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
111734 A. BUILDING __________
B. WING ______________ 		02/17/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
BRIDGEWAY HOSPICE 200 BUSINESS CENTER DRIVE, SUITE 204, STOCKBRIDGE, GA, 30281
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 Based on review of clinical records and staff interviews, it was determined the hospice failed to ensure that program requirements were met at 42 C.F.R. Part 418. Requirements for Hospices, C.F.R. 418.100 (L500) Patients Rights, 418.52(b)(4)ii Exercise of the Patient Rights, (L505) Grievances, and 418.52(c)(1)(L512) Pain Rights of the Patient, CFR 418.56(c)(2) (L547) Content of Plan of Care, C.F.R. 418.62(L583) Licensed Professional Services,C.F.R.418.64(b)(2)(L591) Nursing Service,C.F.R. 418.100 Organizational Environment (L648); C.F.R.418.100(c)(2) Services,C.F.R.418.100(b) Governing Body, C.F.R.418.100(c)(2) (L653)Nursing Services available 24 hours a day seven days a week. The cumulative effects of this unmet condition of participation resulted in the hospice's inability to effectively monitor and supervise the hospice staff and ensure the overall safety of patient care and services provided to hospice beneficiaries and their caregivers.
L0505      
38966 Based on staff interviews, review of clinical records, complaint logs, and the agency's policy titled " No. 2-006.1-2 dated November 2018 Complaint/Grievance Process Resolution on Patient's Rights", revealed that the hospice agency violated the rights of two of eight patients (P#2, P#7). The hospice failed to investigate and document that patient and/or family concerns were addressed and resolved. Findings include : Review of the agency's complaint log from October 2020 to February 2021, for P#7 revealed a complaint dated 1/26/21 and for P#2 complaint's where dated on 1/21/21 and 1/25/21. Each complaints indicated the patients were not satisfied with the services being provided and were seeking discussions with the agency's staff to rectify their concerns. The complaint involved agency staff not coming when requested and not providing the services as ordered. The agency failed to provide evidence that the patient's concerns were investigated and resolved. Review of agency policy "No. 2-006.1-2 dated November 2018. Complaint/Grievance Process Resolution", revealed that all complaints documented in a complaint log will be investigated by a Supervisor not more than 5 business days from the date the complaint was received. Appropriate personnel will conduct investigation, document the grievances and make an effort to resolve the grievance to the patient's satisfaction. Response to the patient regarding the complaint will occur within ten days of receipt. The hospice agency could not provide evidence that patient complaints were investigated and documented in accordance with their established procedures. On 2/15/21 at 2:00 p.m., an interview was conducted with the Clinical Manager (CM) and the Director of Clinical Services (DCS), who stated they were not trained and were not even aware that they had to document investigated complaints or grievances. They further stated problems were always resolved even though they had no records to prove that it was done. According to the hospice agency policy, the CM or DCS must document on the complaint forms all complaints and grievances that come to the office via on-call weekdays or weekends, from patients or patients' families. The surveyor reviewed the agency complaint log and found that it was blank, this observation was verbally confirmed by CM, DCS and Vice President.
L0512      
38966 Based on staff and family interviews and record review it was determined that the agency failed to ensure effective pain management for one of one patients (P#2) reviewed for pain and symptoms related to the terminal illness. Finding include; On 2/15/21 review of P#2 medical record the patient was admited to the hospice agency on 5/22/20 with a diagnosis of chronic obstructive pulmonary disease unspecified and pain. On 1/21/21 at 5:48 p.m., it was documented that P#2's family called the agency and reported that the patient had ran out of Tramadol 50 milligrams (MG) tablet oral and Morphine 15 mg extended release tablet oral for pain. The family went to the store and purchased over the counter pain medications and a enema for constipation. During a telephone interview on 2/15/21 at 1:50 p.m., with P#2's family it was stated that they received the ordered pain medications two weeks after calling the agency. Upon review of P#2's medication administration records (MAR), it was documented that the medication was ordered on 1/25/21, ( five day's) after the patient's family called and it was received on 2/5/21 (15 day's) after P#2's family had called the hospice agency. On 2/15/21 at 1:50 p.m., during the telephone interview with P#2's family it was stated they called the hospice's office on 1/21/21 at 5:48 p.m., because they had not received medications for two weeks. Patient #2's family member stated that her mother did not receive medications for constipation or pain for two weeks from hospice. When P#2's family asked the agency why her mother had not received the medications, "they gave a lot of different excuses." She stated that she had to go to the store to get enemas and over-the-counter pain remedies, but P#2's pain was not controlled during this time. On 2/15/21 at 3:00 p.m., an interview was conducted with the Clinical Manager (CM), who stated that she was not aware that P#2 ran out of her pain medications for two weeks. CM stated that ,"P#2's daughter called the office and she ordered P#2's medications including pain medications twice on 1/25/21." On 2/5/21 (11 days later) the medications were delivered to the patient's home. The CM stated, "they were short of Registered Nurse's (RN's) from October 2020 to January 2021." CM further stated that "she and the Director of Clinical Service were the two nurses doing on-call in addition to their jobs, so they were all overwhelmed."
