Survey Report for 261581

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	261581	A. BUILDING __________ B. WING ______________	07/06/2021
NAME OF PROVIDER OR SUPPLIER	STREET ADDRESS, CITY, STATE, ZIP
CROSSROADS HOSPICE OF KANSAS CITY, L C	14310 EAST 42ND STREET SOUTH, UNIT 600, INDEPENDENCE, MO, 64055
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)
L0500
L0500	17006 Based on policy review, record review, and interview, the agency failed to promote and protect the following patient rights: - The patient has the right to receive effective pain management and symptom control from the hospice for conditions related to the terminal illness (L512). The cumulative effect of this deficient practice has the potential to affect all patients served by the agency.
L0512	Rights Of The Patient 418.52(c)(1) Corrected On: 08/11/2021
	17006 Based on policy review, record review and interview the agency failed to ensure the patient received effective pain management for uncontrolled symptoms related to the patient's terminal illness in one (Record/Patient #1) of three records reviewed when the agency failed to adequately assess pain control, provide timely follow up and assessment of pain control interventions and failed to ensure that timely inpatient care was available or explore other timely alternatives for provision of inpatient care for uncontrolled symptoms. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency policy titled, "Pain and Symptom Management and Measurements," revised 11/10/2020, showed in part: - The hospice ensures that patient's symptoms are managed and controlled to promote comfort and dignity throughout the hospice admission and dying process and will use stringent guidelines, follow regulations, consistent assessment reviews and obtain as appropriate, physician orders for all pain and symptom management issues and ensure that the patient/family needs are met; - The agency will utilize consistent pain measurement scales for individual patient's needs which include the numeric, descriptive, Baker-Wong (a scale that uses facial expressions to assess pain) and/or FLACC (face, legs, activity, cry, consolability, a pain scale used for people that cannot communicate their pain) and associated pain scale for patients to ensure the proper assessment and ratings of patient pain and symptoms; - A numeric scoring key can be used to assess the severity of end of life symptoms to assess the effectiveness of interventions; - The numeric symptom assessment key showed 0=no symptom, 1-3=mild symptoms, 4-6=moderate symptoms and 7-10=severe symptoms; - Staff may also use typical terms such as mild, moderate and severe as well as using the key as long as the patient's needs are met and that the assessments are consistent and effective; - The nurse will assess for presence, location, characteristics, and type of pain and/or symptoms upon admission/assessment, at the time of the comprehensive assessment and at each visit and will document findings as appropriate; - The nurse will assess, monitor and document if indicated for the potential physiological signs of pain and/or symptoms, including, but not limited to tachycardia (rapid heart rate), elevated blood pressure, tachypnea (rapid breathing), diaphoresis (sweating), dilated pupils, nausea, muscle tension and pallor (paleness); - The nurse will assess, monitor, document and intervene based off established plan of care and/or will contact the physician/practitioner for further orders, as indicated, when the patient is exhibiting symptoms, including but not limited to nausea, vomiting, shortness of breath, constipation, agitation, anxiety, restlessness, cough diarrhea and pruritus (itching); - The agency will obtain an order (as appropriate) for pain medications needed to palliate other symptoms from the primary care physician and/or the hospice medical director; - The agency will utilize any route, medication or dosage that has been deemed safe to palliate pain and/or end of life symptoms that are contributing or secondary to the terminal condition; - The nurse will perform teaching with patient/patient representative regarding pain management, symptom management, drug usage, dosage and side effects as appropriate and document such teachings; - The IDG (interdisciplinary group) members, especially the medical director will be consulted and collaborate as appropriate to ensure adequate pain and symptom control measures are utilized; - A complete, accurate and legible entry will be documented regarding medications/treatments and non-pharmacological pain control measures as appropriate; - Pain will be managed at a level acceptable to the patient; - Agency will notify the physician of ineffective pain management following the administration of the analgesic prescribed; - Agency will administer analgesics as prescribed to prevent severe pain from reoccurring; - Agency will use around the clock dosing as required to ensure adequate pain relief; - Agency will use rescue dosing (use of short acting pain medications to provide relief of intermittent breakthrough pain) as appropriate to ensure adequate pain relief; and - Agency will evaluate effectiveness and/or educate patient/family/facility to evaluate effectiveness of pain medications within two hours of administration and to report any ineffective treatments and/or increase in symptoms. Review of the agency policy titled, "Patient and Family Rights Employee Education," dated 04/01/2010 showed in part, the patient has the right to receive competent and compassionate pain management and symptom control interventions to alleviate distress and discomfort to the fullest extent safely possible. Review of the patient/family bill of rights given to patients at admission to the agency showed in part, the patient has the right to receive competent, compassionate and effective pain management and symptom control interventions from the agency to alleviate distress and discomfort for conditions related to, when receiving hospice services, the terminal illness to the fullest extent safely possible. Review of the agency policy titled, "General Inpatient Care-Inpatient for Symptom Control related to the Terminal Illness," revised 09/19/2011, showed in part: - The hospice provides the appropriate level of care at all times. Inpatient care is provided to the hospice patient when: Symptoms are not controlled and need a highly skilled approach to regain a level of comfort for the patient; Inpatient care is provided in contract facilities only. Hospice remains in control of the patient's plan of care as it relates to the terminal illness and works in collaboration with the facility staff to meet the needs of the patient; - Guidelines included: Pain: Investigation, which requires frequent evaluation by physicians/nurses; Active treatment to control pain; *Titrations (gradual increases) of dosages with frequent changes; - Control of other symptoms included any symptom that cannot be controlled in a home, long term care or assisted living setting; - Assess the patient/family needs and recognize when a change in the patient's condition may warrant a change in level of care; - Communicate to the registered nurse (RN) in change of the patient's care of the possible need for inpatient care or change in condition; - The role of the RN is to contact the clinical director or team leader to advise of the need and for assistance in making arrangements for the transfer; - Contact the attending physician regarding the change in status and determine if acute inpatient care is needed; - Contact the medical director regarding the change in status; and - Discuss the situation with the patient/family to determine if they are in agreement with inpatient care. RECORD/PATIENT #1: Review of the physician orders showed: - On 03/11/2021 an order to start MSIR (morphine sulfate immediate release, fast acting narcotic pain medication) 15 milligrams (mg) one to two tablets (the order did not specify when to use one tablet and when to use two tablets) every four hours as needed for pain; - On 03/22/2021 an order to start MSER (morphine sulfate extended release, long acting narcotic pain medication) 60 mg one tablet every eight hours for pain; and - On 03/30/2021 an order for Flomax (for urinary retention) 0.4 mg two times a day for seven days for kidney stones. During an interview on 06/29/2021 at 1:25 PM the clinical director stated that if an order was for one or two tablets, the order should be specific as to when each amount should be taken. Review of a comprehensive patient assessment report dated 04/06/2021 showed: - Pain level three (pain is rated on a 0-10 scale with 0 meaning no pain and ten meaning the worst severe pain); - Reported Flomax (for urinary retention) has helped urination tremendously; - Reports left groin, kidney and testicle pain. There is a palpable knot in the area, and the nurse reported this to the physician; - The patient requested an increase in morphine medication and the nurse is awaiting the physician's decision for this request; - Upon exit reported pain a level of three; and - The assessment failed to include the recent history of pain levels, the patient's acceptable level of pain, how often the patient used the MSIR for breakthrough pain, whether the patient took one or two tablets for breakthrough pain and what level the MSIR brought the pain level down to. Review of a physician order dated 04/06/2021 showed an order to discontinue the MSER 60 mg three times a day and start MSER 60 mg four times a day for pain. During an interview on 06/30/2021 at 1:05 PM, the RN education coordinator stated that he/she expected a complete pain assessment to be documented. He/she would expect the assessment to include what and how much pain medication the patient was taking. The RN showed the surveyor a phone visit report that showed on 04/06/2021 the nurse called the medication change into the pharmacy and provided education to the patient. Review of a phone call patient assessment report dated 04/07/2021 from 8:45 AM to 9:00 AM showed: - Phone check with patient. No new needs or concerns. Educated patient on covid-19 precautions. Patient aware to contact hospice 24/7 with any new questions or concerns; and - The phone assessment failed to include any documented pain assessment, including, whether the new order for pain medication was effective. Review of a comprehensive patient assessment dated 04/13/2021 (seven days after the increase in pain medication without a documented follow up assessment of whether the increase in pain medication was effective) showed: - The patient reported a pain level of three in the groin and left testicle; - The nurse contacted the physician who would be doing a home visit to assess the patient; - The patient is taking both scheduled and as needed pain medications; and - The assessment failed to include the recent history of pain levels, the patient's acceptable level of pain, how often the patient used the MSIR for breakthrough pain, whether the patient took one or two tablets for breakthrough pain and what level the MSIR brought the level down to. Review of the IDG (interdisciplinary group) meeting notes/plan of care (POC) dated 04/14/2021 showed: - The patient took scheduled and as needed morphine. The patient had a new lump to the left groin with pain going into the testicle. The physician was doing a home visit that day. Monitor pain and medication effectiveness; - The POC showed the patient's testicular pain would be assessed at each visit and the pain would be tolerated at an acceptable level; and - The pain in the right groin and left flank area showed the nurse would assess for signs and symptoms of pain each visit, document pain with each visit, assess effectiveness of medications and the patient would exhibit decreased signs and symptoms of pain. Review of the physician recertification dated 04/14/2021 showed in part: - The patient had lung cancer with metastasis to the spine and adrenal glands (these glands produce hormones that help regulate metabolism, immune system, blood pressure, response to stress and other essential functions); - PPS (palliative performance scale, used to assess functional performance and progression toward end of life) decreased to 50%, spent most of his/her time in the chair, no curative treatment; and - Prognosis less than six months and was hospice appropriate. Review of a phone call patient assessment report dated 04/15/2021 from 8:45 AM to 9:00 AM showed the nurse spoke to the patient regarding the physician's visit yesterday. The patient wanted the nurse to contact the physician for changes. The nurse informed the patient he/she would contact the physician later that afternoon. There were no other issues or concerns. Review of another phone call patient assessment report dated 04/15/2021 from 4:00 PM to 4:30 PM showed the patient was upset after the physician informed him/her that the groin/testicle pain was not a kidney stone but was a tumor from cancer. The patient had been