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
261645 A. BUILDING __________
B. WING ______________ 		07/22/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
CROSSROADS HOSPICE OF SAINT LOUIS, LLC 15450 SOUTH OUTER FORTY DRIVE, SUITE 100, CHESTERFIELD, MO, 63017
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)
L0509      
05766 Based on clinical record review, policy review, record review, and interview, the hospice provider failed to ensure investigations and/or documentation of all complaints were conducted in accordance with agency policy. The agency did not follow-up with a complete investigation within 48 hours of receipt and document a resolution to a family complaint in two of three complaint records reviewed (Records/Patients #2 and #3). This deficient practice has the potential to affect the investigation and resolution of complaints made by all hospice patients and/or caregivers. Findings included: 1) Review of the agency policy/procedure, Number 125: PATIENT AND FAMILY CONCERN AND GRIEVANCE PROCEDURES, last revised 11/12/18, showed in part the following: -The agency Clinical Director and/or Executive Director are responsible for investigating concerns or grievances and shall make every effort to resolve the concern/grievance to the patient and/or family's satisfaction; and -The complainant will receive a response within 48 hours of submitting the complaint/concern. 2) Review of the agency policy/procedure: PATIENT AND FAMILY RIGHTS AND RESPONSIBILITIES, last revised 11/29/2018, showed the patient has the right: -To exercise their rights, be treated with respect, voice grievances, and be protected from discrimination or reprisal for exercising these rights; -To be free from mistreatment, neglect, verbal, mental, sexual, and physical abuse, including injuries from unknown source and misappropriation of patient property; and -To receive hospice and palliative care services in a manner that neither physically nor emotionally abuses the patient, nor neglects the patient's needs. RECORD/PATIENT #1: Based on review of the clinical record and the hospice complaint file, the hospice failed to investigate the patient's family members' complaint about payment for medications within 48 hours per agency policy. Review of a clinical note documented by the licensed practical nurse (LPN B) on 02/26/2020 showed: - The patient's responsible caregiver (family member #1) complained about being given conflicting answers about who pays for what medications; - Family member #1 reported he/she was told hospice should pay for all medications; - The LPN documented that he/she told family member #1 that the hospice pays for comfort medications and medications pertaining to the hospice diagnosis; and - The LPN documented on the clinical note, "CM (case manager) please follow up." The RN case manager (RN A) documented a patient visit on 02/27/2020. The RN failed to address the concern about payment of hospice medications with family member #1. Review of the hospice complaint file showed: - No documentation of the complaint regarding payment of medication received by the LPN on 02/26/2020; and - A complaint received from family member #1 on 03/05/2020 regarding multiple issues that included, "Family was paying for medications that should have been covered by CRH." (CRH = Crossroads Hospice) Documentation by the clinical director regarding investigation of the complaint showed: - The clinical director failed to contact family member #1 about payment of medications until 03/08/2020; - The clinical director reviewed the patient's medications and identified two medications that hospice may have needed to pay for; - The hospice offered to reimburse for these medications and the family member should send receipts for 2019 and 2020; - Family member #1 stated the charges had been used as a tax deduction; and - No receipts were received by the hospice as of 04/01/2020. These findings were reviewed with the clinical director on 07/21/2020 at 4:00 PM. The clinical director acknowledged the findings and stated the hospice had not received any receipts from the family member to this date. RECORD/PATIENT #3: Review of the agency complaint file showed a complaint, dated 03/18/2020, received from the patient's family member. This complaint documentation showed: - The patient's family member stated he/she felt the CNA (Certified Nurse Assistant) that provided care the night before was unprofessional and did not seem to know much about the patient prior to initiating personal care; - The patient's family member stated the CNA was using words such as "fat rolls" in front of the patient and family when providing care; - The patient's family member also reported he/she felt as though the CNA was too rough with the patient; - The intervention and follow up showed the social worker reported the grievance to the Director and the social worker provided support and active listening to the family; - The agency documented no further follow-up was required; - The agency documented the physician was not notified; - The form was reviewed by the Clinical Director; - The problem was entered on the problem prone log; - There was no evidence the agency initiated an investigation; and - There was no documented resolution to the reporter regarding the complaint. During an interview on 07/22/2020 at 10:00 AM, the clinical manager said: - The grievance should have been investigated as a potential for abuse and neglect; - Staff did not clarify what the patient's family member meant when he/she said the CNA was rough; - The patient's family member was not asked details about the complaint; - Nursing staff had not made a visit to assess the patient for any injuries; - There was no investigation; - The CNA received coaching regarding the complaint but this was not documented; - The CNA continued to care for other patient's; and - There was no abuse and neglect policy and procedure because the corporate compliance officer directs steps on abuse and neglect investigation.
L0582      
05766 Based on policy review, record review, and interview the agency failed to perform/document infection control education to patients, family members, and caregivers regarding standard precautions to prevent the spread of COVID-19 in two (Patients/Records #1 and #3) of three cases reviewed. This deficient practice has the potential to result in unsafe infection control practices or increased infection transmission between staff/patients/family/caregivers. Findings included: 1) Review of policy/procedures: UNIVERSAL STANDARD INFECTION CONTROL PRECAUTIONS, last revised 07/20/20, showed in part: - Policy Statement: The agency strives to ensure that patient, family members and staff will remain safe and free from communicable diseases and agency staff will utilize universal precautions including proper hand washing techniques; - Purpose: To provide guidelines and processes for hand washing techniques; - Patient/Family Education on Hand Washing - Instruct patient/family regarding Universal Precautions: Hand Washing; and - Record the following: Patient/Family instruction given. Patient/Family response to instruction and their level of understanding. 2) Review of policy/procedures, Number 249: EXPOSURE CONTROL PLAN / INFECTION CONTROL PLAN AND REPORTING OF COMMUNICABLE AND CONTAGIOUS DISEASE, last revised 07/20/20, showed in part under the section titled Safety Program, Data Sheets, QAPI and Education: - During the registration process and the admission processes, staff will question patient/patient representative regarding the potential of contact with individuals with a known or suspected contagious illness; - These contacts will be reported to the Agency Executive Director and/or Clinical Director and then to the Chief Compliance Officer; - Patients / families will always receive instruction regarding standard precautions and the prevention and control of infection; - When an infection is present, appropriate action will be taken to control its spread between staff and patients; - This may include providing written and verbal instructions on infection control, providing teaching sheets or safety booklets. RECORD/PATIENT #1: Review of Patient #1's medical record showed the start of care date as 03/30/2020. Review of the patient's admission packet showed no written information provided regarding infection control, standard precautions, or COVID-19. Review of the initial/comprehensive assessment dated 03/30/2020 showed no documentation that education regarding standard precautions as related to COVID-19 was given/taught. During an interview on 07/22/20 at 10:08 A.M., the clinical director stated that the agency did not routinely provide any educational material for patients/families regarding Covid-19 and that the patient admission packet did not contain any information regarding universal/standard precautions. RECORD/PATIENT #3: Review of Patient #3's medical record showed the start of care date as 03/14/2020. Review of the patient's admission packet showed no written information provided regarding infection control, standard precautions, or COVID-19. Review of the initial/comprehensive assessment completed by the RN showed no documentation that education regarding standard precautions as related to COVID-19 was given/taught. During an interview on 07/22/2020 at 10:25 AM, the RN site educator stated the agency did not provide written infection control information to patients on admission. He/she talked to each patient about handwashing but does not document this information. He/she did not realize the initial / comprehensive assessment had an infection control question.
