Survey Report for 261511

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
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION	261511	A. BUILDING __________ B. WING ______________	06/13/2022
NAME OF PROVIDER OR SUPPLIER	STREET ADDRESS, CITY, STATE, ZIP
BJC HOSPICE	670 MASON RIDGE CENTER DRIVE, STE 300, SAINT LOUIS, MO, 63141
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)
L0536
L0536	31099 Based on policy review, record review, and interview, the agency failed to: - Provide education and training for the caregiver as appropriate to their responsibilities (L544); - Develop an individualized plan of care with frequency of services necessary to meet the specific patient and family needs (L547); and - Provide medical supplies and appliances necessary to meet the needs of the patient (L550). The cumulative effect of these deficient practices has the potential to affect all patients served by the agency.
L0544
L0544	31099 Based on policy review, record review, and interview the agency failed to provide/document education and training for the caregiver as appropriate to their responsibilities in one (Record/Patient #1) of six records reviewed. This deficient practice has the potential to affect all patients serve by the agency. Findings included: Review of the policy, last reviewed 05/02/2022, titled "Patient Education Process," showed in part, the following: - Purpose: To provide guidelines for giving specific instruction and information to patients and family/caregivers regarding hospice services; - Policy: Patients and family/caregivers will receive education in verbal, visual and written format, as appropriate. The scope of teaching will be determined by the assessed needs, abilities, learning preferences, and readiness to learn of the patient and family/caregiver, as well as by the plan of care. Education will be the responsibility of each interdisciplinary group member and will focus on, as appropriate: * Facilitating the patient's and family/caregiver's understanding of his/her health status, healthcare options, and consequences of options; * Maintaining the patient's and family/caregiver's health status; * Assisting the patient's and family/caregivers ability to cope with hospice care and the patient's impending death; * Pain and symptom management; -Procedure: As part of the comprehensive assessment, the following will be assessed and included in the plan of care (POC), as appropriate; * The atmosphere for conducive learning; * The pertinent information needed by the patient and family/caregiver in relation to the care being rendered; * The level of knowledge of the patient and family/caregiver in relation to the diagnosis, POC, required activities by patient and family/caregiver, lifestyle changes and etc.; * The ability and readiness of the patient and family/caregiver to learn; * Emotional barriers that might affect learning; * Physical and/or cognitive limitations, as well as communication and language barriers to learning; - The comprehensive assessment will be used as the basis for planning patient and family/caregiver education. In the event that any barriers to learning exists, these barriers, as appropriate, will be discussed with the patient and family/caregiver as well as the Clinical Supervisor. If they cannot be overcome, the patient's physician will be contacted; - Unless otherwise ordered by the physician (or other authorized licensed independent practitioner), the patient and family/caregiver will receive verbal, and as appropriate, written instructions on: * The patient's disease process and prognosis; * Medication management and administration; * Pain management; * Safe, effective use of equipment and supplies; - Documentation of patient and family/caregiver education will consist of: * Describing what was taught to the patient; * Describing the patient's response to the teaching, including the level of understanding and the ability to repeat or demonstrate what was taught; * The patients and family/caregiver's knowledge, skills, and behaviors will be assessed during hospice visits. Re-education, when appropriate, will be provided; and * Individual needs and learning styles will be evaluated when identifying appropriate methods and resources for patient education. RECORD/PATIENT #1: Review of the plan of care dated 05/23/2022 to 05/27/2022 showed: - Instruct maintain tube patency: Instruct patient/caregiver on methods to maintain tube patency and prevent tube clogging. Instruct on flush feeding tube immediately before and after intermittent feedings, flush at standardized intervals for continuous feedings, flush before and after medication administration; - Instruct on enteral access care: Skilled nurse/patient/caregiver to perform care to enteral access daily and as needed (PRN). Enteral access type for venting. Frequency PRN. - Instruct on enteral feeding: Instruct patient/caregiver in administration of enteral tube feedings per med list; - Instruct on methods to open clogged feeding tube: Instruct on methods to open clogged feeding tube. Instruct on instilling warm water and applying gentle back and forth motion; - Instruct on