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)
L0591
L0591	17006 Based on policy review, record review and interview, the agency failed to ensure the nursing needs of the patient were met in three (Record/Patient #1, #2 and #3) of four records reviewed. 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," revised 06/25/2018, showed: - An initial assessment will be performed on admission to determine the patient's immediate needs, including pain and symptoms; - Patient pain and symptom management interventions, and past pain history will be assessed and documented; - The hospice and palliative care will utilize consistent pain measurement scales for individual patient needs which include 0-10 (zero meaning no pain and ten meaning the worst pain) numeric pain scale, Baker-Wong pain scale (uses a series of facial expressions to describe pain), FLACC scale (a behavioral assessment used for individuals who are unable to report their level of pain) and any other scale necessary to monitor and evaluate pain levels; - Hospice will assess pain/symptoms at each visit and document as appropriate; - The hospice nurse will assess for presence, location, characteristic and type of pain upon admission, at the time of the comprehensive assessment and at each visit and document findings as appropriate; - The hospice will obtain orders for pain medications and medications needed to palliate symptoms from the primary care physician and/or the hospice medical director; - The hospice nurse will notify the physician of ineffective pain management following the administration of the analgesic prescribed; - The hospice nurse will evaluate or coordinate the evaluation of the effectiveness and/or educate patient/family/facility to evaluate effectiveness of pain medications within two hours of administration; and - All pain assessments, interventions, goals and outcomes related to pain and symptom management will be documented within the hospice record. RECORD/PATIENT #1: Review of the initial comprehensive registered nurse (RN) assessment dated 07/28/2021, completed by RN D, showed the patient had pain and a diagnoses that included cancer with metastasis to the brain. (The nurse failed to rate pain or what meds were being given for pain.). Review of nursing assessment dated 07/30/21 completed by RN B showed the patient reported pain in the lymph nodes. The patient reported the pain was being managed with ibuprofen. (The RN failed to document when patient had last taken ibuprofen, how often the patient was taking ibuprofen, and any other measures being used to control pain.) Review of the nursing assessment dated 08/05/2021 completed by RN B showed the patient was not in pain at the time of the visit, the patient did not show signs of pain, the patient's pain was intermittent and rare, the patient's level of pain was 02/10, the patient has a "low pain tolerance", the patient's spouse reported pain was relieved by ibuprofen. (The RN failed to document frequency of ibuprofen, other methods used to relieve pain, and last dose of ibuprofen.) Review of the patient's plan of care last updated 08/08/2021 showed the agency staff failed to complete a pain plan of care for the patient. During an interview on 08/10/2021 at 11:50 AM RN B said the following:-The patient had brain cancer and would get headaches at times; -The patient took ibuprofen for pain; -The patient should have a pain plan of care but when the patient doesn't have pain at the time of visit the pain plan of care is not triggered and he/she did not know how to do a pain plan of care without it being triggered; -The patient took ibuprofen very infrequently. During an interview on 08/10/2021 at 12:10 PM RN D said the following: -He/she was the agency's admission nurse; -He/she thinks it was a documentation error that the patient had pain; -The patient has to have pain at the time of the assessment for the pain plan of care to trigger; -The patient didn't have pain and therefore a pain plan of care was not triggered; -He/she felt all hospice patients should have a plan of care for pain. During an interview on 08/10/2021 at 7:00 PM the patient's spouse said the following: -The patient has pain in his/her hip; -The patient had fallen prior to being admitted to hospice; -The patient was told he/she had cancer in his/her hip and may be causing the pain; -The patient took one to two ibuprofen a day for the patient's pain. During an interview on 08/11/2021 at 1:50 PM, Support Service Director RN said the following: -The staff failed to develop a pain plan of care for the patient; -He/she would expect a pain plan of care for all patients; -He/she expected the staff to document when and frequency of when the patients take their pain medications; -He/she expected staff to document any other pain relieving devices besides medications. RECORD/PATIENT #2: Review of the initial comprehensive registered nurse (RN) assessment dated 07/24/2021, showed the following: -Diagnoses included lung cancer; -The patient had moderate pain; -The patient's pain was chronic; -The patient verbalized "hurts all over"; -The patient took Tramadol (narcotic like pain reliever used to treat moderate to severe pain) 50 milligrams (mg) one to two every six hours as needed for pain. Review of nursing assessment dated 07/26/2021 completed by RN C showed the following: -The patient had no pain; -Patient's