldn't anymore, she took one last struggling deep breath, but she couldn't catch that last breath. That's the part that really bothered me. She struggled so much that her whole body was moving and twisting." The "Nursing-Updated Comprehensive Assessment" form dated 10/21/19 at 11:20 PM, revealed RN B, an after-hours nurse, made an unplanned visit to patient #1 to address symptoms of respiratory distress. Patient #1 had low blood pressure, 78/45, and her respiratory rate was 38 breaths per minute, more than twice the normal rate. A normal respiratory rate is 12 to 18 breaths per minute (www.medlineplus.gov). The form indicated patient #1 had increased difficulty breathing, took shallow breaths and did not use oxygen. According to the Hospice Foundation of America, signs of approaching death can include drops in body temperature and blood pressure, a change in respiratory status with either very rapid breathing or long pauses in breathing, and noisy breaths as fluid accumulates in the throat. (www.hospicefoundation.org) During telephone interviews with RN B on 11/25/19 at 5:03 PM and 11/27/19 at 1:10 PM, she explained she was new to the specialty area of hospice nursing. She confirmed patient #1 had rapid, labored respirations when she arrived at her home on 10/21/19. RN B stated she called the physician for an order for oxygen, but did not request medication to treat respiratory distress, nor discuss any other possible interventions including initiating continuous care in the home. When asked to verbalize appropriate interventions to treat respiratory issues, RN B stated oxygen and breathing treatments. She was silent when asked what medication would be effective to treat respiratory distress. RN B was asked regarding use of Morphine and said, "I went through the medication list on my phone. There was none. My immediate concern was to get oxygen." RN B was informed patient #1 had Ativan tablets for anxiety in the home and she said, "I guess in a stretch you could use it." RN B acknowledged Morphine would have helped, but repeated the primary intervention was to order oxygen. She was not able to list any non-pharmacological interventions to ease respiratory distress. RN B said, "I was not 100% sure she was dying. I'm getting better at identifying symptoms as time goes on." RN B explained she requested delivery of the oxygen as soon as possible, but there was a 4-hour window, and to find a nurse to be at patient #1's bedside for continuous care would have taken even longer. She validated patient #1's respiratory distress was not managed in a timely manner. She said, "It's a concern. Four hours is too long. Even 1 hour is too long." RN B explained ordering and obtaining medication at night was sometimes a challenge as there were few 24-hour pharmacies. She stated the process of traveling to the patient's home, doing an assessment, calling the physician for an order, filling the prescription and getting someone to pick up the medication could take 4 hours or more. She said, "I had no quick options. Anything I did would have taken hours ... When I left she looked the same. She still had labored, rapid breathing. She did not look comfortable..." Review of the hospice admission packet revealed an informational booklet "Where Do I Turn for Help?" that indicated the hospice would provide pain and symptom management. The packet included the "Florida Patient's Bill of Rights and Responsibilities" that revealed every patient had the right to "receive effective pain management and symptom control from [hospice] for conditions related to the terminal illness." Review of educational material provided to hospice nurses revealed a "WINK (What I Need to Know)" for respiratory symptoms. The document listed interventions to "Manage dyspnea [difficulty breathing] in the actively dying patient' such as remaining with the patient, elevating the head of the bed, positioning with a wedge pillow for support, turning the head to the side to promote drainage of secretions, discussing heavy sedation for severe distress, and providing cool air with an electric fan. A booklet titled "Symptom Management" provided information on common end of life symptoms, the causes and appropriate interventions. The document indicated difficulty breathing affected up to 50% of patients and "Requires immediate attention." The booklet listed pharmacological interventions including opioids (such as Morphine) and anti-anxiety medications (such as Ativan). Review of patient #1's medical record revealed physician's orders included Ativan 0.5 milligrams (mg) every 6 hours as needed for anxiety, 2 tablets Tylenol 325 mg twice daily and every 6 hours as needed for pain or fever, and Levsin 0.125 mg every 4 hours as needed for secretions. On 11/25/19 at 3:48 PM, Patient Care Administrator (PCA) D explained the hospice no longer provided emergency medication kits for patients' homes. She said, "As an organization we determined there was often waste of the medications as most were not used." PCA D stated the current process was to provide diagnosis specific medications based on assessment