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
111692 A. BUILDING __________
B. WING ______________ 		02/07/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
AMITY CARE 161 VILLAGE PARKWAY, BUILDING 7, MARIETTA, GA, 30067
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      
38966 The agency failed to investigate an allegation of neglect when the on-call nurse did not visit a patient timely to provide pain management, comfort care and a dignified death for 1of 3 sampled patients (P)#1 as she transitioned . The immediate jeopardy was related to the agency's noncompliance with the program requirements Patients' Rights; ( Refer to L509) 42 CFR Part 418.52 (b)(4)(ii) Patient Rights, (Refer to L512) 42 CFR Part 418.52(c), Rights of the patient. The following Condition and Standard level deficiencies were cited:
L0509      
38966 Based on clinical record review, staff and family interviews it was determined the agency failed to investigate an allegation of neglect when the on-call nurse did not visit a patient in a timely manner or administer morphine for pain management for 1 of 3 patients (P#1). The findings include: Patient #1 resided in an Assisted Living Facility (ALF) and was admitted to hospice services on 10/31/20, with diagnoses of chronic kidney disease (CKD) stage 4, Alzheimer's disease and hyperlipidemia. A review of the Chaplain notes dated 12/22/21, revealed when he called P#1's daughter she complained about RN BB. It was documented that P#1's daughter said she placed a call to RN BB and wanted her to come and visit her mother, but RN BB told P#1's daughter that "this is the natural dying process, and you have to be patient". On the second call, after P#1's daughter stated she was "begging her to come out", the daughter stated RN BB arrived one hour later after the second phone call. It was further noted, according to P#1's daughter RN BB couldn't locate the morphine and apparently the patient never got any and was gasping for breath. P#1's daughter reported to the chaplain that RN BB told her repeatedly that "You need to leave the room." That didn't set well with P#1's daughter because she really wanted to be holding her hand, kissing and supporting her mother; she did finally leave and came back in just before her mother transitioned. It was documented in the notes, it sounds like P#1's daughter and RN BB never connected at all, and P#1's daughter did used the words "cold and unfeeling" to describe RN BB. The daughter said, "I just don't want this to happen to anyone else." (sic) On 1/18/22, at 12:15 p.m., an interview was conducted with Registered Nurse (RN) BB who stated she was on-call on 12/19/21. RN BB stated she left to go to the facility at 3:12 a.m., and arrived at the facility at 4:08 a.m., when she arrived P#1's daughter requested morphine (used to treat pain) to be given. RN BB and the Medication Tech (MT) were not able to find the morphine. RN BB stated she administered Ativan ( used for anxiety) because the morphine was not available. On 1/19/22, at 10:40 a.m., an interview was conducted with the Assisted Living Facility Director of Nursing (DON) who stated on 12/20/21, around 10:00 a.m., she received a phone call from P#1's daughter indicated RN BB response on 12/19/21, "was inappropriate" and she had to beg her to come to the facility to see her dying mother. RN BB was not able to locate the morphine and she watched her mother suffer and die in severe pain. The hospice agency failed to investigate the allegation of neglect when the agency on-call nurse did not visit P#1 in a timely manner upon notification by the family and the ALF staff. The hospice nurse failed to administer morphine for pain management as prescribed by the Medical Doctor.