holding out on taking more pain medication or trying new medication because he/she thought the pain was from a kidney stone and would be temporary. The patient wanted to change the pain medication regimen to have better pain control and management. The nurse received a verbal order from the physician to change the morphine from 60 mg four times a day to morphine 90 mg three times a day to see if that helped. The note failed to include whether the patient was educated on this change in dosage. Review of the record showed no written physician order to change the morphine dosage to 90 mg three times a day. During an interview on 06/30/2021 at 10:05 AM the RN education coordinator stated that their process when a new order was received, the nurse completes a phone order form and submits it to the team leader with their daily activity log. The team leader then enters the orders and updates the medication profile. During an interview on 06/30/2021 at 1:10 PM, the RN education coordinator stated that he/she did not find an order to change the morphine dosage to 90 mg three times a day or documentation that the patient was informed of the dosage change, but expected an order to be written and documentation that the patient was educated on the change. Review of a routine assessment report dated 04/16/2021 showed: - Pain level three and some discomfort in the abdomen; - The patient took a scheduled and as needed opioid (medications used to treat moderate to severe pain); - Upon exit the patient reported his/her pain level was at two; and - The assessment failed to include how much and how often the patient took the morphine, the recent history of pain levels, the patient's acceptable level of pain, how often the patient used the MSIR for breakthrough pain, whether the patient took one or two tablets for breakthrough pain and what level the MSIR brought the pain level down to. Review of a comprehensive patient assessment dated 04/20/2021 showed: -The patient stated that his/her pain was adequately managed with present interventions. The patient presently used MSER 100 mg three times a day and has MSIR as needed for pain management; and - The assessment failed to include the recent history of pain levels, the patient's acceptable level of pain, how often the patient used the MSIR for breakthrough pain, whether the patient took one or two tablets for breakthrough pain and, and what pain level the MSIR brought the level down to. Review of the record showed no written physician order to change the morphine dose to 100 mg three times a day between 04/15/2021 and 04/20/2021. Review of a routine patient assessment report dated 04/22/2021 showed: - The nurse documented a FLACC score of one; - The patient had generalized mild, dull, intermittent pain; - The patient stated the new pain medication order was effective and was taking the as needed pain medication twice a day (did not specify whether the patient took one or two tablets) for breakthrough pain; and - The assessment failed to include the patient's stated level of pain, the patient's acceptable level of pain, whether the patient took one or two tablets of MSIR for breakthrough pain, and recent history of pain levels. Review of a phone call patient assessment report dated 04/26/2021 from 9:45 AM to 10:00 AM showed: - Phone call placed and patient requested a refill on medication. Request called into the pharmacy. The patient verbalized understanding to call 24/7 with questions, concerns or changes. No documentation regarding the patient's pain management. Review of a comprehensive patient assessment dated 04/27/2021 showed: - The patient rated his/her pain a level of five. The nurse documented a FLACC score of one; - Pain to LLQ (left lower quadrant) dull, severe, intermittent; - The patient took his/her morphine at 8:00 AM, 4:00 PM and midnight; - The majority of the visit focused on pain management which the patient stated was a major concern; - The MSER 100 mg three times a day provided relief for three plus hours with the as needed medication taken eight times a day per patient. The patient stated that the as needed medication was slow to address pain; - The nurse informed the patient he/she would follow-up. The patient stated previous discussion regarding adjusting morphine to 100 mg four times a day. The nurse would discuss with the physician. Review of a physician order dated 04/27/2021 showed: - A clarification order for 04/16/2021 to discontinue MSER 60 mg three times a day; - Start MSER 100 mg three times a day; - A new order for 04/27/2021 to discontinue MSER 100 mg three times a day; and - Start MSER 150 mg three times a day for pain management. During an interview on 06/30/2021 at 2:15 PM with the RN education coordinator and team leader at the multiple location, the team leader stated the nurse that saw the patient on 04/16/2021 got the order for the change in morphine but did not write the order because he/she had to leave for a family emergency. The nurse that saw the patient on 04/27/2021 wrote the clarification order when he/she did not find the order for 04/16/2021. Review of phone call patient assessment report dated 04/27/2021 from 5:00 PM to 5:30 PM showed the nurse reviewed the phone call with the primary physician/medication changes with the patient. Encouraged to call with any questions or concerns. Verbalized understanding. No documentation regarding the patient's current pain status. Review of the IDG discussion notes/POC dated 04/28/2021 showed: - Morphine changed to 90 mg then 100 mg three times a day, MSIR is available, the patient wanted 100 mg four times a day. Will speak with physician for change; - Did not include the order from 04/27/2021 to increase the MSER to 150 mg three times a day; - The POC showed on 04/22/2021 generalized pain, FLACC score one, assess effectiveness of medications; and - The POC showed on 04/27/2021 showed pain LLQ, FLACC score one, assess effectiveness of medications. Review of the record showed no follow-up regarding the patient's pain status after the change in medication order until 04/29/2021. Review of a phone call patient assessment report dated 04/29/2021 from 11:30 AM to 12:00 PM showed: - Call from patient returned; - The patient stated that the MSSR (unsure if this meant MSER) order changed from 150 mg three times a day to 130 mg three times a day as the MSSR 150 mg dosage strength is unavailable; - Call placed to patient and education of medication change and rationale given. Patient verbalized understanding; and - No assessment of the patient's current pain status. Review of a physician order dated 04/29/2021 (time showed N1400 (unsure if this meant 2:00 PM) showed: - Discontinue MS Contin (MSER) 150 mg three times a day - Dose unavailable; - Start MS Contin 100 mg one tablet three times a day for pain and MS Contin 30 mg one tablet three times a day for pain; and - Give MS Contin 100 mg plus 30 mg to equal 130 mg three times a day. Review of another phone call patient assessment report dated 04/29/2021 at 3:42 PM showed: - Order from primary physician for MSER 150 mg three times a day, did not respond to prescription from the pharmacy (unsure what this meant), signed by hospice medical director. Per the hospice medical director change the dose of MSER to 100 mg tablets and 30 mg tablets three times a day as the 150 mg dose is not available; - Call to family member who stated the patient was taking MSER 160 mg (no order found for this) and will upset (unsure what this meant). Per patient RN call to patient and educated regarding dose changes and to take 130 mg dose; - Family member verbalized care concerns regarding case manager being on leave, tailbone discomfort and changes to mass areas; and - Call placed to patient and stated that he/she does not mind the two nurses who see him/her in place of the case manager and would like to have the case manager when he/she returned and does not want to change. Stated he/she noticed color change to mass area this morning and had not told anyone and did verbalize some tailbone discomfort to this nurse. Discussed offloading tailbone every two hours as the best option. Reviewed possible changes to mass and when it is ok to leave open to air and when treatment may need to be initiated. Discussed discomfort when he/she slept as he/she cannot lay flat and has a standard mattress he/she does not like. The patient qualifies for a LAL (low air loss mattress). Call placed to medical director for new order for LAL. To be delivered tomorrow per patient's request. Encouraged patient to call with any changes or concerns 24/7. Review of the record showed no follow up with the patient regarding pain management after the new order on 04/29/2021 until 05/03/2021 (four days later). Review of the comprehensive patient assessment dated 05/03/2021 showed: - The patient rated his/her pain a level of eight out of ten in the left groin. The pain was sharp, severe, intermittent and increased with movement; - Patient was on MSER 100 mg three times a day, MSER 30 mg three times a day and has MSIR 15 mg every four hours as needed for breakthrough pain; - The patient stated that his/her pain is increased today and stated that his/her pain would never be below a six; - He/she had a high pain tolerance; - The patient took breakthrough medication during the visit; - The patient's pain was down at the end of the visit; - No notification of the physician of the patient's increased pain; and - The assessment failed to include what level the pain was at the end of the visit and whether it was acceptable to the patient, the patient's recent history of pain levels, how often and how much of the MSIR the patient used, and what level the MSIR brought the pain level down to. Review of the record showed no follow up of the patient's pain until 05/06/2021 (three days later) after the patient reported increased pain at a level of eight. Review of a phone call patient assessment report dated 05/06/2021 from 1:45 PM to 2:00 PM showed: - The patient answered the phone; - The nurse reviewed pain management; - The patient stated he/she was having a good day with minimal discomfort but yesterday, "not so much"; - The patient remained on MSER 130 mg and MS (unsure if this meant MSIR) 15 mg for breakthrough pain. The patient was taking the prn medication on a four hour basis; - No documentation regarding the patient's current pain level or recent history of pain levels, whether the patient was taking one or two tablets of MSIR every four hours, what level the medication brought the pain down to, whether the pain level was acceptable to the patient or discussion with the patient/physician of whether the scheduled MSER needed to be increased since the patient had to utilize the breakthrough pain medication the maximum of every four hours; and - The patient would call over the weekend if changes in his/her pain level. Review of the comprehensive patient assessment dated 05/10/2021 from 2:15 PM to 3:30 PM showed: - The patient rated his/her pain a level of nine out of ten in the left side of the groin; - The patient took MSER 130 mg three times a day and MSIR 15 mg every four hours as needed; - The patient stated that he/she utilized the as needed medication (no documentation whether the patient utilized one or two tablets) every four hours this last week; - Care coordinated with the hospice physician and awaiting response; - No documentation of what the patient's pain level was at the end of the visit or whether the pain level was acceptable to the patient; and - Educated the patient and caregiver to call 24/7 with any questions or concerns. Review of a physician order dated 05/10/2021 at 4:00 PM showed: - Start MSER 15 mg three times a day to current dose of 130 mg for pain; - Give MSER 100 mg tablet plus MSER 30 mg tablet and MSER 15 mg tablet to equal 145 mg three times a day for pain. Review of the record showed no follow up on 05/10/2021 after the patient reported a pain level of nine and change in medication dose. Review of the on call log report dated 05/11/2021 at 7:27 AM, the patient called and stated he/she would like for the nurse to call. He/she stated that he/she had a rough night and needed to go ahead and start the other medication as soon as possible. Review of the record showed no documentation of a call to the patient on 05/11/2021. Review of a physician order dated 05/11/2021 showed: - Discontinue MSER 100 mg; - Discontinue MSER 30 mg; - Discontinue MSER 15 mg; - Start Methadone (used to treat moderate to severe pain) 10 mg one tablet by mouth in the AM; - Methadone 10 mg one tablet in the evening; and - Methadone 5 mg one-half tablet in the afternoon. Review of a watch care patient assessment report dated 05/12/2021 from 10:30 AM to 11:15 AM showed: - The patient's pain was a level of nine to the left groin that was sharp, severe, ongoing and worse with movement; - The patient was currently on Methadone ten mg in the AM, five mg in the afternoon, and ten mg in the evening; - Start daily visits for