| 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 |
| 111651 | A. BUILDING __________ B. WING ______________ |
10/20/2020 | |
| NAME OF PROVIDER OR SUPPLIER | STREET ADDRESS, CITY, STATE, ZIP | ||
| COMPASSUS-ATHENS | 2470 DANIELS BRIDGE ROAD BLDG 100 SUITE 181, ATHENS, GA, 30606 | ||
| 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 |
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| 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) |
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| L0505 | |||
| 38966 Based on review of company "Policy and Procedure C 06A - Complaints and Grievances Revision dated on 01/11/18," medical record review, staff and family interviews, agency failed to investigate, document and file the verbal complaints and grievances made by Patient (P#1)'s daughter, related to pain management and medication issues, in the grievance or call log. Finding Include: During an interview with P#1's family, it was revealed that hospice staff were not communicating with P#1's daughter. when she continued to call the hospice office, nurses and physician, the responses of hospice nurses were not satisfactory and P#1's family was frustrated. They felt they did not have the support and cooperation of hospice nurses, since there was no one to explain the medication issues and update them on P#1 medical status. Again, nothing was documented by the Director of Clinical Services (DCS #1) to show that she investigated or filed in the grievances in call log. On 10/20/20 at 12:29 p.m., DCS #1 told Surveyor, "I forgot, and I will take the blame." According to Compassus hospice policy and procedure, the DCS is responsible to investigate patient's or family complaints within five days, make a resolution, complete documentation, and file the complaints in call log. A review of P#1 medical record revealed that she was admitted to Compassus hospice on 9/4/20 with a diagnosis of Chronic Systolic Congestive heart failure, Type 2 diabetes, Cellulitis of left upper limb, and Dementia. It also revealed that there was a discrepancy in P#1 medications. Some of the medications were discontinued by the hospital and were reconciled by Registered Nurse (RN AA hospice admission on-call nurse) but the Medication Administration Record (MAR) from hospice does not match THE Assisted Living Facility (ALF) MAR, which resulted in P#1 not receiving her medications for four days from 9/5/20 to 9/8/20. Patient (P#1) was on Cymbalta 60 Milligrams (mg) (Antidepressant) oral daily started on 9/4/20, docusate sodium(Stool softner) 100mg oral twice daily, Hydrocodone (Narcotic)7.5mg oral every six hours, Eliquis (Anticoagulant) 2.5mg oral twice daily, Linzess 145 Micrograms (MCG) (Irritable bowel syndrome) oral daily, Trazodone 50mg (Antidepressant) oral at bedtime, Synthroid 50mcg (Thyroid hormone) oral daily, Torsemide 20mg (Diuretic) oral daily, Tylenol extra strength 500mg (Analgesics) oral twice daily, Aspirin 81mg (Anti-inflammatory) oral daily, and hospice comfort kits medications, all ordered on 9/4/20. A copy of all medications dated on 9/4/20 was given to Surveyor. Nurses' notes revealed that the dressing to wounds on the bottom and left fourth finger, was done by RN AA on 9/4/20 per physician's order. Medication Administration logs revealed that physician ordered Lorazepam 0.5mg (Anti-anxiety) oral, give one tablet every six hours, 20 tablets, was filled by Assisted living facility (ALF) pharmacy two days after the order was received from physician. (ALF) Medication Technician administered lorazepam 0.5mg oral two tablets dated 9/9/20, 9/17/20 and 9/19/20 signed from comfort kits. During an interview with RN AA on 10/20/20, and upon review of P#1 record, it was revealed that there was communication issues between hospice nurses, ALF staff and P#1's family. The medications were administered as ordered, and reconciliation was done. But according to P#1's family, the hospice nurses did not take time to explain to them. On 10/20/20 at 12:29 p.m., an interview was conducted with Director of Clinical Service (DCS #1), stated that she remembered that there was an issue of medication reconciliation during the admission. The case manager was RN BB. DCS #1 stated that P#1's daughter called her and complained about how the hospital discontinued P#1 medications, but DCS #1 stated that she forgot to document or write a grievance report: "I forgot and I will take the blame." On 10/20/20 at 1:39 p.m., an interview was conducted with RN AA, stated that she did P#1 admission, obtained the order from physician, and changed bottom and left fourth finger dressing as ordered. RN AA stated that did medication reconciliation and faxed the order to P#1 Pharmacy as requested by P#1's daughter, since that was where her mother got all her medications. RN AA stated that she communicated well with P#1's family and explained the medication issue with them. RN AA stated that P#1's daughter appreciated her and said no one had explained or updated her the way RN AA did. On 10/20/20 at 1:55 p.m., an interview was conducted with DCS #2, stated that P#1's daughter expressed her