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
101545 A. BUILDING __________
B. WING ______________ 		08/07/2020
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)
L0500      
28608 Based on record review and staff interview, the agency failed to ensure the Condition of Participation for Patient's Rights was met by failing to protect and promote the rights of 1of 3 sampled patients to ensure that Patient #1was free from neglect. Patient #1's home caregiver failed to care for the patient and the agency failed to report all incidents of neglect to the Department of Children and Families. For several months, Patient #1's condition declined. During this time the patient developed infected pressure sores, severe malnutrition, dehydration and sepsis, which contributed to suffering, pain and death. These conditions resulted in the Condition of Participation for Patient Rights. Immediate Jeopardy (IJ) was identified at 5:15pm on 8/6/20, which is ongoing. On 8/11/20 at 11:30am, Patient Care Administrator and General Manager were notified of the IJ determination. IJ was removed as of the date of the IJ removal plan, 8/12/2020. The IJ revisit ocurred on 8/24/2020. The Findings include: Cross reference L517 The agency failed to ensure that Patient #1 was free from neglect. The Agency failed to call the state abuse agency to report caregiver neglect for Patient#1. Patient #1 was admitted to hospice services on 10/21/19. The patient experienced a decline in condition due to lack of care by a disabled caregiver, which was identified by the agency. The patient was taken to the hospital by EMS on 2/24/20, where she died on 3/5/20.
L0517      
28608 Based on record review and staff interviews, the agency failed to ensure 1 of 3 sampled patients (Patient #1) was free from neglect. The agency failed to report and investigate all incidents of suspected abuse/neglect to State agency. For several months, Patient #1's condition declined due to home caregiver neglect. During this time the patient developed infected pressure sores, severe malnutrition, dehydration and sepsis, which contributed to suffering and death. Immediate Jeopardy (IJ) was identified at 5:15p.m. on 8/6/20, which is ongoing. On 8/11/20 at 11:30 am the Patient Care Administrator and General Manager were notified of the IJ determination. IJ was removed as of the date on the IJ removal plan, 8/12/2020. The IJ revisit ocurred on 8/24/2020. The findings include: Patient #1 was admitted to hospice services on 10/21/19. The plan of care included Skilled nurse (SN) every 2 weeks, Medical Social Worker (MSW) every 3 months, Chaplain every 3 months and as requested and Home Health Aide (HHA) 5 x week. The initial nursing assessment on 10/21/19 revealed Patient #1 was bed bound, cognitively impaired, required total assistance with all Activities of Daily Living (ADL). She was incontinent of bowel and bladder, unable to transfer out of bed or re-position self in bed. She also could not feed herself or drink fluids on her own. There was no skin breakdown. She resided at home with son as the sole caregiver. Skilled nurse (SN) note 11/8/19 found patient soaking wet on every visit, also observed caregiver leaves sandwich at bedside. However, she had no idea how to eat and tried eating plate. Physician progress noted dated 11/20/19 revealed a face to face visit, patient is dependent on 6 of her ADL's, has extensive bruising on upper extremities and hematoma to right arm. Son requested an increase in dementia medications and wanted her to remain on morphine ER and hydrocodone. The son has a history of drug abuse and alcoholism. SN note dated 12/3/19 found Patient #1 soaked in urine on arrival. On 12/12/19, found her with foul smelling diarrhea and bladder pain. On 12/17/19, SN documented was moaning and grimacing, rapid breathing when turned and positioned. Review of MSW note dated 12/10/19, revealed she attempted to schedule plan of care meeting with son to address concerns of care. Per HHA, the patient was found wet from top to bottom daily. HHA believed the caregiver was not caring for patient as needed. The Caregiver was angered by allegation and declined meeting visit. Review of the physician progress note dated 12/18/19, MD revealed the nurse was called out today, son concerned stool coming out of urethra, loose stool from rectum. Patient sits in stool all day, HHA reports that she is soaked from head to toe every time she comes. Nurse recommends IV fluids because she appears very dehydrated. It was recommended patient to go to inpatient unit for fluids. The son adamantly refused to sign DNR. The son was advised to push fluids. Patient will be monitored closely. There was no documentation that Patient #1 received IV fluids. On 12/20/19 the HHA reported to RN team manager that Patient #1 was always found soaked with urine and covered with feces at every visit. On 12/23 HHA, again reported to RN team manager that Patient #1 was found soaked in urine and covered with feces. SN note dated 12/27/19 revealed Patient #1 was completely soaked on visit, also there were Stage 3 wounds documented to left and right hip and lumbar spine. Wound care orders were obtained but frequency of visits was not increased. On 12/27/19, an unannounced home visit was made by Team Manager, RN and Social Worker due to concerns of HHA always finding patient soaked in urine and feces and home dirty with roaches. There was no documentation regarding findings of the home visit. During an interview with Team Manager on 7/30/20 at 4:40pm, she was asked what determination was made at conclusion of the visit. She said that patient was clean and dry when they arrived. Asked if she had seen the wounds, she said "no." The son requested an air mattress and was provided. When asked if the team had made any follow up visits to the home to reassess due to continued concerns from staff about being left soaked in urine, development of multiple