L0547      
38966 Based on clinical records reviewed, it was determined that the hospice agency failed to follow the plan of care policy "No. 4-027.1, titled. "The Plan Of Care" No 4 on page 1. The plan of care will identify the patient's needs and services to meet those needs, including the management of pain and discomfort and symptom relief. It must state, in detail, the scope and frequency of services needed to meet the patient's and family/caregiver's needs, goals and outcome achievement". The agency failed to follow the plan of care for Patient (P#2) who exhibited pain. The agency failed to followed the plan of care for physician's scheduled visit orders for 8 of 8 patients P#1, P#2, P#3, P#4, P#5, P#6, P#7 and P#8. The sample size was 8. Findings include: 1. On 2/15/21 during review of the clinical record it was documented that the hospice agency failed to follow physician's orders related to Registered Nurse (RN) Supervision visits. Patient #1 was admitted to hospice care on 11/9/20, diagnosed with Parkinson's disease. Upon review of P#1 medical record documented that P#1's family had requested visits. On 12/5/20 Chaplain visit was missed. Skilled Nurse (SN) visits were missed on 12/26/20, 1/23/21, 1/29/21, 1/30/21, 2/4/21 and 2/6/21. There was no documentation of physician notification of the missed visits. RN Supervision notes were not documented. 2. Patient #2 was admitted to hospice care on 5/22/20 with a diagnosis of chronic obstructive pulmonary disease unspecified. Patient #2 medical record revealed RN supervision visits were missed on 12/31/20, 1/18/21, 2/1/21, and 2/15/21. Skilled Nurses visits were missed on 12/12/20, 12/17/21, 12/19/21, 1/2/21, 1/8/21 and 1/27/21. The Social Worker missed visits on 12/20/20, 12/26/20, 1/4/21, 1/6/21, and 2/9/21. Chaplain missed visits on 1/2/21, 2/5/21 and 2/8/21. There was no documentation found that the hospice staff notified the physician regarding the missed visits including the RN Supervision visits. On 1/21/21 the family called the agency regarding pain and constipation. On 2/15/21 review of P#2 clinical record revealed that hospice agency failed to manage P#2 pain symptoms when the patient ran out of pain medication for over a two week period. There was no documentation that a agency nurse visited P#2 during that time. 3. Patient #3 was admitted to hospice care on 12/28/20 with a diagnosis of unspecified atherosclerosis, and chronic obstructive pulmonary disease unspecified. Skilled Nurses visits were missed on 1/9/21, 1/23/21, 1/30/21, 2/5/21, 2/6/21 and 2/13/21 Chaplain visits were missed on 1/2/21, 1/5/21 and 1/8/21. RN Supervision visits were missed for the months of November 2020 and December 2020. There were no documenation that the hospice staff notified the physician regarding the missed visits, including RN Supervision missed visits. 4. Patient #4 was admitted to hospice care on 1/16/21 with a diagnosis of Malignant Neoplasm of Stomach unspecified, and secondary malignant neoplasm of unspecified site. Skilled Nursing visits were missed on 1/20/21, 1/23/21, 1/28/21, 1/30/21, 2/6/21 and 2/13/21. RN Supervision visits scheduled for 1/18/21, 1/25/21, 2/5/21, 2/12/21, 2/15/21 were missed. There were no RN supervision visits documented for November and December 2020. The was no documentation that the hospice staff notified the physician regarding missed visits, including the RN Supervision missed visit. 5. Patient #5 was admitted to hospice care on 11/10/20 with a diagnosis of end-stage mental illness. The Social Worker missed visits was noted on 12/7/20 and 1/21/21. Chaplain missed visits were noted on 12/5/20, 1/9/21, 1/18/21 and 2/15/21. Skilled Nursing missed visits were noted on 12/4/20, 12/18/20, 1/10/21, 1/15/21, 1/16/21, 1/22/21, 1/23/21, 1/30/21, 2/6/21, 2/13/21, 2/14/21, and 2/19/21. There was no RN Supervision visits documented in the month of January 2021. RN Supervision visits were scheduled but not done on 1/12/21, 1/19/21, 1/29/21 and 2/4/21. There was no documented evidence that the hospice staff notified the physician regarding the missed visits, including RN Supervision missed visits. 