prevention of pulmonary aspiration: Instruct patient/caregiver on prevention of pulmonary aspiration (keep head of bed elevated at 30 to 45 degrees at all times during administration of feedings); and - Ostomy care: Type of Ostomy two-piece. Change ostomy device daily and PRN for leaking or irritation. Cleanse with normal saline, apply skin prep. Family or caregiver may do in skilled nurse absence. Instruct family on care of ostomy, signs and symptoms of infection, and emptying of device. Review of the initial nursing visit dated 05/23/2022, showed: -Gastrointestinal: * Issues: Ascites (fluid collects in spaces within your abdomen); * Pattern: Ostomy (life-saving procedure that allows bodily waste to pass through a surgically created stoma on the abdomen into a prosthetic known as a pouch); * Ostomy type: Colostomy (a surgical operation in which a piece of the colon is diverted to an artificial opening in the abdominal wall so as to bypass a damaged part of the colon); and - No documentation of education , level of understanding, or ability to repeat or demonstrate what was taught regarding how to: maintain tube patency, perform care to enteral access daily, administration of enteral tube feedings, method to opening a clogged feeding tube, prevention of pulmonary aspiration, and how to provide ostomy care. Review of the Telephone Encounter with hospice Registered Nurse (RN) B, dated 05/25/2022 at 8:26 AM, showed: - Summary: Ostomy question; - Contact person: Patient's spouse; and - Communication details: Spoke with patient's spouse who reported a one piece ostomy bag (Plan of Care (POC)shows two piece ostomy device) was placed over puncture site on stomach and is filled up with fluid and they do not know how to empty it. Instructed spouse to release the clip at the bottom of the bag and empty into a container. Advised bag does not need to be rinsed out. Encouraged spouse to call hospice triage at any time. During an interview on 06/03/2022 at 9:09 AM, with the hospice admitting registered nurse (RN) A stated that: - The patient's caregivers included the patient's spouse and mother. They provided education to the patient's spouse but he/she was not certain they understood as he/she was crying, but did nod his/her head and verbalized understanding and comprehension; - When asked about the primary caregivers coping ability, he/she stated the spouse was crying. The patient's mother was interactive but wasn't crying and verbalized understanding of the education; - The RN felt like the patient's spouse was prepared and handled the visit and situation of the patient being admitted to the hospice well; - The patient's spouse/caregiver was crying the whole time during the teaching, so he/she pulled the patient's mom to the side and also educated her on the patient's medications; - The patient had a tube to drain infection, it started leaking stool and the hospital staff placed an ostomy bag over the whole thing. When the RN asked the family about it, they said it was the only place the patient had pain. The RN got a lidocaine patch out of the bag, but the patient was having so much pain that he/she didn't want the RN to touch the area. The hospital had sent home a couple ostomy bags with the family; - The spouse/caregiver was distraught the whole time but the patient's mom was there and he/she felt like the teaching/education went through. There was a lot of people there and it was a small home. The teaching/education was done with the spouse and mom of the patient. She taught about draining and burping the ostomy bag. She did not teach on changing the bag, just the maintenance. The hospital staff had taught the family how to change the ostomy bag; and - He/she documented the education to the caregivers in the interventions on the plan of care (POC). (However, upon review of the documentation there was no education on burping the ostomy bag and no evidence of return demonstration on providing care to the ostomy bag.) During interview on 06/07/2022 at 1:11 PM with the patient's caregiver (spouse), he/she stated that: - The patient had an ostomy bag that was put on four to five days prior to the patient being discharged from the hospital on 05/23/2022 (same day he was admitted to hospice.) There was no education from the hospital staff or the hospice staff regarding the ostomy bag care; - The ostomy bag was about to explode on Wednesday (05/25/2022) and the caregiver called hospice to see what to do. The triage nurse had to tell the caregiver what to do, and the caregiver/spouse and the patient's mom had to figure out, how to take care of the ostomy bag; - There was no education given to either of the caregivers on admission; - There was no education given on the ostomy; - There was also a tube that was put in the patient's neck to drain fluid (it was placed in his neck 2 to 3 days prior to discharge (05/23/2022) from the hospital) and the caregivers learned how to drain it in on their own into a Tupperware bowl. They were not educated, but they figured it out on their own, there was a big drain bag and a tab that said open or close so they just learned to drain it on their own.