pressure sores and report of roaches, she said, "no." She was asked why DCF was not notified regarding the continued lack of care by the caregiver resulting in severe wounds, she stated she brought her concerns to the PCA at the agency at the time and was told not to report. She then brought her concerns to the General Manager at that time and was told not to report. She was asked why she did not call, she said in retrospect they should have. She was asked if it was this hospice's policy that nursing staff in the field were not allowed to call DCF, only administrative staff. She said the IDT team discussed those situations in the care meetings and team to investigate need to call. On 1/3/20 a Foley catheter was ordered, son refused. SN documented the wounds on left hip Stage 4 x 5 x 3 cm with yellow tissue and foul odor. Skin paper thin and tears easily. Also has skin breakdown left distal and medial ankle. The caregiver was instructed to premedicate prior to dressing changes as patient screamed, yelled and moaned when dressings changed. Review of the physician progress note dated 1/23/20 revealed, patient had 6 bed sores noted and on Monday mornings she was covered in urine and feces from the weekend without an HHA. The son said he could not lift her due to back pain. Review of the orders found no increase in frequency of HHA's or RN visits. The RN was only visiting weekly despite the need for more frequent dressing changes. SN note dated 1/30/20 found wounds trying to heal but patient always soaked with urine and they reopen. On 2/7/20, SN documented the skin in terrible shape, multiple small sores on back, both hips and feet. The caregiver leaves patient 14-16 hours in urine and feces despite many conversations regarding skin care. Also, roaches were seen in patients' room. On 2/13/20, patient complained of pain when moved she moans, yells, push hands away and points at different areas. Stage 4 wounds left hip 5 x 6 cm second area 2 x 3 cm tendon exposed, full thickness dried blood and foul odor. Both heels unstageable full thickness. Patient premedicated for procedures still anxious, yells and moans. Caregiver alcoholic, drug addict, has no job, nowhere to go once mom dies very panicked. States he will do anything to keep her alive. Caregiver disabled and leaves patient in urine 16 hours. On 2/17/20 SN attempted to insert Foley catheter, patient scratched and screamed and pulled hands away. Patient was hallucinating, antibiotic started for urine infection, patient dehydrated need to increase fluids. Review of HHA note dated 2/18/20, wounds are getting worse, son still leaving her in urine. On 2/20/20 patient barely eating or drinking, has more skin breakdown and son keeps leaving her in urine. SN note dated 2/21/20 revealed new 9 cm x 5 cm wide skin tear down right shin. Son pulled pillow from between legs and skin tore. Review of physician progress note dated 2/24/20, revealed patient has large skin tear down her back and right shin and bed was full of blood. She has necrotic areas of the heels; she has multiple decubitus ulcers. Left hip 5 x 6 cm with tendon visible. Also, one large area on her sacrum, another of her ankle. EMS was activated, paramedics want to call Department of Children and Families (DCF). The patient's son considering transferring her to ER. The conditions at home are harsh. There are cockroaches everywhere. The patient clenching both hands and has contractures. Her oral intake is markedly reduced. Her dentures no longer fit. Patient will be monitored closely. SN note dated 2/24/20, revealed extreme pain from new wound to right lower leg, Patient dehydrated and observed with milky urine, scant amount and foul odor. Son instructed to call 911. Emergency Medical Services (EMS) arrived and transferred to hospital. As result of multiple infected pressure sores, malnutrition and dehydration, Patient #1 died at the hospital on 3/5/20. Review of the hospital records dated 2/24/20 revealed she was severely underweight, cachectic. Nursing reported feces in her hands and caked in the perineum area. Patient contracted with severe contractures of hands. Patient had severe wounds of all 4 extremities especially right leg. Assessment from hospital records: sepsis likely secondary to multiple wounds, open leg wound, patient with various severe wounds that had not been attended to adequately, will need multiple debridement and plastic surgery, patients condition deplorable and neglected elder. Patient #1 died on 3/5/20. Review of the agency policy and procedure "reporting of abuse, neglect and exploitation and reporting crimes" included: state law requires health care practitioners, social workers and clergy and in some states any individuals to report all suspected or known incidents of abuse, neglect or exploitation of children, dependent adults and elders.. The policy includes report to proper authorities and instances of real or suspected abuse, neglect or exploitation. For those persons perceived to be immediate danger, the local law enforcement shall be notified, annually notify all covered individuals of their obligation to report a suspicion of a crime, refrain from retaliating against any employee who reports a suspicion of a crime against an individual receiving care. Post a notice in a conspicuous location that informs all covered individuals of their reporting obligation and right to file a complaint with the state survey agency if they feel the agency has retaliated. Objective: to ensure that all the hospice agency employee are knowledgeable regarding their legally, mandated responsibilities in reporting (1) instances of known or suspected neglect, abuse or exploitation. Procedure: assure adults immediate safety, this may include calling the police or paramedics, immediately report by telephone to either County Adult Protective Services agency or DCF, notify immediate supervisor, a conference should be convened