6. Patient #6 was admitted to hospice care on 10/3/20 with a diagnosis of heart failure unspecified. It was noted that Skilled Nursing visits were missed on 1/9/21, 1/15/21 and 2/2/21, and no RN Supervision visits was done in the months of November 2020 and January 2021. There was no documented evidence found that the hospice staff notified the physician regarding the missed visits including RN Supervision missed visits. 7. On 2/15/21 at 12:35 p.m., an interview was conducted with hospice nurse AA, nurse BB, scheduler CC, nurse DD and nurse EE, all stated that they were short of Nurses because a lot of Registered Nurses resigned as a result of the Hospice's new policy. The Hospice staff told surveyors that they are in a nursing shortage crisis, to the extent that the Fulton and Clayton County patients have no Registered Nurses Case Managers. Instead, the agency used Licensed Practical Nurses for services. 8. According to the hospice agency on-call policy, "staff will respond to a page within 15 minutes and must be able to reach a patient within one hour". Patient #7 was admitted to the hospice on 1/24/21 with a diagnosis of colon cancer. It was documented on 1/26/21 P#7 family called the agency and requested a visit because the patient had blood in the stool. On 1/29/21 at 7:00 p.m. (3 days later) the hospice nurse visited the patient. 9. On 2/15/21 at 1:30 p.m., an interview was conducted with P#8's wife who stated that the service was "below substandard" and "chaotic" and that the patient was transferred to another hospice at her request in January 2021. The "poor service was adding to my stress, which I did not need". She stated that "agency issues included inadequate staffing, nurses not knowing what medications her husband was taking, and turnover in nurses (which meant they never had the same nurse come more than once or twice). Patient #8's wife further stated that "the good nurses left, and we asked for some of the nurses not to come back". She added that, "some nurses did not do a comprehensive assessment; they only took her husband's vital signs and asked a few okay questions". On 2/15/21 at 4:00 p.m., an interview was conducted with the Clinical Manager (CM) and the Director of Clinical Services (DCS), both stated the hospice agency failed to perform scheduled visits. The CM and DCS confirmed there was no documented physician notification of missed visits. They further stated, " the agency was in a Registered Nurse shortage crisis and they have been covering on-call after hours and weekends since October 2020."
L0583      
38966 Based on review of clinical records and staff interviews, it was determined the hospice failed to ensure the program requirements were met at 42 C.F.R. Part 418. Requirements for Hospices, C.F.R. 418.100 (L500) Patients Rights, 418.52(b)(4)ii Exercise of the Patient Rights, (L505) Grievances, and 418.52(c)(1)(L512) Pain Rights of the Patient,CFR 418.56(c)(2) (L547) Content of Plan of Care, C.F.R. 418.62(L583) Licensed Professional Services,C.F.R.418.64(b)(2)(L591) Nursing Service,C.F.R. 418.100 Organizational Environment (L648); C.F.R.418.100(c)(2) Services, C.F.R.418.100(b) Governing Body, C.F.R.418.100(c)(2) (L653)Nursing Services available 24 hours a day seven days a week. The cumulative effects of this unmet condition of participation resulted in the hospice's inability to effectively monitor and supervise the hospice staff and ensure the overall safety of patient care and services provided to hospice beneficiaries and their caregivers.