Methadone monitoring; - The patient utilized MSIR 15 mg one to two tablets every four hours as needed for breakthrough pain; - No documentation of time the Methadone was taken; - The patient's worst pain was a level of ten out of ten, average was a level of eight out of ten and best was a level of six out of ten; - No signs and symptoms of toxicity at this time; - The patient stated today is just "fucked" and was hurting; - The patient also stated that he/she had to jump through hoops again to try to get pain under control; - The patient had utilized two doses of MSIR so far with the last dose at 9:30 AM; - The patient stated that he/she was struggling today; - The nurse provided reassurance to the patient and caregiver regarding the Methadone process and both verbalized understanding; and - The nurse educated the caregiver and patient to call 24/7 with any questions or concerns. Review of the record showed no further follow up with the patient on 05/12/2021 after reporting his/her pain level was nine and that he/she was struggling that day. Review of the IDG discussion notes/POC dated 05/12/2021 showed: - Day one of Methadone, five mg afternoon, ten mg evening; - MSIR one to two tablets, using several doses; - No signs of toxicity at this time; - Patient states not a good day; - Frustrated about pain control; - Education provided about process; - The plan was to continue monitoring methadone, breakthrough use and comfort; - POC showed on 05/03/2021 pain in left groin, numeric level eight, assess signs and symptoms of pain and effectiveness of medications each visit and document pain with each visit; - POC showed on 05/10/2021 pain in groin, numeric level nine, acknowledge patient's experience, assess signs and symptoms of pain and effectiveness of medications each visit and document pain with each visit; and - POC showed on 05/12/2021 pain in groin, numeric level nine, acknowledge patient's experience, assess signs and symptoms of pain and effectiveness of medications each visit and document pain with each visit. Review of the on call log report dated 05/12/2021 at 10:51 PM showed the caller needed a nurse to come out because his/her spouse was in severe pain. The patient started medications but they were not working, and is having out of control pain. They have been trying to wait but no longer can. Action taken showed the caregiver had given all available pain medication and the patient had just started Methadone today. He/she stated that the patient had been uncomfortable all day. Advised to call going forward at the onset to not let pain get out of control. Nurse sent for emergent visit and new orders received. Review of an emergent visit report dated 05/12/2021 from 11:45 PM to 1:45 AM (05/13/2021) showed: - Upon arrival the patient sat on the edge of the bed, dry heaving; - States that he/she is due for night time Methadone dose 10 mg and took MSIR 15 mg less than ten minutes ago before vomiting; - Stated that his/her pain had been uncontrolled all day and currently the pain was at a level of ten out of ten, and the patient was diaphoretic (sweaty) and restless; - The patient was agitated and stated he/she knew this would happen and no one listened; - At 12:20 AM attempted a cracker with Zofran but vomited; - Contacted the medical director who recommended a slurry of methadone and MSIR with slow administration, and if this attempt failed then it was ok to give the same slurry rectally once for pain control. The patient vomited three more times during the oral slurry administration; - At 1:00 AM the nurse gave MSIR slurry rectally then phenergan (used to treat nausea and vomiting) suppository; - At 1:30 AM the nurse gave Methadone 10 mg rectally; - At 1:45 AM the patient stated that his/her pain has improved some and was at a level of eight; - He/she stated he/she did not think this was going to work; - Educated the caregiver regarding medication administration and to call with any questions. He/she stated he/she understood and has written the medication schedule down, but asks multiple previously answered questions. The patient was calm, quiet and lying in bed at the end of visit. FUPC (unsure if this meant follow up phone call) at 4:00 AM to assess pain and provide support on how to slurry MSIR; and - No documentation of follow up with the physician that the patient's pain remained at a level of eight or discussion regarding providing continuous care (this level of care is provided around the clock in the home for brief periods when the patient is experiencing a crisi
	s) or inpatient care (a level of care provided in an inpatient facility for pain and symptom control) to ensure the patient's pain decreased to an acceptable level. Review of a physician order dated 05/13/2021 at 12:20 AM showed: - Ok to give Methadone 10 mg tablet, Zofran 4 mg tablet and MSIR 15 mg tablets times two as needed rectally for pain management if unable to tolerate by mouth. Review of the on call log report dated 05/13/2021 at 2:50 AM showed the caller stated the nurse just left about 45 minutes ago, but the patient could not sit still and is saying he/she is dying. The caller stated medications were changed today, everything is backwards, and seemed to not be getting any relief. The caller stated they needed more help, something better. Second call (unsure of time) caregiver stated no relief from medication given rectally and they were considering going to the emergency room. The nurse was sent for an emergent visit and received new orders from the medical director. Review of an emergent visit report dated 05/13/2021 from 3:45 AM to 8:15 AM showed: - Patient and spouse upset that pain remains unrelieved; - Received orders from the medical director to give dose of MSIR by mouth or rectally now and can give every hour as needed for pain; - Initiated continuous care per the medical director's order; - At 3:45 AM MSIR 30 mg given rectally. The patient denied improvement; - At 4:06 AM order for STAT (immediate) CADD pump (continuous ambulatory delivery device, it is set to deliver a safe amount of pain medication 24 hours a day) hydromorphone (used to treat severe pain) two mg continuous every hour with two mg bolus (an extra, single dose of medication) every 30 minutes as needed for breakthrough pain. Called to on call pharmacy. Estimated time of arrival was 8:00 AM to 9:00 AM (four to five hours later); - The patient and spouse stated they felt better knowing there was a plan; - At 4:45 AM MSIR 30 mg given rectally. The patient reported some improvement and no longer felt angry. The patient was still vomiting and dry heaving (pain level not documented); - At 5:45 AM MSIR 30 mg administered rectally. The patient was more conversational and ambulated in his/her room. Encouraged crackers but still unable to tolerate (pain level not documented); - At 7:00 AM MSIR 30 mg and phenergan/Compazine suppository given rectally. The patient stated his/her pain was still at a level of ten out of ten but no longer radiated to his/her testicles and he/she felt more in control of the situation. Reviewed the plan of care and verbalized understanding (no documentation of follow up with the physician that the CADD pump would not be there until 8:00 to 9:00 AM, that pain remained at a level of ten, or whether further interventions could be provided until the hydromorphone could be started); - At 8:00 AM MSIR 30 mg and Zofran eight mg given rectally. The patient asked if there was more they could do for the pain. Reminded that the CADD pump will be delivered within a couple of hours and would continue to have a nurse at the bedside to administer morphine hourly if needed; - At 8:15 AM report given to oncoming nurse; - The patient experienced high levels of pain for at least nine hours with no documentation of follow up with the physician regarding that the CADD pump would not be there until 8:00 AM to 9:00 AM, that the patient's pain remained at a level of ten, whether further interventions could be provided until the hydromorphone could be started, or discussion of inpatient care for pain control. Review of a physician order dated 05/13/2021 at 3:45 AM showed to initiate continuous care for uncontrolled pain. Review of another order dated 05/13/2021 at 4:06 AM showed: - Ok to administer MSIR 15 mg one to two tablets now and then give one to two tablets every hour by mouth or rectally as needed for pain; and - STAT CADD pump hydromorphone two mg continuous every hour with two mg bolus every 30 minutes as needed for breakthrough pain. Review of an emergent patient assessment report dated 05/13/2021 from 8:30 AM to 3:30 PM showed: - At 8:00 AM arrived to patient's home and received report from nurse; - The patient stated he/she was only having three seconds of relief at a time. The patient rated his/her pain at a level of ten out of ten. The patient received MSIR 15 mg two tablets rectally at 8:00 AM; - At 8:15 AM the patient stated he/she was hurting so bad. The patient occasionally moaned with pain and continued to state his/her pain was a level of ten (no documentation of update with physician); - At 9:00 AM the CADD pump arrived but were awaiting supplies to start the pump. MSIR 30 mg given rectally; - At 9:15 AM the patient's pain level remained at ten; - At 9:30 AM the patient stated no relief from MSIR (no update with physician that patient continued to have no relief); - At 9:45 AM the pain radiated down the patient's groin to testicles. The patient reported he/she was still nauseated but hoped getting the pain under control would help; - At 10:00 AM MSIR 30 mg given rectally. Another nurse arrived to assist with set up of CADD pump and delivered supplies; - At 10:15 AM started hydromorphone five mg/ml, give two mg/hour with two mg bolus every 30 minutes. Initial bolus given. Hospice physician called and updated; - At 10:50 AM the patient gave a two mg bolus. The patient rated his/her pain a level ten out of ten; - At 11:00 AM MSIR 30 mg administered rectally; - At 11:21 AM the patient gave a bolus per CADD pump; - At 11:30 AM the patient appeared to be a little more comfortable. The spouse remained concerned and stated if this did not work, the patient needed to go to the hospital. The patient stated he/she was hurting but wasn't there yet; - At 11:45 AM the pain remained a level ten out of ten; - At 11:51 AM the patient gave a bolus dose; - At 12:00 PM the patient took Zofran eight mg by mouth to see if he/she could tolerate by mouth medications. The patient wanted to wait on MSIR and try to eat something and take pain medication by mouth; - At 12:15 PM the patient took MSIR 30 mg by mouth with five bites of oatmeal; - At 12:22 PM the patient gave a bolus; - At 1:00 PM the patient took his/her afternoon medication and MSIR 30 mg; - At 1:15 the patient appeared more comfortable and was tolerating by mouth medication; - At 1:30 PM, physician called and new orders received for hydromorphone 3 mg/hour basal with a 2 mg demand dose every 30 minutes and MSIR 15 mg one to two tablets every four hours as needed; - At 1:45 PM the patient's basal rate was increased to 3 mg/hour. The patient stated the pain was a level of eight out of ten with no radiating pain to the testicles; - At 2:00 PM the patient gave a bolus dose; - At 2:15 PM the patient stated his/her pain was manageable with walking; - At 2:30 PM bolus dose given. The patient rated his/her pain at a level of six out of ten with radiating to the testicle at eight out of ten but the radiating pain did not stay; - At 3:00 PM care coordinated with the physician and ok to end continuous care. Patient and caregiver only would like a follow up phone call this evening and this nurse will follow up tomorrow; and - At 3:30 PM continuous care ended. Educated patient and caregiver to call 24/7 with any questions or concerns. Review of another order dated 05/13/2021 at 1:45 PM showed: - Discontinue previous hydromorphone order for CADD pump; - Start hydromorphone five mg/milliliter (ml) give three mg/hour basal rate (the amount of medication given as a continuous infusion and is set per hour) with a bolus dose of two mg every 30 minutes per CADD pump for pain; and - Discontinue Methadone 10 mg, Zofran 4 mg and MSIR 15 mg rectally times two as needed rectally. Review of a phone call assessment report dated 05/13/2021 from 6:30 PM to 6:45 PM showed the patient stated that he/she is feeling the best he/she has in a while. His/her pain is at his/her baseline of six out of ten. He/she was still having a few surges of pain to the groin. They do not last long. He/she had nothing but great things to say about the nurse and the help he/she gave. Educated to call with any change in condition or questions and concerns. Review of a phone call patient assessment report dated 05/14/2021 at 9:45 AM to 10:00 AM showed: - The patient stated that he/she had a good night and slept six hours straight; - Rated his/her pain a level of six out of ten; - Patient very pleased with pain control; - Stated there was 28.1 ml left according to