L0583      
05766 Based on review of policies, clinical records, on-call log, complaint file documentation, and staff interviews, the hospice failed to ensure the licensed professional registered nurse (RN) and licensed practical nurse (LPN) provided/documented skilled assessments and nursing care to patients in accordance with the hospice plan of care, developed a comprehensive hospice plan of care that included all medications and treatments ordered by the physician, and/or coordinated with other members of the interdisciplinary group (IDG) to ensure that the care needs of each hospice patient was effectively met ( See L585). The cumulative effect of these deficient practices resulted in the inability of the licensed professional skilled nursing staff to effectively provide nursing care to meet the needs and expectations of the patient and family.
L0585 Licensed Professional Services
418.62(b)
Corrected On: 01/28/2021
05766 Based on review of hospice policies, clinical records, on-call log, complaint file documentation, and staff interviews the licensed professional hospice nurses failed to provide care according to the plan of care and/or coordinate care with the hospice interdisciplinary group (IDG) in three (Records/Patients #1, #2, and #3) of three cases. The licensed professional nurses failed to: - Document written physician orders for all medications and treatments changed by verbal order; - Establish or update the plan of care based on the patient's condition/needs; - Perform/document coordination of care with the other members of the interdisciplinary group as the patient's condition and/or levels of care changed; - Implement standing orders per agency policy; - Document follow-up of patient response to medication/treatment changes; and - Establish or update the hospice aide plan of care to include specific instructions and safety precautions. These deficient practices have the potential to affect the quality of licensed professional nursing care and coordination of hospice care provided to all patients. Findings included: The hospice agency used the 24-hour clock (military time) for clinical record documentation which is reflected in these findings. 1) Review of policy/procedure, Number 299-37: STANDARDS OF PRACTICE FOR INTERDISCIPLINARY GROUP, last revised 11/11/19, showed in part: - Crossroads ensures that each and every discipline within the hospice interdisciplinary group follows the standards of practice for each professional discipline, to ensure that the safety of the patient is maintained and that highly qualified professionals are hired and retained by the hospice; - This policy encompasses all staff including registered nurse, nurse practitioner, and licensed practical nurse; - All licensed staff must meet all qualifications and follow standards of practice for their specific discipline including ...documentation; - Clinical staff will be supervised by and report to a designated supervisor; - All clinical staff will document all visits, interactions, phone calls with patient/family within the patient's medical record; - All documentation must be timely, concise, detailed, legible (if handwritten) and complete; - All clinical staff will ensure coordination of care and timely communication to ensure patient/family needs are met and that all State, Federal and CHAP guidelines are met. 2) Review of policy/procedure, Number 299-86: VERBAL/TELEPHONE ORDERS (PHYSICIAN/PRACTITIONER ORDERS), last revised 01/19/19, showed in part: - Verbal communication of medication/treatment orders from a physician/practitioner should be used in situations where any delay in writing the order could cause delay in treatment and/or care, patient harm, patient suffering, and/or have a possible negative outcome; - A verbal order must be authenticated by the person who issued it at the earliest opportunity, preferred within 10 days but no more than 30 days after issued; - Authentication consists of the prescriber initialing and dating the transcribed order; - A registered nurse, nurse practitioner, licensed practical nurse, or physician assistant can accept and transcribe verbal/telephone orders within the scope of their practice; - All medications, treatments, written and verbal orders will be communicated with contracted facility personnel to ensure coordination of and avoid duplication of care. - Copies of signed orders will be provided to the facility (unless a duplicate order, per facility policy, is obtained by the facility; - Once a verbal order is written, it will be logged into the tracking system and sent to the physician/physician extender for signature; and - Once returned from the prescriber, it will be reviewed for completion, will be marked return in the physician log or electronic tracking system and will be filed in the medical record or uploaded into the EMR (electronic medical record). 3) Review of policy/procedure, Number 299-86A: AUTHORIZED PRESCRIBER ORDERS (STANDING ORDERS), last revised 01/19/19, showed in part: - Upon implementation of any medication or treatment indicated within the individualized authorized prescriber's orders, the nurse will then notify the physician within 72 hours of use by recording the order as "implemented" in the clinical note; - The nurse will add the order to the medication/treatment profile as now a valid, instituted order; - The nurse will either write a "telephone order" or add to the physician's fax order form, or will notify the physician via secured email or secured fax which will then be sent or submitted to the physician for signature and read receipt; - These orders are not a replacement for good communication and planning with the physician and/or to replace the RN's assessment and planning processes necessary in this type of home-based care as part of being proactive and understanding end of life disease processes to plan for needs of the patient; - These orders are designed to be limited in scope, to remove any non-prescriber's choice; - Once the treatment/medication from the authorized standing order list is implemented, the treatment is now part of the patient's plan of care and medication/treatment profile; and - Once the notification verbal order is written (via any of the methods above) it will be sent to the physician/physician extender for signature and when returned will be file in the medical record or uploaded into the EMR. 4) Review of policy/procedure, Number 229: LEVELS OF CARE - CONTINUOUS HOME CARE (CHC OR CC), last revised 11/07/12, showed in part: - Crossroads provided skilled services on a continuous basis through the Continuous Home Care benefit as appropriate. - Continuous Home Care may be provided only during a period of crisis; - A period of crisis is a period in which a patient requires continuous care which is primarily nursing care to achieve palliation or management of acute medical symptoms; - Homemaker of hospice aide services may be provided to supplement the nursing care; - The hospice must provide a minimum of 8 hours of care during a 24-hour day, which begins and ends at midnight; and - The care need not be continuous. - The role of the skilled nurse is to: * Discuss with patient/family their options in meeting the skilled level of care needed; * Notify the Clinical Director/Team Leader/On-call Triage Nurse of the need to initiate/discontinue CHC; * Update the hospice Plan of Care and Comprehensive Assessment; * Complete the Change in Level of Care Form; and * Communicate with physician and transcribe any received physician orders on physician order form and CHC visit record. - The role of the Clinical Director/Team Leader is to: * Review and ensure CHC is the appropriate level of care; * Ensure appropriate staffing and notify the other group members of the change in level of care; and * Ensure hospice plan of care is updated as appropriate. 