L0512      
38966 Based on clinical record review, staff and family interviews it was determined the agency failed to provide pain and symptom management during transition into death. The serious outcome resulted in a painful death for 1 of 3 patients (P#1). The findings include: Patient #1 resided in an Assisted Living Facility (ALF) and was admitted to hospice services on 10/31/20, with diagnoses of chronic kidney disease (CKD) stage 4, Alzheimer's disease and hyperlipidemia. On 1/18/22, at 12:00 p.m., an interview was conducted with agency Registered Nurse (RN) AA who stated she was the assigned case manager to P#1 and she aware the morphine was locked in the Assisted Living Facility (ALF) Administrator's office, but the on-call nurse did not call me. On 1/18/22, at 12:15 p.m., an interview was conducted with RN BB, who stated she was on-call 12/19/21, and received a phone call at 12:38 a.m., from the ALF's medication technician (MT) who said P#1 had some breathing changes but was comfortable and the daughter was anxious. RN BB said she asked the staff to let her speak to the patient's daughter who told RN BB she had been at the facility for some time and her mother's breathing was changing. RN BB told P#1's daughter that breathing changes was a normal occurrence as patient's decline. RN BB stated at 2:30 a.m., the daughter told the ALF staff to call the on-call nurse a second time, the MT called RN BB who talked to P#1's daughter and she requested morphine (used for pain) be given and asked RN BB to come and visit. RN BB stated she left for the facility at 3:12 a.m., and arrived at the facility at 4:08 a.m., at that time P#1's daughter again requested morphine be given to her mother. RN BB went to the MT, and they could not find the morphine. RN BB stated she administered Ativan (used for anxiety) because the morphine was not available. On 1/19/22, at 10:40 a.m., an interview was conducted with the agency Director of Nursing (DON) who stated on 12/20/21, around 10:00 a.m., she received a phone call from P#1's family who reported that Nurse RN BB response on 12/19/21, was inappropriate and she had to beg the nurse before she came to the facility to see her dying mother, and RN BB was unable to locate morphine while she watched her mother suffered and die in severe pain. The DON confirmed she did not investigate the missing morphine or document the incident in the complaint or grievance log. Review of the Chaplain notes dated 12/22/21, revealed he called to follow up with P#1's daughter. It was documented the daughter complained about RN BB, P#1's daughter said she placed a call to RN BB and wanted her to come and visit her mother, but RN BB told P#1's daughter that "this is the natural dying process, and you have to be patient". On the second call, after P#1's daughter stated she was "begging her to come out", the daughter stated RN BB arrived one hour later after the second phone call. It was further noted, according to P#1's daughter RN BB couldn't locate the morphine and apparently the patient never got any and was gasping for breath. P#1's daughter reported to the chaplain that RN BB told her repeatedly that "You need to leave the room." That didn't sit well with P#1's daughter because she really wanted to be holding her hand, kissing and supporting her mother; she did finally leave and came back in just before her mother transitioned. It was documented in the notes, it sounds like P#1's daughter and RN BB never connected at all, and P#1's daughter did used the words "cold and unfeeling" to describe RN BB. P#1's daughter said, "I just don't want this to happen to anyone else." The hospice agency failed to respond to P#1's family members telephone call when informed that P#1 was crying out in pain. This failure resulted in a painful death for P#1.
L0536      
38966 The agency failed to communicate with the Assisted Living Facility (ALF) staff where Patient (P) #1 resided. The patient did not receive medication for pain as ordered by the physician and as care planned. This failure resulted in an immediate jeopardy as 1 of 3 patients (P) #1 transitioned to death, lacked dignity, pain management and comfort care. The immediate jeopardy was related to the agency's noncompliance with the program requirements for Refer to L546) 42 CFR Part 418.56 (c)(1), Interventions to manage pain and symptoms. The following Condition and Standard level deficiencies were cited:
L0546      
38966 Based on clinical record review, staff and family interviews the agency failed to include in the current plan of care the location of pain medications necessary for the management of pain and related symptoms, resulting in failure to relieve pain and suffering (used for pain) during transitioning and death for 1of 3 patients (P#1). The finding include: Patient #1 resided in an Assisted Living Facility (ALF) and was admitted to hospice services on 10/31/20, with diagnoses of chronic kidney disease (CKD) stage 4, Alzheimer's disease and hyperlipidemia. P#1 had a physician's order for morphine sulfate (concentrate) 20mg/ml solution (id:10785129)-0.25-1 ml every 2 hour oral as needed pain/SOB (short of breath) (20)mg/ml solution) dated 10/27/21. The Assisted Living Facility (ALF) staff and the hospice on-call Registered Nurse (RN) reported that P#1's morphine was not accessible as needed on 12/19/21. On 1/18/22, at 12:00 p.m., an interview was conducted with the agency's Registered Nurse (RN) AA, who stated she was the assigned case manager to P#1, and the morphine was locked in the ALF Administrator's office, but the on-call nurse did not call her. On 1/18/22, at 12:15 p.m., an interview was conducted with RN BB who stated she was on-call on 12/19/21. RN BB stated she left to go to the facility at 3:12 a.m., and arrived at the facility at 4:08 a.m., when she arrived P#1's daughter requested morphine (used for pain) to be given. RN BB stated when she went to the Medication Tech (MT) she indicated she was not able to find the morphine. On 1/19/22, at 1:45 p.m., an interview was conducted with P#1's family member who stated that RN BB came to visit her mother four hours after P#1 had been experiencing severe pain and when RN BB arrived she was not able to locate the morphine pain medication. The hospice agency failed to administer morphine to manage P#1's pain and symptoms. This failure caused a serious adverse outcome for P#1 as she transitioned to death. The agency failed to have a system in place that ensured staff had access to the location of morphine to manage P#1's pain and other distressing symptoms in accordance with the current care plan dated 10/26/21.
