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 ______________	11/10/2020
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)
L0512
L0512	33162 Based on record review and interview, the Hospice's staff failed to ensure the provision of a refill of a patient's scheduled medication for 1 of 3 sampled patients (Patient #1). The findings included: Review of Patient #1's record documents the patient was admitted to the Hospice's services on 07/20/20. A "Physician Visit Note" for "date of encounter," 10/20/20 documents Patient #1 had a diagnosis of Lung Cancer with Metastasis to the Brain, was alert and oriented to person and place and walked with unsteady gait. This "Physician Visit Note" documents Patient #1 was on Decadron as well as Methadone (a long acting pain medication) and Morphine (opioid pain medication), was taking these medications as prescribed and reported their pain was "better controlled" at the time of the visit. Patient #1's "Nursing Updated Comprehensive Assessment" dated 10/13/20 documents their pain as "headache" made worse by "tumor growth," that the patient rated their pain as "0" or "2" (on a scale of "0" to "10" with "10" being the worst) and under "pain" that their regimen included Decadron 2 MG. (milligrams) by mouth every 6 hours. Under the heading "Neurosensory" documentation reveals the patient was "confused "slow thinking process noted," and was able to make needs known. Patient #1's "Nursing Updated Comprehensive Assessment" dated 10/20/20 documents the patient rated their pain as "2" or "3" out of "10," their pain regimen included Decadron 2 MG. (milligrams) by mouth every 6 hours. There was no evidence of documentation of how many "as needed" doses of pain medication the patient had taken in the prior 24 hours although it was documented that the patient took 30 MG. of Morphine IR (instant release) at the time of the visit and had no pain at the end of the visit. Under "Neurosensory" documentation reveals the patient was "confused" and "slow thinking process noted," had Ativan (anti-anxiety medication) "PRN" ("as needed") for anxiety, and "HA, meds in use" (headache with medications in use). Review of an entry to the "After Hours On Call" system record for call date and time of 10/28/20 at 7:03 PM by LPN (Licensed Practical Nurse), Staff "A" documents Patient #1 called the Hospice to report they were "out of Decadron (Dexamethasone) 2 MG. and needed more, that their current medication list was reviewed and included "Decadron 2 MG., take 1 tablet orally every 6 hours for pain," that the patient was also on Morphine and Methadone, that Staff "A" did not feel comfortable obtaining a "local fill" for the patient ... and that the patient was told they were on Morphine 30 MG. and Methadone 10 MG. and "to follow up with them accordingly." This entry also documents Patient #1's response that they "stated they "doesn't care and wants more of the Decadron 2 MG." that the patient requested the team physician be contacted regarding why they were placed on Morphine and Methadone but Decadron was not refilled and that they agreed to a Nurse visit. There was no evidence of documentation that Staff "A" checked when the patient's Decadron was last filled or that a physician was contacted about the Decadron, as the patient requested. Review of an entry for the "After Hours On-Call" system record documents Staff "A" called Patient #1 back on 10/28/20 at 7:29 PM during which the patient reported that they took their last Decadron 30 minutes prior, as well as Morphine, Methadone and Ativan (anti-anxiety medication)a since that was how the timing of their medications worked out, reported uncontrolled pain of "7" out of 10 and Staff "A" advised the patient that a nurse was being sent to evaluate the patient. Review of an entry for the "After Hours On-Call" system record documents by an RN (Registered Nurse), Staff "B" documents Patient #1 called again on 10/28/20 at 7:50 PM to report they were out of Decadron and needed it that night but had no one to pick it up for them and that they were told that someone was "dispatched" to them. There was no documentation that the Medical Director was advised Patient #1 was out of Decadron and had Brain Cancer with Metastases, or that Staff "A" decided not to obtain an emergency 4-day supply of Decadron locally so the patient could receive it that night. Review of Patient #1's medication list dated 10/29/20 revealed he was on Decadron (dexamethasone) 2 MG every 6 hours for pain since their Hospice "Start of Care," on 07/20/20 and it was not discontinued at any point. There was no evidence of documentation of inquiry to a physician regarding whether Patient #1 should be on Dexamethasone, no evidence of inquiry to the pharmacy for the patient's latest Dexamethasone refill and whether there were remaining refills and no evidence of further communication about this to the "On-Call" nurse who documented that the patient was on Dexamethasone but that she didn't want to refill it locally due to her concerns..." During a telephonic interview with Patient #1's Registered Nurse Case Manager, Staff "E" on 11/10/20 at 12:16 PM, she reported Patient #1's Dexamethasone was not discontinued, it was prescribed to reduce brain swelling due to Metastatic Brain tumors that she was not informed of the patient's reported pain level of "7" or that the patient reported they had "run out" of Dexamethasone and Staff "E" stated the physician should have been contacted if there was a question of whether to refill the patient's Dexamethasone. The American Cancer Society website documents, "Steroid medicines, such as Dexamethasone, are often used to reduce swelling in the brain around the metastases. This can often help with symptoms right away...," accessed at https://www.cancer.org/treatment/understanding-your-diagnosis/advanced-cancer/brain-metastases.html, site last revised September 10, 2020. The website, Drugs.com documents in regard to Dexamethasone documents "Patients should understand that this drug is a corticosteroid and that it is important not to stop therapy abruptly," accessed at https://www.drugs.com/dosage/dexamethasone.html, last updated on Sep 18, 2019.