CADD pump; and - Educated patient that he/she would call later today and check on him/her Review of a phone call patient assessment report dated 05/14/2021 from 3:45 PM to 4:00 PM showed: - The patient just woke from a nap; - Rated his/her pain a level of five out of ten; - Patient stated there was 23.6 ml left according to the CADD pump; - Educated that a nurse would be coming tomorrow to change the bag; - The patient had used four to five boluses that day and one dose of MSIR at breakfast; - Educated patient on dosing of how many hours should be left with what the pump was reading; - The patient was receiving three mg/hour with a bolus of two mg every 30 minutes; - The patient should have enough medication for 20-21 hours, if maximum dose is used patient has enough for 16 hours; and - The nurse educated the patient to call 24/7 with any questions or concerns. Review of a routine patient assessment report dated 05/15/2021 showed: - Pain assessment 7/10 Dilaudid (hydromorphone) PCA (patient controlled analgesia); - Patient reports pain is adequately managed with present interventions; - Continues to use MSIR as needed for breakthrough pain last taken earlier this morning and denies nausea over the past 24 hours; - The pain assessment failed to include the patient's recent levels of pain, the patient's acceptable level of pain, how often and how much breakthrough medication was used, what level it brought the pain to and no documentation of how many bolus doses were given; - No documentation the physician was notified that the pain was still at a level of seven out of ten; and - New bag of 50 ml hydromorphone five mg/ml with a three mg/hour basal rate and a two mg bolus with a 30 minute lock out started. Review of the record showed no follow up with the patient until 05/17/2021. Review of the comprehensive patient assessment dated 05/17/2021 showed: - On arrival the patient was sleeping; - Rates pain at a level of five out of ten in the left groin area; - States sleeping better since CADD pump started; - Discussed with patient and caregiver that the CADD pump was temporary. Frustrated with why change something that is working; - Educated regarding no long acting medications with hydromorphone; - Patient unsure if wants to start Methadone again and would let the nurse know at next visit; - Caregiver does not want spouse to be a trial case with managing his/her pain; - Nurse provided active listening and reassurance; - Nurse changed and cleared CADD pump. Hydromorphone five mg/ml, give 3 mg/ml basal rate with two mg demand (bolus) dose every 30 minutes, doses given 38, doses attempted 43. Patient has enough medication possibly until Wednesday; - Nurse educated patient and caregiver to call 24/7 with any questions or concerns; - The assessment failed to include the patient's recent levels of pain, acceptable level of pain, how much and how often the breakthrough medication was used, what level it brought the pain down to, or discussion regarding that the bolus doses of hydromorphone attempted exceeded the doses given. Review of the on call log report dated 05/18/2021 at 7:31 AM showed the patient stated he/she was in pain and would like the nurse to give him/her a call. Action taken showed the patient requested to talk to the case manager this morning regarding an increase in pain medications. Case manager notified and will follow up this AM. Review of a phone call patient assessment report dated 05/18/2021 at 9:21 AM showed: - The patient reported puking, unable to keep anything down, no food or water; - The patient stated this was the worst pain he/she had ever had; - Physician notified; and - Educated patient that nurse would head that way. Review of an emergent patient assessment report dated 05/18/2021 at 10:00 AM showed: - Emergent visit due to uncontrolled pain with nausea and vomiting; - Patient found lying in hospital bed moaning and grimacing; - Refused to let nurse administer Compazine/phenergan suppository; - CADD pump in place with hydromorphone five mg/ml, three mg/hour basal rate with demand dose two mg/hour every 30 minutes; - The patient refused to administer the demand dose due to making the patient have increased nausea and vomiting; - The patient continued to say that something broke away on the left side of his/her back; - The patient continued to have sweating and chills, no temperature noted; - Family upset due to uncontrolled symptoms; - Nurse continues to be in contact with the hospice physician; - The hospice physician and team leader were working on GIP (general inpatient care); - At 11:15 AM patient with increased nausea. Continued to refuse to let nurse administer suppository for nausea and vomiting or demand dose from CADD pump; - Patient upset due to taking so long to hear back from the doctor/hospital and stated, "If this was their father, they wouldn't take so long"; - At 11:30 AM patient refusing to try Ketamine (a medication with sedative and pain relieving effects, sometimes used for patients who have been taking opioids (narcotic pain medications) for pain and found them to be ineffective) due to it would take hours for it to get there; - The team leader called the nurse to inform him/her that the hospital they called did not have beds available for GIP and that they did not take the patient's insurance; - Patient and family upset and wanting to know what other hospitals they could go to; - The team leader stated two other hospitals (these were hospitals the hospice agency had GIP contracts with) and the patient and family stated that any of them would be fine; - At 11:40 AM the patient agreed to let the nurse administer Compazine/phenergan suppository for nausea; - The patient's spouse went outside to calm another family member; - The nurse received a phone call from the team leader prior to administration of the suppository regarding that the medical director did not recommend the other two hospitals for pain management (unsure what this meant); - The nurse relayed this information to the patient; - The nurse stated if the patient wanted to go to the emergency room, he/she could revoke (the patient can decide to stop hospice care, usually to seek curative treatment. If an emergency room visit is for symptom management due to their terminal illness, this is not considered curative treatment) hospice services so the bill is covered. The patient stated that "Then I would have to start all over with this shit"; - The nurse asked the patient if he/she wanted the nurse to go outside to get his/her spouse to discuss the patient's options, and the patient stated "yes"; - The nurse went to get the spouse; - At 11:46 -11:47 AM the nurse went ahead of the spouse into the home; - The patient was seen walking out of the bathroom/storage area in the basement; - The patient pointed a gun at the nurse and stated "get out"; - The nurse ducked to the left side by a bench in the garage; - The spouse screamed for the patient to put the gun down; - The patient stated get out and close the door or this would be a murder, suicide; - A gunshot was heard and the spouse ran to the patient; - The nurse was on the phone with 911 reporting the event; - The dispatcher asked if the patient was still alive and the nurse stated yes; - The police arrived and the nurse and spouse exited the home; - Another family member screamed and stated if the nurse had done his/her job this wouldn't have happened; - The nurse placed a call to the team leader at 11:54 AM; - The patient left the home around 11:55 AM to 12:00 and was still alive; and - The nurse gave his/her statement to the police, waited until police were finished inside the home then left. During an interview on 06/29/2021 at 3:20 PM, the clinical director stated that they had two full GIP contracts and others that would require a patient specific contract. Some of the larger hospitals had their own hospices and would not contract with them. During an interview on 06/29/2021 at 3:35 PM the patient's case manager stated that he/she took over as the patient's case manager on 05/03/2021. He/she remembered the patient took MSER and MSIR, then tried Methadone. If the patient can't manage his/her symptoms they start continuous care until the symptoms can be managed. On 05/03/2021 he/she should have documented what the patient's pain level was at the end of the visit. He/she could not remember if he/she followed up with the patient on 05/10/2021 but thought if it wasn't charted then probably not. He/she remembered they increased the MSER to 145 mg because the patient was hesitant to take Methadone. He/she stated that the patient called on 05/11/2021 and wanted to switch to Methadone. He/she called the physician. The physician said ok and would figure out the equivalent of Morphine to Methadone. He/she called it in to the pharmacy to deliver that night. The patient took the first dose at midnight and they started daily visits for Methadone monitoring. On 05/13/2021 the patient was happy with his/her pain level at a six when he/she left. He/she talked with the patient about four times a day. He/she offered a visit but the patient declined. The patient thought a phone call would be sufficient. When asked about the statement regarding the CADD pump being temporary, he/she stated that they normally initiate that for patients that can't tolerate medication by mouth. The physician said they would try the CADD pump and see how it goes. When he/she spoke with the physician, the goal was to get the patient back to taking medications by mouth as long as he/she could tolerate it. On 05/18/2021 he/she stated that it was his/her first experience trying to do GIP. He/she let the physician know he/she was going to see the patient. He/she did an assessment and called the physician. The physician suggested a lot of things including Ketamine. He/she did not know why the patient thought it would take hours to get there. The physician and team leader were working on GIP. It was 1 ½ hours before the patient let him/her administer anything. The patient would not take the demand dose. He/she told the patient it would probably be best to come off services and go through the emergency room. He/she went to get the patient's spouse and when he/she walked back in the patient pointed a gun at him/her. During an interview on 06/29/2021 at 4:55 PM the clinical director stated that on 05/18/2021 even though the medical director did not recommend the two hospitals for GIP they still checked with both and they did not have beds available. They also checked with a hospital that would require a patient specific contract. They presented ER as an option, Ketamine at home as an option, but the patient kept refusing the options and did not want to take the medications that were in the home. When asked about revoking hospice to go to ER as an option, he/she said if the pain was something that could be treated at home and the patient refused, that could be outside the plan of care. When asked if the ER was an option for symptom management related to the terminal illness, he/she did not know if he/she could speak to that. The ER probably would have done what we could have done at the home. Some hospitals do not like to give Ketamine because they are not used to doing that, but they had given Ketamine in the home before. During an interview on 07/01/2021 at 10:40 AM with the clinical director, assistant executive director and executive director (by phone), the clinical director stated that pain assessments should include the patient's interpretation of pain, a description of pain, sometimes a FLACC assessment with the nurses' assessment per the patient if needed, assess the patient's acceptable level of pain initially and as time goes on. The staff ask the patient's at each visit if the pain level is acceptable. There should be a full pain assessment with each visit including a history of pain, how much pain medication that patient was taking and how often to determine if the medication was meeting the patient's need. If the patient was having issues with pain, depending on the severity of the issue, the staff should call at least four hours later to follow up and document how the pain was doing. If they ask a caregiver to give medication, he/she preferred they call back within an hour to see how the patient was doing and would expect documentation that they educated the patients and caregivers regarding medication administration and document how the pain was doing. When asked about the nurse leaving on 05/13/2021 at 1:45 AM when the patient's pain was at a level of eight, he/she stated that it would be hard to say without seeing the patient but if the patient was comfortable it could go either way. When asked if he/she would have expected the nurses to update the physician on 05/13/2021 that the patient's pain continued to be at a level of ten and the CADD pump not scheduled to arrive until 8:00 -9:00 AM, he/she stated that it would be difficult to say, but it may take the medication a few hours to start working.
