Survey Report for 261603

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	261603	A. BUILDING __________ B. WING ______________	03/21/2022
NAME OF PROVIDER OR SUPPLIER	STREET ADDRESS, CITY, STATE, ZIP
PREFERRED HOSPICE OF MISSOURI	423 BUSINESS HIGHWAY 60 WEST BOX 99, DEXTER, MO, 63841
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)
L0520
L0520	29559 Based on clinical record review, policy review, and staff interviews, the hospice provider failed to ensure that a registered nurse (RN) gathered the critical information necessary on the initial assessment to treat the patient's immediate care needs. The single deficiency example was identified at an condition level due to substantial risk to adversely affect health and safety to hospice patients (L522). The effect of this deficient practice has the potential to affect nursing services for all patients on service with the agency.
L0522
L0522	29559 Based on policy review, record review, observation, and interviews, the hospice provider failed to ensure that the registered nurse (RN) completed an initial assessment within 48 hours after the election of hospice care, to assess the patient's immediate physical status related to the terminal illness, for an effective plan of care in two of three patients sampled (Records/Patients #1 and #2). The deficient practice has the potential to affect all patients on service with the hospice provider. Findings included: On survey entrance the hospice initial and comprehensive assessment policy was requested. Review of the provided "clinical services procedures" policies showed no mention of frequency for wound measurements, or wound assessments by a registered nurse. Review of a hospice policy, undated, titled "Wound Monitoring and Measurements" states in part that home patients' wounds will be assessed with each visit for changes or signs of worsening, Measure wounds from the farthest outer edges in length and width. The skin should be assessed at a minimum weekly. Review of the hospice policy titled "Nursing Services" dated 08/2021, showed in part that the registered nurse was responsible for "initial and ongoing assessment of the patient's physical symptoms". "Scope and frequency of services are based on initial and ongoing assessments of the patient's needs". "The registered nurse shall make at least monthly on-site visits and document that the licensed practical nurse (LPN) is routinely providing nursing services in accordance to the plan of care". Review of the hospice policy titled "Telehealth", dated 03/2020, states in part that "The hospice will conduct telehealth visits only when in-person visits are limited /denied due to lack of access to our patients from an outside source such as a pandemic". "LPN or RN utilizing a competent CNA (certified nursing assistant) or nurse on the in-person assessment or RN utilizing an LPN for an initial assessment as per the 1135 waiver". "The hospice team will perform telehealth admissions only when required by the facility or when no RN is available and the patient is ready for admission" RECORD/PATIENT #1: Review of the hospice initial plan of care showed the following: - The patient was admitted on 03/11/2022 with a terminal diagnosis of senile degeneration of the brain; - The patient had identified problems of advance directives, knowledge deficit, self care deficit, alteration on neurological status, alteration in nutrition, alteration in discomfort, alteration in respiratory system and impaired skin integrity; and -The interventions listed for alteration in skin integrity included education of the caregiver, pressure relieving devices as needed, assessment for changes in skin integrity, provide wound care as ordered, and to encourage patient to reposition every two hours as tolerated. Review of the hospice initial assessment dated 03/11/2022 showed the following: - The document was signed by a registered nurse and titled "RNIA Telehealth"; - The patient was admitted on 03/11/2022 with a terminal diagnosis of senile degeneration of the brain; - The patient resided in a private residence, the patient's spouse and in-home care aide were the primary caregivers; - The patient had mild pain; - The patient's integumentary status was "poor"; - The patient was at moderate risk of developing pressure sores (it should be noted that the patient already had pressure sores on admission); - The patient had five wounds; - The patient had a stage III pressure sore (Stage III Pressure sore-a full thickness of skin loss, exposing the subcutaneous tissues, presents as a deep crater with or without undermining adjacent tissue) to the left heel identified as wound #1. The length or width of the wound was not documented; - The patient had a stage III pressure sore to the outer left foot. There were no measurements of the wound identified as "wound #2"; - The patient had a stage III pressure sore to the right heel. There were no measurements of the wound identified as "wound #3"; - The patient had an unstagable black eschar (Eschar-dead skin that is usually dry, tough, leathery, and black in color, tightly attached to a wound bed) area to the coccyx. There were no measurements of the area. The wound was identified as "wound #4"; - The patient had a stage II pressure sore (Stage II Pressure Sore-a partial thickness loss of skin layers that presents clinically as an abrasion, blister, or shallow crater) to the left buttock. There were no measurements of the wound identified as wound #5; - The narrative section showed "admission completed with LPN (LPN-A) at pt's [patient's] bedside"; and - It should be noted that the wound to the patient's left hand/forearm from an infiltrated intravenous (IV) site that the hospice LPNs were dressing with hydrogel and a non-adhering dressing since admission was not assessed or documented. Review of the plan of care, provided on 03/14/2022, showed wound care orders for four wound sites as follows: - Cleanse left gluteal area with wound cleanser, apply calcium alginate and cover with Optifoam twice weekly; - Cleanse coccyx with wound cleanser, and cover with Optifoam twice weekly; - Cleanse area apply skin prep and heel protector. This order was incomplete for