findings. She explained prescriptions could be filled at local pharmacies. PCA D said, "It could take an hour to get the med." When asked if she felt that was a reasonable timeframe, she validated, "An hour is a long time." PCA D confirmed the hospice's goal was to manage patients' symptoms immediately. Hospice emergency kits or comfort kits usually include medications used to treat the common symptoms that occur at the end of life, pain, shortness of breath, anxiety and secretions. (www.jpsmjournal.com) On 11/25/19 at 4:13 PM, PCA E stated it was important to have emergency medications in patients' homes. She confirmed RN B should have ordered appropriate medication to alleviate patient #1's symptoms. PCA E said, "I wish we had the comfort pack." During interviews on 11/26/19 at 10:41 AM and 1:42 PM, the Clinical Educator (CE) explained newly hired nurses participated in a symptom management class during the orientation process. She stated for the first 2 to 3 weeks, day shift nurses met with the education department daily to review their documentation. However, she acknowledged the education department did not meet with new after-hours nurses on a regular basis. The CE confirmed the hospice no longer ordered comfort kits for patients' homes so the primary nurses who worked during the day were expected to address potential symptoms ahead of time. She stated it would have been appropriate for RN B to ask the physician to prescribe Morphine for respiratory distress and to ask if she could administer a dose of Ativan. The CE validated it would take a minimum of 3 hours for a patient to be assessed by a nurse and receive newly ordered medication. She acknowledged that timeframe was not satisfactory for symptom management. On 11/26/19 at 2:31 PM, when the Medical Director was informed of patient #1's uncontrolled respiratory distress for hours prior to her death, she asked, "Were there any opioids in the home?" She explained RN B could have used non-pharmacological interventions such as repositioning and a fan blowing on the face. She confirmed the hospice discontinued providing emergency kits for patients about one year ago because the medications were often unnecessary, inappropriate and not used. The Medical Director felt patient #1 had a sudden change in condition that was not foreseen by the primary nurse. She explained oxygen was not necessarily an effective intervention at the end of life and acknowledged Morphine would have been an appropriate drug to treat patient #1's respiratory distress. On 11/26/19 at 4:50 PM, the chaplain stated patient #1's daughter was disappointed in the type of death her mother experienced. She stated the daughter saw her mother struggling and suffering as she died. The chaplain explained hospice offered patients and families comfort by managing symptoms. She said, "We had nothing in that home for her. I told her I was so sorry she had that experience." In a telephone interview with Social Worker (SW) C on 11/27/19 at 7:04 AM, she confirmed she was assigned to patient #1's death visit on 10/22/19. She recalled patient #1's daughter was traumatized by watching her mother in severe respiratory distress for the hours prior to her death. SW C said, "The daughter kept describing and demonstrating the patient's labored breathing, and I think it left a troubling image in her brain." SW C stated she was so concerned about the events that she e-mailed general manager (GM) G after she left patient #1's home on 10/22/19. She read from the e-mail, "Here is another way we might be better able to manage symptoms. Remember that Morphine isn't just for pain it can be used for labored breathing." SW C stated she felt an actively dying patient in respiratory distress who received an order for oxygen and not Morphine possibly indicated there was a need to educate all staff, not just the after-hours nurse. SW C explained patients at the end of life stage were often not able to verbalize pain, discomfort, anxiety and fear so hospice staff were responsible for recognizing the symptoms associated with active dying. SW C said, "I was surprised that there was no Morphine in the home and that none was ordered." SW C explained since the hospice stopped providing comfort kits she was aware of situations where medications were ordered but not delivered, and she sometimes had to pick up medications from pharmacies at night. SW C said, "It is frustrating to not have medication on hand, and that is even when a continuous care nurse is there. The number 1 thing we promise our patients is comfort through symptom management... It was an unfortunate situation." On 11/27/19 at 12:07 PM, patient #1's team physician confirmed he signed her death certificate and determined the immediate cause of death was respiratory distress. He explained this was usually the last symptom of patients with dementia. The team physician stated RN B should have involved the physician more in order to manage patient #1's symptoms. He confirmed appropriate interventions for respiratory distress would include Morphine and initiating a higher level of care. On 11/27/19 at 1:32 PM, General Manager (GM) G explained the goal of hospice was to provide comfort care through symptom management. GM G confirmed patient #1 did not have her symptoms controlled in a timely manner. She said, "It was not done ... If there is no medication in the home we cannot meet their immediate needs." GM G validated both patient #1 and her daughter were significantly affected by the circumstances of the death. She explained although comfort kits with emergency medications were no longer standard, some patients received small amounts of Morphine in pre-filled syringes. GM G acknowledged in patient #1's situation, a single pre-filled syringe of Morphine in the home might have offered comfort for the patient and the family at the end of life.
