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
261511 A. BUILDING __________
B. WING ______________ 		04/26/2022
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)
L0552      
29559 Based on policy review, Medicare benefit manual review, record review, and interview, the hospice failed to ensure that the hospice interdisciplinary group (IDG) documented consideration of level of care changes for uncontrolled symptoms in one (Record/Patient #1) of three sampled patient records. This deficient practice has the potential to affect all patients served by the hospice. Findings included: Review of the agency's policy titled, "Continuous Care Services," last revised in 2019 stated in part, the following: - Continuous care to achieve palliation to manage acute symptoms, and to maintain the patient in his/her residence; and - The hospice nurse confirms appropriateness of continuous care and will contact the physician and interdisciplinary group members to report the patient's condition, assessment, and relevant information. Review of the Medicare benefit manual section "40.2.1 - Continuous Home Care (CHC-Revision 188)" shows in part that continuous home care may be provided only during a period of crisis as necessary to maintain an individual at home. A period of crisis is a period in which a patient requires continuous care which is predominantly nursing care to achieve palliation or management of acute medical symptoms. RECORD/PATIENT #1: Review of medical record showed the 17 year old patient was admitted to hospice service on 12/03/2021 with a terminal diagnosis of Alveolar Rhabdomyosarcoma (cancer). The patient's guardian and caregiver was his/her parent. The patient had a patent (operational) central venous catheter from admission to his/her death on 01/23/2022. Review of the plan of care orders from 12/04/2022 showed the patient had immediate release Zofran tablets and scoplomine patches (anti-emetic agents) as needed (PRN) for control of nausea and vomiting. Review of a hospice nurse "telephone encounter" entry, dated 12/04/2022 at 1:42 AM showed the patient's guardian/primary caregiver called the nurse on-call and reported "pt symptoms of intractable nausea and vomiting since this morning following dose of oxycodone" given by (caregiver). The patient had 8 out of 10 pain (scale where 10 is the worst pain) with wrenching and dry heaving. The caregiver/guardian requested an intravenous (IV) antiemetic. The nurse educated the caregiver to give the dissolving Zofran as prescribed. Review of a nurse visit note dated 12/04/2021 at 11:30 AM through 1:40 PM by registered nurse (RN-A), showed the patient was in 8 out of 10 pain. The patient "vomited/wretch/dryheave" for the "next many hours" after oxycodone was provided. The nurse educated the primary caregiver to use the available scoplomine patch and "may take up to 24 hours to be effective". The scopolamine patch was applied by the hospice nurse at 12:30 PM. The caregiver informed the nurse that the patient was resistant to medications by mouth due to the patient's history of an ileus (lack of movement within the intestines). Review of a hospice nurse "telephone encounter" entry, dated 12/04/2021 at 2:03 PM by RN-A showed the patient's caregiver/guardian made multiple "calls and texts between 2:03 PM and 6:08 PM that the patient continued to vomit with shaking, that the patient threw up pain meds and ativan". The caregiver/guardian stated that the patient "was not getting what he/she needs". Review of the coordination notes showed no discussion with the IDG team regarding changing the patient's level of care or plan of care based on uncontrolled symptoms. Review of a hospice nurse "telephone encounter" entry, dated 12/04/2021 at 4:01 PM by RN-A showed the patient's caregiver/guardian reported "intractable vomiting/wrenching", and the Zofran tablets and current medication regimen were ineffective. The nurse called the hospice physician and a "plan" was made to start IV morphine (an opiate narcotic) by an infusion pump. Review of a nurse visit note dated 12/04/2021 at 6:23 PM through 8:01 PM by RN-A showed the patient was in nine out of 10 pain. The patient reported the constant need to vomit. IV morphine via an infusion pump was started by the hospice nurse. The IV morphine was delayed due to the pharmacy failure to supply a key to the infusion pump. The caregiver/guardian requested IV Zofran. Oral Haldol PRN was started for nausea and vomiting. Review of the coordination notes showed no discussion with the IDG team regarding changing the patient's level of care based on uncontrolled symptoms. Review of a hospice nurse "telephone encounter" entry, dated 12/04/2021 at 8:32 PM by RN-A showed the caregiver/guardian reported that the patient was now throwing up blood "suggested that this may be the result of so many hours of ongoing wretching/dry heaving and vomiting". The nurse instructed the caregiver to stop providing the patient ibuprofen. The nurse relayed the information to the hospice physician. The physician directed to continue treatments as ordered and "if not in alignment, to revoke hospice service and seek treatment in the emergency room". Review of the coordination notes showed no discussion with the IDG team regarding changing the patient's level of care based on uncontrolled symptoms. Review of the clinical record showed no follow-up on the patient's uncontrolled symptoms until 12/05/2021 at 3:33 PM. Review of a hospice nurse "telephone encounter" entry, dated 12/05/2021 at 3:33 PM by RN-A, showed the caregiver/guardian reported the patient vomited eight times since the last hospice nurse visit on 12/04/2021. The patient had the nausea and vomiting until 3:00 PM. During an interview with RN-A on 04/25/2022 at 1:35 PM, he/she stated the following: - The patient had uncontrolled nausea and vomiting the weekend of his/her on-call; - When asked why IV Zofran was not considered, he/she stated that it was a safety risk, and the dissolving Zofran tablets were not effective; -When asked if general inpatient (GIP) level of care was offered for the uncontrolled nausea and vomiting, he/she stated that hospitalization was offered but the patient's caregiver/guardian refused. (It should be noted that the 12/04/2021 at 8:32 PM entry stated that the hospital intervention would require revocation of the patient's hospice benefit). - When asked if continuous care was offered, he/she stated that the patient historically became anxious when hospice nurses were present so continuous care was not offered. Review of a written statement from the caregiver/guardian of the patient showed: - The patient had uncontrolled symptoms until the day he/she died; - To control the patient's uncontrolled nausea, he/she was told by hospice staff that the option was to revoke hospice and go to the emergency room; and - The patient and caregiver/guardian elected hospice because he/she did not want to the patient to go back into a hospital.