L0562
L0562	17006 Based on policy review, record review and interview the agency failed to ensure the agency followed their policy regarding follow up of a patient incident in one of one incident reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency policy tiled, "Patient/Family/Staff Incidents," revised 02/15/2013 showed in part: - The following procedures will be followed in regards to incidents; - The hospice will record all incidents and perform adequate follow up and tracking; - Incidents will be immediately reported to hospice supervisor (s), which include, but not limited to: Staff endangerment or injury; Patient or family injury; and *Patient related suicide or homicide threats, attempts, or completion. - The hospice QAPI (quality assessment performance improvement) will be informed of and will review all patient related suicide or homicide threats, attempts or completion; - The hospice will ensure that all incidents involving a premature death, accidental death or suicide will receive an intensive evaluation to identify the root cause and prevent a similar event; - The hospice will ensure all incident reports are reviewed and summarized with patterns and trends analyzed on a regular basis; and - The clinical director, executive director or team leader will maintain all incident reports. All patient related incident reports will be logged and maintained within the problem prone QAPI log. The team leader (or designee) will summarize all incidents with patterns and trends and submit to the hospice executive director and hospice clinical director. INCIDENT #1: Review of an agency form titled, "KSC Incidents" presented by the clinical director as the agency investigation showed: - QAPI (Quality Assessment Performance Improvement) incident type: General incident (not problem prone); - Date of incident: 05/18/2021; - Is incident related to a patient? Yes; - Source of incident: Patient; - Were other individuals involved: Yes; - List names of other individuals involved: Listed the nurse present at the home, the patient's spouse and another family member; - Did injury occur? Yes; - Describe injury: Death of patient via self- inflicted gunshot wound to the right frontal lobe; - Description of non-problem prone incident: The nurse went to visit the patient due to pain crisis. Upon the nurses' arrival, he/she informed the physician the patient was having increased pain with nausea and vomiting. The patient had not taken anything for nausea and vomiting and no additional pain medication due to the nausea and vomiting. The nurse educated the patient he/she needed to take his/her Phenergan/Compazine suppository to assist with the nausea and vomiting so he/she could take something for pain. The patient declined the suppository and also declined to take any pain medications at that time. The nurse called the team leader and the physician asking for suggestions. The physician made multiple phone calls to the other medical director for suggestions on how to manage the patient's pain at this time, but since the patient was not willing to take something for the nausea and vomiting they weren't sure what they could do. The team leader called the clinical director to ask if GIP would be appropriate for the patient, updated nurse that we would try to admit patient at a local hospital (per the clinical director this was a hospital they would need to do a patient specific contract with), but it may take some time. This writer (team leader) called CM (unsure what this was) at the hospital, call was returned about 30 minutes later to inform this writer there were not a bed available at this time but would let us know as soon as they had one. This writer updated the nurse on the situation and that the medical director has recommended to try Ketamine for the patient and if he/she could speak with the patient to see if he/she would be willing to try that, at this point the patient still had not taken anything for nausea, vomiting or pain. The nurse updated this writer the patient was not willing to try the Ketamine. This writer updated the nurse that we had no other place to send the patient at this time for GIP and that the family could take the patient to the ER of their choice and either be financially responsible or choose to discontinue hospice services. The nurse was outside the patient's home educating the spouse on this and when returning, upon entering the patient was standing pointing a gun at the nurse. The nurse ducked behind a bench, dialed 911 and instructed the spouse to close the door which he/she did and they heard a gunshot. Upon the spouse entering the room the patient had shot him/herself in the head. The police arrived on the scene shortly thereafter. - Intervention showed: The nurse called 911 and gave a statement to the police. The patient was rushed to the hospital and passed away; - Is further follow up required? Yes; - Describe required follow up: To be determined; - Was physician notified? Yes; - Form completed by: Listed the name of the team leader; - Information recorded in QAPI problem prone log: Yes/No/Not applicable: This section was blank - Interdisciplinary Clinical Note (this was presented with the above form and was documented by the team leader) dated 05/18/2021 showed: - The nurse was in contact with the team leader and medical director (unsure if this meant the medical director or hospice physician at the multiple location site) while at visit. The patient was declining to take nausea and vomiting medications or additional pain medications. The team leader and MD discussed possible GIP. The team leader contacted the clinical director at 10:35 AM to inform him/her of possible GIP at (named local hospital) for placement and had to leave a message. The clinical director spoke with the medical director who recommended ketamine for the patient to control pain in the home. The team leader passed this on to the case manager who responded that the patient declined ketamine. The team leader received a call back from the hospital at 10:59 AM that they had no beds available for GIP at this time but would call back when they did. The team leader updated the case manager of this. Also placed call to another hospital for possible GIP. Spoke with the clinical director regarding GIP at (named two hospitals, per the clinical director these were the hospitals they had GIP contracts with). Neither hospital would accept incoming GIP patients. At 11:49 AM the team leader received a text from the case manager that stated "he shot him/herself". The team leader and MD immediately attempted to reach case manager. Notified the clinical director. Case manager called the team leader at 11:54 AM extremely shaken and telling team leader that the patient had shot him/herself in the head, that the police were on scene, family member in background screaming at the case manager. Case manager was unable to leave as he/she had to give a statement and his/her equipment was in the home. The team leader stayed on the phone with the case manager until he/she was able to leave; - Another interdisciplinary clinical note dated 05/18/2021 at 11:44 AM showed the patient's family member called and was upset and didn't feel he/she knew what was going on and why the patient was not in respite yet. This nurse educated that the hospital did not have a bed available at this time to take the patient. This upset the family member even more and stated "You have an order to do GIP." Educated that we do not and we are just trying to complete one. He/she asked about GIP at (named the two hospitals the agency had GIP contracts with) and this nurse explained that they would not accept our outside GIP's. This nurse also educated that they could not use (named two other hospitals) due to that they have their own hospice and will not take GIP's. Educated that they could only help if the patient allowed the nurse to administer medications which the patient had not been doing that morning. Also educated that they could take the patient to the emergency room of their choice but they could be financially responsible for the bill or choose to come off hospice at that time. The family member hung up; - At 3:57 PM the family member was extremely belligerent yelling that our "shit" was on the curb and yelled about how incompetent the hospice and their nurse was and that his/her family member wanted to die in peace and we didn't offer that. This nurse listened. There is nothing this nurse could say to make him/her feel better; and - On 05/19/2021 the clinical director reported the incident to the state agency. During an interview on 07/01/2021 at 1:40 PM when asked if the agency had done a review of the patient's record or a root cause analysis, the assistant executive director reviewed the information presented to the surveyor as the agency's investigation. He/she stated that he/she did not feel what was presented was a full investigation with a root cause analysis.
L0587
L0587	17006 Based on policy review, record review, and interview, the agency failed to: - Ensure nursing needs of the patients were met when nursing staff failed to document complete pain assessments, provide timely follow up when high pain levels were reported and changes in pain medication occured and notification of the physician when indicated regarding high pain levels (L591); and - Failed to ensure the social worker provided/documented education with the patient/family regarding gun safety in the home (L594). This deficient practice has the potential to affect all patients served by the agency.
L0591	Nursing Services 418.64(b)(1) Corrected On:
	17006 Based on policy review, record review and interview the agency failed to ensure the nursing needs of the patient were met patient in 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/standard of practice titled, "Pain and Symptom Management and Measurements," revised 11/10/2020, showed in part: - The hospice ensures that patient's symptoms are managed and controlled to promote comfort and dignity throughout the hospice admission and dying process and will use stringent guidelines, follow regulations, consistent assessment reviews and obtain as appropriate, physician orders for all pain and symptom management issues and ensure that the patient/family needs are met; - The agency will utilize consistent pain measurement scales for individual patient's needs which include the numeric, descriptive, Baker-Wong (a scale that uses facial expressions to assess pain) and/or FLACC (face, legs, activity, cry, consolability, a pain scale used for people that cannot communicate their pain) and associated pain scale for patients to ensure the proper assessment and ratings of patient pain and symptoms; - A numeric scoring key can be used to assess the severity of end of life symptoms to assess the effectiveness of interventions; - The numeric symptom assessment key showed 0=no symptom, 1-3=mild symptoms, 4-6=moderate symptoms and 7-10=severe symptoms; - Staff may also use typical terms such as mild, moderate and severe as well as using the key as long as the patient's needs are met and that the assessments are consistent and effective; - The nurse will assess for presence, location, characteristics, and type of pain and/or symptoms upon admission/assessment, at the time of the comprehensive assessment and at each visit and will document findings as appropriate; - The nurse will assess, monitor and document if indicated for the potential physiological signs of pain and/or symptoms, including, but not limited to tachycardia (rapid heart rate), elevated blood pressure, tachypnea (rapid breathing), diaphoresis (sweating), dilated pupils, nausea, muscle tension and pallor (paleness); - The nurse will assess, monitor, document and intervene based off established plan of care and/or will contact the physician/practitioner for further orders, as indicated, when the patient is exhibiting symptoms, including but not limited to nausea, vomiting, shortness of breath, constipation, agitation, anxiety, restlessness, cough diarrhea and pruritus (itching); - The agency will obtain an order (as appropriate) for pain medications needed to palliate other symptoms from the primary care physician and/or the hospice medical director; - The agency will utilize any route, medication or dosage that has been deemed safe to palliate pain and/or end of life symptoms that are contributing or secondary to the terminal condition; - The nurse will perform teaching with patient/patient representative regarding pain management, symptom management, drug usage, dosage and side effects as appropriate and document such teachings; - The IDG (interdisciplinary group) members, especially the medical director will be consulted and collaborate as appropriate to ensure adequate pain and symptom control measures are utilized; - A complete, accurate and legible entry will be documented regarding medications/treatments and non-pharmacological pain control measures as appropriate; - Pain will be managed at a level acceptable to the patient; - Agency will notify the physician of ineffective pain management following the administration of the analgesic prescribed; - Agency will administer analgesics as prescribed to prevent severe pain from reoccurring; - Agency will use around the clock dosing as required to ensure adequate pain relief; - Agency will use rescue dosing (use of short acting pain medications to provide relief of intermittent breakthrough pain) as appropriate to ensure adequate pain relief; and - Agency will evaluate effectiveness and/or educate patient/family/facility to evaluate effectiveness of pain medications within two hours of administration and to report any ineffective treatments and/or increase in symptoms. RECORD/PATIENT #1: Review of a comprehensive patient assessment report dated 04/06/2021 showed: - Pain level three (pain is rated on a 0-10 scale with 0 meaning no pain and ten meaning the worst severe pain); - Reported Flomax (for urinary retention) has helped urination tremendously; - Reports left groin, kidney and testicle pain. There is a palpable knot in the area, and the nurse reported this to the physician; - The patient requested an increase in morphine (narcotic pain medication) medication and the nurse is awaiting the physician's decision for this request; - Upon exit reported pain a level of three; and - The assessment failed to include the recent history of pain levels, the patient's acceptable level of pain, how often the patient used the MSIR for breakthrough pain, whether the patient took one or two tablets for breakthrough pain and what level the MSIR brought the pain level down to. Review of a physician order dated 04/06/2021 showed an order to discontinue the MSER 60 mg three times a day and start MSER 60 mg four times a day for pain. During an interview on 06/30/2021 at 1:05 PM, the registered nurse (RN) education coordinator stated that he/she expected a complete pain assessment to be documented. He/she would expect the assessment to include what and how much pain medication the patient was taking. The RN showed the surveyor a phone visit report that showed on 04/06/2021 the nurse called the medication change into the pharmacy and provided education to the patient. Review of a phone call patient assessment report dated 04/07/2021 from 8:45 AM to 9:00 AM showed: - Phone check with patient. No