L0517
L0517	36489 Based on interview and record review, the hospice failed to provide necessary care and services to ensure comfort at the end of life for an actively dying patient, and failed to provide education and support for grieving family, for 1 of 5 sampled residents, (#1). These failures led to prolonged respiratory distress that contributed to an uncomfortable death for patient #1 and caused psychosocial harm for patient #1's daughter. On 10/21/19 at approximately 10:30 PM, patient #1's daughter notified the hospice her mother was experiencing respiratory distress. The after-hours nurse who responded to the home failed to identify patient #1 was actively dying, and did not obtain appropriate orders for symptom management, educate the caregiver on the dying process or attempt non-pharmacological interventions to promote comfort. The nurse left patient #1 with no medication orders or treatments in place, in her daughter's care. Patient #1 continued with respiratory distress and struggled to breathe until she died on 10/22/19 at approximately 3:30 AM. The hospice's failure to prevent neglect resulted in Immediate Jeopardy starting on 10/21/19. Cross Reference to L512. Findings: On 11/27/19 at 8:48 AM, during a telephone interview with patient #1's daughter she explained her mother's health was declining in the nursing home, so she decided to bring her home to be with family and provide good care for her in the last days of life. The daughter stated she chose the hospice agency after interviewing others because "The main thing they emphasized was that they would keep her comfortable." The daughter explained during the week preceding her mother's death there was a change in her breathing, throat congestion and signs of pain with touch. She stated during the regular nursing visit on 10/21/19, Registered Nurse, (RN) A asked if there was an oxygen concentrator in the home and promised to order one when she discovered there was none. The daughter stated she asked RN A about pain management since her mother only had Tylenol pills that had to be crushed and given in applesauce or pudding. She said, "I asked [RN A] what would happen when she couldn't swallow the Tylenol that way anymore." The daughter stated RN A did not order liquid Morphine or explain that her mother's congestion indicated she was closer to dying. She stated hospice staff did not provide a nurse or medication for her mother in her time of need and said, "They know more about dying than I do. They said they would keep her comfortable." Patient #1's daughter recalled by the time RN B arrived at her home on the night of 10/21/19, her mother's breathing was faster than when she placed the call to hospice. The daughter stated RN B checked her mother's eyes with a flashlight and commented that her feet and hands were cold. She asked if her mother was dying, but RN B did not respond to that question or to her suggestion about morphine. She stated the nurse explained her mother needed oxygen, but it would not arrive for hours. She said, "I was depending on [hospice] ... I was focused on the oxygen because if she was dying it would be a calmer way to die. I sat right there. I didn't know what to do and the nurse was gone. The way I saw her gasping was horrible. I was promised comfort and that's what they failed to give her... That's why I was surprised the nurse left." Patient #1's daughter stated her mother's breathing worsened while the nurse was there, and she continued to have extreme difficulty breathing for another 3 hours afterwards. She said, "When she couldn't anymore, she took one last struggling deep breath, but she couldn't catch that last breath. That's the part that really bothered me. She struggled so much her whole body was moving and twisting." Patient #1's daughter began crying and said "I try to block it out of my mind. That's not how I wanted to remember her. It is still traumatic to me. They failed at the most important moment ... I don't know what I'll do to get over it. I would never be willing to do any grief support with [hospice]. The memory is too hurtful." Patient #1 was admitted to hospice services on 9/20/19. She was 92 years old with a terminal diagnosis of Alzheimer's disease and other diagnoses including chronic kidney disease, heart disease, anxiety and pain. Patient #1 was transferred from a nursing