and attended by all appropriate team members. The agency nurse supervisor will notify the patient care manager, the psychosocial supervisor and the general manager, telephone report of the situation to primary physician, notify patient family, written report of the abuse/neglect must be submitted to APS within 2 working days, copies of the abuse report must be distributed as follows: original to the appropriate county agency, patient medical record, supervisor, psychosocial supervisor, patient care manager, senior program manager. An interview was conducted with Registered Nurse (Employee A) on 7/30 at 5:10pm. She was the primary nurse for Patient #1. She was asked how long she was assigned to Patient #1, she stated since she was admitted in October 2019. She was asked about the caregiver; she said the son was her sole caregiver. He would put her in a wheelchair and wheel her out to the living room to watch TV, but the patient stated she wished he wouldn't do that because he leaves her there all day. She was asked about the frequency of visits, she stated the visits started out 3 x a week for a week, then twice a week for a week and when she would attempt to drop them down to weekly, something would happen and she would have to see her more often. She was asked about communication with the HHAs. She admitted the aide called her frequently with reports of patient being wet or soiled then with wounds. She was asked to describe the physical environment of the home and she indicated the house was cluttered, with dog and goat feces on the floor, it also had a strong odor of urine and feces. She stated she was frequently educating the son on the effects the dirty house and roaches was having on the patient and he would attempt to do better about cleaning, but he was also disabled. When asked about wounds, Employee A stated she didn't really recall any wounds when patient was first admitted but at that time she was eating and drinking and was also consuming 2-3 Ensures a day. She noticed a decline in the skin approximately 3-4 months after admission. She was asked if at any time she thought the conditions and the care for the patient should have been reported to DCF or Adult Protective services and she said that Vitas policy was any concerns about neglect, abuse or exploitation were brought to the IDT meetings held weekly and if a consensus agreed that reporting was appropriate, the Team Manager would be the one making the report. An interview was conducted with HHA (Employee B) on 7/30/20 at 5:25pm. She was asked if she provided care to Patient #1, she stated she went 5 x weeks, Mon-Fri. When asked what care she provided, she said she bathed her, incontinent care and repositioned her. She was bed bound. She was usually in the home for about an hour. The son was her caregiver; however, he did not give her the care she needed. Every time she went to the home, she was soaked with urine and feces and had not been repositioned since she left the day before. On Mondays it was worse because she had no aide on the weekends. She would be wet from top to bottom. When asked if she had reported this to her supervisor. She said she always told the RN, the Team Manager in the office and the social worker. However, nothing was done. She wanted to call DCF but was told the IDT team would make that decision. An interview was conducted on 7/30/20 at 5:15pm with National Patient Care Administrator. She started out by saying that the previous PCA of this office and the General Manager (GM) were no longer with the agency. She was asked when she was made aware of what happened with Patient #1, she said not until a State agency came into investigate an allegation of neglect, did not have exact date. She was asked if it was the policy of the hospice agency to not allow staff to call DCF for suspected abuse/neglect, she stated "no." The staff were educated to notify their Supervisor of any concerns so it can be brought to the team meeting. She was asked if she was made aware that staff were instructed not to call DCF. She was not aware until after the previous management, the PCA and GM were no longer employed.
L0536      
28608 Based on record review and staff interview, the agency failed maintain a system of communication and integration, in accordance with the hospice's own policies and procedures, to ensure that the interdisciplinary group maintains responsibility for directing, coordinating supervising the care and services provided for 1 or 3 sampled patients (Patient #1). The agency failed to ensure the Interdisciplinary Group (IDG) maintained responsibility for directing, coordinating and supervising the care and services for Patient #1 to address caregiver neglect. Patient #1 was admitted to hospice services on 10/21/19. The patient experienced a decline in condition due to lack of care by the caregiver, which was identified by the agency. Patient #1 suffered from pain, severe pressure ulcers to upper and lower extremities, severe weight loss, dehydration and sepsis. The patient was taken to the hospital by EMS on 02/24/20, where she died on 03/05/20. These conditions resulted in Immediate Jeopardy (IJ). The Immediate Jeopardy (IJ) was identified on 8/11/20. On 8/11/20 at 11:30 am the Patient Care Administrator and General Manager were notified of the IJ determination. The IJ was ongoing at the time of exit. IJ was removed as of the date of the IJ removal plan 8/12/2020. The IJ revisit ocurred on 8/24/2020. The Findings include: Cross reference L 554, L556 The agency failed to ensure that the IDG Group acted by notifying DCF of caregiver neglect upon discovery. They failed to revise the plan of care for Patient #1 to increase visits to assist with Activities of Daily Living to prevent decline, dehydration and severe skin ulcer that contributed to her untimely death. They failed to a system of communication for all staff to report suspected abuse/neglect to DCF.