L0557
L0557	33162 Based on review of the Hospice's Policy and Procedure, documentation review, record review and interview, the Hospice "On Call" staff failed to relay the patient's needs to the patient's "Primary Care Team, including the patient's physician, for follow up," to ensure pain and distress were addressed for 1 of 3 sampled patients as evidenced by the failure of the "On Call" staff to relay to the patient's "Primary Care Team" the patient's reports of markedly increased pain in their head with a known diagnosis of Brain Metastasis (cancerous tumors that had spread from another area of the body to the brain), that they were out of their prescribed scheduled medication to reduce brain swelling, Dexamethasone or that they had stated intent and method to take their own life and failed to follow their Policy and Procedure to notify the patient's primary caregiver of this threat (Patient #1). The findings included: The Hospice Standard titled, "Responding to Suicidal Ideation or Suicide (Patient or Family), updated 06/12/19" documents, "If team member receives notification via a phone call from a patient or family member that threat for suicide is immediate: a) The team member should: call 911, explain the situation and give the location; immediately notify (make verbal contact) team manager or manager on call; go to the patient/family's home/facility once emergency staff have arrived (if safe); b) The team manager/ manager on call should call the Hospice social worker to visit the home/facility immediately (if safe); call the PCA (Patient Care Administrator) and GM (General Manager) immediately; notify the attending physician and Hospice medical director; (and) notify the other team members" and "The primary caregiver should always be contacted for any of the scenarios above. Care should be taken at every step to document and care plan the entire incident in detail, including a thorough psychosocial assessment and risk-specific care planning." The website, Drugs.com documents in regard to Dexamethasone (Decadron) "Patients should understand that this drug is a corticosteroid and that it is important not to stop therapy abruptly," accessed at https://www.drugs.com/dosage/dexamethasone.html, last updated on Sep 18, 2019. The American Cancer Society website documents, "Steroid medicines, such as Dexamethasone (Decadron), are often used to reduce swelling in the brain around the metastases. This can often help with symptoms right away...," accessed at https://www.cancer.org/treatment/understanding-your-diagnosis/advanced-cancer/brain-metastases.html, site last revised September 10, 2020. Review of Patient #1's record documents admission to the Hospice services on 07/20/20. A "Physician Visit Note" for "date of encounter," 10/20/20 documents Patient #1 had a diagnosis of Lung Cancer with Metastasis to the Brain, was alert and oriented to person and place and walked with unsteady gait. This "Physician Visit Note" documents Patient #1 was on Decadron as well as Methadone (a long acting pain medication) and Morphine (opioid pain medication), was taking these medications as prescribed and reported their pain was "better controlled" at the time of the visit. Patient #1's "Nursing Updated Comprehensive Assessment" dated 10/13/20 documents their pain as "headache" made worse by "tumor growth," that the patient rated their pain as "0" or "2" (on a scale of "0" to "10" with "10" being the worst) and under "pain" that their regimen included Decadron 2 MG. (milligrams) by mouth every 6 hours. Patient #1's "Nursing Updated Comprehensive Assessment" dated 10/20/20 documents the patient rated their pain as "2" or "3" out of "10," their pain regimen included Decadron 2 MG. (milligrams) by mouth every 6 hours and that the patient denied any pain at the end of the visit. Review of an entry to the after hours "on call" system record for call date and time of 10/25/20 at 10:51 AM documents Patient #1 called and reported he took 2 methadone at 7 AM instead of methadone and morphine as he should have, last took morphine the night before, and is "always in pain." The same entry documents he was advised he could take morphine if he was in pain and to wait 12 hours from the 7 AM dose before taking the next methadone. Review of an "entry," to the "After Hours On-Call System," for call date and time of 10/25/20 at 10:51 AM documents Patient #1 called and reported a "mistake" they made with their medications, reported they took 2 Methadone at 7:00 AM instead of Methadone and Morphine as they should have, last took Morphine the night