Survey Report for 261585

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	261585	A. BUILDING __________ B. WING ______________	12/29/2021
NAME OF PROVIDER OR SUPPLIER	STREET ADDRESS, CITY, STATE, ZIP
AVALON HOSPICE	2024 MAIDEN LANE, SUITE 202, JOPLIN, MO, 64804
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	29559 Based on policy review, record review, grievance file review, and interview, the hospice failed to enure patients received effective pain management and symptom control for conditions related to the terminal illness (L512). The effect of the deficient practice resulted in a finding of immediate jeopardy for two patients (Patient/Records #4 & #5) and has the potential to affect all patients served by the agency.
L0512
L0512	29559 Based on agency policy review, clinical record review, and interviews, the agency failed to ensure that patients received effective pain management and symptom control for conditions related to the terminal illness and related conditions in two of five records reviewed (Records/Patients #4 & #5). This deficient practice has the potential to affect the pain and symptom management of all of the agency's patients. Findings included: Review of the "Kindred at Home- Hospice Division" hospice policy titled "Patient Bill of Rights 2-002", last updated November 2020 showed the patient bill of rights defines that the patient has the right to effective pain management. Review of the "Kindred at Home- Hospice Division" hospice policy titled "Interdisciplinary group plan of care 4-031", last updated November 2020 showed in part the following: - The hospice interdisciplinary group will retain professional management responsibilities for the provision of services and will insure that services are furnished in a safe and effective manner; and - It's the responsibility of the case manager to facilitate communication about changes in the patient's status between interdisciplinary group members and the patient's physician if any. Review of the "Kindred at Home- Hospice Division" hospice policy titled "Pain Assessment 4-046", last updated November 2020 showed: - The pain assessment occurs during the initial assessment and ongoing basis. The nurse will complete a pain assessment to identify pain; and - Pain assessment to include history, location, intensity, quality, onset, duration, patterns, medication regimen and effectiveness. Record/Patient #4: Review of the hospice record showed that the patient was admitted to Avalon Hospice on 10/25/2021 with cancer of the bladder. The patient had heart disease, COPD (chronic obstructive pulmonary disease), and kidney disease. Review of the hospice complaint log showed that on 12/08/2021 at 9:47 AM, a hospice manager received a complaint from the patient's primary caregiver. The description section of the complaint log showed "Patient (caregiver) reports that nurse stated (he/she) would order medication for shortness of breath during (his/her) visit on Monday. Patient (caregiver) then spoke with the nurse on Tuesday and nurse reported (he/she) would address the medication. Patient's (caregiver) reports patient was uncomfortable all night and (the caregiver) ended up texting their family doctor him/herself for medications to address the issue". During an interview with the patient's primary caregiver/family on 12/22/2021 at 2:00 PM, he/she stated the following: - The patient has COPD (chronic obstructive pulmonary disease), and has needed a nebulizer for treatment of the COPD in the past. The patient had a nebulizer machine in the house, but no medications for it; - On 12/06/2021 he/she informed the registered nurse (RN-B) that the patient was coughing intermittently, and caused shortness of breath; - On 12/07/2021 he/she again told the hospice nurse (RN-B) by phone that at night the patient has coughing episodes and was short of breath, needed medications; and - The night of 12/07/2021 (the patient) was" bad short of breath with cough and was miserable". He/she ended up calling the previous family physician him/herself to get medications for the patient. During an interview on 12/22/2021 with RN-B, he/she stated the following: - The patient's family asked for medications for the patient's cough on 12/06/2021. The patient did not appear to be in any distress on the 12/06/2021 visit; - The family again asked on 12/07/2021 for medications for cough and shortness of breath. "I cannot recall if I called" (the physician) for orders; - He/she did not follow-up on the family's request, "I dropped the ball"; - The branch clinical manager talked to me after the incident, "I know now" to follow-up; and - The patient's respiratory status has declined, the patient is now on oxygen and uses nebulizer treatments regularly. Review of the nurse visit note on 12/06/2021 by RN-B showed: - The patient had a "cough and abnormal breath sounds"; - The patient had a "productive" cough; and - The nurse documented that the caregiver "would like me to speak to the patient's Combivent, or nebulizer treatment". Review of