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
151521 A. BUILDING __________
B. WING ______________ 		08/27/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
PROMEDICA HOSPICE 2720 DUPONT COMMERCE COURT, SUITE 210, FORT WAYNE, IN, 46825
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See reverse for further instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation
LABORATORY DIRECTOR’S OR PROVIDER/SUPPLIER REPRESENTATIVE’S SIGNATURE

 TITLE

 (X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
(X4) ID
PREFIX
TAG		 SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY SHOULD BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
L0512      
42909 Based on observation, record review and interview, the agency failed to ensure all patients received effective pain management and symptom control for 1 of 3 patient records reviewed for symptom management (#1). Findings include: Review of an agency policy #620 dated 6/2016 titled "Pain Management" stated "All patients have the right to appropriate assessment and management of pain ... consider alternate supportive measures of reducing pain ... consult with physician ...." Review of a reference document titled "Providing Care and Comfort at the End of Life / National Institute on Aging" website https://www.nia.nih.gov/health/providing-comfort-end-life stated "Morphine is an opiate, a strong drug used to treat serious pain. Sometimes, morphine is also given to ease the feeling of shortness of breath ...." Review of a reference document titled "Pain Assessment IN Advanced Dementia (PAINAD)" website geriatricpain.org stated "... Monitor changes in the total score over time and in response to treatment to determine changes in pain ...." Review of a reference document titled "Early deficits in cortical control of swallowing in Alzheimer's disease" dated 7/23/2010 website: www.ncbi.nlm.nih.gov > pmc > articles > PMC2891325 stated "... Dysphagia, or swallowing impairment, is a growing concern in Alzheimer's Disease (AD). It frequently leads to aspiration pneumonia, a common cause of death in this population [1], particularly in the later stage of AD [1-4] ...." 2. Clinical record review for patient #1 was completed on 11/18/2020 with a hospice election date of 11/4/2020, benefit period 11/4/2020 - 2/1/2021, and primary diagnosis of Alzheimer's disease, unspecified. During a home visit on 11/17/2020 at 8:30 a.m., person A (private duty caregiver) indicated the patient was on no special diet, she cooked her whatever was available, the patient had trouble chewing and swallowing, the previous day the patient had a bad coughing spell while eating and it scared her (person A), she coughed a long time, and couldn't catch her breath. The patient presented sitting in bed with the head of the bed elevated. The patient was pleasant, smiled, answered simple questions, but demonstrated significant confusion. She denied pain and showed no non-verbal signs of pain. Employee F (registered nurse) entered the home at 9:00 a.m. and began her visit. She indicated the patient wasn't on a special diet, and she received supplemental nutrition drinks. She requested person A to assist with turning and positioning for wound care. During this time, the patient screamed, exhibited significant guarding (involuntary reaction to protect an area of pain, such as striking out), grimaced, and both legs were very rigid with limited range of motion. After wound care was completed, employee F and person A dressed the patient and transferred her to a wheelchair. The patient could not bear her own weight, could not fully extend her legs, and cried out during this time. Once seated and allowed to rest, the patient ceased all screaming, guarding, and grimacing. When asked if the patient always screamed out in pain with movement and wound care, person A stated "Yes, she always screams in pain. Employee A stated, "I think it's more out of fear." Surveyor observed morphine in the refrigerator, employee A indicated it was full, and none had ever been given. Review of a document dated and signed on 11/4/2020 by employee E (registered nurse), and employee J (registered nurse) titled "Hospice Certification and Plan of Care" stated "... Hospice nurse to monitor pain level ... report changes in pain level to physician ... Hospice nurse to provide observation / assessment of nutrition and hydration status ... Patient's pain level will be at their acceptable level AEB [as evidenced by] PAINAD score is 0... Nutritional requirements: Regular diet ... morphine ... as needed ... pain ...." During an interview on 11/17/2020 at 4:02 p.m., after sharing concerns observed during home visit, employee B (registered nurse, director of quality and data) stated "We're sending a nurse today to follow up on the wounds, wound care, and pain management." Review of a document dated and signed on 11/18/2020 by employee F evidenced documentation of the nursing visit made on 11/17/2020 with surveyor present. The document stated "... Pain ... 0 [verbal pain scale rating of 0-10, with 0 being no pain, and 10 being worst pain] ... confused ... disoriented ... frightened ... anxiety ... unable to understand why or what's happening. Very freafull [sic] of any movement ... abnormal breath sounds ... diminished breath sounds ... patient has an illness or condition which made him/her change the kind and/or amount of food they eat ... high nutritional risk ... PAINAD assessment ... repeated, troubled calling out. Loud moaning or groaning. Crying ... sad, frightened, frown ... rigid ... pulling or pushing away ... striking out ... PAINAD score total ... 