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
241573 A. BUILDING __________
B. WING ______________ 		04/27/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
OUR LADY OF PEACE HOSPICE 2076 ST ANTHONY AVENUE, SAINT PAUL, MN, 55104
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)
L0579      
30922 Based on observation, interview, document review, the hospice failed to ensure hand hygiene (sanitizing with alcohol based hand rub or hand washing) was completed to prevent the spread of COVID-19 and other infections for 1 of 2 patients (P11) observed for infection control during personal cares. Findings include: P11's patient information, dated 4/23/20, noted an admission to residential hospice following a hospital stay from 4/13/20 to 4/23/20. P11's diagnoses included chronic obstructive pulmonary disease (COPD) and respiratory failure. On 4/23/20, at 11:25 a.m. nursing assistant (NA)-Z was observed in the tub room handling equipment and at the nursing station desk. At 11:30 a.m. NA-Z entered P11's room, put on gloves and did not sanitize his hands. NA-Z adjusted his mask and pants. A registered nurse (RN)-Q entered room and did not sanitize hands, put on gloves to provide emesis basin on the table near P11 and left. NA-Z handled the emesis basin, then the tissues, pop and water cup and eye glasses on P11's tray table and touched P11's face near eye asking if he wanted a trim. NA-Z raised the bed, touched the alarms and adjusted P11's head with pillows. NA-Z removed gloves and sanitized hands before exiting room. On 4/23/20, at 11:45 a.m. RN-Q and NA-Z were observed standing in the hallway conversing. RN-Q tied his shoelaces. RN-Q and NA-Z both entered P11's room and put on gloves without sanitizing or washing hands. NA-Z raised P11's bed with controls. NA-Z and RN-Q rolled P11 and adjusted his positioning and pillows to his side and legs. NA-Z and RN-Q removed gloves and performed hand hygiene prior to exiting room. The nurse manager, (RN)-Z explained hands should be sanitized prior to patient care and after touching contaminated items. On 4/23/20, at 11:50 a.m. NA-Z reported he was supposed to sanitize his hands prior to working with each patient upon entering room. NA-Z did not respond as to why he did not do so prior to caring for P11. RN-Q reported he was not aware that he tied his shoelaces and did not sanitize hands. RN-Q noted he should sanitize hands after touching contaminated items. On 4/24/20, at 3:08 p.m. the infection preventionist (IP) explained she expected staff to sanitize hands prior to entering patient rooms and after touching contaminated items. The Covid-19 Incident Command Structure Implemented, last revised 4/22/20, directed staff, " Hand hygiene competency was offered and required of all staff." and "Perform hand hygiene before putting on gloves." The Word Health Organization fact sheet entitled "Hand Hygiene: Why? How? & When?", dated August 2009, directed "Clean your hands by rubbing them with an alcohol-based formulation, as the preferred mean for routine hygienic hand antisepsis if hands are not visibly soiled. It is faster, more effective, and better tolerated by your hands than washing with soap and water. Wash your hands with soap and water when hands are visibly dirty or visibly soiled with blood or other body fluids or after using the toilet." The fact sheet further directed five examples of when hand hygiene needed to be performed: "1. Before touching a patient. 2. Before clean/aseptic procedure. 3. After body fluid exposure risk. 4. After touching a patient. 5. After touching patient surroundings."
