Survey Report for 261578

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	261578	A. BUILDING __________ B. WING ______________	07/22/2020
NAME OF PROVIDER OR SUPPLIER	STREET ADDRESS, CITY, STATE, ZIP
REGIONAL HOSPICE	3405 WEST MOUNT VERNON, SUITE 100, SPRINGFIELD, MO, 65802
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)
L0556
L0556	17006 Based on policy review, record review, and interview the agency failed to ensure that the care and services provided were based on all assessments of the patient and family needs for one (Record/Patient #1) of three records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency policy titled, "Interdisciplinary Team (IDT)," (undated) showed: -All hospice services are delivered under the direction, supervision, and evaluation of the IDT; -The primary members of the IDT consist of the physician, director of clinical services (DCS), registered nurse (RN), pastoral/counselor, and social worker; and -The responsibilities of the IDT include reviewing, assessing and recommending changes in the plan of care (POC), initiate recommendations of the IDT, establish the scope of services and revise changes when appropriate, and provide and facilitate the exchange of information to the IDT, patient, attending physician, and family/caregiver. RECORD/PATIENT #1: Review of the POC progress summary dated 01/22/2020 showed: -Diagnosis that included colon cancer, chronic kidney disease and dementia; -No change in the level of care since the last IDT meeting; -The patient resided in a long term care facility (LTCF); -IDT discussion included POC and medication review with no changes at this time; and -The patient continued to be appropriate for continued hospice care. Review of a nursing progress note dated 01/27/2020 at 3:30 PM to 3:45 PM showed Licensed Practical Nurse (LPN) B documented: -LPN B was contacted by the hospice aide of a change in status. On assessment the patient was noted to be making loud gurgling noises in the back of his/her throat while breathing. The patient held his/her mouth closed and does not expectorate after productive cough. The patient was resistant to mouth swabbing in an attempt to rid this of the patient's mouth as it its beginning to run out. The patient had a large amount of frothy white sputum. During the visit the patient's eyes became glassy and fixed. A large amount of mottling was noted to both feet which were very cold to touch. The hospice aide reported this was not present even moments before during the patient's shower. Patient is agitated and moves in bed and rips at his/her covers and appeared unaware of staff presence. The patient had a large bowel movement and the nurse and aide provided incontinent care. A towel was placed for fluids that are still coming in small amounts from his/her mouth; -LPN B reported signs and symptoms of active dying phase to the charge nurse, director of nursing, patient staff family member (The patient had a family member who worked at the LTCF) who would contact the patient's son. Patient has comfort medications (did not specify what medications) in place and the facility staff are encouraged to utilize this as needed and contact the hospice team for further needs or concerns; -LPN B failed to document he/she notified the RN case manager, IDT, or physician of the patient's change in condition. Review of a nursing progress note dated 01/27/2020 at 6:15 PM showed RN C (who no longer worked for the agency) documented: -He/she visited with the patient and family to provide support and to answer any questions; -Performed a brief assessment. Heart rate 82, oxygen saturation 88% on two liters of oxygen (unsure of when the oxygen was started), respiratory rate 16, pupils are non-reactive to light, patient without bowel sounds in three quadrants and rattling of excess secretions heard in upper lung fields and in throat/neck area. This writer suctioned but no secretions or fluids removed. Patient noted to open eyes briefly after suctioning. His/her gaze continued to be glassy like and fixed for a brief period, before closing again. Reported findings to family and explained what the active dying process is. Family is in denial and repeatedly report that they cannot believe how quickly this happened. Family then asks how long patient was experiencing breathing difficulties, how long he/she was without supplemental oxygen, and for a report of all the vital signs. RN C notified the RN case manager (RN) A for vital signs which were temperature 97.9, blood pressure 138/78, pulse 74, respirations 22, and oxygen saturation 90% on room air. The family questioned whether the patient had a stroke or if he/she had pneumonia and requested a chest X-ray. RN C attempted to educate the family on the dying process, but they thought the patient could be treated. The facility charge nurse offered a mobile chest X-ray order but that it would not be done until the following day. The family wanted the chest X-ray in case he/she could be treated. RN C offered to answer further questions or concerns prior to departure, and the family reported they did not have any at that time. The family asked what medications were given and RN C informed them that Atropine 1% was given for secretions and Roxanol was given for air hunger/discomfort (unsure if this was during the hospice nurse visit or if this was administered by the LTCF charge nurse). The family stated morphine would not work because it did not work on anyone in their family. RN C gave report to the charge nurse and encouraged them to contact on call number for any further questions or concerns; and -RN C failed to document he/she notified the physician or IDT regarding the patient's change in condition and the family's report of morphine not working for them. During an interview on 07/22/2020 at 9:29 AM, LPN B stated: -On 01/27/2020, he/she could not remember if the hospice aide contacted him/her directly or the hospice office; -When he/she saw the patient, the patient showed signs of the dying process; -He/she went to notify the family; -The patient had changed so fast and he/she was trying to make sure the charge nurse and family knew; -He/she did not remember texting or notifying the hospice physician; and -He/she did not think he/she notified the physician because they had in place what they needed. During an interview on 07/22/2020 at 11:00 AM, the agency DCS stated that the physician and IDT members should be notified about a change in condition and when a patient is imminent. During an interview on 07/22/2020 at 1:49 PM the agency DCS stated: -When a patient had a change in condition the staff person that sees the patient sends a group text to all the IDT members; and -The nurse should have sent and documented he/she sent a group text to the IDT and notified the case manager when the patient had a change of condition on 01/27/2020.