6 ... severe pain ... were PRN [as needed] medications needed for pain since last visit? ... No ... Wound care was completed with the assistance of [person A] for turning and comforting [patient] ... [patient] was very calm at start of visit ... Became upset and fearful when we had to turn her ... became upset again with dressing, butt [sic]calmed when we got her up off bed to wheelchair ...." The document evidenced employee F contacted person B (attending physician) for orders for antibiotics related to wounds but failed to evidence the physician was notified of patient's dysphagia or severe pain. Review of a document dated and signed on 11/18/2020 by employee L (registered nurse) stated "... During visit, [person A] fed pt [patient] mechanical soft food and liquids, no difficulty swallowing was observed. Orders received from [employee M- RN, nurse practitioner] for speech therapy ... new orders for norco [narcotic pain medicine] ... BID [twice daily] and morphine ... to be given 1/2 hour prior to dressing changes ...." During an interview on 11/18/2020 3:45 p.m., employee C (administrator) indicated the nurse tried to re-visit the patient last night, but the spouse declined, the patient was seen today by employee L, employee M, and employee B, and the agency was re-educating employee F. Employee B indicated the patient did have pain with movement, she was medicated prior to wound care for pain relief, and new orders were received for further pain management.
L0517      
42909 Based on observation, record review and interview, the hospice failed to ensure its patients were free from neglect and received all treatments and services necessary to meet their needs for 1 of 3 records reviewed (#1). Findings include: Review of a reference document N Engl J Med 1995 Feb 16; 332(7):437-43 titled "Abuse and Neglect of Elderly Persons" stated "[patient neglect, defined as] "the failure of a designated caregiver to meet the needs of a dependent." Review on 8/26/2020 of a reference document dated 2019, titled Wound, Ostomy and Continence Nurses Society. Wound, Ostomy and Continence Nurses Society's guidance on OASIS-D integumentary items: Best practice for clinicians. Mt. Laurel, NJ: Author stated "... Stage 1 Pressure Injury ... intact skin ... Stage 2 Pressure Injury ... partial thickness skin loss ... wound bed is ... pink or red ... slough [yellow devitalized tissue] ... not present ... Stage 3 Pressure Injury ... full thickness skin loss ... slough ... may be visible ...." Clinical record review for patient #1 was completed on 11/18/2020 with a hospice election date of 11/4/2020, benefit period 11/4/2020 - 2/1/2021 which indicated a primary diagnosis of Alzheimer's disease, a skilled nurse frequency of 3 times per week and an aide 2 times per week. During a home visit on 11/17/2020 at 8:30 a.m., the patient was pleasant, smiled, answered simple questions, but demonstrated significant confusion. Person A (private duty caregiver) indicated the patient had wounds on both heels, one wound on the back of her leg, one above her tailbone, and one on the top/back of her right thigh (near her buttocks), which "... was bleeding real bad yesterday." Furthermore, she indicated the patient was dependent for all care and required extensive assistance. Employee F (registered nurse) entered the home at 9:00 a.m. and began her visit. She requested person A to assist with turning and positioning for wound care. Surveyor observed the right heel had a hard, dark brown eschar (hard, dead tissue) area, approximately 7 cm (centimeter) in diameter, the left heel had a soft dark brown eschar area that had opened, with a large amount of purulent (thick, creamy, odorous, often a sign of infection) drainage on the old dressing and draining from the wound. Surveyor also observed wounds on the right sacral (lower back)/buttocks. The upper wound had a dark pink non-blanchable (skin that does not fade when pressed, indicating lack of blood flow) approximately 10 cm in diameter, with four small areas of dark brown/black eschar present within the total area, and the lower wound was full-thickness (damage extended below all layers of the skin) with purulent drainage, approximately 5 cm long, and 3 cm wide. The surveyor also observed a "quarter sized" closed, non-blanchable red area on the left ischium (just below the buttock), an open, full thickness area draining serosanguinous (yellowish with small amounts of blood) fluid, approximately three inches long on the back of the left calf. The nurse was observed providing wound care to all six of the wounds listed above. However, a closed, non-blanchable area on the top of the patient's left great toe approximately 1 cm in diameter was observed and the RN failed to provide wound care or acknowledge that wound. After wound care was completed, surveyor also observed an empty prescription bottle for cephalexin (antibiotic). During this time, when asked if the patient had completed her previous prescription for antibiotics, employee F indicated she didn't know. Employee F indicated she was the patient's case manager, and the patient was seen by the nurse 3 times weekly, on Mondays, Wednesdays, and Fridays. When asked who performed wound care on non-nursing days, employee F was not aware, and indicated aides were only utilized 1-2 times weekly with this hospice agency. During an interview on 11/17/2020 at 4:02 p.m., after sharing concerns observed during home visit, employee B (registered nurse, director of quality and data) stated "We're sending a nurse today to follow up on the wounds, wound care, and pain management." During an interview on 11/18/2020 3:45 p.m., employee C (administrator) indicated the nurse tried to re-visit the patient last night, but the spouse declined, the patient was seen today by employee L, employee M, and employee B, and the agency was re-educating employee F. Employee B indicated the patient did have four new wounds (nine total), that wounds from yesterday were unstageable, educated spouse on wound care, now has private duty caregivers in evening as well as daytime, and increased nursing and aide visits (will go together) every other day.