L0547
L0547	31099 Based on record review and interview, the agency failed to ensure the plan of care (POC) included the correct frequency of visits needed for the skilled nurse in one (Record/Patient #5) of six records reviewed to meet the specific patient and family needs. This deficient practice has the potential to affect all patients served by the agency. Findings included: RECORD/PATIENT #1: Review of the Inpatient Discharge Summary, dated 05/23/2022, showed the patient's platelets down to 11,000 (normal is 150,000 to 400,000 platelets per microliter) on the day of discharge and family made aware about possible spontaneous bleed. Review of the initial registered nurse visit note dated 05/23/2022, showed: - Urgent Needs: Rapid decline. - The patient was unable to get out of bed on his/her own; - He/she has been unable to keep any food down and has had multiple episodes of nausea and bilious vomiting; - Patient has a drain tube; - Endorses failure to thrive, shortness of breath, increasing abdominal distention, some leakages around the drain tube, etc.; and - He/she is using accessory muscles with 5 liters of oxygen. Review of the POC's dated 05/23/2022 through 05/27/2022 ordered skilled nursing to visit one to two visits every week for 13 weeks and six visits as needed. Review of the Telephone Encounter, dated 05/25/2022 at 8:26 AM, showed: - Summary: Ostomy question; - Contact person: Patient's spouse; - Communication details: Spoke with patient's spouse who reported a one piece ostomy bag placed over puncture site on stomach is filled up with fluid and they do not know how to empty it. Instructed spouse to release the clip at the bottom of the bag and empty into a container. Advised bag does not need to be rinsed out. Encouraged spouse to call hospice triage at any time. Review of the Telephone Encounter, dated 05/25/2022 at 12:52 PM, showed: - Summary: Symptom; - Contact person: Patient's spouse; - Communication details: Received phone call from patient's spouse wanting to know when a nurse will be coming to see patient since only a certified nurse aide (CNA) is assigned, and when will they receive supplies. Patient's spouse reports patient is changing, becoming minimally responsive and his/her breathing is more labored. Reports administering morphine. Instructed on use of morphine for breathing and pain and side effects of medication. Instructed the supplies come from a vendor and usually take 1 to 2 days for delivery by FedEx, but when the nurse comes today, she may have some stock in her car to assist. Instructed on end-of-life symptoms. Instructed to keep patient comfortable, keep lights low, conversations low and that hearing is the last sense. Answered all questions and emotional support given. Review of the Telephone Encounter, dated 05/25/2022 at 2:35 PM (third call in six hours), showed: - The patient's spouse called concerned with change in the patient. Reports his/her breathing is more labored, despite Oxygen at 5L, head of bed up and morphine. Reports patient is barely responsive and his/her lower extremities are very cold. Instructed on decreased circulation due to dying process. Instructed to give 0.5 mL (10 mg) Morphine now and repeat in one hour for the labored breathing and to assess in two hours patient's breathing if nurse has not arrived. Instructed may call this nurse for any changes, concerns or questions this afternoon. (no mention of whether or not a nurse is enroute to address caregiver's concerns in person) During an interview on 05/25/2022, at 2:36 PM, the family member calling the hotline stated that the physician had told the family the patient's platelet (pieces of very large cells that help form blood clots to slow or stop bleeding) count is 11,000 and normal is over 100,000 and when the patient gets to 5,000, he/she will probably bleed out and the patient and his/her spouse had a one year old residing in the home with them. During interview on 06/02/2022 2:54 PM and 3:23 PM, the hospice director stated he/she had no knowledge about the patient's platelet count and the patient possibly bleeding out. During an interview on 06/03/2022 at 9:09 AM with the hospice admitting registered nurse (RN) A, he/she stated: - When asked about the primary caregiver's coping ability, he/she stated the spouse was crying the whole time; - When the surveyor asked if the patient's family or caregiver mentioned that the patient's platelet count was low and that he/she will probably bleed out, the RN stated that they said the count was low and the hospital staff said he/she would only live approximately seven days; and - When the surveyor asked the RN if the family was OK with the nurse only coming two times a week, he/she told the family the schedule and they knew hospice was only coming twice a week, but if the patient declined and symptoms were not controlled they would visit daily. The admitting RN did not know the schedule the patient was to be seen. He/she just scheduled/ordered twice a week. During an interview on 06/03/2022 at 9:48 AM with the patient's family member, he/she stated the following: - The patient's caregiver/spouse called the hospice agency on Tuesday, (05/24/2022) a day after the patient was admitted and asked when a nurse was coming. He/she was told it would be Wednesday but when Wednesday came it was only a bath tech that came; - The ostomy bag was full and the caregiver called on 05/25/2022 at 8:26 AM asking if they would change the bag and was told no. The family was told there were no nurses on the schedule, and no one scheduled for him/her; and - There was no urgency or humanity at this point and no nurse scheduled to come until Thursday, until I called the hotline and a nurse was sent out Wednesday and stayed about 10-15 minutes. During an interview on 06/07/2022 at 1:11 PM with the patient's caregiver (spouse), he/she stated that: - "Hospice basically left us here to find it out on our own;" - No hospice staff was coming for two days and we had to call and talk to about 100 people before they sent someone out; - On Tuesday (05/24/2022) he/she called hospice to find out when the nurse was to come, and was told it would be tomorrow and come to find out, it was only a bath tech that showed up; and - On Wednesday (05/25/2022) the he/she called hospice in the morning to have a nurse come and he/she was told someone would be coming in the morning (Thursday - 05/26/2022) and then the patient's sister called and that's when they sent someone out to see the patient on Wednesday. During a telephone interview on 06/13/2022 at 11:00 AM, the Executive Director Home Care stated he/she could not answer if a nursing visit was scheduled to go out and see the patient on 05/25/2022 prior to the family calling.