L0581      
30922 Based on interview and document review, the hospice failed to ensure timely tracking of a suspected COVID-19 related illness for 1 of 1 residential hospice patients (P7) reviewed with suspected COVID-19. This has the potential to impact all residential hospice patients. Findings include: P7's patient information, last revised 4/11/20, noted a diagnosis of malignant neoplasm of pancreas. P7's admission form, dated 4/11/20, noted an admission to residential hospice on 4/11/20. P7's temperature was noted as 97.7 F [degrees Fahrenheit]. P7's had 13 respirations per minute, which was noted as normal. P7's oxygen saturation [02 sats] was 98% on room air. P7 was noted to have clear respiration and lung sounds and no dyspnea (shortness of breath). P7 had a pulse of 89 beats per minute, noted as regular and a blood pressure of 96/57. P7's vital records, dated 4/20/20, noted temperatures of 101.1 F, 101.5 F, 103.8 F and 101.6 F. P7 had a pulse of 123 beats per minutes and a blood pressure of 146/76. P7 had oxygen saturation of 87%. P7's progress notes, dated 4/20/20, revealed, "Current problems includes new increased SOB [shortness of breath], questionable respiratory infection." and "Noted to have bilateral crackles in lung bases, new onset. Irregular breathing pattern observed on and off. 02 sats have measured in the high 80's on RA [room air]. He has a productive cough-clear sputum into [facial tissues]. 02 [oxygen] was begun at 2 L [liters], 02 increased to 3 L." The progress notes further revealed, "Again he had audible crackles and dyspnea." and P7 told staff "cough won't let me rest." P7's progress notes, dated 4/21/20, revealed, "He began having fevers at 4 pm starting at 103.8 [F]" and "At 9pm he was coughing and gasping for air." P7's April Medication and Treatment Record [MAR/TAR] revealed P7 was administred guaifenesin DM (medication used to loosen congestion) and acetaminophen [a medication used to treat pain and fevers] on 4/20/20 and 4/21/20. P7's laboratory results showed a laboratory test for COVID-19 was performed. A review of the Our Lady of Peace Residential Hospice Infection Control Log for January 2020 through April 2020 revealed no indication P7's potential infection was listed on the log. On 4/24/20, at 3:08 p.m. the infection preventionist (IP) confirmed P7's infection was not on the infection tracking log, but he should have been. IP reported she was the only one who had access to the log. IP reported she was aware of P7's potential infection and had not updated the log. IP reported a nurse should verbally and then in writing inform supervisor of any potential infections. The Evaluating and Maintaining Records of Infections Among Patients, dated October 2014, directed staff "The infection identification patient report form is completed when any of the following occur: A. A new, actual or suspected infection is observed by personnel." and also should be completed if "Patient has a temperature greater than 101 degrees F." The Performance Improvement Coordinator summarizes, trends and analyzes the reports."
L0650      
28651 Based on observation, interview and document review, the facility failed to provide hospice care consistent with family and patient needs related to restricting any visits for patients for 4 of 6 patients (P1, P4, P5, P11) reviewed. The facility made a blanket decision to not allow any visitors in the building due to COVID. Findings include: P1's Patient Information sheet printed 4/23/20, identified P1 was admitted to the hopsice on 3/9/20, with diagnosis of centrilobular emphysema. P1 expired on 3/25/20. P1's Team Care Plan (POC) initiated 3/9/20, update 3/23/20, identified patient has no emotional or spiritual distress. Support system includes husband and family member (FM)-A. Due to visitor restrictions related to COVID-19 intermittent calls are held between patient family via iPad. Patient and family goal to continue to have window chats as long as able with patient and for patient to have a peaceful transition. P1's initial social work (SW) initial assessment visit note dated 3/9/20, identified husband and daughter as being very caring and attentive. Husband was primary care giver prior to admission. SW visit dated 3/18/20, identified both husband and FM-A were doing well and voiced appreciation for phone call. No needs were voiced at this time. SW continue to provide supportive, listening presence and remain available to help respond to questions/concerns. No other SW notes were provided. Spiritual counselor (SC) visits were performed 3/9, 3/17, 3/18, 3/19, 3/23, and 3/24/20. SC note dated 3/23/20, identified a call was placed to FM-A assuring her of her mother's good care and peace. A SC note dated 3/24/20, identified patient was non responsive and looking close to transition. Husband was called and message was left with update. A skilled nursing note (SN) dated 3/24/20, identified a phone call was received from FM-A requesting to face time with her mother. Facetime was completed with daughter and the note identified P1 opened her eyes and tried to speak, speech was difficult to understand. "I love you" spoken by P1 could be understood at end of conversation. P1 very somnolent most of day. FM-A's phone number was given to registered nurse (RN) as FM-A was asking about visitor rights and compassionate visits. FM-A was called back by the RN. SN note only identified FM-A was upset about "no visitor policy" and FM-A stated she felt facility was violating her mother's rights by not allowing her to visit in person. 