L0554      
28608 Based on record review and staff interview, the agency failed to ensure the Interdisciplinary Group maintained responsibility for directing, coordinating and supervising the care and services for 1 of 3 sampled patients to prevent neglect. (Patient #1) Immediate Jeopardy (IJ) at a scope of J (isolated) was identified at 5:15pm on 8/6/20, which is ongoing. On 8/11/20 at 11:30 am the Patient Care Administrator and General Manager were notified of the IJ determination. IJ was removed as of the date of the IJ removal plan, 8/12/2020. The IJ revisit ocurred on 8/24/2020. The findings include: Patient #1 was admitted to hospice service on 10/21/19. The plan of care included Skilled nurse (SN) every 2 weeks, Medical Social Worker (MSW) every 3 months, Chaplain every 3 months and as requested and Home Health Aide (HHA) 5 x weeks. The initial nursing assessment on 10/21/19 revealed Patient #1 was bed bound, cognitively impaired, required total assistance with all Activities of Daily Living. She was incontinent of bowel and bladder, unable to transfer out of bed or re-position self in bed. She also could not feed herself or drink fluids on her own. There was no skin breakdown. She resided at home with son as the sole caregiver. The Interdisciplinary group (IDG) included the RN, Team Manager, MSW, Chaplain and Patient Care Administrator (PCA). The IDG meets weekly to assess the needs of the patients and update the plan of care to reflect current needs. Review of the initial Plan of Care (POC) on 10/29/19 revealed Patient #1 was very confused, difficulty following simple commands, oxygen as needed, weight loss, poor appetite, provide supplemental Ensure, current UTI, educate caregiver for proper pericare, HHA 5 x week, provide emotional support and respect wishes. POC dated 11/12/19 included recent agitation, physician ordered Ativan, bed bound, total care HHA 5 x week. POC 11/26/19 discontinue Norco, continue with Morphine. POC 12/24/19 caregiver stated patient in a lot of pain, treatment effective. POC 1/7/20 bed sores, pressure ulcers to left and right hip and lumbar spine. Education for caregiver reinforced. On 1/21/20, air mattress for Stage 3 pressure wounds, patient confused increased agitation. 2/4/20 bedbound, complete muscle wasting, foam boots for heels. 2/9/20 multiple pressure ulcers on back, hips, ankles and now hallucinating. POC dated 2/18/20 revealed entire body breakdown, patient in urine 14-16 hours a day, confused, hallucinating. The POC's did not address the RN and HHA observations of Patient #1 being found saturated in urine and feces, not repositioned between staff visits, development of multiple pressure sores on all extremities, weight loss, dehydration or filthy living conditions and roaches, there was no discussion and documentation by the IDG regarding neglect in the home or need to call DCF. There were no recommendations to increase HHA visits to include weekends and increase RN visits to provide adequate wound care. On 12/27/19, an unannounced home visit was made by Team Manager, RN and Social Worker due to concerns of HHA always finding patient soaked in urine and feces and home dirty with roaches. There was no documentation regarding findings of the home visit. During an interview with Team Manager on 7/30/20 at 4:40pm, she was asked what determination was made at conclusion of the visit. She said that patient was clean and dry when they arrived. Asked if she had seen the wounds, she said "no." The son requested an air mattress and was provided. When asked if the team had made any follow up visits to the home to reassess due to continued concerns from staff about being left soaked in urine, development of multiple pressure sores and report of roaches, she said "no." She was asked why DCF was not notified regarding the continued lack of care by the caregiver resulting in severe wounds, she stated she brought her concerns to the PCA at the agency at the time and was told not to report. She then brought her concerns to the General Manager at that time and was told not to report. She was asked why she did not call, she said in retrospect they should have. She was asked if it was this hospice's policy that nursing staff in the field were not allowed to call DCF, only administrative staff. She said the IDG team discussed those situations in the care meetings and team to investigate need to call. An interview was conducted with Registered Nurse, Employee Aon 7/30/20 at 5:10pm, she was the primary nurse for Patient #1. She was asked how long she was assigned to Pt. #1, she stated since she was admitted in October 2019. She was asked about the caregiver; she said the son was her sole caregiver. He would put her in a wheelchair and wheel her out to the living room to watch TV, but the patient stated she wished he wouldn't do that because he leaves her there all day. She was asked about the frequency of visits, she stated the visits started out 3 x a week for a week, then twice a week for a week and when she would attempt to drop them down to weekly, something would happen and she would have to see her more often. She was asked about communication with the HHA's, she admitted the aide called her frequently with reports of patient being wet or soiled then with wounds. She was asked to describe the physical environment of the home and she indicated the house was cluttered with dog and goat feces on the floor; it also had a strong odor of urine and feces. She stated she was frequently educating the son on the effects the dirty house and roaches was having on the patient and he would attempt to do better about cleaning, but he was also disabled. When asked about wounds, Employee A stated she didn't really recall any wounds when the patient was first admitted but at that time, she was eating and drinking and was also consuming 2-3 Ensures a day. She noticed a decline in the skin approximately 3-4 months after admission. She was asked if at any time she thought the conditions and the care for the patient should have been reported to DCF or Adult Protective services and she said that Vitas policy was any concerns about neglect, abuse or exploitation were brought to the IDT meetings held weekly and if a consensus agreed that reporting was appropriate, The Team Manager would be the one making the report.