L0550
L0550	31099 Based on record review and interview, the hospice failed to ensure the plan of care included all services necessary for the palliation and management of the terminal illness and related conditions, including medical supplies and appliances necessary to meet the needs of the patient in, but not limited to, one of six records reviewed (Record/Patient #1). The deficient practice has the potential to affect all patients on service with the hospice Findings included: RECORD/PATIENT #1: Review of the skilled nurse (SN) hospice assessment dated 05/23/2022, showed in part, the following was completed by registered nurse (RN) A: - Patient was diagnosed with metastatic colon cancer in September 2021; - Gastrointestinal: * Issues: Ascites (fluid collects in spaces within your abdomen); * Pattern: Ostomy (life-saving procedure that allows bodily waste to pass through a surgically created stoma on the abdomen into a prosthetic known as a pouch); * Ostomy type: Colostomy (a surgical operation in which a piece of the colon is diverted to an artificial opening in the abdominal wall so as to bypass a damaged part of the colon); - Genitourinary: * Decreased urine volume; -Musculoskeletal: * Musculoskeletal assessment: Weakness; * Ambulation assist: Non-ambulatory; - Modified Activities of Daily Living (ADL): * Toileting: Total dependence; * Transfer: Total dependence; * Continence: Total dependence; - Problem: Impaired elimination: * Intervention: Ostomy care; *Type of ostomy two piece. Change ostomy device daily and PRN for leaking or irritation. Cleanse with normal saline (NS), apply skin prep. Family or caregiver may do in skilled nurse absence. Instruct family on care of ostomy, signs and symptoms of infection, and emptying of device; and - Currently unable to get out of his/her own bed and has some leakage around the drain tube etc. Review of the plan of care, dated 05/23/2022, showed no intervention or supplies listed for the use of urinal, chux, and graduate/container to drain fluids from the ostomies. Review of the skilled nurse hospice visit, dated 05/25/2022 at 4:10 PM showed: Patient has a colostomy in right lower quadrant (RLQ) (placed 09/13/2021). Noted right psoas malignant cecal perforation with abscess drain (placed 05/12/2022). It was noted the drain continued to have significant feculent discharge around it, and it is covered with colostomy bag. Patient indicates extreme pain when the area is touched/moved. Spouse and mother emptied bag earlier. Patient has a percutaneous Tran's esophageal gastrostomy (nonsurgical technique that creates an esophagostomy and allows enteral access in patients with hostile abdomen, altered gastric anatomy, massive ascites, and carcinomatosis) placed 05/20/2022 to decompress and ease pain. It is draining to gravity: dark green black noted. There is no documentation that the caregivers were given anything to empty it in (using a plastic bowl from the kitchen). During an interview on 06/03/2022 at 9:09 AM with the hospice admitting registered nurse, RN A, he/she stated that: - There were no supplies taken to the home, the patient had four bags of stuff sent from the hospital (there was no documentation of what was in the bags); and - When the surveyor asked why the chuxs/pads and incontinence supplies were purchased by the family, RN A responded that the patient was continent on admission (Admission assessment shows total dependence for toileting and initial RN visit note states "rapid decline"). During an interview on 06/03/2022 at 9:48 AM with the patient's family member, he/she stated the following: - The hospice agency left no supplies. Last week when the patient was in the hospital, he/she didn't have strength to get up out of bed and was told he/she would lose control of his/her bowel and bladder. The family had to go buy a urinal for him/her to urinate in and chux for the bed as he/she was bedbound; - The ostomy bag had to be emptied in a Tupperware container because they were not given anything to empty it into; and - It was really hard on the family not having the supplies they needed. During interview on 06/07/2022 at 1:11 PM with the patient's caregiver (spouse), he/she stated that: - There were no supplies left at the home. The family received supplies on the day of the patient's death of 05/27/2022 and the day after the patient's death. One of the shipments showed it had not been shipped until 05/26/2022 and the patient died on 05/27/2022; and - I (caregiver/spouse) was really upset due to no supplies and no pads/chux left for the patient and when he/she urinated it got on the bed and they had no way of rolling and caring for him very easy to change the sheets because there were no pads.