before and is "always in pain;" the same entry documents the patient was advised they could take Morphine if they were in pain and to wait 12 hours from the 7:00 AM dose before taking the next Methadone. Further review reveals there was no evidence of documentation as to whether Morphine was effective for their pain. There was no evidence of documentation that the patient was offered a Nurse's visit that the patient received a Nurse's visit before 10/27/20 or that the "On Call Nurse" inquired further regarding the patient's statement that they are "always in pain." The most recent "Nurse Visit" documentation in the patient's record, prior to this telephone call was dated for the visit on 10/20/20 and the next "Nurse's Visit" was documented as 10/27/20. Patient #1's "Nursing Updated Comprehensive Assessment" dated 10/27/20 documents the patient rated their pain as "0 to 2 out of 10" and under the heading "Pain" to "continue pain management as order" (sic) and "pt. (patient) comfortable with pain regimen." Review of an entry to the "After Hours On Call" system record for call date and time of 10/28/20 at 7:03 PM by LPN (Licensed Practical Nurse), Staff "A" documents Patient #1 called the Hospice to report they were "out of Decadron (Dexamethasone) 2 MG. and needed more, that their current medication list was reviewed and included "Decadron 2 MG., take 1 tablet orally every 6 hours for pain," that the patient was also on Morphine and Methadone, that Staff "A" did not feel comfortable obtaining a "local fill" for the patient ... and that the patient was told they were on Morphine 30 MG. and Methadone 10 MG. and "to follow up with them accordingly." This entry also documents Patient #1's response that they "stated they "doesn't care and wants more of the Decadron 2 MG." that the patient requested the team physician be contacted regarding why they were placed on Morphine and Methadone but Decadron was not refilled and that they agreed to a Nurse visit. There was no evidence of documentation that Staff "A" checked when the patient's Decadron was last filled or that a physician was contacted about the Decadron, as the patient requested. Review of an entry for the "After Hours On-Call" system record documents Staff "A" called Patient #1 back on 10/28/20 at 7:29 PM during which the patient reported that they took their last Decadron 30 minutes prior, as well as Morphine, Methadone and Ativan (anti-anxiety medication)a since that was how the timing of their medications worked out, reported uncontrolled pain of "7" out of 10 and Staff "A" advised the patient that a nurse was being sent to evaluate the patient. Review of an entry for the "After Hours On-Call" system record documents by an RN (Registered Nurse), Staff "B" documents Patient #1 called again on 10/28/20 at 7:50 PM to report they were out of Decadron and needed it that night but had no one to pick it up for them and that they were told that someone was "dispatched" to them. Review of an entry for the "After Hours On-Call" system record by Staff "B" for call date/time 10/28/20 at 7:59 PM that is documented, in place of name, "Continued Note" documents a suicidal statement with a firearm," ... " Pt asked if ... (they are) is feeling to harm ... (them)self. Pt stated, "Just bring my medications"" (sic). Review of further entries to the "After Hours On-Call" system record documented a Team Manager, "AOC" (Administrator On Call) and the Medical Director were advised of the patient's statement and the Medical Director stated the patient should be assessed by a ... (Hospice) nurse and recommended the patient be placed on "CC" ("Continuous Care" whereby ... (Hospice) staff would stay with ... (patient) in ... (their) home) or "IPU" (an Inpatient Unit where staff would be available around the clock), as well as assessed for increased pain; that a nurse had been dispatched and that the Team Manager advised to have a Social Worker sent out for psychosocial support. There was no evidence of documentation that the Medical Director was advised Patient #1 was out of Decadron and had Brain Metastasis or that Staff "A" did not to call in a 4-day refill (of Decadron) to a local pharmacy so that the patient could receive it that night. A "Nursing Updated Comprehensive Assessment" dated/timed for a visit on 10/28/20 at 9:30 PM, by Registered Nurse, Staff "C", documented Patient #1 rated their pain as "7," made worse by "disease process," that the patient's care plan goal for pain was "0," the patient had taken "0" breakthrough doses in the previous 24 hours for a total amount