5) Review of policy/procedure, Number 299-58: EVENMORE® CARE (EMC), last revised 02/15/13, showed in part: - EVENMORE Care is a non-billable, non-Medicare recognized level of care; - This care will ensure that the patient and family are visited as frequently as needed to ensure that their needs are met throughout the hospice admission; - EVENMORE Care is provided to the patient/family as deemed necessary by the Case Manager and IDG team; - EVENMORE Care is provided to patients when the patient requires additional care, increased visits, or around the clock care, and this care does not meet the Medicare Continuous Care or General Inpatient billable guidelines; and - The length of time a patient is placed on EVENMORE Care is left up to the discretion of the IDG team, based on the conditions, symptoms or need of the patient/family. 6) Review of policy/procedure, Number 295: CROSSROADS "WATCH STATUS," last revised 10/01/12, showed in part: - The "Watch Status" is not a recognized Medicare level of care, but is billed and recognized as "routine" but is an increased care model established internally to increase contact / visits with hospice patients that are experiencing a change in condition; - The change in condition is not significant enough to meet the guidelines required for Continuous Care, General Inpatient, or Respite, but the patient's condition may indicate the need for closer evaluation from the hospice IDG; - Any member of the IDG can initiate a Watch Status; - The staff member should notify the Team Leader or On Call Triage Nurse / On Call ACD of the need for the change; - The Watch status can be set at a frequency of contact appropriate for the condition of the patient; - A phone call or visit must occur within the period established; - Document the contact/visit; - Note the change in care in the Hospice Plan of Care and Comprehensive Assessment; and - Complete a Change in Level of Care form. Based on clinical record review and confirmed by the clinical director, patient visits made in accordance with the "Watch Status" policy/procedure are documented as "Watch Care" visits. RECORD/PATIENT #1: Review of the clinical record showed the patient's admittance to hospice on 03/30/2020 with a terminal diagnosis of end stage dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgement). Other diagnosis included post brain aneurysm (a bulge or ballooning in a blood vessel in the brain that can leak or rupture, causing bleeding into the brain). The patient lived with family. Review of the clinical record identified the following issues regarding provision of care, coordination of care, and documentation by the licensed professional skilled nurses who provided nursing visits from 03/30/2020 until 04/03/20: 03/30/2020 - RN D completed an initial assessment visit: - RN D documented the patient's temperature as 100.3 (normal range = 97 to 100.3 degrees Fahrenheit), and instructed the family to place ice packs to bilateral axillary and groin. - RN D assessed the patient as having falls and needed a hospital bed with ½ rails, bed to lowest point and the patient to be monitored by caregiver 24/7. The initial and ongoing physician orders and the plan of care, developed by the RN case manager with other members of the IDG, failed to address the ice packs, hospital bed with ½ rails being at lowest point or the need to be monitored by the caregiver 24/7. 03/31/2020 - The comprehensive assessment completed by the RN showed: - The patient as a two person assist, stand, and pivot into wheelchair for mobility. - The hospice aide plan of care and the comprehensive hospice plan of care failed to address the two person assist, stand, and pivot into wheelchair for mobility. 04/02/2020 - An email documented by LPN C in lieu of a "Watch Care" visit clinical note showed: - The patient's temperature of 100 degrees. LPN C instructed the family to apply ice to forehead, groin, and axilla. - The patient's oxygen saturation on room air showed 73% (normal range= 90 to 100%) and oxygen at four liters per nasal cannula. - The need for "Watch Care" visits was noted. - The hospice plan of care failed to be updated for "Watch Care" visits or oxygen needs, or use of ice packs for temperature control. - The LPN failed to document a written physician order for four liters of oxygen per nasal cannula. 04/03/2020 - RN C documented a routine patient assessment visit: - RN C documented that the family administered Roxanol (highly concentrated solution of the narcotic analgesic morphine sulfate for oral administration) as ordered and the family said that the patient could not go four hours between doses as ordered. The nurse documented he/she would contact the physician and get an order for every two hours as needed for the Roxanol. - The RN updated the medication profile for Roxanol 20 milligram (mg) per milliliter (ml) 0.5 ml every two hours as needed for pain or air hunger but failed to document the written interim physician order. During an interview on 07/21/2020 at 3:30 P.M., the clinical director acknowledged the findings and said there were no other written orders in the electronic medical record. The clinical director confirmed that on 04/02/2020, LPN C made a visit but failed to document a clinical note. RECORD/PATIENT #2: The hospice recertified the patient from 01/14/20 to 03/13/2020 for continued hospice care with a terminal diagnosis of pancreatic cancer with lung metastasis. The patient moved from independent living to an assisted living facility (ALF) on or about 03/02/2020. Review of the clinical record identified the following issues regarding provision of care, coordination of care, and documentation by the licensed professional skilled nurses: 02/24/2020 - A face to face encounter documented by the nurse practitioner indicated the patient took Miralax (used for constipation) 17 grams daily as needed and Colace (stool softener) 100 milligrams (mg) one capsule daily as needed. The nurse practitioner failed to obtain a written physician order for these medications or update the plan of care for interventions/goals for assessment and treatment of constipation. 02/26/2020 - The licensed practical nurse (LPN B) documented an Emergent Care visit at 17:30. LPN B: - Identified signs and symptoms of a urinary tract infection (UTI) and obtained a verbal order from the attending physician for Cipro (antibiotic). - LPN B failed to document a written physician interim order for this medication and failed to include the UTI as a problem with interventions/goals on the plan of care. - In addition, the skilled nurse clinical note contained no documentation of notification of the other IDG members (medical director, social worker, and chaplain) of this new problem. 