L0591      
38966 Based on record review, staff and family interviews, the hospice agency failed to follow physician's orders to provide Social Worker, Chaplain, Skilled Nursing visits and Registered Nurse (RN) Supervision Visits for nursing care services for six of eight patients (P#1, P#2, P#3, P#4, P#5 and P#6). The sample size was 8. Finding include: On 2/15/21 at 2:19 p.m., review of the above patients' medical records reveled that the hospice agency failed to follow physician's orders and RN Supervision Visits during October 2020 to February 17, 2021. 1. Patient #1 was admitted to hospice care on 11/9/20, diagnosed with Parkinson's disease. Review of P#1"s medical record revealed the family requested visits. Skilled Nurse (SN) visits were missed on 12/26/20, 1/23/21, 1/29/21, 1/30/21, 2/4/21 and 2/6/21. The hospice failed to document physician notification of missed visits and RN Supervision missed visits. 2. Patient #2 was admitted to hospice care on 5/22/20 with a diagnosis of chronic obstructive pulmonary disease unspecified. Patient #2 medical record revealed four missed RN Supervision Visits on 12/31/20, 1/18/21, 2/1/21, and 2/15/21. Skilled Nurses missed visits on 12/12/20, 12/17/21, 12/19/21, 1/2/21, 1/8/21 and 1/27/21. Social Worker missed visits on 12/20/20, 12/26/20, 1/4/21, 1/6/21, and 2/9/21. Chaplain missed visits on 1/2/21, 2/5/21 and 2/8/21. The hospice failed to document physician notification of missed visits and RN Supervision missed visits. 3. Patient #3 was admitted to hospice care on 12/28/20 with a diagnosis of unspecified atherosclerosis, and chronic obstructive pulmonary disease unspecified. Skilled Nurses visits were missed on 1/9/21, 1/23/21, 1/30/21, 2/5/21, 2/6/21, and 2/13/21. Social Worker missed visit on 1/29/21. Chaplain missed visits on 1/2/21, 1/5/21 and 1/8/21. RN Supervision visits were missed for the months of November 2020 and December 2020. The hospice failed to document physician notification of missed visits and RN Supervision missed visits. 4. Patient #4 was admitted to hospice care on 1/16/21 with a diagnosis of Malignant Neoplasm of Stomach unspecified, and secondary malignant neoplasm of unspecified site. Skilled Nursing visits were missed on 1/20/21, 1/23/21, 1/28/21, 1/30/21, 2/6/21 and 2/13/21. RN Supervision Visits scheduled for 1/18/21, 1/25/21, 2/5/21, 2/12/21, 2/15/21 were missed. There were no RN Supervision Visits documented for November and December 2020. The hospice failed to document physician notification of missed visits and RN Supervision missed visits. 5. Patient #5 was admitted to hospice care on 11/10/20 with a diagnosis of end-stage mental illness. Social Worker missed visits was noted on 12/7/20 and 1/21/21. Chaplain missed visits were noted on 12/5/20, 1/9/21, 1/18/21 and 2/15/21. Skilled Nursing missed visits were noted on 12/4/20, 12/18/20, 1/10/21, 1/15/21, 1/16/21, 1/22/21, 1/23/21, 1/30/21, 2/6/21, 2/13/21, 2/14/21, and 2/19/21. There was no RN Supervision Visits done on 1/12/21, 1/19/21, 1/29/21 and 2/4/21. The hospice failed to document physician notification of missed visits and RN Supervision missed visits. 6. Patient #6 was admitted to hospice care on 10/3/20 with a diagnosis of heart failure unspecified. It was noted that Skilled Nursing visits were missed on 1/9/21, 1/15/21 and 2/2/21, and no RN Supervision visits was done in the months of November 2020 and January 2021. The hospice failed to document physician notification of missed visits and RN Supervision missed visits. 7. On 2/15/21 at 12:35 p.m., an interview was conducted with hospice nurse AA, nurse BB, scheduler CC, nurse DD and nurse E. They all stated the agency was short of Registered Nurses due to the Hospice's new policy. The Hospice staff stated they were in a RN Case Manager crisis shortage for Fulton and Clayton County patients. Instead, the agency used Licensed Practical Nurses for services. 8. On 2/15/21 at 1:30 p.m., an interview was conducted with P#8's wife who stated "the service was "below substandard and chaotic and the patient was transferred to another hospice at her request in January 2021". She continued to say, "poor service was adding to my stress, which I did not need." She stated "agency issues included inadequate staffing, nurses not knowing what medications her husband was taking and turnover in nurses (which meant they never had the same nurse come more than once or twice). P#8's wife further stated "the good nurses left and we asked for some of the nurses not to come back." She added "some nurses did not do a comprehensive assessment; they only took her husband's vital signs and asked a few okay questions". On 2/15/21 at 4:00 p.m., an interview was conducted with the Clinical Manager (CM) and the Director of Clinical Services (DCS), both stated the hospice agency failed to perform scheduled visits. The CM and DCS confirmed there was no documented physician notification of missed visits. They further stated the agency was in a Registered Nurse shortage crisis and they have been covering on-call after hours and weekends since October 2020.