L0556      
28608 Based on record review and staff interview, the agency failed to maintain a system of communication to report suspected abuse/neglect and ensure care and services were based on patient assessments and family needs for 1 of 3 sampled patients. (Patient #1) Immediate Jeopardy (IJ) at a scope of J (isolated) was identified at 5:15pm on 8/6/20, which is ongoing. On 8/11/20 at 11:30 am, the Patient Care Administrator and General Manager were notified of the IJ determination. IJ was removed as of the IJ removal plan, 8/12/2020. The IJ revisit ocurred on 8/24/2020. The findings include: Review of the Nursing updated comprehensive assessments completed by RN, Employee A on 12/27/19, 1/3/20, 1/31, 2/7, 2/13, 2/18 revealed Patient #1 moans and grimaces at times during ADL's; soaked in urine upon arriving. Reinforced with caregiver importance of cleaning perineal area. Stage 3 wounds, decrease appetite, does like Ensure, caregiver overwhelmed, very anxious and unwilling comply to instructions, increase pain related to multiple dressing changes. Nurse documented son had no home or money if mother dies. HHA continues to report patient soaked in urine at each visit and left wet for hours. Roaches observed in home and patient room. 2/13/20 wounds to left and right hip Stage 4, full thickness and tendons exposed. Nurse documented caregiver an alcoholic, drug addict with no job, nowhere to go once mother dies, very panicked told her he will do anything to keep her alive. There was no documentation that the MSW was made aware of caregiver concerns, lack of care and oversight of Patient #1 that resulted in severe neglect. On 2/18/20, SN documented Patient #1 has pain when moved or repositioned, she was in fetal position with hands contracted. Calls prior to visit to have caregiver give pain medication to be able to do dressing changes, otherwise very dramatic, screams and yells. Instructed caregiver to increase fluids for patient dehydrated. Son leaves her for many hours in wet urine-soaked bed. Skin in very bad shape, new wound to right shin 6cm x 3 cm and bloody. Despite the ongoing documented neglectful treatment by the caregiver, the agency failed to report to DCF. An interview was conducted with Registered Nurse (Emp. A) on 7/30 at 5:10pm, she was the primary nurse for Patient #1. She was asked how long she was assigned to Pt. #1, she stated since she was admitted in October 2019. She was asked about the caregiver; she said the son was her sole caregiver. He would put her in a wheelchair and wheel her out to the living room to watch TV, but the patient stated she wished he wouldn't do that because he leaves her there all day. She was asked about the frequency of visits, she stated the visits started out 3 x a week for a week, then twice a week for a week and when she would attempt to drop them down to weekly, something would happen and she would have to see her more often. She was asked about communication with the HHA's, she admitted the aide called her frequently with reports of patient being wet or soiled then with wounds. She was asked to describe the physical environment of the home and she indicated the house was cluttered, with dog and goat feces on the floor. It also had a strong odor of urine and feces. She stated she was frequently educating the son on the effects the dirty house and roaches was having on the patient and he would attempt to do better about cleaning, but he was also disabled. When asked about wounds, Employee A stated she didn't really recall any wounds when patient was first admitted but at that time she was eating and drinking and was also consuming 2-3 Ensures a day. She noticed a decline in the skin approximately 3-4 months after admission. She was asked if at any time she thought the conditions and the care for the patient should have been reported to DCF or Adult Protective services and she said that Vitas policy was any concerns about neglect, abuse or exploitation were brought to the IDT meetings held weekly and if a consensus agreed that reporting was appropriate, the Team Manager would be the one making the report.
L0559      
28608 Based on record review and staff interview, the agency failed to ensure the Condition of Participation for Quality Assessment/Performance improvement requirement was met by failing to ensure the implementation of an ongoing quality assessment program to monitor effectiveness, safety of services and quality of care. The agency failed to identify patients who were high risk, high volume or problem prone areas. There was no mechanism in place to address incidences, prevalence or severity of problems at the time incidents occurred. The agency had no system in place to track adverse events or reporting of abuse/neglect or implement plan of action immediately following incident regarding caregiver neglect of Patient #1, in which the agency failed to report to the state abuse agency. The neglect caused avoidable suffering to Patient #1 and contributed to her death. Immediate Jeopardy (IJ) was identified at 5:15 p.m. on 8/6/20, which is ongoing. On 8/11/20 at 11:30 am the Patient Care Administrator and General Manager were notified of the IJ determination. IJ was removed as of the date of the IJ removal plan, 8/12/2020. The IJ revisit ocurred on 8/24/2020. The Findings include: Cross reference L517, L560, L573 The facility failed to promote and protect the rights of Patient#1 when her son, caregiver was unable to manage the patient's care resulting in neglect of the patient. The patient suffered dehydration, severe bedsores and was in sepsis when hospitalized. The facility failed to revise the care plan to ensure Patient #1 received the necessary care and services to prevent suffering and pain. The facility failed to report neglect to DCF that would have prevented her from severe neglect that contributed to her death.