L0648      
38966 The agency failed to coordinate interventions that ensured medications were available 24/7. The agency's staff failed to administer pain medication when 1 of 3 patients (P)#1 experienced pain and symptoms of imminent death. This failure resulted in an immediate jeopardy in which the agency failed to provide pain management and comfort care. P#1 was not administered morphine to relieve pain and suffering as she transitioned to death The immediate jeopardy was related to the agency's noncompliance with the program requirements for (Refer to L653) 42 CFR Part 418.100(c)(2), Nursing services and physician services and drugs and biologicals.
L0653      
38966 Based on review of clinical records, staff and family interviews it was determined the agency failed to administer morphine due to the medication not being accessible to the on-call hospice nurse on a 24/7 basis. This failure resulted in P#1 crying out in pain as she transitioned to death. The failure affected 1 of 3 sampled patients. The findings include: Patient #1 resided in an Assisted Living Facility (ALF) and was admitted to hospice services on 10/31/20, with diagnoses of chronic kidney disease (CKD) stage 4, Alzheimer's disease and hyperlipidemia. P#1 had a physicians order for morphine (used for pain). It was reported by the agency that morphine was not accessible to the hospice on-call nurse on 12/19/21, at the time of P#1's death. The hospice agency failed to administered morphine sulfate (concentrate) 20mg/ml solution (id:10785129)-0.25-1 ml every 2 hour oral as needed pain/SOB (short of breath) (20)mg/ml solution) per the physicians orders dated 10/27/21. A record review dated 12/19/21, at 12:38 a.m., revealed the ALF's medication technician (MT) called the hospice on-call nurse to report P#1 had some breathing changes but was comfortable and the daughter was anxious. RN BB said she asked the staff to let her speak to the patient's daughter who told RN BB she had been at the facility for some time and her mother breathing was changing. RN BB told P#1's daughter that breathing changes was a normal occurrence as patient's declined. RN BB stated at 2:30 a.m., the daughter told the ALF staff to call the on-call nurse a second time, the MT called RN BB who talked to P#1's daughter and she requested morphine (used for pain) be given and asked RN BB to come and visit P#1. RN BB stated she left for the facility at 3:12 a.m. On 1/19/22 at 1:45 p.m., an interview was conducted with P#1's daughter who stated RN BB came to visit her mother four hours after P#1 has been experiencing severe pain and when RN BB, arrived she was unable to locate morphine pain medication and RN BB administered Ativan (used for anxiety) which was too late P#1 stopped breathing few minutes after RN BB arrived.
L0686      
38966 The agency failed to ensure access to medication availability for pain management for one (1) of three (3) Patients (P) #1 who transitioned into death. The immediate jeopardy was related to the agency's noncompliance with the program requirements for (L700) 42 CFR 418.106(e)(3)(ii) Discrepancies in the acquisition, storage, dispensing, administration, disposal of controlled drugs.
L0700      
38966 Based on clinical record review, staff and family interviews it was determined the agency failed to ensure medications were properly stored, counted and available to be administered. This created a failure to administer morphine as ordered for pain management when one (1) of three (3) patients (P)#1 transitioned into death. The findings include: Patient #1 resided in an Assisted Living Facility (ALF) and was admitted to hospice services on 10/31/20, with diagnoses of chronic kidney disease (CKD) stage 4, Alzheimer's disease and hyperlipidemia On 1/19/21, at 11:00 a.m., an interview was conducted with the agency's Director of Nursing (DON) who stated P#1's daughter called her on 12/20/21, and reported the incident regarding the on-call nurse's failure to administer morphine to a dying family member. T The Assisted Living (ALF) staff reported the morphine was missing from the medication cart. There was no evidence or documentation in the complaint or grievance logs regarding the incident of medications not being available. The agency DON confirmed the incident was not recorded or investigated. The hospice agency and ALF staff was not aware of the missing 30 tablets of Ativan for anxiety, 8 tablets of Tramadol pain, and 60 syringes of liquids morphine for pain until surveyor discovered the missing medications during the complaint investigation.