facility to her daughter's home on 9/25/19 and continued to receive hospice services. A "Pre-Admit Evaluation" dated 9/20/19 revealed patient #1's goals of care were comfort and symptom management. The evaluation indicated she was non-verbal, dependent on her caregivers for activities of daily living care, and had a poor appetite. Review of "Nursing-Updated Comprehensive Assessment" forms revealed on 9/26/19 patient #1 had diminished lung sounds and no congestion. On 10/03/19 her blood pressure was 125/76 and her lungs were clear. On 10/10/19, patient #1's blood pressure was 117/80, her lungs were clear, and the daughter was educated on use of the medication Levsin to prevent excess secretions. A "Home Health Aide / Homemaker Note" dated 10/21/19 at 9:35 AM revealed patient #1 was less agitated than usual and had not eaten or taken medications that morning. Later that afternoon at 2:00 PM, a "Nursing-Updated Comprehensive Assessment" form completed by RN A, indicated patient #1 showed no signs and symptoms of pain or anxiety. However, her blood pressure was 93/67, continuing a downward trend. The respiratory section of the form indicated patient #1 had congestion and used oxygen at 2 liters per minute as needed. RN A noted she provided oxygen safety education and taught the daughter how to use Levsin to treat secretions. Review of the after-hours call log revealed on 10/21/19 at 10:26 PM, patient #1's daughter called the hospice to report that her mother was breathing heavily and fast and sounded like she had mucous in her throat. The log read, " ... she can see the belly rising quickly ..." The daughter was instructed to give a dose of Levsin for the congestion and keep the head of the bed elevated. She was informed that a nurse would be dispatched to assess her mother for respiratory distress and excess secretions. The "Nursing-Updated Comprehensive Assessment" form dated 10/21/19 at 11:20 PM revealed RN B, an after-hours nurse, made an unplanned visit to patient #1 to address symptoms of respiratory distress. Patient #1's blood pressure was even lower at 78/45, and her respiratory rate was 38 breaths per minute, more than twice the normal rate. A normal respiratory rate is 12 to 18 breaths per minute (www.medlineplus.gov). The form indicated patient #1 had increased difficulty breathing, took shallow breaths and did not use oxygen. This conflicted with RN A's note written earlier that day regarding patient #1 using oxygen. RN B obtained a new order for an oxygen concentrator "STAT" (a medical term that means urgently or immediately). RN B documented that she reviewed patient #1's medications for effectiveness and availability during the visit and the caregiver was satisfied with current symptom management. Review of patient #1's medical record revealed physician's orders included Ativan 0.5 milligrams (mg) every 6 hours as needed for anxiety, 2 tablets Tylenol 325 mg twice daily and every 6 hours as needed for pain or fever, and Levsin 0.125 mg every 4 hours as needed for secretions. The after-hours call log indicated RN B called the hospice's answering service on 10/22/19 at 12:05 AM to report patient #1 had " ...rapid shallow breathing and they don't have a concentrator in the house." There was no information regarding new medication orders for patient #1's respiratory distress. The log indicated an order for the concentrator was placed a few minutes later at 12:17 AM and RN B's visit ended at 12:30 AM. The log showed patient #1's daughter called again on 10/22/19 at 3:31 AM to report her mother just took her last breath. She was informed a staff member would be dispatched to attend the death. The after-hours staff e-mailed Social Worker (SW) C a few minutes later at 3:39 AM regarding the need for a patient death visit, then notified the medical equipment staff at 3:52 AM that patient #1 no longer required delivery of the oxygen concentrator. The "Report of Death" form dated 10/22/19 at 4:25 AM revealed patient #1's daughter told SW C her mother died after struggling to breathe, and the daughter was uncomfortable with the manner of death. During telephone interviews with RN B on 11/25/19 at 5:03 PM and 11/27/19 at 1:10 PM, she explained she was new to the specialty area of hospice nursing. She confirmed she was sent to patient #1's home on 10/21/19. She said, "When I got there, I was somewhat taken aback that there was no oxygen. She was having rapid, labored breathing." RN B stated she reviewed patient #1's medications and decided the primary intervention should be oxygen. She acknowledged she called the physician for an order for oxygen, but did not request medication to treat respiratory distress, nor discuss any other possible interventions including initiating continuous care in the home. RN B explained she requested delivery of the oxygen as soon as possible, but there was a 4-hour window, and to find a nurse to be at patient #1's bedside for continuous care would have taken even longer. RN B could not explain why she did not attempt any measures to alleviate patient #1's acute respiratory distress while she was in the home. She