location/site; - Cleanse left heel with wound cleanser, pat dry, and apply a calcium alginate dressing covered with non-adhering dressing and kerlix gauze; and - It should be noted that there were no wound care orders for the patient's left forearm infiltrated intravenous (IV) site that the hospice LPNs were dressing with hydrogel and a non-adhering dressing since admission. During an interview with RN-A on 03/15/2022 at 10:20 AM, he/she stated the following: - Admission with Patient #1 was completed in person by a licensed practical nurse (LPN-A), and he/she phoned the patient for telehealth assessment while LPN was physically assessing the patient; - The COVID waiver allowed for a telehealth initial assessment; - When asked if the LPN should have measured all of the patient's wounds he/she responded "yes"; and - When asked if all of patient #1's wounds should have been assessed on the initial assessment, he/she responded "yes". During an interview with LPN-A on 03/15/2022 at 10:57 AM and 03/16/2022 at 11:15 AM, he/she stated the following: - Admission with Patient #1 was completed in person by him/herself, with RN-A on the phone for telehealth assessment; - The COVID waiver allowed for telehealth initial assessment according to corporate management; - When asked if the he/she measured the patient #1's wounds on the initial assessment, he/she responded "no"; - Patient #1 had the open wound on the left forearm since admission. The wound was from an infiltrated intravenous (IV) site from the last hospitalization; - The patient was provided pain medication 30 minutes before the dressings were changed on 03/16/2022; and - Patient #1 has not been physically assessed by a RN since the admission. During a home visit observation on 03/16/2022 at 9:20 AM through 11:15 AM, the following was observed: - The patient was lying in a standard hospital bed in a private residence living room; - The patient had systemic visible edema; - The patient was on a standard hospital mattress, no pressure relieving mattress; - LPN- A changed dressings to the patient's left hand and left forearm, right heel, left heel, and coccyx area; - The patient's left heel had an open wound that had a foul odor, the nurse removed and re-applied a calcium aginiate dressing after cleaning the wound; - The patient's coccyx wound was irregular large eschar tissue, the nurse removed and reapplied a foam dressing after cleaning the wound; - The patient's left forearm wound had skin slough and was reddened throughout, the nurse removed and reapplied a hydrogel and non-adhering dressing after cleaning the wound. (it should be noted that this wound had not been identified on the initial assessment, and no treatment orders on the plan of care for this wound); - After the dressings were changed the patient was lifted into a sling by a mechanical lift, and a new pressure relieving mattress was applied to the patient bed; and - The patient was log rolled multiple times for the dressing changes, and to be placed on the mechanical lift sling. The patient was grimacing and moaning during these movements. Review of the LPN visit note from 03/16/2022 showed LPN-A documented the following: - A low air loss mattress was delivered during the visit; - Edema was noted to all extremities; - Patient with a new area to left inner foot and and blister to left upper thigh; - Wound #1 left heel pressure ulcer was now a stage IV. The wound was a stage III on admission which indicates worsening of the wound since admission. This wound measured 2cm (centimeters) x 2cm x 0.5cm (length by width by depth). A stage IV pressure sore is a full thickness skin loss with extensive destruction, tissue death or damage to muscle tissue; - Wound #2 to the right heel pressure ulcer "suspected deep tissue injury" was 2cm x 2cm x 0cm; - Wound #3 pressure ulcer to the patient's coccyx was documented as "unstagable" measuring 6.5cm x 6cm x 0cm; - Wound #4 to the left buttock stage III pressure ulcer was 2cm x 2cm x 0.3cm; - Wound #5 to the left hand was 7cm x 6.5cm x 0.0cm; - Wound #6 to the left inner foot 1cm x 2.5 cm (no depth was documented); - Wound #7 to the left upper thigh blister was 5cm x 1.5cm; - Wound #8 to the left upper thigh abrasion was 4cm by 0.4cm; - It should be noted that wound site location identifiers I.E. "wound #2, #3, #4, etc." had changed site locations from the initial assessment visit; and - It should be noted that the pressure relief device (low-air loss mattress) should have been been placed at admission due to the patient's pressure sores and physical condition. Review of all available nurse visit records from 03/11/2022, 03/12/2022, 03/13/2022 and 03/16/2022 showed that no registered nurse physically assessed the patient. All visits were completed in person by a LPN. RECORD/PATIENT #2: Review of the initial assessment dated 03/03/2022 showed that the patient was admitted to hospice for terminal heart failure; - The patient resides in a skilled nursing facility (SNF); - The initial assessment document was signed by a registered nurse (RN-A) and titled "RNIA Telehealth", there was no co-signature by the LPN; - The narrative section showed "admission completed with LPN (LPN-A) at pt's bedside". Review of all available nurse visit records from 03/03/2022, 03/07/2022, and 03/10/2022 showed that no registered nurse physically assessed the patient. All visits were completed in person by a LPN. During an interview with RN-A on 03/15/2022 at 10:20 AM, he/she stated the following: - Admission with Patient #2 was completed in person by a licensed practical nurse (LPN-A), and he/she phoned the patient for telehealth assessment while LPN was physically assessed the patient; - The COVID waiver allowed for telehealth initial assessment; and - No hospice RN has physically assessed the patient. During an interview with LPN-A on 03/15/2022 at 10:57 AM and 03/16/2022 at 11:15 AM, he/she stated the following: - Admission with Patient #2 was completed in person by him/herself, with RN-A on the phone for telehealth assessment; - The COVID waiver allowed for telehealth initial assessment according to corporate management; and - Patient #2 has not been physically assessed by a RN since their admission.