4/1/20 bereavement evaluation husband feels emotionally well supported by family, friends and work. Husband did not identify any bereavement needs while patient was at facility. During interview with FM-A on 4/23/20, at 11:14 a.m. she stated on 4/16/20, she had a voice message from a RN on 3/16/20, after 3 p.m. asking her to call facility. She stated when she called back she was told they had until noon 3/17/20, to say their goodbyes to their loved one as the facility would no longer be allowing visitors in. She stated on 3/17/20, she was told they had to leave at noon. She stated she had to buy an I pad so she could see her mother as there was no other way for her to see her mom. She stated the first couple days were the only days she could communicate with her mom. She stated when she would talk to her she would ask me "where are you, why are you not here? when are you coming?" The nurse called me one day because she was so agitated and she said, "why can't you come get me?" She stated after the 17th she was only able to talk to her mom 3 times. She stated it was very difficult to get ahold of staff to be able to talk to her mom. She stated she asked if they could set up a schedule to face time and was told they could not do that. She stated her mom was confused and was not able to use the phone herself so needed staff help. She stated the SW called the 18th the first day they could not see her. FM-A stated her dad is a very quiet man and does not say much. FM-A added, "There is no sense of closure for him or me. I keep thinking that I will still get to see her. I didn't get to say goodbye." She stated it is a waking nightmare for her everyday, "I don't know if they took care of her or not since I couldn't be there." FM-A stated she talked to the CEO of the agency and he told her they were not looking into changing the policy and they have the right to do what is best for their staff. She stated she was told by the CEO that if she did not like it she could move her family member to a different facility. P4's Patient Information sheet printed 4/23/20, identified P4 was admitted to the hospice on 4/7/20, with diagnosis of malignant neoplasm of esophagus. P4's POC initiated 4/7/20, identified interventions including validate patient's feelings of loss, loneliness, guilt, injustice, powerlessness, offer validation to wife. P4's initial SN visit dated 4/7/20, identified primary caregiver as wife (FM)-B and family included a step-son. The initial SW assessment visit note dated 4/7/20, identified wife was coping adequately. A SW clinical note dated 4/11/20, identified FM-B was contacted by SW to offer words of encouragement and support to her. FM-A stated she had talked to P4 on the phone and reported he was sad and commented that he thought staff were ready for him to die. A SW visit note dated 4/18/20, identified FM-B "wishes she could be with him at facility but knows it would be difficult to witness his declining health." FM-A availability included daily by phone or e-mail or Facetiming during this time of COVID-19 pandemic and no visiting policy. A SC note dated 4/15/20, identified SC call FM-B who talked a long time and was very lonely for P1. FM-B also has health issues. FM-B talked a lot about missing patient but assuring writer she is going to be ok. During interview on 4/24/20, at 2:05 p.m. FM-B stated it has been hard. She stated, "It is terrible when your loved one is dying and you can't even hold their hand, tell them it will be ok. It's just horrible. I haven't been able to see him since the third when he went to the hospital. I spoke to him in the beginning when he could talk. Today there was nothing, he had his last rights yesterday. I have been struggling with this a lot. It has just been hard, so hard. That is the sad part about it, I know if I could see him it would be better for both of us. They call me everyday and talk to me they have been really wonderful that way. I know they are so strict with that COVID stuff." FM-B stated she had a friend who was in the hospital and her roommate was able to go say goodbye. FM-B added, "They put her in garb and she was able to go in. This place is small, you would think if I garbed up for protection that I would be able to say goodbye to my husband. I don't have have that on my phone