L0591
L0591	17006 Based on policy review, record review, and interview the agency failed to ensure the nursing needs of the patient were met for one (Record/Patient #1) of three records reviewed when nursing staff failed to: -Perform a full physical assessment including vital signs when the patient had a rapid decline in condition; -Notify the physician of the rapid decline in condition; -Document notification of the registered nurse case manager regarding the patient's change in condition; and -Document/assess the need for medications, who administered the medications and effectiveness of medications administered at the time of the visit. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency policy titled, "Nursing Services, Registered Nurse (RN) Coordination of Care," (undated) showed: -An RN is responsible for the coordination of all hospice services. The scope and frequency of services are based on initial and ongoing assessments of the patient's needs. Nursing services are provided in accordance with standard nursing practice and the interdisciplinary (IDT) team plan of care (POC); -Hospice nursing provides symptom management and comfort care interventions; -Support and teaching for the family; -Documentation of problems and appropriate goals and interventions; -Documentation of patient/family participation in and response to the POC; and -Coordination of all patient/family hospice services. RECORD/PATIENT #1: Review of the POC progress summary dated 01/22/2020 showed: -Diagnosis that included colon cancer, chronic kidney disease and dementia; -No change in the level of care since the last IDT meeting; -The patient resided in a long term care facility (LTCF); -IDT discussion included POC and medication review with no changes at this time; and -The patient continued to be appropriate for continued hospice care. Review of the medication list dated 01/23/2020 showed: -An order for Atropine (used to decrease secretions) 1% sublingual (under the tongue) two drops every four hours as needed (as needed reason not indicated) with a start date of 12/12/2020; and -An order for Roxanol (morphine, used for pain or difficulty breathing) 20/milligrams (mg) per milliliter (ml) 10 mg sublingual 0.5 ml every two hours for pain as needed with a start date of 12/12/2020. Review of a nursing note dated 01/27/2020 at 1:10 PM to 1:55 PM showed RN A documented: -Facility physician order sheet compared with hospice orders. New order for mucus relief 400 milligrams (mg) one tablet every 12 hours; -The patient was more talkative than during previous assessments; -Blood pressure 138/78, heart rate 74, respirations 22, temperature 97.9 (route not documented); oxygen saturation (level of oxygen in the blood) 90% on room air; -Collaborated with the LTCF charge nurse who reported increased nasal drainage, cough, complaints of sore throat and wet lung sounds; -RN A documented the nasal drainage was notable, lung sounds adventitious (abnormal) and copious amounts of discolored sputum on the bed sheet; lung sounds faintly coarse with wheezes auscultated to the right upper lobe of the lungs, otherwise remained diminished. The patient had a wet cough once during the visit and did not expectorate (cough up) the sputum and noted a large amount of clear nasal drainage; -Notified the hospice physician of all symptoms. The physician reported that these symptoms were most likely viral and does not recommend antibiotics unless there is evidence that it is is (unsure of what this meant). Reported symptoms have lasted approximately three days and there is not recent/current fever. The hospice physician recommended that the facility/hospice staff continue to monitor symptoms for now; and -Encouraged facility staff to contact hospice with any changes or concerns. Review of a nursing progress note dated 01/27/2020 at 3:30 PM to 3:45 PM showed Licensed Practical Nurse (LPN) B documented: -LPN B was contacted by the hospice aide of a change in status. On assessment the patient was noted to be making loud gurgling noises in the back of his/her throat while breathing. The patient held his/her mouth closed and does not expectorate after productive cough. The patient was resistant to mouth swabbing in an attempt to rid this of the patient's mouth as it its beginning to run out. The patient had a large amount of frothy white sputum. During the visit the patient's eyes became glassy and fixed. A large amount of mottling (occurs when the heart is no longer able to pump effectively and appears as a red or purple mottled appearance) and cold was noted to both feet which were very cold to touch. The hospice aide reported this was not present even moments before during the patient's shower. Patient is agitated and moves in bed and rips at his/her covers and appeared unaware of staff presence. The patient had a large bowel movement and the nurse and aide provided incontinent care. A towel was placed for fluids that are still coming in small amounts from his/her mouth; -LPN B reported signs and symptoms of active dying phase to the charge nurse, director of nursing, patient staff family member (The patient had a family member who worked at the LTCF) who would contact the patient's son. Patient has comfort medications (did not specify what medications) in place and the facility staff are encouraged to utilize this as needed and contact the hospice team for further needs or concerns; -LPN B failed to document a physical assessment of the patient to include vital signs, heart and lung sounds, respiratory status, or oxygen saturation (measures the level of oxygen in the blood), discussion of whether there was a need for oxygen, whether there was a need for comfort medications or whether comfort medications had been administered at that time, and failed to document he/she notified the physician, IDT, or RN case manager. Review of the LTCF medication administration record showed: -Atropine 1% two drops sublingual every four hours as needed administered at 4:01 PM