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
261554 A. BUILDING __________
B. WING ______________ 		08/25/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
SERENITY HOSPICECARE 5272 FLAT RIVER ROAD, PARK HILLS, MO, 63601
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)
L0540      
05766 Based on policy review, clinical record review, and staff interview, the agency failed to ensure that the registered nurse (RN) provided all coordination of care, ensured continuous assessment of each patient and family's needs and implemented the interdisciplinary plan of care when the agency failed to notify the family after the patient's fall, failed to make telephone contact and/or visit the day after the fall and failed to make a follow-up visit after pain medication was increased in one (Record/Patient #1) of three cases. This deficient practice has the potential to affect all patients served by the hospice. Findings included: Review of the agency's policy titled, "General Pain Assessment," revised 04/2020, showed the agency staff were to: - Screen the patient for the presence of pain during each visit; - The nurse will keep both the patient and family informed and knowledgeable regarding any need for change in pain medications, including the dosage, route, time to be administered, medication safety, possible side effects and adverse reactions; - The patient/family/caregiver will be fully involved in the plan of care; - The nurse will notify the physician of change in the patient's condition and increased pain; - Any pain reported to the nurse during the visit described as moderate to severe will receive a follow-up phone call from the primary nurse or on-call nurse (if appropriate) within 24 hours to address pain interventions and effectiveness; and - A follow-up nursing/on-call visit will be made when deemed appropriate by the primary or on-call nurse. RECORD/PATIENT #1: Review of the clinical record showed the patient's admittance to hospice on 09/04/19. The admitting diagnosis was unspecified dementia without behavioral disturbance (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgement) and abnormal weight loss. The patient resided in a long term care facility (LTCF). Review of the 05/12/2020 routine nurse visit note from RN A showed no new patient problems documented. Review of the 05/13/2020 narrative note from RN B showed the LTCF called and reported the patient had slid out of his/her chair and was found on the floor. The patient had a large skin tear to his/her right foot. The facility nurse cleansed the wound with wound cleanser and applied a dressing and said there was no other injuries and declined a visit from hospice staff. There was no documentation to show the family was notified of the fall. Review of the 05/15/2020 hospice aide visit note from certified nurse assistant (CNA) D showed the patient was very agitated and yelled upon manipulation in bed, held legs when moved and patient's legs and feet are abnormally swollen, CNA D notified RN A of these findings. Review of the 05/15/2020 routine visit note from licensed practical nurse (LPN) C showed CNA D had called and reported increased pain. The patient was lying in bed upon the nurse's arrival. Patient yelled out when arm moved to take blood pressure. The facility nurse reported patient experienced a fall a few days ago from chair. Right foot opened from fall, cleaned and re-bandaged per care plan. Documented pain as severe. New order for Fentanyl (pain medication) patch due to increased pain and patient unwilling to take any medications by mouth. Review of the 05/18/2020 hospice aide visit note from CNA E showed the patient having pain with any movement and moans out, notified nurse of pain condition. Review of physician orders dated 05/18/2020, showed a new order for Fentanyl 75 micrograms (mcgs) transdermal every 72 hours obtained by RN A. There was no documentation in the clinical record that showed the LTCF or family was notified of the medication changes and no visit was documented by the hospice nurse. Review of the 05/19/2020 hospice aide visit note from CNA E showed the patient moaned out while moving extremities and lower extremities had discoloring and edema. Review of the 05/20/2020 routine visit note from RN A showed the patient had mild pain, right lower calf/ankle swelling and redness. Facility nurse was asked by RN A to clarify if family wanted x-rays and was told family did not want x-rays at this time. New order obtained to increase Fentanyl patch to 100 mcgs and Roxanol (pain medication) five milligrams PRN (as needed). Review of the 05/22/2020 routine visit note from RN A showed the patient had a right leg fracture from his/her fall and a walking boot still in place on his/her right foot. There was no order for a walking boot and the IDG plan of care was not updated for the boot. There was no documentation to show a follow-up phone call or visit was made after pain medications increased on 05/15/2020 and 05/18/2020. A skilled nurse visit was not made until 05/20/2020. During an interview on 08/25/2020 at 9:20 AM, CNA E stated he/she went to see patient for a routine visit and noticed leg was bruised and swollen. Staff said the patient fell out of chair. He/she notified RN A that the patient