03/03/2020 - During an Emergent Care visit to the assisted living facility (ALF) at 16:00, the registered nurse (RN B) documented: - The patient had a new onset of 3+ pitting edema (significant swelling that when pressed with a finger leaves an indentation that takes 30 seconds to rebound) of the bilateral lower extremities (BLE) with weeping of fluid from the left leg. - The nurse documented that a dressing was changed during the visit (location unknown) without evidence of a physician order. The nurse documented a message was left for the attending physician regarding the problem and the physician would notify the ALF directly with any new orders. - The on-call RN B failed to document notification of the patient's responsible caregiver (family member #1) of the change in condition. - The "Plan of Care Report" showed the hospice updated the plan of care for the problem of 3+ pitting edema of the BLE on 03/03/2020 but the intervention said only to assess for edema and record findings. 03/04/2020 - The RN case manager (RN A) documented a visit to assess the patient at 09:00. RN A: - Failed to assess/document the status of BLE edema or the condition of any dressing. - Documented a written interim physician order dated 03/04/2020 for Lasix (used to remove excess fluid from the body to decrease swelling) 20 mg (no route or frequency of administration noted) for 5 days, then reweigh. - Added the Lasix to the medication profile; but the plan of care did not address the new medication, need to reweigh in five days, patient/caregiver education needs, or a dressing change. The IDG Meeting Notes for 03/04/2020 indicated the IDG discussed the edema and noted the legs may be wrapped with rolled gauze but no interim physician order was documented. 03/05/2020 - During an Emergent Care visit from 12:45 TO 15:45, the RN case manager (RN A) documented: - A new onset of copious projectile vomiting with the appearance of blood. - RN A contacted the attending physician and documented on the clinical note that a hospital bed was ordered, all medications except those in the "Comfort Pack" were discontinued, and that the patient would be put on twice daily nursing visits. - The RN informed family member #1 of the new orders but failed to document a plan for when the second visit of that day would be made by a nurse. - During the three hour visit, the RN case manager failed to document that any medication for treatment of the vomiting was offered or administered. - RN A failed to document a written physician order to specify which medications were discontinued and which medications were to be used for symptom management. - According to the "Medication Profile" maintained in the clinical record, all medications were discontinued except ondansetron hydrochloride (Zofran) 4 mg one tablet by mouth every 6 hours as needed for nausea with a start date of 11/15/2019. This medication is not part of the Comfort Pack and there is no physician order to continue ondansetron (Zofran). - The RN case manager failed to document a discussion with the attending physician regarding the continuance of ondasteron (Zofran) or if the Lasix prescribed on 03/04/2020 for increased BLE edema for 5 days should be continued (this medication showed a discontinued date of 03/06/2020). - The Medication Profile identified the medications in the Comfort Pack as the following "EKIT" medications: * EKIT Morphine sulfate 20mg/ml 0.5 ml (10 mg) sublingual (under the tongue) or po (by mouth) every 2 hours as needed for pain/air hunger; * EKIT Lorazepam 0.5 mg one tablet by mouth every 4 hours as needed for anxiety; * EKIT Promethazine 25 mg one tablet by mouth or per rectum every 4 hours as needed for nausea and vomiting; * EKIT Acetaminophen 650 mg one rectal suppository every 4 hours as needed for pain/fever; and * EKIT Hyoscyamine 0.125 micrograms one tablet sublingual every 4 hours for excessive secretions. Based on review of the "Plan of Care Report", the nurse failed to: - Update the plan of care on 03/05/2020 to reflect the severity of the vomiting and new orders/interventions obtained. The Plan of Care Report showed an update on 03/06/2020 for "Vomiting" with a goal for the patient to remain free of signs and symptoms of vomiting, and the sole intervention stated was to administer antiemetic medications as ordered. - Update the plan of care for the hospital bed, discontinuation of medications, use of comfort pack medications only, increase to twice daily nursing visits, or consideration of other measures to promote patient comfort and safety. - Document information on the 03/05/2020 clinical note or a communication note to show that the RN coordinated with the other members of the IDG (medical director, social worker or chaplain) or the clinical director regarding the increased vomiting or the need for a second visit that evening. 03/05/2020 - Review of the hospice on call log, showed: - A call to the hospice by family member #1 received at 18:57 on 03/05/2020. The on call log showed the patient was having a hard time and spitting up blood constantly. The caller stated the nurse said she would be there around 5:00 PM and he/she has not heard or seen anyone. The on call nurse (LPN C) made a visit to the facility (see below). - The on-call log also showed a call received from the ALF nurse (FN 1) at 18:56 that showed the patient was vomiting blood continuously. - The on-call log showed a second call from the facility nurse (FN 1) at 20:15. The caller stated he/she had called earlier regarding the patient vomiting up blood and no one had called him/her back and would like to speak to the nurse. 03/05/2020 - Review of the clinical record showed RN E returned a call to the facility nurse (FN 1) at 20:30. This documentation showed: - RN E apologized for the failure of the on-call triage nurse to return FN 1's original call received (at 18:56). FN 1 stated the patient had been vomiting copious amounts of blood and neither the facility nor family felt supported by the hospice. - RN E initiated "EVENMORE Care" and contacted the hospice aide on call to proceed to the facility. - RN E contacted the nurse on call (LPN C) to confirm his/her presence at the facility and implement "EVENMORE Care." 03/05/2020 - On-call LPN C documented a "Watch Care Visit" from 20:15 to 22:45. LPN C documented: - The patient had no shortness of breath and clear lung sounds, black and watery vomitus last occurred at 19:00, abdomen distended with no bowel sounds, no urine output that day, and patient was alert and oriented with some confusion. The LPN ordered an oxygen concentrator. - LPN C documented giving instructions to the home health aide (HHA) who arrived during the visit to provide "EVENMORE Care." LPN C instructed aide B to "monitor vital signs and notify the nurse if patient diaphoretic, short of breath, respiratory distress, elevated temperature, level of consciousness, complains of pain and/or discomfort." - The clinical record contained no plan of care established for "EVENMORE Care" and no written guidance to the aide given. - There was no documented guidance for how long the aide should remain with the patient or instructions regarding use of oxygen. - LPN C documented coordination with both family member #1 and the facility nurse (FN 1) but no specifics were documented regarding what they were told about the plan for "EVENMORE Care." - No evidence of the attending physician or other IDG members being informed of the events surrounding the need for "EVENMORE Care" begun on 03/05/2020 in response to the evening on call visit. 