L0648      
38966 Based on review of clinical records and staff interviews, it was determined the hospice failed to ensure that program requirements were met at 42 C.F.R. Part 418. Requirements for Hospices, C.F.R. 418.100 (L500) Patients Rights, 418.52(b)(4)ii Exercise of the Patient Rights, (L505) Grievances, and 418.52(c)(1)(L512) Pain Rights of the Patient,CFR 418.56(c)(2) (L547) Content of Plan of Care, C.F.R. 418.62(L583) Licensed Professional Services,C.F.R.418.64(b)(2)(L591) Nursing Service,C.F.R. 418.100 Organizational Environment (L648); C.F.R.418.100(c)(2) Services, C.F.R.418.100(b) Governing Body ,C.F.R.418.100(c)(2) (L653) Nursing Services available 24 hours a day seven days a week. The cumulative effects of this unmet condition of participation resulted in the hospice's inability to effectively monitor and supervise the hospice staff and ensure the overall safety of patient care and services provided to hospice beneficiaries and their caregivers.
L0651      
38966 Based on staff and family interviews, clinical record reviews it was determined the Governing Body failed to ensure the hospice agency was administered in a manner that enabled it to use resources effectively and efficiently to ensure each patient receiving hospice services maintained the highest possible level of care and service; Refer to the following Conditions of Participation through out this report that were not met Conditions of Participation 42 C.F.R. Part 418. Requirements for Hospices, C.F.R. 418.100 (L500) Patients Rights, 418.52(b)(4)ii Exercise of the Patient Rights, (L505) Grievances, and 418.52(c)(1)(L512) Pain Rights of the Patient CFR 418.56(c)(2) (L547) Content of Plan of Care, C.F.R. 418.62 (L583) Licensed Professional Services, C.F.R.418.64(b)(2)(L591) Nursing Services, C.F.R. 418.10 Organizational Environment (L648), C.F.R.418.100(c)(2) Services, C.F.R.418.100(c)(2) (L653)Nursing Services available 24 hours a day seven days a week
L0653      
38966 Based on staff and family interviews, review of the answering services reports, on-call logs, clinical records, complaint logs, and policy "No. 4-036.2, titled On-Call/Weekend Services," dated November 2018, the agency failed to provide nursing visits for three of eight Patients (P#2 #7, #8) who exhibited significant change in their condition. The agency's failure to respond to patients and/or families were documented on the call log which revealed that patients' families called hospice and requested for services. The agency failed to respond timely and/or provide nursing services for the patients. The sample size was 8 Findings include: 1. Review of P#2's medical record revealed the admission date to the hospice agency as 5/22/20, with a diagnosis of chronic obstructive pulmonary disease unspecified and pain. On 1/21/21 at 5:48 p.m., P#2's family called the agency and reported that the patient ran out of Tramadol 50 milligrams (MG) tablet oral, and Morphine 15 mg extended release tablet oral for pain. P#2's family stated they received the medications two weeks after calling the office. Upon review of P#2's medication administration records (MAR) documentation the medications was ordered on 1/25/21 five days after the patient's family had called. The medication was received on 2/5/21, (15 days) after the family called the hospice agency. On 2/15/21 at 12:25 p.m., an interview was conducted with scheduler (CC) who stated "they have lost 12 nurses in the past two months because the company required that a no compete contract be signed, stating that employees could not work for any other hospice while employed there, or even for two years after their employment at agency has ended. CC stated that a lot of the nurses were not replaced, or when replaced, not immediately. CC stated on-call nurse lasted only two days." On 2/15/21 at 12:35 p.m., an interview was conducted with nurse AA, nurse BB and scheduler CC. They stated, the agency experienced a Registered Nurse (RN) Case Managers staffing crisis which affected Fulton and Clayton County patients. They futher stated " the agency was now only using Licensed Practical Nurses for services and they report to the Clinical Manager and Director of Clinical Services for issues. CC stated they only had four RNs to assign for the census of 220-250 patients. CC further stated that two new RNs started in January 2021, and that they had four RNs to conduct admissions. However, when the admission RNs are scheduled for routine visits, they usually leave them undone. CC stated when admit RN