of "0" MG., the Response to Care "c/o (complaint of) pain", that their anxiety level was 4 and care plan goal for anxiety was 1 and that the patient had "Ativan 0.5 MG." with no indication of whether the patient took it. This "Nursing Updated Comprehensive Assessment" documented, under "Other, c/o (complaint of) pain in head 7 on pain scale, stated that medication Dexamethasone was not ordered, pt.'s profile indicated that pt. is no longer prescribed." There was no evidence of documentation of an inquiry to the patient's physician regarding whether Dexamethasone should be refilled or if it was "ok" to stop the Dexamethasone since the patient "ran out" of it that morning after taking 2 MG. 4 times daily since July, no evidence of documentation of an attempt to verify the last refill date or remaining refills and no evidence of further communication about this to Staff "A" who documented the patient was still on Dexamethasone but that she didn't want to fill it locally due to her concerns ..." There was no evidence of documentation in the 10/28/20 "Nursing Updated Comprehensive Assessment" of inquiry to Patient #1 regarding their telephone suicidal threat with a firearm and the "Psychosocial" area of the assessment indicated "knowledge deficit" and the handwritten words, "cousin supportive." There was no evidence of documentation Patient #1 was offered "Continuous Care" or to go to the "Inpatient Unit," as advised by the Medical Director. A "Supplemental Interdisciplinary Note," dated 10/28/20 documents the "On Call" Social Worker, Staff "D" called Patient #1 (no time documented) but the patient refused a visit saying the Nurse was there and became frustrated when asked about suicidal ideation, said they didn't want to talk and did not answer the telephone when she tried calling again after the Nurse left. During telephonic interview on 11/6/20 at 9:28 AM, Staff "D" confirmed Patient #1 refused a visit over the telephone and reported no attempt to visit the patient or to call "911" or their primary caregiver; Staff "D" reported that Staff "C" reported to herself after their visit that Patient #1 had denied suicidal ideation or having any weapons in the home, had caregivers around the clock that Staff "C" felt the patient was safe in their home and that she felt the same. There was no evidence of documentation that any staff attempted to contact the Medical Director to report the outcome of the visit and telephone contact that a "Suicide Risk Assessment" could not be completed by the Social Worker or the Nurse, or that Patient #1 refused "Continuous Care" or to go to the "Inpatient Unit," so as to obtain further direction from the Medical Director. There was no evidence of documentation that staff called "911" to report Patient #1's threat to end their life that implied access to a firearm by which to carry out this threat. During telephonic interview with Patient #1's Registered Nurse Case Manager, Staff "E" on 11/10/20 at 12:16 PM, she reported Patient #1's Dexamethasone was not discontinued and was prescribed to reduce brain swelling due to Metastatic Brain Tumors that she was not informed at any point the next day of the report of pain level of "7" or that the patient was out of Dexamethasone and the process for such instance is to call a 4-day supply to a local pharmacy so the patient would have it until they received the medication refill from their usual pharmacy by mail, typically in 2 days; Staff "E" denied Patient #1 having any question of medication improper use and stated the nurse should have called the physician if there was a question of whether to refill the Dexamethasone; Staff "E" reported that she was not informed of the patient's suicidal statement until the Social Worker told her around 5:00 PM the following day, after he said he had just learned of it himself. During telephonic interview with Patient #1's team Social Worker, Staff "F" on 11/10/20 at 11:22 AM, he reported he received an "E-Mail on 10/29/20 around 4:40 PM from Social Worker, Staff "D" who had been "on call" the night before, called her back, learned about the patient's suicidal statement the night before and called the patient who agreed to a visit the following day. Staff "F" denied receiving an "on call" morning report that day or receiving this information from the Team Manager or by any other means prior to Staff "D"'s "E-Mail around 4:40 PM on 10/29/20. There was no evidence of documentation that the Hospice staff called "911" or contacted the patient's primary caregiver to notify them of Patient #1's threat of self-harm.