03/06/2020 - At 08:45 the RN case manager arrived at the facility and documented the beginning of "Billable Continuous Care." - The RN case manager provided continuous care from 08:45 through 18:15. The RN documented education of family members #1 and #2 about continuous care and provided a list of hospice employees who would be providing the care. - The RN documented an explanation to the family regarding the vomiting as most likely caused by obstruction due to the pancreatic cancer. The RN described the small amounts of vomiting that occurred during the night as tea-colored. - The RN documented the patient's diet as "NPO" (nothing by mouth), but in the nursing narratives documented throughout the day, the patient was offered or had consumed sips of water, ice chips, soda, milk shake, juice, jello, and broth. - The RN documented the attending physician was updated on the patient's condition and no new orders obtained. - The RN case manager failed to document coordination with the other members of the IDG regarding the patient status or need for continuous care level of care or update the plan of care. The RN offered a chaplain visit and the family declined. - The RN case manager documented an interim physician order faxed to the attending physician for signature that stated only to initiate continuous care. The interim order failed to specify the reason for continuous care, the time for continuous care to begin, medications or treatments to be administered during continuous care, or dietary order changes. - At 10:15, the RN case manager documented the patient's oxygen saturation measured at 88 percent (Per Mayo Clinic, normal pulse oximeter readings usually range from 95 to 100 percent with values under 90 percent considered low). The RN placed oxygen on the patient at 2 liters per nasal cannula. The patient's oxygen saturation improved to 97 percent. At that time, the RN documented the patient declined Zofran (ondansetron 4 mg tablet by mouth every 6 hours as needed) even though the attending physician had discontinued all medications except for those in the Comfort Pack as documented on the skilled nursing visit completed on 03/05/2020. Zofran was not listed as a "Comfort Pack" medication on the hospice medication profile. - At 10:30, the RN case manager documented education to the patient and family about the importance of taking Zofran to help with vomiting. - At 13:15, the RN case manager documented the patient had "some nausea" and declined medication. - At 13:45, the RN case manager documented the patient had a little nausea and refused medications. - At 14:00, the RN case manager documented Zofran given (no strength, dosage or route of administration specified), noted there was no vomiting, and updated (facility) staff on patient's condition. - At 15:15 - 15:30, the RN case manager documented an update to the attending physician on the patient's condition and no new orders received. The RN documented that he/she explained the conversation with the attending physician to the family members who acknowledged understanding. The RN failed to document the specific information shared. - At 15:45, the RN case manager documented the patient had several bouts of emesis (act of vomiting), dark red. The RN documented no offer of the EKIT medication, Promethazine for nausea and vomiting. - After the RN left at 18:15, hospice aides provided continuous care throughout the night with no evidence of documented instructions from the RN. 03/07/2020 - RN I documented a "Watch Care Visit" from 04:00 until 08:00. - RN I documented the patient slept, had no emesis, and two family members were with patient throughout the night. - At 07:00, the RN documented that medications given to patient per facility but failed to identify/document what medications were administered or follow-up regarding patient response. 03/07/2020 - The RN case manager documented a "Continuous Care Visit" at 08:00 to 08:45. - The RN documented the patient appeared "better," no emesis since yesterday, edema improved, bowel sounds in right upper quadrant of abdomen but no bowel movement, continued large amount of ascites in abdomen (fluid in abdominal cavity evidenced by abdominal swelling) and decreased confusion. - The RN documented the diet as "clear liquid." - The RN documented the patient had infrequent urination with very little output, 100 ml this AM. - Family members #1 and #2 were at the bedside. The RN documented that he/she discussed switching the patient to "EVENMORE Care" and explained that "we will still be there but may not always be a nurse but could be another team member." The RN reassured the family that hospice was there for them, discussed the plan of care with the facility nurse on duty, and that the family acknowledged understanding of the updated plan of care. - The "EMC Timeline" provided by the executive director showed that "Continuous Care" stopped on 03/07/2020 at 08:45 and "EVENMORE Care" started at 09:45. - The RN case manager failed to update the attending physician about the patient's gastrointestinal or urinary status, or obtain a written physician order to stop "Continuous Care." - The clinical record failed to show coordination with the other members of the IDG regarding the change in the patient's status, the decision to change the level of care from "Continuous Care" to "EVENMORE Care" or to define in the care plan what care would be provided and the expected frequency. 03/07/2020 - LPN A documented a "Watch Care Visit" from 10:00 until 11:30. - LPN A documented that patient was talking with two family members. LPN A documented that "family member #2 indicated that if patient is stable when returning to place catheter we can stop the EMC (EVENMORE Care). Facility nurse was present and asked for an explanation about the visits and LPN A "informed staff nurse of how QID visits work." (QID means four times a day) 03/07/2020 - LPN A documented an "EVENMORE Care" visit from 15:15 until 18:30. - LPN A documented two unsuccessful attempts to place a 16 French and then a 14 French Coude catheter (special catheter used for men with an enlarged prostate) for urinary drainage. - During the procedures, LPN A documented no "flash" (urine return) and blood clots at the catheter tip. There is no documented coordination with the RN case manager regarding a need for a Coude catheter placement and no physician order. - The clinical record did not contain documentation of communication between the RN case manager and the LPN regarding a need for a urinary catheter (tube placed in bladder to drain urine), a physician order for catheter placement, communication with family member #1 about the need for a catheter, or a plan for when the catheter was to be placed. - The start and stop time of this visit are inaccurate based on additional information in the agency complaint investigation file that showed the LPN actually left the facility for a period of time (see below). 