new needs or concerns. Educated patient on covid-19 precautions. Patient aware to contact hospice 24/7 with any new questions or concerns; and - The phone assessment failed to include any documented pain assessment, including, whether the new order for pain medication was effective. Review of the record showed no documented follow up assessment of whether the increase in pain medication was effective until 04/13/2021 (seven days later). Review of a comprehensive patient assessment dated 04/13/2021 showed: - The patient reported a pain level of three in the groin and left testicle; - The nurse contacted the physician who would be doing a home visit to assess the patient; - The patient is taking both scheduled and as needed pain medications; and - The assessment failed to include the recent history of pain levels, the patient's acceptable level of pain, how often the patient used the MSIR for breakthrough pain, whether the patient took one or two tablets for breakthrough pain and. what level the MSIR brought thepain level down to. Review of a phone call patient assessment report dated 04/15/2021 from 4:00 PM to 4:30 PM showed the patient was upset after the physician informed him/her that the groin/testicle pain was not a kidney stone but was at tumor from cancer. The patient had been holding out on taking more pain medication or trying new medication because he/she thought the pain was from a kidney stone and would be temporary. The patient wanted to change the pain medication regimen to have better pain control and management. The nurse received a verbal order from the physician to change the morphine from 60 mg four times a day to morphine 90 mg three times a day to see if that helped. The note failed to include whether the patient was educated on this change in dosage. Review of the record showed no physician order to change the morphine dosage to 90 mg three times a day. Review of a routine assessment report dated 04/16/2021 showed: - Pain level three and some discomfort in the abdomen; - The patient took a scheduled and as needed opioid (medications used to treat moderate to severe pain); - Upon exit the patient reported his/her pain level was at two; and - The assessment failed to include whether the patient was taking the morphine as ordered on 04/15/2021, the recent history of pain levels, the patient's acceptable level of pain, how often the patient was using the MSIR for breakthrough pain, whether the patient took one or two tablets for breakthrough pain and. what level the MSIR brought the level down to. Review of a comprehensive patient assessment dated 04/20/2021 showed: -The patient stated that his/her pain was adequately managed with present interventions. The patient presently used MSER 100 mg three times a day and has MSIR as needed for pain management; and - The assessment failed to include the recent history of pain levels, the patient's acceptable level of pain, how often the patient used the MSIR for breakthrough pain, whether the patient took one or two tablets for breakthrough pain and, and what pain level the MSIR brought the pain level down to. Review of the record showed no physician order for the changes in morphine dosages between 04/15/2021 and 04/20/2021. Review of a routine patient assessment report dated 04/22/2021 showed: - The nurse documented a FLACC score of one; - The patient had generalized mild, dull, intermittent pain; - The patient stated the new pain medication order was effective and was taking the as needed pain medication twice a day (did not specify whether the patient took one or two tablets) for breakthrough pain; and - The assessment failed to include the patient's stated level of pain, the patient's acceptable level of pain, whether the patient took one or two tablets of MSIR for breakthrough pain, and recent history of pain levels. Review of a phone call patient assessment report dated 04/26/2021 from 9:45 AM to 10:00 AM showed: - Phone call placed and patient requested a refill on medication. Request called into the pharmacy. The patient verbalized understanding to call 24/7 with questions, concerns or changes. No documentation regarding the patient's pain management. Review of a comprehensive patient assessment dated 04/27/2021 showed: - The patient rated his/her pain a level of five. The nurse documented a FLACC score of one; - Pain to LLQ (left lower quadrant) dull, severe, intermittent; - The patient took his/her morphine at 8:00 AM, 4:00 PM and midnight; - The majority of the visit focused on pain management which the patient stated was a major concern; - The MSER 100 mg three times a day provided relief for three plus hours with the as needed medication taken eight times a day per patient. The patient stated that the as needed medication was slow to address pain; - The nurse informed the patient he/she would follow-up. The patient stated previous discussion regarding adjusting morphine to 100 mg four times a day. The nurse would discuss with the physician. Review of a physician order dated 04/27/2021 showed: - A clarification order for 04/16/2021 to discontinue MSER 60 mg three times a day; - Start MSER 100 mg three times a day; - A new order for 04/27/2021 to discontinue MSER 100 mg three times a day; and - Start MSER 150 mg three times a day for pain management. Review of phone call patient assessment report dated 04/27/2021 from 5:00 PM to 5:30 PM showed the nurse reviewed the phone call with the primary physician/medication changes with the patient. Encouraged to call with any questions or concerns. Verbalized understanding. No documentation regarding the patient's current pain status. Review of the record showed no follow-up regarding the patient's pain status after the change in medication order on 04/27/2021 until 04/29/2021. Review of a phone call patient assessment report dated 04/29/2021 from 11:30 AM to 12:00 PM showed: - Call from patient returned; - The patient stated that the MSSR (unsure if this meant MSER) order changed from 150 mg three times a day to 130 mg three times a day as the MSSR 150 mg dosage strength is unavailable; - Call placed to patient and education of medication change and rationale given. Patient verbalized understanding; and - No assessment of the patient's current pain status. Review of a physician order dated 04/29/2021 (time showed N1400 (unsure if this meant 2:00 PM) showed: - Discontinue MS Contin (MSER) 150 mg three times a day - Dose unavailable; - Start MS Contin 100 mg one tablet three times a day for pain and MS Contin 30 mg one tablet three times a day for pain; and - Give MS Contin 100 mg plus 30 mg to equal 130 mg three times a day. Review of another phone call patient assessment report dated 04/29/2021 at 3:42 PM showed: - Order from primary physician for MSER 150 mg three times a day, did not respond to prescription from the pharmacy (unsure what this meant), signed by hospice medical director. Per the hospice medical director change the dose of MSER to 100 mg tablets and 30 mg tablets three times a day as the 150 mg dose is not available; - Call to family member who stated the patient was taking MSER 160 mg (no order found for this) and will upset (sentence not finished, unsure what this meant). Per patient RN call to patient and educated regarding dose changes and to take 130 mg dose; - Family member verbalized care concerns regarding case manager being on leave, tailbone discomfort and changes to mass areas; and - Call placed to patient and stated that he/she does not mind the two nurses who see him/her in place of the case manager and would like to have the case manager when he/she returned and does not want to change. Stated he/she noticed color change to mass area this morning and had not told anyone and did verbalize some tailbone discomfort to this nurse. Discussed offloading tailbone every two hours as the best option. Reviewed possible changes to mass and when it is ok to leave open to air and when treatment may need to be initiated. Discussed discomfort when he/she slept as he/she cannot lay flat and has a standard mattress he/she does not like. The patient qualifies for a LAL (low air loss mattress). Call placed to medical director for new order for LAL. To be delivered tomorrow per patient's request. Encouraged patient to call with any changes or concerns 24/7. Review of the record showed no follow up with the patient regarding pain management after the new order on 04/29/2021 until 05/03/2021 (four days later). Review of the comprehensive patient assessment dated 05/03/2021 showed: - The patient rated his/her pain a level of eight out of ten in the left groin. The pain was sharp, severe, intermittent and increased with movement; - Patient was on MSER 100 mg three times a day, MSER 30 mg three times a day and has MSIR 15 mg every four hours as needed for breakthrough pain; - The patient stated that his/her pain is increased today and stated that his/her pain would never be below a six; - He/she had a high pain tolerance; - The patient took breakthrough medication during the visit; - The patient's pain was down at the end of the visit; - No notification of the physician of the patient's increased pain; and - The assessment failed to include what level the pain was at the end of the visit and whether it was acceptable to the patient, the patient's recent history of pain levels, how often and how much of the MSIR the patient was using, and what level the MSIR brought the pain down to. Review of the record showed no follow up of the patient's pain until 05/06/2021 (three days later). Review of a phone call patient assessment report dated 05/06/2021 from 1:45 PM to 2:00 PM showed: - The patient answered the phone; - The nurse reviewed pain management; - The patient stated he/she was having a good day with minimal discomfort but yesterday, "not so much"; - The patient remained on MSER 130 mg and MS (unsure if this meant MSIR) 15 mg for breakthrough pain. The patient was taking the prn medication on a four hour basis; - No documentation regarding the patient's current pain level or recent history of pain levels, whether the patient was taking one or two tablets of MSIR every four hours, what level the medication brought the pain down to, whether the pain level was acceptable to the patient or discussion of whether the scheduled MSER needed to be increased since the patient had to utilize the breakthrough pain medication every four hours; and - The patient would call over the weekend if changes in his/her pain level. Review of the comprehensive patient assessment dated 05/10/2021 from 2:15 PM to 3:30 PM showed: - The patient rated his/her pain a level of nine out of ten in the left side of the groin; - The patient took MSER 130 mg three times a day and MSIR 15 mg every four hours as needed; - The patient stated that he/she utilized the as needed medication (no documentation whether the patient utilized one or two tablets) every four hours this last week; - Care coordinated with the hospice physician and awaiting response; - No documentation of what the patient's pain level was at the end of the visit or whether the pain level was acceptable to the patient; and - Educated the patient and caregiver to call 24/7 with any questions or concerns. Review of a physician order dated 05/10/2021 at 4:00 PM showed: - Start MSER 15 mg three times a day to current dose of 130 mg for pain; - Give MSER 100 mg tablet plus MSER 30 mg tablet and MSER 15 mg tablet to equal 145 mg three times a day for pain. Review of the record showed no follow up on 05/10/2021 after the patient reported a pain level of nine or that the patient was notified of the change in medication dose. Review of the on call log report dated 05/11/2021 at 7:27 AM, the patient called and stated he/she would like for the nurse to call. He/she stated that he/she had a rough night and needed to go ahead and start the other medication as soon as possible. Review of the record showed no documentation of a call to the patient on 05/11/2021. Review of a physician order dated 05/11/2021 showed: - Discontinue MSER 100 mg; - Discontinue MSER 30 mg; - Discontinue MSER 15 mg; - Start Methadone (used to treat moderate to severe pain) 10 mg one tablet by mouth in the AM; - Methadone 10 mg one tablet in the evening; and - Methadone 5 mg one-half tablet in the afternoon. Review of a watch care patient assessment report dated 05/12/2021 from 10:30 AM to 11:15 AM showed: - The patient's pain was a level of nine to the left groin that was sharp, severe, ongoing and worse with movement; - The patient was currently on Methadone ten mg in the AM, five mg in the afternoon, and ten mg in the evening; - Start daily visits for Methadone monitoring; - The patient utilized MSIR 15 mg one to two tablets every four hours as needed for breakthrough pain; - The patient's worst pain was a level of ten out of ten, average was a level of eight out of ten and best was a level of six out of ten; - No signs and symptoms of toxicity at this time; - The patient stated today is just "fucked" and was hurting; - The patient also stated that he/she had to jump through hoops again to try to get pain under control; - The patient had utilized two doses of MSIR (no documentation of whether the patient utilized one or two tablets) so far with the last dose at 9:30 AM; - The patient stated that he/she was struggling today; - The nurse provided reassurance to the patient and caregiver regarding the Methadone process and both verbalized understanding; and - The nurse educated the caregiver and patient to call 24/7 with any questions or concerns. Review of the record showed no further follow up with the patient on 05/12/2021 after reporting his/her pain level was nine and that he/she was struggling that day. Review of the on call log report dated 05/12/2021 at 10:51 PM showed the caller needed a nurse to come out because his/her spouse was in severe pain. The patient started medications but they were not working, and is having out of control pain. They have been trying to wait but no longer can. Action taken showed the caregiver had given all available pain medication and the patient had just started Methadone today. He/she stated that the patient had been uncomfortable all day. Advised to call going forward at the onset to not let pain get out of control. Nurse sent for emergent visit and new orders received. Review of an emergent visit report dated 05/12/2021 from 11:45 PM to 1:45 AM (05/13/2021) showed: - Upon arrival the patient sat on the edge of the bed, dry heaving; - States that he/she is due for night time Methadone dose 10 mg and took MSIR 15 mg less than ten minutes ago before vomiting; - Stated that his/her pain had been uncontrolled all day and currently the pain was at a level of ten out of ten, and the patient was diaphoretic (sweaty) and restless; - The patient was agitated and stated he/she knew this would happen and no one listened; - At 12:20 AM attempted a cracker with Zofran but vomited; - Contacted the medical director who recommended a slurry of Methadone and MSIR with slow administration, and if this attempt failed then it was ok to give the same slurry rectally once for pain control. The patient vomited three more times during the oral slurry administration; - At 1:00 AM the nurse gave MSIR slurry rectally then phenergan (used to treat nausea and vomiting) suppository; - At 1:30 AM the nurse gave Methadone 10 mg rectally; - At 