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
231547 A. BUILDING __________
B. WING ______________ 		03/24/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
WINGS OF HOPE HOSPICE 530 LINN STREET, SUITE A, ALLEGAN, MI, 49010
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      
30027 Based on record review and interview, it was determined the hospice failed to abide to agency patient rights policies to ensure the patient received effective pain management from the hospice as related to the terminal illness for 1 of 3 records reviewed, (MR #1), resulting in the patient dying without comfort and effective pain relief. Findings included: Agency Policy as documented in the "Information for Patient and Family Admission Booklet": "Patient, Family Rights and Responsibilities, and Grievance Procedures." The Policy States, You have the right to receive services appropriate to your needs and expect the Agency to provide safe, professional care at the level of intensity needed; To have access to necessary professional services 24 hours a day, 7 days a week; to receive care/services from staff who are trained and qualified to carry out the duties for which they are assigned; To adequate and appropriate pain and symptom management as a basic and essential element of your medical treatment; To have your reports of pain believed and responded to quickly by staff trained and qualified in pain management; and to receive verbal and/or written instruction regarding pain relief measures, including possible side effects." {sic} MR#1: The patient was admitted to the hospice on 12/26/2019 with a terminal diagnosis of Diffuse Large B-cell Lymphoma that had spread to his stomach, spleen, pancreas, adrenal glands, colon and diaphragm, Atherosclerotic heart disease of native coronary artery without angina pectoris, Essential hypertension, and Anxiety disorder. The following information was obtained during an interview with the patient's wife on 3/22/2022, at 4:00 pm: The wife stated, "My daughter was alone with my husband on 2/4/2020, and he was screaming in pain. The pain medication was ordered to be given rectally. She didn't know how to give the pain medication rectally and felt uncomfortable in administering medicine rectally to her own dad. My daughter called the night nurse three times asking him to come and give the suppository, and he said "no, I'm not coming" all three times. My husband died screaming, crying, and yelling in pain, which was horrifying and traumatic for my daughter to witness as her father died in such a manner. My daughter is devastated and still has nightmares regarding the painful and unmerciful death of her father, a memory, I'm sure will last the rest of her life. When the night nurse finally did come to the house to pronounce my husband's death, he asked if we (Wings of Hope) had kept him comfortable? This was an uncanny comment to make considering the patient (my husband) died with excruciating pain due to the refusal of the nurse to make the visit. When I lodged a complaint to the agency, the Administrator (ADM-B) asked "who told your daughter that the nurse would come out to give the suppository if she couldn't do it ...that was where the breakdown was." The complainant stated, "that didn't matter if someone had told my daughter that or not. When she called 3 times, the nurse should have got his butt out there {sic}." The agency failed to ensure the Registered Nurse abided by the Agency's policies, procedures, and patient's rights. The result was the patient and family were denied the right to comfort care, quality of life, peace and support at the end of life for their loved one (the very premise and purpose of Hospice Care); and mental trauma for the patient's daughter who witness her father crying, screaming, and yelling during a painful death.