03/07/2020 - According to clinical record documentation a hospice aide provided "EVENMORE Care" starting at 11:15 with hourly narrative documentation. The aide documented the last narrative entry at 14:15. The time of 15:15 is listed with no narrative entry. Review of hospice complaint file showed written documentation from family member #1 that on Saturday (03/07/2020) the hospice "wrote up an 'EVENMORE Care' plan where they would provide an aide 24/7 until Monday so I could hire a private nursing firm which I did ...Crossroads encouraged us to leave and enjoy the nice day and evening." Family member #1 stated he/she left the patient's room around 12:30 and family member #2 left shortly thereafter. Family member #1 stated he/she returned to the facility at 4:30 PM (16:30) and was totally surprised to find the patient alone with no urinal within reach and unable to reach the call button, and too weak to get to the bathroom independently. While he/she was in the patient's room, he/she received a telephone call from LPN A who reported that the patient was doing fine but he/she was unable to get a catheter in the patient. LPN A told family member #1 that family member #2 gave them (hospice staff) permission to leave. Family member #1 contacted family member #2 who denied giving hospice permission to leave. The facility nurse told family member #1 that hospice staff
left the facility around 3:30 PM (15:30). Family member #1 documented that he/she contacted the RN case manager who then contacted his/her boss. Family member #1 stated the hospice agreed to put aides in place again. Family member #1 indicated the LPN A then showed up at the ALF around 5:20 PM (17:20). Further review of the hospice complaint file showed documentation by the clinical director of the phone call on 03/07/2020 from the RN case manager to the hospice clinical director (no time noted) to report that family member #1 was upset because LPN A stopped "EVENMORE Care" and sent the hospice aide home. The clinical director called and instructed LPN A to continue "EVENMORE Care" and to remain with the patient until the aide arrived. According to the "EMC Time Line" a hospice aide resumed "EVENMORE Care" at 17:15 and was continued throughout the night. 03/09/2020 - RN H documented an "EVENMORE Care" patient assessment from 03:30 until 05:00. - RN H documented the patient had been given Zofran at approximately 22:30 because of nausea and a later began vomiting dark, brownish emesis with 7-8 episodes during the night. - The clinical record contained no documentation that this increase in vomiting was reported to a hospice nurse by the hospice aide sitting with the patient overnight for "EVENMORE Care." - RN H failed to assess/document if the medication in the EKIT for nausea and vomiting (Promethazine) was offered or administered by the facility. - The clinical record contained no documentation to indicate the attending physician or hospice medical director were informed of the increased vomiting to determine if other medications could be tried to promote patient comfort. Review of the "EMC Timeline" showed "EVENMORE Care" visits ended at 08:30 on 03/09/2020. The clinical record contained no documentation to show when private duty caregivers hired by the family were started to replace the hospice aides provided under "EVENMORE Care." Per written documentation from family member #1 in the hospice complaint file, private caregivers started at noon on 03/09/2020. The hospice IDG failed to update the plan of care for the change in the level of care or the frequency of skilled nursing visits to be made ongoing. 03/09/20 - RN G documented a "Comprehensive Assessment Patient Assessment" visit from 10:15 to 11:15. - This clinical note indicated the patient was alert and oriented, identified a new diet of "Thickened Liquids/Nectar Thick," oxygen at 4L per nasal cannula with and oxygen saturation of 91%, a large, round, hard, board-like abdomen, infrequent incontinence of urine, no pain and no nausea or vomiting reported since the previous nursing visit. - RN G failed to assess/document whether the patient was offered or administered any medications by the facility nurse in the approximately five hours since the previous nursing visit. - RN G failed to update the plan of care for the new diet instructions or show evidence of a physician order. 03/10/2020 - LPN B documented a "Watch Care" assessment of the patient at 09:00 to 11:00. - LPN B noted non-verbal signs of discomfort exhibited by the patient and ongoing nausea. - LPN B called the attending physician and received verbal orders to stop all current medications and new orders for routine scheduled doses of morphine sulfate for pain, lorazepam Intensol for anxiety, scopolamine patch for nausea, and to check for impaction and administer Fleet's Enema if needed for constipation. - LPN-B documented coordination of these changes with the hospice clinical director, family member #1, facility director of nurses, and the facility charge nurse. - The clinical record contained no written physician order for these changes. 03/10/2020 - Documentation by the clinical director during a "Watch Care" visit at 12:09 - 13:40 showed: - The clinical director documented coordination of care with the family and facility nurse regarding newly prescribed medications (noted above) and a plan to "Review QID (four times a day) plus as needed." - The hospice plan of care was not updated for increased frequency of visits to QID. - The clinical director failed to document coordination with other members of the IDG regarding the patient's change in status. - The clinical director consistently documented an incorrect first name of the patient five times when referring to the patient in the narrative portion of the note. No further patient contacts were documented by the hospice on 03/10/2020 to assess if new medications were delivered, started by facility as ordered, or the patient response. Only two of four planned contacts/visits were completed. 03/11/2020 - RN I documented the next "Watch Care" visit occurred 03/11/2020 from 04:30 to 05:30. - RN I documented he/she was unable to obtain a blood pressure, temperature 99.2 axillary, respirations 18 and shallow, and oxygen saturation 88%. - The patient was moaning and had brown to black coffee ground emesis, staining his face and under his chin. - RN I asked for the facility nurse to administer morphine. - RN I failed to assess/document if the other comfort medications prescribed on 02/10/2020 were started and administered as ordered. 