needed a visit and another nurse did a visit. During an interview on 08/25/2020 at 9:25 AM, RN A stated the following: - He/she did not know he/she was the case manager for the patient. RN B took the call when the patient fell and never contacted him/her regarding if the patient needed to be seen. - LPN C saw the patient on 5/15/2020 after the fall and contacted him/her regarding the fall; - He/she thought LPN C was taking care of the patient and contacting the family; - He/she contacted the clinical manger to find out about the patient and the clinical manager told her they sent LPN C and forgot to tell RN A about the patient; - On 5/18/2020 he/she called the medical director to get the patient's Fentanyl patch increased due to the facility saying the patient needed it; - He/she normally called the medical director or the clinical manager directed him/her whom to call; - He/she did not recall contacting the patient's family regarding change in the Fentanyl but he/she would normally contact family at the time of any changes; - After the patient's fall the facility nurses contacted the family regarding x-rays being obtained and the facility nurse reported family did not want x-rays; - He/she could not remember which facility nurse he/she contacted; - The facility put the boot on the patient's foot/leg to help stabilize and help with the resident's pain; - The assistant director of nursing (ADON) of the facility was not happy because he/she did not know of the resident's fall until several days after it happened; - The facility got a x-ray at some point and the resident had a broken bone. During an interview on 08/25/2020 at 10:04 AM, the clinical manager stated the following: - RN-A had been assigned as the patient's case manager from 2/24/2020 until the time the patient was discharged from services however, RN B was acting as the patient's case manager March and April and RN B was case managing from home; - It was a "communication nightmare"; - We should have reassigned case manager duties to RN A in May when RN B was no longer acting case manager so there was no confusion on who the patients case manager was; - We sent LPN C out to see the patient (on 05/15/2020) because he/she was close by the facility and the patient was in pain; - LPN C should have notified the family of any medication changes; - The facility put the walking boot on the patient for pain and stabilization purposes; - If there is not an order for the boot in the patient's chart, then we probably do not have an order; - When RN B received the call that the resident had fallen on 08/13/2020, he/she should have sent a nurse out for assessment the next day and should have notified the patient's family; - A nurse should have seen the patient for any change in medications and or conditions within 24 hours; and - They have not done any formal in-service training since they identified communication issues within the agency but try to communicate better.
L0582      
05766 Based on policy review, record review, and interview the agency failed to perform/document infection control education to patients and caregivers regarding standard precautions and measures to prevent the spread of COVID-19 in one (Patient/Record #2) of one case reviewed. This deficient practice has the potential to result in unsafe infection control practices or increased infection transmission between staff/patients/caregivers. Findings included: Review of policy 2.07-A: Emergency Preparedness Policy: COVID-19, last revised 8/2020, showed in part: - Policy Statement: The agency considers the safety and wellbeing of clients and employees as a priority in the event of an epidemic which includes, but is not limited to, COVID-19. - Teaching handouts are available to assist families in caring for family members infected with the flu virus. Additional handouts in relation to other communicable diseases are available to families when the need arises via online resources such as Centers for Disease Control (CDC), World Health Organization (WHO), Department of Health and Senior Services (DHSS), etc. Policy failed to include a statement or procedure regarding education for patients/caregivers regarding standard precautions and prevention of transmission of COVID-19 and documentation of the education. The Administrator provided a patient binder that included all written information left in the patient's home at the time of admission. The binder included a one page document labeled Infection Control at Home which included Waste Disposal Tips, Symptoms of Infection and Wash Your Hands. The document failed to include education regarding other standard precautions and information for prevention of transmission of COVID-19. RECORD/PATIENT #2: Review of Patient #2's medical record showed the start of care date as 07/08/2020. Review of the initial/comprehensive assessment dated 07/08/2020 showed no documentation that education regarding standard precautions as related to COVID-19 was given/taught. During an interview on 08/25/20 at 10:45 A.M., the clinical manager and administrator stated that the agency did not document the education provided to the patients/families regarding infection control and COVID-19, but there were teaching hand-outs available as needed for COVID-19.