on 01/27/2020 and was effective; and -Morphine 20 mg/ml 0.5 ml oral every two hours as needed administered at 4:01 PM on 01/27/2020 and was effective. Review of a nursing progress note dated 01/27/2020 at 6:15 PM showed RN C (who no longer worked for the agency) documented: -He/she visited with the patient and family to provide support and to answer any questions; -Performed a brief assessment. Heart rate 82, oxygen saturation 88% on two liters of oxygen (unsure of when the oxygen was started); respiratory rate 16, pupils are non-reactive to light, patient without bowel sounds in three quadrants and rattling of excess secretions heard in upper lung fields and in throat/neck area. This writer suctioned but no secretions or fluids removed. Patient noted to open eyes briefly after suctioning. His/her gaze continued to be glassy like and fixed for a brief period, before closing again. Reported findings to family and explained what the active dying process is. Family is in denial and repeatedly report that they cannot believe how quickly this happened. Family then asks how long patient was experiencing breathing difficulties, how long he/she was without supplemental oxygen, and for a report of all the vital signs. RN C notified the RN case manager (RN) A for vital signs which were temperature 97.9, blood pressure 138/78, pulse 74, respirations 22, and oxygen saturation 90% on room air. The family questioned whether the patient had a stroke or if he/she had pneumonia and requested a chest X-ray. RN C attempted to educate the family on the dying process, but they thought the patient could be treated. The facility charge nurse offered a mobile chest X-ray order but that it would not be done until the following day. The family wanted the chest X-ray in case he/she could be treated. RN C offered to answer further questions or concerns prior to departure, and the family reported they did not have any at that time. The family asked what medications were given and RN C informed them that Atropine 1% was given for secretions and Roxanol was given for air hunger/discomfort (unsure if this was during the hospice nurse visit or if this was administered by the LTCF charge nurse). The family stated morphine would not work because it did not work on anyone in their family. RN C gave report to the charge nurse and encouraged them to contact on call number for any further questions or concerns; and -RN C failed to document who administered the Atropine and Roxanol, when it had been administered and whether it had been effective. RN C failed to document he/she notified the hospice physician or IDT regarding the patient's change in condition and the family's report of morphine not working for them. During an interview on 07/22/2020 at 9:12 AM, RN A stated: -He/she was the patient's case manager; -On 01/27/2020 he/she was shocked the patient started doing bad since his/her visit earlier that day; -The RN that saw the patient that night contacted her about what the vital signs had been during his/her visit; -The nurses try to do a physical assessment and vital signs with every visit unless the patient did not want it; -The patient's attending physician had told him/her before that he/she could contact the hospice physician for needs; and -He/she called the hospice physician about the nasal drainage, sputum production and lung sounds. The hospice physician asked if the patient was running a fever. The patient had not run a fever. The hospice physician usually did not recommend antibiotics unless there was a fever. During an interview on 07/22/2020 at 9:29 AM, LPN B stated: -On 01/27/2020, he/she could not remember if the hospice aide contacted him/her directly or the hospice office; -When he/she saw the patient, the patient showed signs of the dying process; -The patient's feet were mottled; -He/she went to notify the family; -The patient had a family member who worked at the LTCF; -He/she typically would do an assessment and take vital signs; -The patient had changed so fast and he/she was trying to make sure the charge nurse and family knew; -He/she was "pretty sure" the charge nurse had given the patient atropine for secretions; -He/she did not remember texting or notifying the hospice physician; and -He/she did not think he/she notified the physician because they had in place what they needed. During an interview on 07/22/2020 at 10:00 AM, the assistant director of clinical services (DCS) at the multiple location site stated: -He/she did not think there had been any significant changes when RN A saw the patient on 01/27/2020; -On 01/27/2020 the hospice aide called to report the patient was struggling more and LPN B went to see the patient; -He/she probably would have done a full assessment of the patient to see what the patient's status was; and -He/she was not sure if the facility called that evening or if he/she sent RN C to check on the patient since he/she was on call that night. During an interview on 07/22/2020 at 11:00 AM, the agency DCS stated: -He/she would have expected the nurses to complete vital signs and a full assessment; and -The physician and IDT members should be notified about a change in condition and when a patient is imminent. During an interview on 07/22/2020 at 1:49 PM the DCS stated: -When a patient had a change in condition the staff person that sees the patient sends a group text to all the IDT members; -The nurse should have sent and documented he/she sent a group text to the IDT and notified the case manager when the patient had a change of condition on 01/27/2020; -The nurse should verify and document whether comfort medications had been given and administer the medications if needed; -The nurses should follow-up and document whether the medications were effective; and -Regarding the family's statement that morphine did not work, if staff gave any medications, they should follow-up and document whether medications were effective. If it was not effective, they should contact the attending physician.