03/11/2020 - The facility notified the hospice that the patient expired at 08:35. LPN B went to the facility and provided post-mortem care and family support. An interview occurred by telephone with the RN case manager (RN A) on 07/22/2020 at 10:35 AM. - When questioned about medications used for symptom management, the RN stated that Zofran (ondansetron HCL) was not discontinued, was used for nausea and vomiting, and was offered to the patient frequently but refused. - The RN had no explanation for why Zofran was not discontinued on 03/05/2020 when he/she documented that all medications but "Comfort Pack" were discontinued. The RN acknowledged that Zofran was not one of the medications included in the "Comfort Pack." - When questioned about use of the "Comfort Pack" medication promethazine suppository for nausea and vomiting, the RN said it had been offered but patient refused a suppository because he/she was a very private person. - The RN stated he/she thought the vomiting was due to an obstruction related to the terminal diagnosis of pancreatic cancer. - The RN had no explanation regarding why medication use was not assessed/documented regularly except that the patient refused medications. Documentation in the hospice complaint file and clinical record, and confirmed by review of findings with the clinical director on 07/21/2020 and 07/22/2020, showed: - The hospice failed to follow the agency's process for start and stop of "Continuous Care" and "EVENMORE Care" or effectively educate hospice staff in these protocols. - The clinical director documented and confirmed that LPN A left the facility during the times of her documented 03/07/2020 visit and did not note this in his/her documentation. It could not be determined exactly how long LPN A was not in the facility except for the observations of family member #1. LPN A was no longer employed by the hospice and was unavailable for interview. - LPN A stopped "EVENMORE Care" without supervisory approval on 03/07/2020 when the family had been promised continual support. - The clinical director instructed LPN A to resume and continue "EVENMORE Care" and have the aide return to the facility to sit with the patient. During an interview on 07/22/2020 at 10:20 AM, the clinical director stated: - The assisted living facility probably had the written physician interim orders missing from the clinical record but the hospice failed to obtain copies. The clinical director said from now on they would need to get copies of physician orders and other documents from the facility for the hospice clinical record. - The clinical director acknowledged the RN case manager failed to update the hospice plan of care for all changes in the patient's condition and needs or show documented involvement and coordination with the other members of the IDG. - Coordination between IDG members frequently occurred by secure email but these documents are not made part of the clinical record and there were none of these communications available for this patient; and - The hospice had a standing order for Foley catheter insertion as needed but did not realize this would not cover a specialized catheter such as a Coude catheter. In addition, the clinical manager voiced no awareness of the Missouri hospice requirement and their own agency policy for standing orders to be specific and not allow for non-prescriber's choice or that the physician must be notified in a manner stated in the policy within 72 hours of implementation of a standing order. RECORD/PATIENT #3: Review of the clinical record showed Patient #2 was admitted to hospice on 03/14/2020 with a terminal diagnosis of unknown carcinoma with metastasis to the lung, abdomen and spine. The patient expired on 03/22/2020. Review of the clinical record identified the following issues regarding provision of care, coordination of care, and documentation by the licensed professional skilled nurses: 03/15/2020 - RN F documented the Initial/Comprehensive Assessment at 13:01. RN F documented the following: - The patient had a stage II pressure ulcer (Partial thickness loss of dermis presenting a shallow open ulcer with a red pink wound bed, without slough) just to the right of his/her coccyx measuring 3 cm (centimeters) x 2 cm with three small areas; one the size of a quarter; one the size of a nickel and one the size of a dime. - RN F failed to notify the physician of the pressure ulcer and obtain treatment orders. - The RN initiated a plan of care on 03/15/2020 that showed the patient had a coccyx pressure ulcer and staff was to assess the wound and a goal to monitor for progression of ulceration. The RN case manager failed to coordinate with the other members of the IDG and document a plan of care that included treatment of the wound or education of the patient/caregiver. - The patient had incontinence dermatitis and barrier cream was applied with each brief change. The RN failed to document an assessment or provide location of the dermatitis. The RN failed to obtain/document a physician's order for barrier cream. The RN failed to establish a plan of care specific to the incontinence dermatitis and treatment. - The patient had oxygen present but was not using the oxygen. The initial physician order for hospice care dated 03/14/2020 showed, "5 L oxygen concentrator." The initial plan of care failed to include a physician order for oxygen flow rate, method of delivery or frequency of use. - The Plan of Care Report showed the problem identified on 03/19/2020 as "Oxygen Use," established the goal for the patient to use oxygen safely, and documented the only intervention as "Teach patient/patient caregiver proper use of oxygen as needed." - The RN case manager failed to coordinate with the other members of the IDG and document a plan of care that included the problem that prompted the use of oxygen or interventions/goals related to an issue with the patient's respiratory status. - The patient had difficulty drinking from a straw. The RN provided teaching on swallowing/aspiration precautions and safety. The caregiver was instructed to have the head of the bed up 90 degrees for drinking or eating; use a regular cup with no straws and chin tuck to swallow. The RN failed to establish a plan of care to address the potential for choking and the patient need for aspiration and swallowing precautions. 03/15/2020 - LPN B completed a "Watch Care" visit assessment from 17:30 to 18:00. - The clinical record contained no plan of care for "Watch Care" visits and no plan for the frequency of visits. - LPN B documented the patient had a 16 French Foley catheter (sterile tube placed in the bladder to drain urine) and the catheter was previously "changed by hospice on 03/17/2020". This inaccurate documentation occurred because the clinician failed to complete the documentation in the electronic medical record for this visit until 03/23/2020 at 06:44 as dated on the clinical note. - Review of the nursing notes showed the Foley catheter was placed by the RN on 03/17/2020. 03/16/2020 - LPN B performed a "Watch Care" visit assessment at 09:51. LPN B documented: - The patient had constipation and a bowel regimen was started. The plan of care failed to address constipation or the specific bowel regimen ordered by the physician. - The LPN taught aspiration/swallowing precautions/safety which included the patient's care giver to have the head of the bed up 90 degrees for drinking or eating and to use regular cup, no straws and chin tuck to swallow. The plan of care did not address aspiration and swallowing precautions or the need for patient/caregiver education. - LPN B applied an Allevyn (absorbent foam dressing) to the stage II pressure ulcer of the patient's coccyx without evidence of a physician order or update to the plan of care by the RN case manager for this treatment. - The patient's "bottom", abdominal folds, and peri area was red. There was no documentation of the size or extent of the reddened areas. The LPN spoke with the physician and received a new verbal order to apply Nystatin (antifungal) twice daily to affected areas. The LPN and RN case manager failed to communicate/coordinate to update plan of care for this new skin problem and treatment, update the medication profile to include Nystatin, and the LPN failed to document a written physician order for Nystatin. - Education was provided on the potential benefits of a Foley catheter to prevent further skin breakdown and the use of "bunny boots" to prevent breakdown of heels. - The LPN documented the patient was on a daily "Watch Visits" due to decline. The clinical record contained no documentation of communication/coordination between the RN case manager and LPN or notification of the other IDG members of daily watch visits. The plan of care did not address daily watch visits. 