1:45 AM the patient stated that his/her pain has improved some and was at a level of eight; - He/she stated he/she did not think this was going to work; - Educated the caregiver regarding medication administration and to call with any questions. He/she stated he/she understood and has written the medication schedule down, but asks multiple previously answered questions. The patient was calm, quiet and lying in bed at the end of visit. FUPC (unsure if this meant follow up phone call) at 4:00 AM to assess pain and provide support on how to slurry MSIR; and - No documentation of follow up with the physician that the patient's pain remained at a level of eight or discussion regarding providing continuous care (this level of care is provided around the clock in the home for brief periods when the patient is experiencing a crisis) or inpatient care (a level of care provided in an inpatient facility for pain and symptom control) to ensure the patient's pain decreased to an acceptable level. Review of a physician order dated 05/13/2021 at 12:20 AM showed: - Ok to give Methadone 10 mg tablet, Zofran 4 mg tablet and MSIR 15 mg tablets times two as needed rectally for pain management if unable to tolerate by mouth. Review of the on call log report dated 05/13/2021 at 2:50 AM showed the caller stated the nurse just left about 45 minutes ago, but the patient could not sit still and is saying he/she is dying. The caller stated medications were changed today, everything is backwards, and seemed to not be getting any relief. The caller stated they needed more help, something better. Second call (unsure of time) caregiver stated no relief from medication given rectally and they were considering going to the emergency room. The nurse was sent for an emergent visit and received new orders from the medical director. Review of an emergent visit report dated 05/13/2021 from 3:45 AM to 8:15 AM showed: - Patient and spouse upset that pain remains unrelieved; - Received orders from the medical director to give dose of MSIR by mouth or rectally now and can give every hour as needed for pain; - Initiated continuous care per the medical director's order; - At 3:45 AM MSIR 30 mg given rectally. The patient denied improvement; - At 4:06 AM order for STAT (immediate) CADD pump (continuous ambulatory delivery device, it is set to deliver a safe amount of pain medication 24 hours a day) hydromorphone (used to treat severe pain) two mg continuous every hour with two mg bolus (an extra, single dose of medication) every 30 minutes as needed for breakthrough pain. Called to on call pharmacy. Estimated time of arrival was 8:00 AM to 9:00 AM (four to five hours later); - The patient and spouse stated they felt better knowing there was a plan; - At 4:45 AM MSIR 30 mg given rectally. The patient reported some improvement and no longer felt angry. The patient was still vomiting and dry heaving (pain level not documented); - At 5:45 AM MSIR 30 mg administered rectally. The patient was more conversational and ambulated in his/her room. Encouraged crackers but still unable to tolerate (pain level not documented); - At 7:00 AM MSIR 30 mg and phenergan/Compazine suppository given rectally. The patient stated his/her pain was still at a level of ten out of ten but no longer radiated to his/her testicles and he/she felt more in control of the situation. Reviewed the plan of care and verbalized understanding (no documentation of follow up with the physician that the CADD pump would not be there until 8:00 to 9:00 AM, that pain remained at a level of ten, or whether further interventions could be provided until the hydromorphone could be started); - At 8:00 AM MSIR 30 mg and Zofran eight mg given rectally. The patient asked if there was more they could do for the pain. Reminded that the CADD pump will be delivered within a couple of hours and would continue to have a nurse at the bedside to administer morphine hourly if needed; - At 8:15 AM report given to oncoming nurse; - The patient experienced high levels of pain for at least nine hours with no documentation of follow up with the physician regarding that the CADD pump would not be there until 8:00 AM to 9:00 AM, that the patient's pain remained at a level of ten, whether further interventions could be provided until the hydromorphone could be started, or discussion of inpatient care for pain control. Review of a physician order dated 05/13/2021 at 3:45 AM showed to initiate continuous care for uncontrolled pain. Review of another order dated 05/13/2021 at 4:06 AM showed: - Ok to administer MSIR 15 mg one to two tablets now and then give one to two tablets every hour by mouth or rectally as needed for pain; and - STAT CADD pump hydromorphone two mg continuous every hour with two mg bolus every 30 minutes as needed for breakthrough pain. Review of an emergent patient assessment report dated 05/13/2021 from 8:30 AM to 3:30 PM showed: - At 8:00 AM arrived to patient's home and received report from nurse; - The patient stated he/she was only having three seconds of relief at a time. The patient rated his/her pain at a level of ten out of ten. The patient received MSIR 15 mg two tablets rectally at 8:00 AM; - At 8:15 AM the patient stated he/she was hurting so bad. The patient occasionally moaned with pain and continued to state his/her pain was a level of ten (no documentation of update with physician); - At 9:00 AM the CADD pump arrived but were awaiting supplies to start the pump. MSIR 30 mg given rectally; - At 9:15 AM the patient's pain level remained at ten; - At 9:30 AM the patient stated no relief from MSIR (no update with physician that patient continued to have no relief); - At 9:45 AM the pain radiated down the patient's groin to testicles. The patient reported he/she was still nauseated but hoped getting the pain under control would help; - At 10:00 AM MSIR 30 mg given rectally. Another nurse arrived to assist with set up of CADD pump and delivered supplies; - At 10:15 AM started hydromorphone five mg/ml, give two mg/hour with two mg bolus every 30 minutes. Initial bolus given. Hospice physician called and updated; - At 10:50 AM the patient gave a two mg bolus. The patient rated his/her pain a level ten out of ten; - At 11:00 AM MSIR 30 mg administered rectally; - At 11:21 AM the patient gave a bolus per CADD pump; - At 11:30 AM the patient appeared to be a little more comfortable. The spouse remained concerned and stated if this did not work, the patient needed to go to the hospital. The patient stated he/she was hurting but wasn't there yet; - At 11:45 AM the pain remained a level ten out of ten; - At 11:51 AM the patient gave a bolus dose; - At 12:00 PM the patient took Zofran eight mg by mouth to see if he/she could tolerate by mouth medications. The patient wanted to wait on MSIR and try to eat something and take pain medication by mouth; - At 12:15 PM the patient took MSIR 30 mg by mouth with five bites of oatmeal; - At 12:22 PM the patient gave a bolus; - At 1:00 PM the patient took his/her afternoon medication and MSIR 30 mg; - At 1:15 the patient appeared more comfortable and was tolerating by mouth medication; - At 1:30 PM, physician called and new orders received for hydromorphone 3 mg/hour basal with a 2 mg demand dose every 30 minutes and MSIR 15 mg one to two tablets every four hours as needed; - At 1:45 PM the patient's basal rate was increased to 3 mg/hour. The patient stated the pain was a level of eight out of ten with no radiating pain to the testicles; - At 2:00 PM the patient gave a bolus dose; - At 2:15 PM the patient stated his/her pain was manageable with walking; - At 2:30 PM bolus dose given. The patient rated his/her pain at a level of six out of ten with radiating to the testicle at eight out of ten but the radiating pain did not stay; - At 3:00 PM care coordinated with the physician and ok to end continuous care. Patient and caregiver only would like a follow up phone call this evening and this nurse will follow up tomorrow; and - At 3:30 PM continuous care ended. Educated patient and caregiver to call 24/7 with any questions or concerns. Review of another order dated 05/13/2021 at 1:45 PM showed: - Discontinue previous hydromorphone order for CADD pump; - Start hydromorphone five mg/milliliter (ml) give three mg/hour basal rate (the amount of medication given as a continuous infusion and is set per hour) with a bolus dose of two mg every 30 minutes per CADD pump for pain; and - Discontinue Methadone 10 mg, Zofran 4 mg and MSIR 15 mg rectally times two as needed re
	ctally. Review of a phone call assessment report dated 05/13/2021 from 6:30 PM to 6:45 PM showed the patient stated that he/she is feeling the best he/she has in a while. His/her pain is at his/her baseline of six out of ten. He/she was still having a few surges of pain to the groin. They do not last long. He/she had nothing but great things to say about the nurse and the help he/she gave. Educated to call with any change in condition or questions and concerns. Review of a phone call patient assessment report dated 05/14/2021 at 9:45 AM to 10:00 AM showed: - The patient stated that he/she had a good night and slept six hours straight; - Rated his/her pain a level of six out of ten; - Patient very pleased with pain control; - Stated there was 28.1 ml left according to CADD pump; and - Educated patient that he/she would call later today and check on him/her Review of a phone call patient assessment report dated 05/14/2021 from 3:45 PM to 4:00 PM showed: - The patient just woke from a nap; - Rated his/her pain a level of five out of ten; - Patient stated there was 23.6 ml left according to the CADD pump; - Educated that a nurse would be coming tomorrow to change the bag; - The patient had used four to five boluses that day and one dose of MSIR at breakfast; - Educated patient on dosing of how many hours should be left with what the pump was reading; - The patient was receiving three mg/hour with a bolus of two mg every 30 minutes; - The patient should have enough medication for 20-21 hours, if maximum dose is used patient has enough for 16 hours; and - The nurse educated the patient to call 24/7 with any questions or concerns. Review of a routine patient assessment report dated 05/15/2021 showed: - Pain assessment 7/10 Dilaudid (hydromorphone) PCA (patient controlled analgesia); - Patient reports pain is adequately managed with present interventions; - Continues to use MSIR as needed for breakthrough pain last taken earlier this morning and denies nausea over the past 24 hours; - The pain assessment failed to include the patient's recent levels of pain, the patient's acceptable level of pain, how often and how much breakthrough medication was used, what level it brought the pain to and no documentation of how many bolus doses were given; - No documentation the physician was notified that the pain was still at a level of seven out of ten; and - New bag of 50 ml hydromorphone five mg/ml with a three mg/hour basal rate and a two mg bolus with a 30 minute lock out started. Review of the record showed no follow up with the patient until 05/17/2021. Review of the comprehensive patient assessment dated 05/17/2021 showed: - On arrival the patient was sleeping; - Rates pain at a level of five out of ten in the left groin area; - States sleeping better since CADD pump started; - Discussed with patient and caregiver that the CADD pump was temporary. Frustrated with why change something that is working; - Educated regarding no long acting medications with hydromorphone; - Patient unsure if wants to start Methadone again and would let the nurse know at next visit; - Caregiver does not want spouse to be a trial case with managing his/her pain; - Nurse provided active listening and reassurance; - Nurse changed and cleared CADD pump. Hydromorphone five mg/ml, give 3 mg/ml basal rate with two mg demand (bolus) dose every 30 minutes, doses given 38, doses attempted 43. Patient has enough medication possibly until Wednesday; - Nurse educated patient and caregiver to call 24/7 with any questions or concerns; - The assessment failed to include the patient's recent levels of pain, acceptable level of pain, how much and how often the breakthrough medication was used, what level it brought the pain down to, or discussion with the patient and/or physician regarding that the bolus doses of hydromorphone attempted exceeded the doses given. During an interview on 06/29/2021 at 3:35 PM the patient's case manager stated that he/she took over as the patient's case manager on 05/03/2021. He/she remembered the patient took MSER and MSIR, then tried Methadone. If the patient can't manage his/her symptoms they start continuous care until the symptoms can be managed. On 05/03/2021 he/she should have documented what the patient's pain level was at the end of the visit. He/she could not remember if he/she followed up with the patient on 05/10/2021 but thought if it wasn't charted then probably not. He/she remembered they increased the MSER to 145 mg because the patient was hesitant to take Methadone. He/she stated that the patient called on 05/11/2021 and wanted to switch to Methadone. He/she called the physician. The physician said ok and would figure out the equivalent of Morphine to Methadone. He/she called it in to the pharmacy to deliver that night. The patient took the first dose at midnight and they started daily visits for Methadone monitoring. On 05/13/2021 the patient was happy with his/her pain level at a six when he/she left. He/she talked with the patient about four times a day. He/she offered a visit but the patient declined. The patient thought a phone call would be sufficient. During an interview on 07/01/2021 at 10:40 AM with the clinical director, assistant executive director and executive director (by phone), the clinical director stated that pain assessments should include the patient's interpretation of pain, a description of pain, sometimes a FLACC assessment with the nurses' assessment per the patient if needed, assess the patient's acceptable level of pain initially and as time goes on. The staff ask the patient's at each visit if the pain level is acceptable. There should be a full pain assessment with each visit including a history of pain, how much pain medication that patient was taking and how often to determine if the medication was meeting the patient's need. If the patient was having issues with pain, depending on the severity of the issue, the staff should call at least four hours later to follow up and document how the pain was doing. If they ask a caregiver to give medication, he/she preferred they call back within an hour to see how the patient was doing and would expect documentation that they educated the patients and caregivers regarding medication administration and document how the pain was doing. When asked about the nurse leaving on 05/13/2021 at 1:45 AM when the patient's pain was at a level of eight, he/she stated that it would be hard to say without seeing the patient but if the patient was comfortable it could go either way. When asked if he/she would have expected the nurses to update the physician on 05/13/2021 that the patient's pain continued to be at a level of ten and the CADD pump not scheduled to arrive until 8:00 -9:00 AM, he/she stated that it would be difficult to say, but it may take the medication a few hours to start working.