all clinical records showed no hospice visit was performed by a nurse 12/07/2021 through 12/09/2021. Review of the plan of care interim orders showed three respiratory treatment orders were added 12/08/2021 at 2:51 PM as follows by registered nurse (RN-C): - "Solumedrol dose pack" (a steroid: the order was incomplete for strength, route, frequency and duration); - Tesslon Perles (cough suppressant: the order was incomplete for strength, route, frequency); - Duoneb (nebulizer: the order was incomplete for strength, route, frequency). Review of a "coordination note report" by RN-C on 12/08/2021 (untimed) showed "Spoke with patient's (family/caregiver) who reported patient was up all night coughing. Family contacted doctor and received orders for solumedrol dose pack and Tesslon Perles". The findings were reviewed with the hospice branch manager on 12/22/2021 at 11:06 AM; no additional information was provided by the survey exit. The branch manager stated that he/she was new to the position, the previous branch manager had resigned the position. Record/Patient #5: The patient was admitted to hospice on 11/01/2021 with a terminal diagnosis of esophageal cancer. The patient was on hospice services until his/her death the morning of 11/09/2021. Review of the patient's hospice plan of care showed that the nurse would observe and assess for altered comfort, anxiety. "The nurse will assess for need of medication, medication changes, and patient/caregiver education". Review of the hospice complaint log showed that on 11/02/2021 at 4:51 PM that a hospice manager received a complaint from the patient's primary caregiver. The description section of the complaint log showed "(caregiver) called again to complain that patient has been waiting all day for pain medications." A follow-up comment showed that the hospice had spoke with the patient's caregiver three times the evening of 11/02/2021 and that the pain medications ordered were sent to the wrong pharmacy. Review of the initial hospice nursing visit dated 11/01/2021 showed the following: - The patient's pain is described as mild (no numerical rating); - The patient was prescribed oxycodone (narcotic analgesic) 5 mg every six hours as needed for pain and lorazepam 0.5 mg tablets, 1-2 tablets as needed for shortness of breath or anxiety; and - The patient had taken oxycodone and Ativan for several years. Review of the hospice nursing visit dated 11/02/2021 at 1:23 PM showed the following: - The pain assessment showed the patient had pain all of the time. The patient's pain at the beginning of the visit was rated an 8, the best the patient's pain had been was a 3, and the highest was an 8 (on a 0-10 high scale) in the past 24 hours. During the visit, the nurse provided education on liquid morphine (it should be noted that there were no orders in the chart for the medication and no documentation of physician communication requesting the medication); * There was no documentation of the LPN (licensed practical nurse) reporting the patient's increased pain (from the initial assessment) to the Interdisciplinary Group (IDG); Review of the hospice call log and case communication notes showed the following: - At an undetermined time on 11/02/2021, the patient's caregiver called to ask about the prescription for liquid morphine: * The nurse checked with the physician and the clinical manager and confirmed that the order for liquid morphine had been signed; * The nurse then called the patient's caregiver and told him/her that the script had been sent to the pharmacy; * The patient's caregiver asked the nurse if, for some reason the pharmacy couldn't fill the prescription, would the agency be able to get it filled somewhere else that would be open later in the day; * The on-call nurse advised the patient's caregiver that he/she would have to check with the pharmacy to see how long it would take for the script to get filled, and check with the pharmacy to see if they would transfer the script; * According to the communication note, untimed on 11/02/2021 the caregiver stated, "I have been waiting all day on this, we may need to leave this company." Then caregiver hung up the phone on the hospice nurse. Call logs from the hospice answering service show that the patient's caregiver called three times on 11/02/2021 as follows: - On 11/02/2021 at 5:15 PM reporting that the medication was still not at the pharmacy; - On 11/02/2021 at 6:33 PM reporting that the medication had not been called into the pharmacy; - On 11/02/2021 at 7:16 PM calling again to report the medication had not been called into the pharmacy. Call logs from the hospice answering service show on 11/02/2021 at 7:43 PM a call from the (pharmacy-B) requesting billing information for the medication. (It should be noted that according to the agency complaint record, the original prescription had been sent to the wrong pharmacy). Review of the hospice nursing visit dated 11/03/2021 at 10:21 AM showed: - The visit documentation failed to contain an assessment of the patient's pain