L0560      
28608 Based on record reviews and staff interviews and the agency's policy and procedure for Quality Assurance Performance Improvement (QAPI), the facility failed to ensure quality assurance monitoring of facility processes related to abuse/neglect and to ensure identification of potential significant problems. The lack of follow up regarding staff reporting of neglect in the home for 1 of 3 patients resulted in the death of Patient #1. Immediate Jeopardy (IJ) at a scope of J (isolated) was identified at 5:15pm on 8/6/20, which is ongoing. On 8/11/20 at 11:30 am, the Patient Care Administrator and General Manager were notified of the IJ determination. IJ was removed as of the date of the IJ removal plan, 8/12/2020. The IJ revisit ocurred on 8/24/2020. The findings include: Patient #1 was admitted to hospice service on 10/21/19. The plan of care included Skilled nurse (SN) every 2 weeks, Medical Social Worker (MSW) every 3 months, Chaplain every 3 months and as requested and Home Health Aide (HHA) 5 x weeks. The initial nursing assessment on 10/21/19 revealed Patient #1 was bed bound, cognitively impaired, required total assistance with all Activities of Daily Living. She was incontinent of bowel and bladder, unable to transfer out of bed or re-position self in bed. She also could not feed herself or drink fluids on her own. There was no skin breakdown. She resided at home with son as the sole caregiver. Skilled nurse (SN) note 11/8/19 found patient soaking wet on every visit, also observed caregiver leaves sandwich at bedside, however, she had no idea how to eat and tried eating plate. Physician progress noted dated 11/20/19 revealed a face to face visit, patient is dependent on 6 of her ADL's, has extensive bruising on upper extremities and hematoma to right arm. Son requested an increase in dementia medications and wants her to remain on morphine ER and hydrocodone, there is likely a diversion of medications here. SN note dated 12/3/19 found Patient #1 soaked in urine on arrival. On 12/12/19 found her with foul smelling diarrhea and bladder pain. On 12/17/19 SN documented was moaning and grimacing, rapid breathing when turned and positioned. Review of MSW note dated 12/10/19 revealed she attempted to schedule plan of care meeting with son to address concerns of care, per HHA the patient is found wet from top to bottom daily. HHA believes the caregiver not caring for patient as needed. The caregiver was angered by allegation and declined meeting visit. Review of the physician progress note dated 12/18/19, MD revealed the nurse was called out today, son concerned stool coming out of urethra, loose stool from rectum. Patient sits in stool all day, HHA reports that she is soaked from head to toe every time she comes. Nurse recommends IV fluids because she appears very dehydrated. It was recommended patient to go to inpatient unit for fluids. The son adamantly refused to sign DNR. The son was advised to push fluids. Patient will be monitored closely. There was no documentation that Patient #1 received IV fluids. On 12/20/19, the HHA reported to RN Team Manager that Patient #1 was always found soaked with urine and covered with feces at every visit. On 12/23/19, HHA again reported to RN Team Manager that Patient #1 was found soaked in urine and covered with feces. SN note dated 12/27/19 revealed Pt #1 was completely soaked on visit, also there were Stage 3 wounds documented to left and right hip and lumbar spine. Wound care orders were obtained but frequency of visits was not increased. On 12/27/19, an unannounced home visit was made by Team manager, RN and Social worker due to concerns of HHA always finding patient soaked in urine and feces and home dirty with roaches. There was no documentation regarding findings of the home visit. During an interview with Team Manager on 7/30/20 at 4:40pm, she was asked what determination was made at conclusion of the visit. She said that patient was clean and dry when they arrived. Asked if she had seen the wounds, she said "no." The son requested an air mattress and was provided. When asked if the team had made any follow up visits to the home to reassess due to continued concerns from staff about being left soaked in urine, development of multiple pressure sores and report of roaches, she said "no." She was asked why DCF was not notified regarding the continued lack of care by the caregiver resulting in severe wounds, she stated, she brought her concerns to the PCA at the agency at the time and was told not to report. She then brought her concerns to the General Manager at that time and was told not to report. She was asked why she did not call, she said in retrospect they should have. She was asked if it was this hospice's policy that nursing staff in the field were not allowed to call DCF, only administrative staff. She said the IDT team discussed those situations in the care meetings and team to investigate need to call. On 1/3/20 a Foley catheter was ordered. Son refused. SN documented the wounds on left hip Stage 4 x 5 x 3 cm with yellow tissue and foul odor. Skin paper thin and tears easily. Also has skin breakdown left distal and medial ankle. The caregiver was instructed to pre-medicate prior to dressing changes as patient screamed, yelled and moaned when dressings changed. Review of the physician progress note dated 1/23/20 revealed, patient had 6 bed sores noted and on Monday mornings she was covered in urine and feces from the weekend without an HHA. The son said he could not lift her due to back pain. Review of the orders found no increase in frequency of HHA's or RN visits. The RN was only visiting weekly despite the need for more frequent dressing changes. SN note dated 1/30/20 found wounds trying to heal but patient always soaked with urine and they reopened. On 2/7/20, SN documented the skin in terrible shape, multiple small sores on back, both hips and feet. The caregiver leaves patient 14-16 hours in urine and feces despite many conversations regarding skin care. Also, roaches were seen in patients' room. On 2/13/20, patient complained of pain. When moved she moans, yells, push hands away and points at different areas. Stage 4 wounds left hip 5 x 6 cm second area 2 x 3 cm tendon exposed, full thickness dried blood and foul odor. Both heels unstageable full thickness. Patient premedicated for procedures still anxious, yells and moans. Caregiver alcoholic, drug addict, has no job, nowhere to go once mom dies very panicked. States he will do anything to keep her alive. Caregiver disabled and leaves patient in urine 16 hours. On 2/17/20, SN attempted to insert Foley catheter, patient scratched and screamed and pulled hands away. Patient was hallucinating, antibiotic started for urine infection, patient dehydrated need to increase fluids. Review of HHA note dated 2/18/20, wounds are getting worse, son still leaving her in urine. On 2/20/20 patient barely eating or drinking, has more skin breakdown and son keeps leaving her in urine. SN note dated 2/21/20 revealed new 9 cm x 5 cm wide skin tear down right shin. Son pulled pillow from between legs and skin tore. Review of physician progress note dated 2/24/20 revealed patient has large