frustration, explaining how her mother had lived with her and her husband, until her husband was diagnosed with cancer, and she, being unable to care for both of them, had to send her mother to ALF. P#1's daughter complained that the ALF staff did not take good care of her mother, and that was why they had medication issue from hospital, because the ALF did not have qualified staff skilled in nursing. P#1's daughter stated that Covid-19 made things even worse because ALF did not allow her or any visitor to see her mother, causing her mother's anxiety to increase and making her to shed tears at the time. DCS #2 stated that Chaplain was there visiting P#1. On 10/20/20 at 2:10 p.m., an interview was conducted with RN BB, stated that she was a case manager for P#1 and took good care of her. RN BB said P#1's daughter called her several times and she responded to her. RN BB stated P#1's daughter called her one weekend and said that her mother ran out of Ativan. RN BB said that she was off that weekend and notified the on-call nurse, which was RN AA. RN BB stated that RN AA went to visit P#1 that weekend and resolved the issue. P#1's daughter preferred pharmacy and hospice nurse faxed the Ativan order to pharmacy per P#1 request, but pharmacy couldn't do bubble pack medication and notified ALF director of nursing. ALF director of nursing faxed the order to ALF pharmacy and Ativan was filled. RN BB said she always did complete assessment including pain assessment, wounds care and medication reconciliation every visit. During an interview on 10/20/20 with RN BB she verbalized that P#1's daughter complained of medications issues and she explained to her that the issue was between hospital and ALF, and it was resolved. RN BB notified DCS #1, and DCS #1 said P#1's family called her to report medication issues, but she forgot to file the grievance or document it in call log. On 10/20/20 at 3:38 p.m., an interview was conducted with P#1's daughter. She was crying and expressed her concern related to what happened between her and the hospice nurses. She verbalized her frustration on issues between her and DCS #2, who told her mother that she was hospice nurse, after P#1's daughter told DCS #2 not to let P#1 know that she works for hospice. P#1's daughter said that the only nurse that she trusted was RN AA. P#1's daughter said nobody explained or updated her on medication issues and her mother's health condition. P#1's daughter further stated that DCS #2 did not assess, reconcile medications or wrap (or dress) her mother's wounded left finger. Surveyor asked DCS #2 why she did not assess P#1, wrap left fourth finger, or do medication reconciliation. DCS #2 denied the allegations. Patient #1's daughter stated her mother was taken off psychiatric medications cold turkey when she was admitted, and she was notified by ALF Medication Technician. P#1's daughter also complained about physician not responding to her call when her mother ran out of Ativan (anti-anxiety) the night before she died. P#1's daughter further stated they were complaining and shouting for help over the weekend and not being heard by physician nor hospice nurses, including DCS #1 and #2. P#1's daughter constantly repeated that the only nurse she trusted was RN AA. | |||
| L0545 | |||
| 38966 Based on medical record review, staff and family interviews, agency failed to follow Plan of Care and Physician's order to administer medication missing doses from 9/5/20 to 9/9/20 for four days. FINDINGS INCLUDE: Upon review of Compassus Hospice Plan of Care "Policy and Procedure C-09A revision and dated 9/27/19," reveals that the admitting Registered Nurse begins the plan of care by reviewing all documented assessment information, diagnoses, and medications reconciliation, communicate and collaborate with facility staff, to make sure that patient receives proper care. A review of P#1 medical record revealed that P#1 was admitted to Compassus hospice on 9/4/20 with a diagnosis of Chronic Systolic Congestive heart failure, Type 2 diabetes, Cellulitis of left upper limb, and Dementia. It also revealed that there was a discrepancy in P#1 medications. Some medications discontinued by the hospital were reconciled by Registered Nurse (RN AA hospice admission on-call nurse) did not match with Assisted Living Facility (ALF) Medication Administration Record (MAR). The medications ordered by hospice physician forPatient (P#1) was on Cymbalta 60 Milligrams (mg) (Antidepressant) oral daily started on 9/4/20, docusate sodium(Stool softner) 100mg oral twice daily, Hydrocodone (Narcotic)7.5mg oral every six hours, Eliquis (Anticoagulant) 2.5mg oral twice daily, Linzess 145 Micrograms (MCG) (Irritable bowel syndrome) oral daily, Trazodone 50mg (Antidepressant) oral at bedtime, Synthroid 50mcg (Thyroid hormone) oral daily, Torsemide 20mg (Diuretic) oral daily, Tylenol extra strength 500mg (Analgesics) oral twice daily, Aspirin 81mg (Anti-inflammatory) oral daily, and hospice comfort kits medications, all ordered on 9/4/20. A copy of all medications dated on 9/4/20 was given to Surveyor. Nurses' notes revealed that the dressing to wounds on the bottom and left fourth finger, was done by RN AA on 9/4/20 per physician's order. These medications ordered were supposed to start on 9/4/20, but ALF MAR did not match the hospice MAR. as a result, P#1 did not receive the above medications for four days, and Hospice nurses did not obtain order from physician to hold or discontinue the medications for four days. Cross reference L653 | |||