L0594
L0594	17006 Based on policy review, record review and interview the agency failed to ensure the social worker provided/documented education with the patient/family regarding gun safety in the home 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, "Patient/Family Education and Teaching and Staff Compliance," revised 04/20/2021 showed in part: -Personnel assigned to teaching will include in the teaching the patient, family and/or significant other as an active partner in the process and coordinate the education with other nurses and/or care providers and the IDG (interdisciplinary group); -Instructions may include safety issues and plans; and -Assessed learning needs and teaching/education will be documented in the medical record. RECORD/PATIENT #1: Review of the nursing visits dated 03/22/2021 through 05/18/2021 showed the nurses' answered yes to the question whether there were guns in the home and interventions provided showed coordination with the social worker to visit and educate the patient on gun safety. Review of a phone call assessment report by the social worker with the caregiver dated 03/23/2021 and 04/30/2021 showed the patient's hobbies included shooting guns but no documentation of discussion/education regarding gun safety in the home. Review of the IDG meeting notes dated 03/31/2021 showed no information regarding the patient having guns in the home. During an interview on 06/30/2021 at 9:25 AM, the case manager stated that there was no indication of the patient being a suicide risk. He/she did not know there were guns in the home. During an interview on 06/30/2021 at 10:20 AM, RN B stated that he/she called the social worker about guns being in the home. The social worker said he/she would follow up with the patient. There was never any indication of suicide risk but he/she reported it to the social worker just because of the fact the guns were there. During an interview on 06/30/2021 at 11:44 AM, the social worker stated that they talk as a team if guns are in the home. There were no immediate concerns regarding suicidal or homicidal ideation. He/she understood that the patient had strict guidelines for safety and kept the guns secure. The family did not express concerns regarding suicide. When asked if he/she asked the family about suicide risk or if they just did not express concerns, the social worker stated they did not express any concerns. He/she did not talk to the patient because the family wanted the calls to go through them. He/she stated that he/she did not document anything regarding a conversation about gun safety. During an interview on 06/30/2021 at 2:28 PM the RN education coordinator stated that he/she would expect the social worker to document his/her conversation/assessment regarding gun safety. The findings were reviewed with the executive director on 07/06/2021 at 10:40 AM. He/she stated that he/she would have expected the social worker to make a visit to assess any risk associated with the guns being in the home and provide education to the patient and/or family. The social worker would then let the team know of any risk associated with the guns being in the home. His/her understanding was that the guns were kept secured in the home.
L0649
L0649	17006 Based on policy review, record review and interview the agency failed to organize, mange and administer agency resources to provide hospice care and services to patients, caregivers and families that was necessary for the palliation and management of the patient's terminal illness when the agency failed to ensure that timely inpatient care was available and/or explore other timely alternatives for provision of inpatient care for uncontrolled symptoms 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, "General Inpatient Care-Inpatient for Symptom Control related to the Terminal Illness," revised 09/19/2011, showed in part: - The hospice provides the appropriate level of care at all times. Inpatient care is provided to the hospice patient when: Symptoms are not controlled and need a highly skilled approach to regain a level of comfort for the patient; Inpatient care is provided in contract facilities only. Hospice remains in control of the patient's plan of care as it relates to the terminal illness and works in collaboration with the facility staff to meet the needs of the patient; - Guidelines included: Pain: Investigation, which requires frequent evaluation by physicians/nurses; Active treatment to control pain; *Titrations of dosages with frequent changes; - Control of other symptoms included any symptom that cannot be controlled in a home, long term care or assisted living setting; - Assess the patient/family needs and recognize when a change in the patient's condition may warrant a change in level of care; - Communicate to the registered nurse (RN) in change of the patient's care of the possible need for inpatient care or change in condition; - The role of the RN is to contact the clinical director or team leader to advise of the need and for assistance in making arrangements for the transfer; - Contact the attending physician regarding the change in status and determine if acute inpatient care is needed; - Contact the medical director regarding the change in status; and - Discuss the situation with the patient/family to determine if they are in agreement with inpatient care. RECORD/PATIENT #1: Review of an emergent patient assessment report dated 05/18/2021 at 10:00 AM showed: - Emergent visit due to uncontrolled pain with nausea and vomiting; - Patient found lying in hospital bed moaning and grimacing; - Refused to let nurse administer Compazine/phenergan suppository; - CADD pump in place with hydromorphone five mg/ml, three mg/hour basal rate with demand dose two mg/hour every 30 minutes; - The patient refused to administer the demand dose due to making the patient have increased nausea and vomiting; - The patient continued to say that something broke away on the left side of his/her back; - The patient continued to have sweating and chills, no temperature noted; - Family upset due to uncontrolled symptoms; - Nurse continues to be in contact with the hospice physician; - The hospice physician and team leader were working on GIP (general inpatient care); - At 11:15 AM patient with increased nausea. Continued to refuse to let nurse administer suppository for nausea and vomiting or demand dose from CADD pump; - Patient upset due to taking so long to hear back from the doctor/hospital and stated, "If this was their father, they wouldn't take so long"; - At 11:30 AM patient refusing to try Ketamine (a medication with sedative and pain relieving effects, sometimes used for patients who have been taking opioids (narcotic pain medications) for pain and found them to be ineffective) due to it would take hours for it to get there; - The team leader called the nurse to inform him/her that one hospital they called did not have beds available for GIP and that they did not take the patient's insurance; - Patient and family upset and wanting to know what other hospitals they could go to; - The team leader stated two other hospitals (these were hospitals the hospice agency had GIP contracts with) and the patient and family stated that any of them would be fine; - At 11:40 AM the patient agreed to let the nurse administer Compazine/phenergan suppository for nausea; - The patient's spouse went outside to calm another family member; - The nurse received a phone call from the team leader prior to administration of the suppository regarding that the medical director did not recommend the other two hospitals for pain management (unsure what this meant); - The nurse relayed this information to the patient; - The nurse stated if the patient wanted to go to the emergency room, he/she could revoke (the patient can decide to stop hospice care, usually to seek curative treatment. If an emergency room visit is for symptom management due to their terminal illness, this is not considered curative treatment) hospice services so the bill is covered. The patient stated that "Then I would have to start all over with this shit"; - The nurse asked the patient if he/she wanted the nurse to go outside to get his/her spouse to discuss the patient's options, and the patient stated "yes"; - The nurse went to get the spouse; - At 11:46 -11:47 AM the nurse went ahead of the spouse into the home; - The patient was seen walking out of the bathroom/storage area in the basement; - The patient pointed a gun at the nurse and stated "get out"; - The nurse ducked to the left side by a bench in the garage; - The spouse screamed for the patient to put the gun down; - The patient stated get out and close the door or this would be a murder, suicide; - A gunshot was heard and the spouse ran to the patient; - The nurse was on the phone with 911 reporting the event; - The dispatcher asked if the patient was still alive and the nurse stated yes; - The police arrived and the nurse and spouse exited the home; - Another family member screamed and stated if the nurse had done his/her job this wouldn't have happened; - The nurse placed a call to the team leader at 11:54 AM; - The patient left the home around 11:55 AM to 12:00 and was still alive; and - The nurse gave his/her statement to the police, waited until police were finished inside the home then left. During an interview on 06/29/2021 at 3:20 PM, the clinical director stated that they had two full GIP contracts and others that would require a patient specific contract. Some of the larger hospitals had their own hospices and would not contract with them. During an interview on 06/29/2021 at 3:35 PM the patient's case manager stated that on 05/18/2021 he/she stated that it was his/her first experience trying to do GIP. He/she let the physician know he/she was going to see the patient. He/she did an assessment and called the physician. The physician suggested a lot of things including Ketamine. The physician and team leader were working on GIP. It was 1 ½ hours before the patient let him/her administer anything. The patient would not take the demand dose. He/she told the patient it would probably be best to come off services and go through the emergency room. He/she went to get the patient's spouse and when he/she walked back in the patient pointed a gun at him/her. During an interview on 06/29/2021 at 4:55 PM the clinical director stated that on 05/18/2021 even though the medical director did not recommend the two hospitals for GIP they still checked with both and they did not have beds available. They also checked with a hospital that would require a patient specific contract. They presented ER as an option, Ketamine at home as an option, but the patient kept refusing the options and did not want to take the medications that were in the home. When asked about revoking hospice to go to ER as an option, he/she said if the pain was something that could be treated at home and the patient refused, that could be outside the plan of care. When asked if the ER was an option for symptom management related to the terminal illness, he/she did not know if he/she could speak to that. The ER probably would have done what we could have done at the home. Some hospitals do not like to give Ketamine because they are not used to doing that, but they had given Ketamine in the home before.