said, "When I left she looked the same. She still had labored, rapid breathing. She did not look comfortable..." When asked if she thought it would have been appropriate to stay with patient #1 and her family until the oxygen concentrator arrived, RN B said, "I don't stay. That's not the way we were trained. I still have my shift to continue. This was at the end of my shift. I hoped that the patient hung on until they delivered the oxygen concentrator. I was not sure if she was dying." RN B acknowledged she did not provide education on end of life symptoms to the daughter because her focus was on obtaining oxygen for patient #1. She confirmed Morphine was used to treat respiratory distress but said, "There have been times when I had to drive to the pharmacy. I don't know why I didn't do it this time. I didn't think of anything past the oxygen." Review of the job description for hospice RN (revised on 8/09/19) revealed a primary function was working with the interdisciplinary team " ...to meet the physical, psychosocial, emotional and spiritual needs of hospice patients and families facing terminal illness and bereavement." Job responsibilities of an RN included completing comprehensive assessments "... in order to provide palliation of end of life symptoms." The hospice RN was expected to educate patients and families, provide nursing care and professionally coordinate the plan of care. Review of educational material provided to nurses revealed a "WINK (What I Need to Know)" for respiratory symptoms. The document listed interventions to "Manage dyspnea [difficulty breathing] in the actively dying patient" such remaining with the patient, elevating the head of the bed, positioning with a wedge pillow for support, discussing heavy sedation for severe distress, and providing cool air with an electric fan. On 11/26/19 at 1:42 PM, the hospice Clinical Educator (CE) stated she was not aware of concerns related to the circumstances of patient #1's death prior to that morning. She said, "I am flabbergasted that a nurse would leave a patient in distress." The CE stated her expectation was any nurse would have intervened to meet patient #1's needs in the home, and if not possible, arranged for a transfer to an inpatient unit. She explained RN B should have asked the physician for a new medication order, discussed use of medication on hand, or escalated the issue to the manager on call. The CE said, "She definitely should not have left, even if just to support the family." On 11/26/19 at 2:31 PM, the Medical Director stated primary nurses assessed patients regularly and ordered appropriate medications to treat symptoms identified during visits. However, she felt patient #1 seemed to have experienced an acute change in condition that was not foreseen by the primary nurse. She confirmed RN B could have brainstormed with the physician while she was in patient #1's home. She explained oxygen was not necessarily an effective intervention at the end of life, but Morphine would have been appropriate to treat respiratory distress. The Medical Director explained there were non-pharmacological interventions that might have been effective in the absence of medication or oxygen, including repositioning and a fan blowing on the face. She described RN B as " ...one nurse who did not do what she should have." On 11/26/19 at 4:50 PM, the chaplain stated she spoke with patient #1's daughter a few days after her mother's death. The chaplain said, "I know the daughter was upset about different things that happened. She was disappointed in the type of death her mom had ... struggling and suffering and not having a comfortable passing." The chaplain explained hospice informed patients and their families that symptoms would be managed, and they would be kept comfortable. However, the chaplain stated she was not able to comfort patient #1's daughter. She described the daughter as "still stuck in the same place, with no improvement in her grief. The chaplain stated she offered patient #1's daughter a keepsake memory bear but she refused and said "If it has anything to do with [hospice] I don't want a part of it. I don't want any memory of [hospice]." The chaplain explained she could only offer active listening and validate the daughter's feelings. She said, "The daughter is still very angry and very hurt. We had nothing in that home for her. I told her I was so sorry she had that experience." On 11/27/19 at 7:04 AM, during a telephone interview with SW C she confirmed she completed patient #1's death visit on 10/22/19. SW C stated patient #1's daughter reported her mother experienced significant respiratory distress while she was dying. SW C said, "The daughter kept describing and demonstrating the patient's labored breathing, and I think it left a troubling image in her brain." SW C stated she sat with patient #1's daughter at the bedside while they awaited the arrival of the funeral home staff. She described the daughter as confused, concerned, sad and perplexed. SW C said, "I tried to reassure her that lack of a concentrator did not expedite the death. I told her