skin tear down her back and right shin and bed was full of blood. She has necrotic areas of the heels; she has multiple decubitus ulcers. Left hip 5 x 6 cm with tendon visible. Also, one large area on her sacrum, another of her ankle. EMS was activated, paramedics want to call DCF. The patient's son considering transferring her to ER. The conditions at home are harsh. There are cock roaches everywhere. The patient clenching both hands and has contractures. Her oral intake is markedly reduced. Her dentures no longer fit. Pt. will be monitored closely. SN note dated 2/24/20 revealed extreme pain from new wound to Right lower leg, Patient dehydrated and observed with milky urine, scant amount and foul odor. Son instructed to call 911. EMS arrived and transferred to hospital. As result of multiple infected pressure sores, malnutrition and dehydration, Patient #1 died at the hospital 3/5/20. Review of the hospital records dated 2/24/20 revealed she was severely underweight, cachectic. Nursing reported feces in her hands and caked in the perineum area. Patient contracted with severe contractures of hands. Patient had severe wounds of all 4 extremities especially right leg. Assessment: sepsis likely secondary to multiple wounds, open leg wound, patient with various severe wounds that had not been attended to adequately, will need multiple debridement and plastic surgery, patients condition deplorable and neglected elder. As a result of severe neglect Patient #1 died on 3/5/20. Review of the agency policy and procedure "reporting of abuse, neglect and exploitation and reporting crimes" included: state law requires health care practitioners, social workers and clergy and in some states any individuals to reported all suspected or known incidents of abuse, neglect or exploitation of children, dependent adults and elders.. The policy includes report to proper authorities and instances of real or suspected abuse, neglect or exploitation. For those persons perceived to be immediate danger, the local law enforcement shall be notified, annually notify all covered individuals of their obligation to report a suspicion of a crime, refrain from retaliating against any employee who reports a suspicion of a crime against an individual receiving care. Post a notice in a conspicuous location that informs all covered individuals of their reporting obligation and right to file a complaint with the state survey agency if they feel the agency has retaliated. Objective: to ensure that all the hospice agency employee are knowledgeable regarding their legally, mandated responsibilities in reporting (1) instances of known or suspected neglect, abuse or exploitation. Procedure: assure adults immediate safety, this may include calling the police or paramedics, immediately report by telephone to either County Adult Protective Services agency or DCF, notify immediate supervisor, a conference should be convened and attended by all appropriate team members. The agency nurse supervisor will notify the patient care manager, the psychosocial supervisor and the general manager, telephone report of the situation to primary physician, notify patient family, written report of the abuse/neglect must be submitted to APS within 2 working days, copies of the abuse report must be distributed as follows: original to the appropriate county agency, patient medical record, supervisor, psychosocial supervisor, patient care manager, senior program manager. An interview was conducted with Registered Nurse (Emp A) on 7/30 at 5:10pm, she was the primary nurse for Patient #1. She was asked how long she was assigned to Patient #1, she stated since she was admitted in October 2019. She was asked about the caregiver; she said the son was her sole caregiver. He would put her in a wheelchair and wheel her out to the living room to watch TV, but the patient stated she wished he wouldn't do that because he leaves her there all day. She was asked about the frequency of visits she stated the visits started out 3 x a week for a week, then twice a week for a week and when she would attempt to drop them down to weekly something would happen and she would have to see her more often. She was asked about communication with the HHA's. She admitted the aide called her frequently with reports of patient being wet or soiled then with wounds. She was asked to describe the physical environment of the home and she indicated the house was cluttered, with dog and goat feces on the floor, it also had a strong odor of urine and feces. She stated she was frequently educating the son on the effects the dirty house and roaches was having on the patient and he would attempt to do better about cleaning, but he was also disabled. When asked about wounds, Employee A stated she didn't really recall any wounds when patient was first admitted, but at that time she was eating and drinking and was also consuming 2-3 Ensures a day. She noticed a decline in the skin approximately 3-4 months after admission. She was asked if at any time she thought the conditions and the care for the patient should have been reported to DCF or Adult Protective services and she said that Vitas policy was any concerns about neglect, abuse or exploitation were brought to the IDT meetings held weekly and if a consensus agreed that reporting was appropriate, the Team Manager would be the one making the report. An interview was conducted with HHA (Emp B) on 7/30/20 at 5:25pm. She was asked if she provided care to Patient #1, she stated she went 5 x weeks, Mon-Fri. When asked what care she provided, she said she bathed her, incontinent care and repositioned her. She was bed bound. She was usually in the home for about an hour. The son was her caregiver; however, he did not give her the care she needed. Every time she went to the home, she was soaked with urine and feces and had not been repositioned since she left the day before. On Mondays it was worse because she had no aide on the weekends. She would be wet from top to bottom. When asked if she had reported this to her supervisor, she said she always told the RN, the Team Manager in the office and the Social Worker. However, nothing was done. She wanted to call DCF but was told the IDT team would make that decision. An interview was conducted on 7/30/20 at 5:15pm with National PCA. She started out by saying that the previous PCA of this office and the General Manger were no longer with the agency. She was asked when she was made aware of what happened with Pat #1, she said nothing until a State agency came into investigate an allegation of neglect. She did not have exact date. She was asked if it was the policy of the hospice agency to not allow staff to call DCF for suspected abuse/neglect, she stated "no." The staff are educated to notify their supervisor of any concerns so it can be brought to the team meeting. She was asked if she was made aware that staff were instructed not to call DCF. She was not aware until after the previous management, the PCA and GM were no longer employed. An interview was conducted with Performance Improvement Specialist (PIS) on 8/6/20 at 1:45pm. She was asked how often Quality Assurance Performance Improvement (QAPI) meetings were