| L0653 | |||
| 38966 Based on medical record review, staff and family interviews, agency failed to administer medications missing doses from 9/5/20 to 9/9/20 for four days. FINDINGS INCLUDE: A review of P#1 medical record revealed that P#1 was admitted to Compassus hospice on 9/4/20 with a diagnosis of Chronic Systolic Congestive heart failure, Type 2 diabetes, Cellulitis of left upper limb, and Dementia. It also revealed that there was a discrepancy in P#1 medications. Some medications discontinued by the hospital were reconciled by Registered Nurse (RN AA hospice admission on-call nurse) but not matched by Assisted Living Facility (ALF) Medication Administration Record (MAR). The medication was ordered by hospice physician for Patient (P#1) was on Cymbalta 60 Milligrams (mg) (Antidepressant) oral daily started on 9/4/20, docusate sodium(Stool softner) 100mg oral twice daily, Hydrocodone (Narcotic)7.5mg oral every six hours, Eliquis (Anticoagulant) 2.5mg oral twice daily, Linzess 145 Micrograms (MCG) (Irritable bowel syndrome) oral daily, Trazodone 50mg (Antidepressant) oral at bedtime, Synthroid 50mcg (Thyroid hormone) oral daily, Torsemide 20mg (Diuretic) oral daily, Tylenol extra strength 500mg (Analgesics) oral twice daily, Aspirin 81mg (Anti-inflammatory) oral daily, and hospice comfort kits medications, all ordered on 9/4/20. A copy of all medications dated on 9/4/20 was given to Surveyor. Nurses' notes revealed that the dressing to wounds on the bottom and left fourth finger, was done by RN AA on 9/4/20 per physician's order., missing doses from 9/5/20/to 9/9/20 for four days. On 10/20/20 at 12:29 p.m., an interview was conducted with Director of Clinical Service (DCS #1), stated that she remembered that there was an issue of medication reconciliation during the admission. The case manager, RN BB, visited P#1 on 9/8/20 and reviewed patient's medications issue. DCS #1 stated that P#1's daughter called her and complained about how the hospital discontinued P#1 medications, but DCS #1 stated that she forgot to document it or write a grievance report. DCS #1 said, "I forgot and I will take the blame." On 10/20/20 at 1:39 p.m., an interview was conducted with RN AA, stated that she did P#1 admission, obtained the order from physician, and changed bottom and left fourth finger dressing as ordered. RN AA stated that she did the medication reconciliation and faxed the order to P#1 Pharmacy as requested by P#1's daughter, since that was where her mother usually got all her medications. RN AA stated that she did not know why the Medication Technician did not administer the medications. On 10/20/20 at 1:55 p.m., an interview was conducted with DCS #2, stated that she did not do the medication reconciliation when she visited P#1 because RN AA had done the reconciliation on phone with Medication Technician before she got there. On 10/20/20 at 2:10 p.m., an interview was conducted with RN BB, stated that she was case manager for P#1, and she took good care of P#1 and reviewed her medications. RN BB said P#1's daughter called her several times and she responded to her. RN BB stated P#1's daughter called her one weekend and said that her mother has ran out of Ativan. RN BB said that she was off that weekend and notified the on-call nurse, which was RN AA. RN AA went to visit P#1 that weekend and resolved the issue. On 10/20/20 at 3:38 p.m., an interview was conducted with P#1's daughter. She was crying and expressed her concern related to what happened between her and the hospice nurses. She verbalized her frustration on issues between her and DCS #2, who told her mother that she was a hospice nurse, after P#1's daughter had told DCS #2 not to let P#1 know that she works for hospice. P#1's daughter said that the only nurse that she trusted was RN AA. P#1's daughter said nobody updated or explained anything to her on her mother's medication issues and health condition. P#1's daughter stated that DCS #2 did not assess, reconcile medications or wrap her mother's wounded left finger. Surveyor asked DCS #2 why she did not assess P#1, wrap left fourth finger, or do medication reconciliation. DCS #2 denies the allegations and said that RN AA did it. P#1's daughter also stated that her mother was taken off psychiatric medications cold turkey when she was admitted, and she was notified by ALF Medication Technician. P#1's daughter further complained about the physician not responding to her call when her mother ran out of Ativan the night before she died. Furthermore, P#1's daughter stated that they were complaining and shouting for help over the weekend and yet not being attended to by the physician and hospice nurses including DCS #1 and #2. Cross reference L0545 | |||