Morphine would possibly have helped and she told me she did not know why it wasn't ordered by either nurse [RNs A and B]. She was traumatized and said that she did not want to describe the last hours to her family members. I think she did not want to traumatize other people. From what we should do and know I think it was a very significant event." SW C stated patient #1's daughter felt RN B might have stayed at the bedside to help resolve her mother's symptoms, and she expressed an overall feeling that hospice should have done more. SW C explained if she were in that situation she would have stayed with patient #1 and the family. She said, "They feel more comfortable because 'the expert' is there." SW C stated she was so concerned about the events that she e-mailed General Manager (GM) G after she left patient #1's home on 10/22/19. She explained the purpose of the e-mail was to inform her of staff education as an area for improvement, but she never received a response from GM G. SW C said, "I feel like seeing a patient in respiratory distress ... in significant trouble and ordering an oxygen concentrator and not morphine, deserves education for all staff, not just [RN B] ... I believe it was possibly a preventable moment. I believe that everything we could have done was not done. This was blatantly one situation where we could have done better." During interviews on 11/25/19 at 3:48 PM and 11/26/19 at 3:49 PM, Patient Care Administrator (PCA) D stated any patients who reported shortness of breath, anxiety, pain and falls were assigned 'Priority 1' high acuity status by after-hours staff and were seen within an hour. PCA D confirmed although RN B ordered oxygen for patient #1 she did not offer appropriate interventions such as medications or a higher level of care. PCA D said, "She could have ordered morphine, given Ativan in the meantime and put [patient #1] on crisis care." PCA D stated after the death, the issue was discussed only at the team level. She explained any nurse who did not perform to standard would be pulled from the field and placed on a performance improvement plan. PCA D stated concerns related to RN B's failure to provide appropriate and effective nursing care and services for patient #1 were not discussed at the recent Quality Assurance and Senior Management meetings. She acknowledged the hospice did not interview the patients and families on RN A's team or those visited by RN B after-hours to identify if there were issues related to provision of care, services and equipment. PCA D validated other patients might be affected by similar actions and inactions of RNs A and B. She said, "We definitely did not do what we were supposed to do." On 11/25/19 at 4:13 PM, PCA E stated RN B should have checked to see what medications were in the home and if necessary requested an order for appropriate drugs. PCA E acknowledged it was neglectful for RN B to leave patient #1 and her family without implementing interventions to alleviate her respiratory distress. On 11/25/19 at 4:18 PM, PCA F confirmed RN B did not administer or order any medication for patient #1. She acknowledged she spoke with patient #1's daughter after her mother's death and said, "It was more of a customer service follow up rather than investigation of neglect." During interviews on 11/25/19 at 4:26 PM and 11/27/19 at 1:32 PM, GM G acknowledged neither RNs A and B nor patient #1's Team Manager (TM) met the hospice's expectations. GM G stated the TMs were responsible for monitoring, checking, correcting and re-directing new employees. In addition, Team Managers were expected to monitor the after-hours call log to identify any concerns that required a higher level of attention or further investigation. GM G explained after-hours nurses did not receive the same orientation as primary nurses, and there was no checklist to test after-hours nurses for competency. Review of the job description for the hospice Team Manager (revised on 5/28/19) revealed a primary function of ensuring " ... patients and families receive continuity and quality of care from admission to discharge or transfer to bereavement." The TM was expected to respond to service issues and challenges and ensure timely and satisfactory resolution. GM G described hospice's goal as "Comfort care, controlling any and all symptoms. Whatever is comfortable for them. It is improving the outcome." She explained since hospice recognized the importance of family members and their needs throughout the end of life process, all care plans included the patient and the caregiver. GM G said, "It is the impact we leave. That daughter will remember this experience at every Thanksgiving holiday." GM G stated RN B could have looked at using medications already in the home, delegated another staff member to go to the pharmacy to pick up other medications, and remained with patient #1 and her daughter until an intervention was effective. When asked if she believed patient #1 and her daughter suffered harm, GM G said, "It had to affect the patient. The daughter will be forever affected by the observation of what took place."