conducted, she said quarterly. She said she facilitated the meetings. She collected the data including Core audits, Comprehensive assessments, visits, admissions, bereavement, human resources, certifications and medications. Focus audits were monthly and decided by corporate. She was asked if a QAPI meeting was held when informed of the issue of neglect, she said "no" however there was one scheduled this month. She was asked if a Performance Improvement Project (PIP) was initiated regarding identified neglect of a patient, she said not yet but would get started. When asked how significant quality of care issues were conveyed to her and what was the protocol for follow up, she said by e-mail or at the QAPI meeting. When issue identified by QAPI committee then a PIP is developed by the team. An interview was conducted on 7/30/20 at 4:55pm with Patient Care Administrator (PCA)Emp C. When asked about her role, she said she was assisting with training the new PCA for this office. She was asked if she was aware of the issues related to Patient #1, she said she was made aware. What measures were taken when the incident was brought to the agency's attention. She stated there was staff training regarding abuse/neglect and reporting. She was asked to provide the training and in-service records, she said she would get them. She was asked if a QAPI meeting was conducted to immediately address the issues. She said there were PIP's done. She was asked to provide all education, in services conducted and all PIP's that were in progress as well as meeting minutes for QAPI meeting. She said she would get them; they are done by corporate. She said that the former PCA and General Manager were no longer employed by the agency. When asked if an audit had been conducted of all home care patient records to ensure there were no other patients at risk for abuse/neglect, she said "not to date." No education records or in-service training records were provided. On 8/6/20, an interview was conducted with PCA Emp C and General Manager on 8/6/20 at 4:30pm. During the interview it was revealed that the home care team manager had reported to the former PCA regarding concerns of neglect for Patient #1 and that DCF should be called. The Team Manager was told not to report concern to DCF. She then went to the GM at the time regarding her concerns and need to report but was told not to report to DCF. She said it wasn't until PCA and GM left employment did the agency become aware of the previous management not allowing staff to report abuse/neglect. When asked if charts had been audited to ensure no further incidents, she stated "no" but would initiate audit immediately. She was asked what measures had been put into place since the agency was made aware of neglect not being reported, she said on 7/31/20 there was self-study education provided to all staff regarding abuse/neglect with a post test and all employees signed attestation that training completed. When asked if QAPI meeting had been held, she said it would take place this month and PIP would be implemented to address reporting abuse/neglect. She was asked if the neglect for Patient #1 had been reported to the State agency, she said not that she was aware.
L0573      
28608 Based on agency staff interview, the agency failed to document any performance improvement activities related to lack of care provided by the caregiver for 1 of 3 patients, resulting in the death of Patient #1. Immediate Jeopardy (IJ) at a scope of J (isolated) was identified at 5:15pm on 8/6/20, which is ongoing. On 8/11/20 at 11:30 am the Patient Care Administrator and General Manager were notified of the IJ determination. IJ was removed as of the date of the IJ removal plan, 8/12/2020. The IJ revisit ocurred on 8/24/2020. The findings include: An interview was conducted on 7/30/20 at 4:55pm with Patient Care Administrator (PCA)Emp C. When asked about her role, she said she was assisting with training the new PCA for this office. She was asked if she was aware of the issues related to Patient #1, she said she was made aware. What measures were taken when the incident was brought to the agency's attention. She stated there was staff training regarding abuse/neglect and reporting. She was asked to provide the training and in-service records, she said she would get them. She was asked if a QAPI meeting was conducted to immediately address the issues. She said there were PIP's done. She was asked to provide all education, in services conducted and all PIP's that were in progress as well as meeting minutes for QAPI meeting. She said she would get them; they are done by corporate. She said that the former PCA and General Manager (GM) were no longer employed by the agency. When asked if an audit had been conducted of all home care patient records to ensure there were no other patients at risk for abuse/neglect, she said "not to date." No education records or Inservice training records were provided. An interview was conducted with Performance Improvement Specialist (PIS) on 8/6/20 at 1:45pm. She was asked how often Quality Assurance Performance Improvement (QAPI) meetings were conducted, she said, quarterly. She said she facilitated the meetings. She collected the data including Core audits, Comprehensive assessments, visits, admissions, bereavement, human resources, certifications and medications. Focus audits were monthly and decided by corporate. She was asked if a QAPI meeting was held when informed of the issue of neglect, she said, "no" however there was one scheduled this month. She was asked if a Performance Improvement Project (PIP) was initiated regarding identified neglect of a patient, she said not yet but would get started. When asked how significant quality of care issues were conveyed to her and what was the protocol for follow up, she said by e-mail or at the QAPI meeting. When issue identified by QAPI committee then a PIP was developed by the team. On 8/6/20, an interview was conducted with PCA Employee C and General Manager on 8/6/20 at 4:30pm. During the interview, it was revealed that the home care Team Manager had reported to the former PCA regarding concerns of neglect for Patient #1 and that DCF should be called. The Team Manager was told not to report concern to DCF. She then went to the GM at the time regarding her concerns and need to report but was told not to report to DCF. She said it wasn't until PCA and GM left employment did the agency become aware of the previous management not allowing staff to report abuse/neglect. When asked if charts had been audited to ensure no further incidents she stated, "no" but would initiate audit immediately. She was asked what measures had been put into place since the agency was made aware of neglect not being reported, she said on 7/31/20, there was self-study education provided to all staff regarding abuse/neglect with a post test and all employees signed attestation that training completed. When asked if QAPI meeting had been held, she said it would take place this month and PIP would be implemented to address reporting abuse/neglect. She was asked if the neglect for Patient #1 had been reported to the State agency, she said not that she was aware.