so can see him." FM-B stated if she was going to see him she wanted to see him in person, not over the phone. She stated the facility has been giving her support to deal with it but she would just like to be able to say goodbye to her husband. P5's Patient Information sheet printed 4/23/20, identified P5 was admitted to the hospice 3/11/20, with diagnosis of adenocarcinoma of the endometrium/uterus. P5 expired on 4/16/20. P5's routine SW visit note dated 3/17/20, identified P5 had one son and was one of 10 children and was emotionally well-supported by her family and friends. The note also identified P5's family had been present and attentive until the facility "no visitors" policy was put into place on 3/17/20. A routine SW visit note dated 4/1/20, identified R5's son and father called daily and R5's 9 siblings take turns calling daily. P5's POC initiated 3/11/20, identified P5 was still in some shock over suddenness of diagnosis. CP update SN note dated 4/3/20, identified P5 was having delirium, was confused and agitated. SN talked to FM-C who was one of P5's health care power of attorneys. SN gave FM-C an update of P5's current status. FM-C questioned why P5 was so confused. SN explained the disease process and that the progression was different for everyone. FM-C then started crying loudly asking if one family member could be there during her last hours. SN reassured FM-C that situation was heat breaking for everyone involved and facility had to adhere to guidelines set by CDC until further notice. SN note dated 4/4/20, identified both sisters FM-C and FM-D who were health care power of attorneys call facility expressing concern at not being able to reach P5 on her cell phone in the last 24 hours. FM-C and FM-D were updated on her condition and med changes. Family repeatedly requested exception be made for at least one family member to be allowed to come and stay or for P5 to be brought to some part of the building so they could see her from outside. They were encouraged by staff to call nursing desk for updates and told about the mobile phone and reminded about the iPad as means of sight and sound communication. SN note from 4/5/20, identified P5 as restless and agitate at 1600 and stated, "I want my brothers and sisters, are they not here?" SC note dated 3/20/20, identified chaplain met with patient at recommendation of charge nurse who noted that patient feels lonely due to patient restrictions. During interview on 4/24/20, at 1:31 p.m. FM-D stated it was hard to tell with her sister how it affected her not having visitors. She stated she declined fast and they felt if they would have been there in person it would have been better. FM-D stated, "We talked to the director and the head nurse and asked if someone could be with her until she passed and they said no. We had some good zoom meetings but we feel it would have been better to have one person stay with her at the end." They proposed to have her tested and she would stay with her until the end so a family member was with her when she passed. FM-D added, "If I had been allowed to do that I could have went back and forth with the family on video. I think that would have been for the best for both [P5] and us as a family." P11's Patient Information sheet, dated 4/23/20, noted an admission to residential hospice following a hospital stay from 4/13/20 to 4/23/20. P11's diagnoses included chronic obstructive pulmonary disease (COPD) and respiratory failure. P11 lived with a family member prior to admission to hospital and hospice residential facility. On 4/23/20, at 11:19 a.m. P11 was observed in his bed. P11 was the only patient assigned to his double room. P11 gestured and stated that he had a hard time hearing surveyor introducing herself and needed her to come closer to hear her. A nursing assistant (NA)-Z and a registered nurse (RN)-Y repositioned P11 in bed. P11 needed RN-Y and NA-Z to repeat themselves while asking him where in his body he experienced pain. P11 was vocalizing "uh uh" and "ouch" and was coughing. P11 was wearing a nasal cannula with tubing connected to oxygen. RN-Y provided pain medication to P11. P11 returned to sleep after receiving pain medications and being repositioned. On 4/23/20, at 1:51 p.m. RN-Z reported she was was informed there were no visitors allowed for patients under any circumstances. RN-Z reported patients and family were informed of that restriction prior to admission. RN-Z reported patients and families had expressed sadness about restrictions, particularly surrounding special days. RN-Z reported there were tablets at the facility for virtual visits but some family members and staff had difficulty with operating technology to make this option feasible. RN-Z reported there were tablets for use at the facility but not for loaning out to family members for visits. RN-Z reported a newly admitted patient, P11 had asked to see family as he had not been able to for