L0650      
42909 Based on observation, record review and interview, the hospice failed to ensure all patients received care that optimized comfort and dignity for 1 of 3 patient records reviewed (#1). Findings include: During a home visit on 11/17/2020 at 8:30 a.m., the patient presented sitting in bed with the head of the bed elevated. She was pleasant, smiled, answered simple questions, but demonstrated significant confusion. She denied pain and showed no non-verbal signs of pain. Employee F (registered nurse) entered the home at 9:00 a.m. and began her visit. She requested person A (private caregiver) to assist with turning and positioning for wound care. During this time, the patient screamed, exhibited significant guarding (involuntary reaction to protect an area of pain, such as striking out), grimaced, and both legs were very rigid with limited range of motion. After wound care was completed, employee F and person A dressed the patient and transferred her to a wheelchair. The patient could not bear her own weight, could not fully extend her legs, and cried out during this time. Once seated and allowed to rest, the patient ceased all screaming, guarding, and grimacing. When asked if the patient always screamed out in pain with movement and wound care, person A stated "Yes, she always screams in pain. Employee A stated, "I think it's more out of fear." Surveyor observed morphine in the refrigerator, employee A indicated it was full, and none had ever been given. Review of a document dated and signed on 11/4/2020 by employee E (registered nurse), and employee J (registered nurse) titled "Hospice Certification and Plan of Care" stated "... Hospice nurse to monitor pain level ... report changes in pain level to physician ... Patient's pain level will be at their acceptable level AEB [as evidenced by] PAINAD score is 0... morphine ... as needed ... pain ...." During an interview on 11/17/2020 at 4:02 p.m., after sharing concerns observed during home visit, employee B (registered nurse, director of quality and data) stated "We're sending a nurse today to follow up on ... pain management." Review of a document dated and signed on 11/18/2020 by employee F evidenced documentation of the nursing visit made on 11/17/2020 with surveyor present. The document stated "... Pain ... 0 [verbal pain scale rating of 0-10, with 0 being no pain, and 10 being worst pain] ... confused ... disoriented ... frightened ... anxiety ... unable to understand why or what's happening. Very freafull [sic] of any movement ... PAINAD assessment ... repeated, troubled calling out. Loud moaning or groaning. Crying ... sad, frightened, frown ... rigid ... pulling or pushing away ... striking out ... PAINAD score total ... 6 ... severe pain ... were PRN [as needed] medications needed for pain since last visit? ... No ... Wound care was completed with the assistance of [person A] for turning and comforting [patient] ... [patient] was very calm at start of visit ... Became upset and fearful when we had to turn her ... became upset again with dressing, butt calmed when we got her up off bed to wheelchair ...." The document evidenced employee F contacted person B (attending physician) for orders for antibiotics related to wounds but failed to evidence the physician was notified of patient's severe pain. Review of a document dated and signed on 11/18/2020 by employee L (registered nurse) stated "... During visit, ... new orders for norco [narcotic pain medicine] ... BID [twice daily] and morphine ... to be given 1/2 hour prior to dressing changes ...." The skilled nurse failed to ensure care was stopped when pain became extensive to ensure optimal comfort was achieved prior to continuation of wound care. During an interview on 11/18/2020 3:45 p.m., employee C (administrator) indicated the nurse tried to re-visit the patient last night, but the spouse declined, the patient was seen today by employee L, employee M, and employee B, and the agency was re-educating employee F. Employee B indicated the patient did have pain with movement, she was medicated prior to wound care for pain relief, and new orders were received for further pain management.