rating and character of pain (as described in the agency's pain management policy); - The family was concerned that the patient had not had a bowel movement and administered Miralax without an order: - The family requested the oxycodone dose be increased to every four hours instead of every six hours (interim physician order was obtained for the increase); Review of the answering service records showed: - On 11/03/202 at 8:41 PM the family called the answering service to report that the patient had stomach pain and his abdomen was hard; and - A registered nurse visit was made with an enema administered. Review of the hospice nursing visit dated 11/04/2021 at 12:00 PM showed the nurse failed to asses the patient's pain, including any pain rating; The patient was, "still constipated," and the family had administered fleets; and Miralax, senna, and Gas-X. Small bowel movement noted; - Interim order received for Miralax, Fleets enema, and Fleet glycerin suppository. Review of the hospice nursing visit dated 11/5/2021 showed: - The patient was lying in bed grimacing and complaining of being uncomfortable; - The nurse administered a fleet enema with results; - The patient complained of muscle pain and diclofenac cream was ordered for hips and shoulders; - The patient reported no appetite and had not had solid food for two days; and - Interim orders were received to increase oxycodone to 5-10 mg every four hours as needed (PRN) for pain, and diclofenac cream to affected area four times per day PRN for pain relief. Call logs from the hospice answering service showed on 11/6/2021 at 10:39 AM. The caregiver called the answering service requesting an increase or an additional pain medication to keep patient comfortable. The current dose of oxycodone 10 mg every four hours was not working. The patient remains in distress with shoulder and neck pain. The Voltaren cream not an option because the patient is allergic to ACE inhibitors and pharmacy did not fill the medication. (it should be noted that no allergies to ACE inhibitors are on the patient's record). RN visit was advised. Review of a 11/06/2021 PRN hospice nursing visit at 5:17 PM (~five hours after the hospice answering service advised a visit for uncontrolled pain) showed that: - The family/caregiver had requested extended release morphine that morning and an order had been received to give 15 mg twice a day; - The family/caregiver had not administered the extended release morphine at the time of the nursing visit; - The documentation failed to contain a pain assessment including pain rating and character; - The patient was still using the oxycodone for pain management; - The patient used Aspercreme (Lidocaine) four times a day for topical pain control; - The patient did not tolerate Ativan, it caused hallucinations, Buspar 10 mg ordered BID; and - An interim order at 5:17 PM to increase nursing visit to daily was written during this visit. Review of an untimed case communication note from 11/06/2021 showed that the nurse called and spoke with the patient's caregiver. The caregiver reported that the patient had been moaning out for a few hours and believes (the patient) is suffering. Caregiver states he/she had been giving the medications as ordered. During the call, the caregiver reported that the patient just began to rest. The nurse instructed the caregiver to call if any further needs. Review of the plan of care interim orders showed on 11/07/2021 at 10:14 AM orders were entered for a fentanyl patch (narcotic pain patch) 100 mcg/hr, change every 48 hours. Review of the case communication showed on 11/07/2021 at 11:36 AM the caregiver/family called the office asking when the nurse would arrive for a visit. Review of the call log showed on 11/07/2021 at 1:09 PM the caregiver called answering/triage service and stated that they were still waiting on the nurse, that the patient was in pain and (the caregiver) was wanting to know the maximum amount of pain medication that could be given. The answering/triage staff member reviewed the medication profile with the caregiver. Oxycodone 5-10 mg every four hours as needed for pain; * Extended release morphine 15 mg twice a day; * Lorazepam 0.5 mg every four hours for anxiety, which the family voiced concern over past issues with breathing when using the medication; and * A nursing visit was scheduled. Review of a nursing visit on 11/07/2021 at 2:04 PM showed the following: - The patient's pain was rated at an 8 at the time of the visit, with the pain rated 5 at best, and a rating of 9/10 at worse; - The caregiver reported that the patient was having increased pain and shortness of breath; and * The physician was notified and orders were received to increase the extended release morphine to every 8 hours and oxycodone to 15 mg every two hours as needed for pain; and * The family stated they would just like the patient to be comfortable. Review of a 11/07/2021 nursing visit at 3:20 PM showed: - The visit documentation does not contain a pain assessment including pain rating or