ten days prior to admission to the residential hospice. RN-Z reported P11 was sad at not being able to visit with his family. RN-Z reported she explained options for using tablet and phone calls. P11 reported he was hard of hearing and those options would be difficult for him. RN-Z reported when she tried to explain a pocket talker could be used P11 shooed her out of the room. During interveiw on 4/23/20, at 1:55 p.m. NA-A stated it is hard for everyone as they miss their family and miss out on being with them when they are dying. NA-A added, "We do our best to spend extra time with them. We offer the support of offering them to communicate by phone, or iPad. It isn't the same but it is the best alternative in this time. Families can call the main number and we use portable phone or they can call the I pad at specified time." When asked about P1 she stated she had a hard time right away without seeing her family all the time. She stated P1's daughter was able to get as much information as she wanted and P1 talked with her husband on the phone and daughter face timed. She stated they try to set up times as best they can for them to call back or set up a schedule. During interview with RN-B on 4/23/20, at 2:05 p.m. she stated she did not remember specific issues people had with not being able to visit. She stated she believed families had a day or two to come see their family before the no visitor policy went into effect. She did not remember anything specific about families being upset with not being able to visit. RN-B stated, "We have had family on Facetime with loved ones when they passed. She stated we always call with change in condition especially when getting close to death." During interview on 4/23/20, at 11:50 p.m. SW-A stated they are trying to make it as comfortable as possible for everyone. SW-A added, "We have window visits available, phone calls, Facetiming. I am in communication with families all the time. I encourage them to email me poems, pictures, letters etc. I take them in and put them up in the resident rooms. We try to coordinate the families for phone calls and Facetime etc. I call the families and offer support. I go over the bereavement program with them. We understand that it is very hard for families since they can't be here. We assure them our staff are with their loved ones and offer reassurance and encouragement." She stated she was in contact daily with P4's wife. She could not remember anything in particular about P1 and stated she would have to look at her notes. During interview on 4/24/20, at 8:44 a.m. bereavement coordinator (BC) stated bereavement is much more challenging now with this visitor restriction. She stated bereavement is making calls earlier to family pushing program up. She stated it is hard for families as there is no closure with no funeral. She stated they are offering more frequent loss groups. She stated she is doing more video conferencing and increased phone calls. She stated if staff refer someone to her she will contact them before death but the SW and spiritual care coordinator are handling the prebereavement needs for the most part. She stated each one is individualized. Everyone needs something different. She stated her conversations with families has changed, she is encouraging people to find new ways to find closure, plant flower, journal etc. She stated she feels SW is doing a good job handling the situation. She stated she has moved up the time of contact and is doing special calls per staff requests. She stated she contacted P1's husband and left a message but did not hear back from him. She stated she did not contact daughter. She stated a rose was sent per protocol. She stated no bereavement needs had been identified with the prebereavement assessment. She was not able to contact to complete follow up bereavement risk. She stated P5's family son and sisters are due to be contacted. During interview with the director of nursing on 4/23/20, at 12:16, the director of nurses stated he thought things were going as well as they could be and the visitor restriction was put into place due to not enough personal protective equipment (PPE), they felt we had no choice. 30922 On 4/23/20, at 12:31 p.m. the RN-L accompanied surveyor to tour the storage room. Surveyor observed N-95 masks, surgical masks, face shields, gowns and gloves available. RN-L explained nurses had access to this room at all times. On 4/24/20, at 3:08 p.m. the infection control lead, reported the hospice had a donation of cloth masks from the community and volunteers and had a sufficient supply. The infection control lead noted no shortage. The Minnesota Department of Health Crisis Standards of Care Personal Protective Equipment for Long Term Care, Skilled Nursing Facilities, Assisted Living, Other Non Acute Care Facilities for Covid-19, undated, directed use of cloth/alternative masks and gloves for compassionate care visits.