03/17/2020 - Review of the comprehensive assessment dated at 21:33, showed RN G documented: - The patient had a Foley catheter size 16 with a five cc balloon placed with 2 liters of amber urine emptied within five minutes. - The RN failed to document notification of the physician for the need for a Foley catheter, a physician order for a Foley catheter, and/or documentation to show that a standing order for Foley catheter was implemented. In addition, there was no documentation of notification of the other members of the IDG of the Foley catheter placement. - The Plan of Care Report showed an update for "Urinary Catheter" on 03/18/2020 that stated only one intervention to teach signs/symptoms of distention/retention and goals for the patient to maintain optimal urinary output and remain comfortable in spite of catheter. The RN failed to include interventions for education of the patient/caregiver regarding care and management of the Foley, signs/symptoms of infection, or the type/size of Foley catheter or frequency of changes ordered. 03/19/2020 - LPN B documented a "Watch Care" visit on 03/19/2020 at 14:11. LPN B documented: - The patient was on daily watch due to decline and the visit frequency was increased to twice daily to watch for decline and symptom management. - The LPN failed to assess the status of the patient's pressure ulcer . - The family reported the patient had some difficulty swallowing and it was hard to get pills down; difficulty sucking water from straw and required verbal cueing to pull water from straw at times. - The family administered MS Contin (narcotic to treat moderate to severe pain) while LPN B was present; the patient had difficulty swallowing and began to cough and a pill appeared to be stuck in his/her throat. The patient required several gulps of water and cueing to get the pill down. The caregiver was educated on raising the head of bed in high fowler's position (the upper half of the body is between 60 and 90 degrees in relation to the lower half of the body), risk for aspiration which could lead to pneumonia, and risk for choking due to inability to get pills down. - The LPN spoke with the family about eliminating some medications and receiving comfort medications due to dysphagia (difficulty swallowing). - Verbal physician orders were received to discontinue baclofen, gabapentin (used to control and prevent seizures, anticonvulsant and nerve pain), and Eliquis (anticoagulant) and to continue dexamethasone (corticosteroid). A new verbal order was documented in the clinical note to start Methadone (treats moderate to severe pain) 5 mg by mouth three times a day. - Education was provided to patient's family on crushing medications and drawing up in a syringe and on not swabbing mouth right after liquid medications are given to avoid wiping medications out of the patient's mouth. - The LPN failed to document a written physician order for medication changes and medications to be crushed. - The LPN documented he/she coordinated the plan of care with the RN case manager, physician and patient's caregiver but failed to document specific detail. - The RN case manager (RN G) failed to update the plan of care or coordinate with the other members of the IDG regarding increase in frequency of "Watch Care" visits, worsening aspiration/swallowing difficulties and needed precautions, changes in techniques for medication administration taught to the family. 03/19/2020 - RN G documented an "Emergent Care Visit" from 15:45 to 16:45. RN G documented: - The patient had pale/grey discoloration around his/her mouth and RN G initiated continuous oxygen. - The RN educated the patient's family on end of life care signs and symptoms. - The family inquired on the patient's decreased ability to swallow and if they should continue his/her medications. The RN educated the caregiver on the need for comfort medications and if they wanted to discontinue the non-comfort medications that patient was unable to swallow they could. The family would decide and let the hospice agency know the next day of their decision. - The hospice "Plan of Care Report" failed to include any goals/interventions for end of life issues except for the problem of terminal restlessness. - RN G failed to document coordination of the plan of care with other members of the IDG or include the need for continuous humidified oxygen or the oxygen flow rate. 3/19/2020 - RN H completed a "Watch Care" assessment visit at 23:19. - RN H documented the patient was appropriate for three times a day visits. - The patient was sensitive to sounds and waved her hand when the environment was too loud. The RN encouraged the family to dim the lights and allow her to rest. - There was no documentation regarding the patient's pressure ulcer or reddened skin areas. - RN H failed to coordinate with the other members of the IDG or update the plan of care for three times a day "Watch Care" visits and comfort interventions addressed during the visit. Throughout the period of care, the hospice plan of care for aide services established by the RN failed to show or be updated to include information specific to the patient's integumentary status, pressure ulcer and coccyx dressing, peri area and abdominal skin fold redness and treatment, Foley catheter care, oxygen needs, or the need for aspiration/swallowing precautions. During an interview on 07/22/2020, Aide E said the following: - He/she said the patient had no pressure ulcers but had a dressing on his/her "bottom"; - He/she didn't remove the dressing because it was not soiled; - If a dressing was soiled he/she would remove it and notify the nurse on call; - He/she put a barrier cream on the patient's skin per the family's request; - He/she didn't think the patient had a Foley catheter and put a brief on him/her; and - If the patient resides at home he/she goes by what the family would like done for the patient and not the plan of care; During an interview on 07/21/2020 at 15:41, the clinical manager said: - He/she was unable to find orders or physician notifications for the patient's Foley catheter; oxygen; pressure ulcer care, and medication changes; - The plan of care was not updated for "Watch" visits, the frequency of the visits or the change in condition to require increased monitoring/visits; - He/she was unable to find wound care sheets to show staff monitored the patient's wound; - The IDG team meets every other week and if the patient had a change in condition he/she would expect the patient's physician to be notified; and - He/she was unable to provide additional information to show the IDG coordinated care for the patient as changes occurred.