would refuse to do a non-admit visit, she would notify previous Administrator, CM or DCS". CC also stated "the previous Administrator would not allow her to go to the DCS." CC stated that patient care probably did suffer, as many patients stated they would go to the hospital if they did not receive hospice services. CC continued to say "only in those instances were nurses sent to see the patients at that time." On 2/15/21 at 1:00 p.m., an interview conducted with P#7's family, it was stated their grandmother was admitted to the hospice on 1/24/21 with a diagnosis of colon cancer. The admission nurse told the family that someone would visit P#7 on 1/26/21. The family called the 24/7 on-call hospice line to ask for the nurse and the aide that she was told would visit P#7 on 1/26/21. During an interview on 2/15/21 the on-call nurse admitted to the surveyor that she replied to P#7's family that she would find out and call P#7's family back, but she never did. The family stated she called the agency on 1/26/21 at 6:45 a.m., to tell the agency that the patient had blood in the stool. On 1/27/21, P#7's family called on-call nurse again and complained that P#7 was not feeling well and was having dark stools. Review of the on call record revealed no documentation on the call. CM was the on-call nurse that day and denied that P#7's family was called on 1/27/21, she further stated that she did not receive a call from P#7's family on 1/27/21. On 1/29/21 (3 days later) it was documented in nurse's note that the hospice nurse visited P#7. On 2/15/21 at 1:30 p.m., in an interview with P#8's wife it was stated "the agency's services were below substandard" and "chaotic," and that P#8 care was transferred to another hospice at her request in January 2021. She stated that "poor service was adding to my stress, which I did not need". She stated the "agency issues included: inadequate staffing, nurses didn't know what medications her husband was taking, turn over in nurses, which meant they never had the same nurse come more than once or twice, the good nurses left, and we asked for some of the nurses not to come back". P#8's wife stated "some nurses did not even do a comprehensive assessment they only took her husband's vital signs and asked a few questions". On 2/15/21 at 1:50 p.m., an interview was conducted with P#2's family member. The family member was asked about the call made to hospice's office on 1/21/21 at 5:48 p.m.,regarding not receiving medications for two weeks. Patient #2's family stated that her mother did not receive medications for constipation or pain for two weeks. When she asked the agency why her mother had not received the medications, she said, "they gave a lot of different excuses." She stated "she had to go to the store to get enemas and over-the-counter pain remedies, but P#2's pain was not controlled during this time". Review of the facility's Policy Guidelines in part included, "the on-call nurse that may require a visit include no BM (bowel movement) for 3 days, suspected bleeding and uncontrolled pain, family/Caregiver/Patient perceives a problem and request a visit and duplicate calls regarding the same problem." On 2/16/21 at 1:50 p.m., in an interview conducted with Nurse DD, it was stated that admission RNs are asked to fill in "once in a while," if staff called out. Nurse DD stated that he received messages from the office requesting help in a group text. Nurse DD stated, "we don't have enough staff to meet patients' needs. New nurses have been hired, but it takes one month to orient them". On 2/16/21 at 3:00 p.m., the surveyor called Nurse FF stated since the company has been bought out, her case load has gone from 15 to 37 due to loss of nursing staff. Nurse FF stated some areas of service area have no nurse (e.g. Conyers, Riverdale and Covington) she has helped these areas at times. She stated one patient who told her he had not received a visit from a nurse since New Year's Eve. Nurse FF stated she could not recall the patient's name. Nurse FF also stated she did not understand why patients continued to be admitted in the areas with no nurse. Review of the "On-call "policy which stated staff will respond to a page within 15 minutes and must be able to reach a patient within one (1) hour. (There may be rare exceptions depending on how far away the patient lives and if the staff member is with another patient at the time of the page.) "The on-call nurse will report his/her evening and/or weekend patient care activities to the Clinical Director."