pain was intermittent; -The patient denied pain at time of visit; -The patient's pain was better with Tramadol; -The patient had Morphine (an opiate pain medication used to treat moderate to severe pain) 0.25 milliliter every four hours as needed for pain; -The patient had Tramadol one to two tablets every six hours as needed for pain. (The RN failed to document when patient last took pain medication, frequency of pain medication and any other treatments used to help the patient with pain.) Review of nursing assessment dated 08/05/2021 completed by RN C showed the following: -The patient denied pain at time of visit; -The patient's pain was better with Tramadol 50 mg every six hours as needed; -The patient took Tramadol in the morning with good effectiveness. (The RN failed to document frequency of pain medication and any other treatments used to help the patient with pain.) Review of nursing assessment dated 08/08/2021 completed by RN C showed the following: -The patient had minimal pain at time of visit; -The patient's pain increased with touch or pressure; -The patient had a skin tear on his/her right forearm causing acute pain. (The RN failed document what helped relieve the patient's pain and the frequency of pain medication.) Review of the patient's plan of care printed 8/10/2021 showed the agency staff failed to complete a pain and narcotic plan of care for the patient. During an interview on 08/09/2021 at 4:20 PM RN C said the following: -He/she had seen the patient; -The patient takes Tramadol but wasn't sure what the patient took Tramadol for; -The patient had not rated the pain when he/she assessed the patient therefore a plan of care for pain was not developed. During an interview on 08/10/2021 at 7:05 PM the patient said the following: -He/she took three to four Tramadol at one time at times for bilateral shoulder pain; -He/she normally took two Tramadol twice a day to help control pain; -The Tramadol seemed to take care of the pain most days. During an interview on 08/11/2021 at 1:50 PM, Support Service Director RN said the following: -The staff failed to develop a pain plan of care for the patient; -He/she would expect a pain plan of care for all patients; -He/she expected the staff to document the frequency of when the patients take their pain medications; -He/she expected staff to document any other pain relieving devices besides medications. RECORD/PATIENT #3: Review of the initial comprehensive registered nurse assessment dated 08/03/2021 showed the patient started having pain to the right lower leg in October or November of 2021 (unsure if this was to be 2020). Pain level is 3-4 during visit and tolerable around a level of four out of ten. Pain is mild, throbbing and increased with standing and decreased with Tylenol and positioning. The pain moves around from right ankle to right thigh and goes to a level of ten at times. The lowest level was a three out of ten after Tylenol and positioning. The patient currently managed pain with Tylenol extra strength 1000 milligrams (mg) two to three times a day as needed and topical rubs and creams. The patient reported he/she is currently content with this regimen if the pain did not increase. Review of the plan of care dated 08/03/2021 showed the patient had variable pain to the right ankle to upper leg. Interventions included for the nurse to teach the patient and caregiver signs and symptoms of increased pain as verbalized/indicated by the patient, assess effectiveness of medications and assess signs and symptoms of pain each visit. Review of a routine patient nursing assessment report dated 08/06/2021 showed RN A documented the patient denied pain at this time. Numeric scale zero. The pain was worse in the AM and PM and has been taking extra strength Tylenol that has been helping but feels the pain is becoming worse. The nurse obtained an order to start Tramadol (narcotic pain medication) 50 mg every six hours as needed. The nurse provided education to the patient and caregiver on use and symptom management. The patient reports a tolerable pain level would be between two and three. The patient also has an order for Tylenol 500 mg two three times a day as needed which he/she has been using. Review of the record on 08/09/2021 showed no documentation of follow up with the patient after receiving the new order for Tramadol. During an interview on 08/10/2021 at 11:30 AM, RN A stated that the patient was not having pain that was not tolerable. He/she talked with the patient on Monday (08/09/2021) and they had administered the Tramadol in the evening and it was effective. He/she did not have anyone follow up with the patient over the weekend. During an interview on 08/10/2021 at 11:48 AM, RN B stated that staff should follow up within two hours to assess efficacy of new pain medication orders. If the order was received on a Friday, they would notify the on call triage nurse to follow up with the patient. During an interview on 08/10/2021 at 2:08 PM, the Support Service Director RN stated that he/she expected there to have been follow up with the patient that evening to make sure the patient did receive the medication and to see if he/she needed to take the new medication. The nurse can send an email to staff for follow up after hours and could also notify the on call triage nurse to follow up or assign someone to follow up with the patient.