character; - Fentanyl patch was applied per family request (~five hours after the physician order); - The family was asking for a backup option for pain medication since patient wasn't swallowing; * The hospice physician was notified and stated patient needs to wear the fentanyl patch at least 24 hours to see effectiveness and patient can utilize oxycodone up to 15 mg every two hours and liquid morphine (it should be noted that there is not an order in the record for this medication) PRN for emergency. Review of the call log on 11/07/2021 at 11:00 PM showed that the caregiver called the answering/triage service reporting that he/she feels that the patient is suffering, moaning and crying. They have been giving the oxycodone 15 mg every two hours and the extended release morphine 15 mg every 8 hours routinely. The answering/triage service documented that the medication is not effective and a nursing visit advised for uncontrolled pain. It should be noted that review of all available clinical records showed no further documentation or visits after the reports of uncontrolled pain by the caregiver/family on 11/07/2021 at 11:00 PM . Review of the the answering/triage service log on 11/08/2021 at 6:19 AM. showed the caregiver/family reported pain medication was not effective and would like a visits as soon as possible. The caregiver reported he/she had given all medications including morphine (extended release) ER, Oxycodone 15 mg, and Ativan 30 minutes ago, and the medications were not working. Review of a nursing visit 11/08/2021 at 7:17 AM (seven hours after the report of uncontrolled pain and recommendation from the answering/triage service advising a nursing visit.) showed: - There was no pain assessment documented including rating or character of pain; and - The nurse contacted the physician about pain control issues; The patient passed away on 11/09/2021 at approximately 2:00 AM. During an interview on 12/22/2021 at 4:00 PM, the administrator stated that: - There are variances in the orders for lorazepam and oxygen; - For the LPN visit dated 11/02/2021, there is not documentation to show that the LPN reported the patient's increased pain to the RN; - Generally the staff communicate emergent symptoms during the morning, "Stand Up Meeting," but the meeting notes failed to contain documentation of the patient's increased pain; - The nursing visits on 11/04/2021, 11/06/2021, and 11/08/2021 failed to contain documentation of a pain assessment per agency policy including but not limited to the patient's numerical pain rating and character of pain; and - On 11/08/2021, they would expect the patient to receive pain medication for management of uncontrolled pain in less than 5 hours. During an interview with the patient's primary caregiver on 12/22/2021 at 10:02 AM, he/she stated the following: - The delivery/management of medications and DME (durable medical equipment) was a problem. They were told that they would get medications and equipment within 2-3 hours, but in reality it was 12-24 hours before meds would be gotten; - It was frustrating watching his/her parent suffer; - The patient was taking oxycodone (prescribed from the oncologist) for several years for pain control. The hospice changed the medication to morphine; - He/she stated she spoke with the administrator several times about concerns; - The night the patient passed away, the suction machine broke. The patient was frothing at the mouth. The suction machine stopped working about two hours before the patient passed. The family called the equipment company and the DME employee was getting ready to come, but the patient passed away in the interim; - "We just watched (the patient) suffer, they told us 'anything you need, we can get in 2-3 hours' but that was not true"; - On the first and second day after admission to hospice, they weren't very responsive, we were blind-sided by the whole "Hospice" thing, but by the time (the patient) was admitted to Avalon, he/she was starting to decline; - The pain was awful, (the patient) was unable to clearly communicate, but was restless and uncomfortable, and was able to cry out in pain; and - The hospice never offered continuous care or general inpatient care when the pain was uncontrolled. In conclusion the patient was admitted to hospice on 11/01/2021 with a terminal diagnosis of esophageal cancer. The patient was on hospice services until his/her death the morning of 11/09/2021. The patient had severe pain throughout the 8 day episode of care. Pain medication delivery was delayed at least once because the prescription was sent to the wrong pharmacy. The daughter called the answering service daily to report uncontrolled pain. The agency staff made changes to the plan of care, but did not achieve pain management. After the caregiver reported pain at six nurse visits and the family/caregiver called the hospice office and after hours triage 10 additional times regarding pain, the hospice never offered continuous care or general inpatient care for the uncontrolled pain.