Survey Report for 261646

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	261646	A. BUILDING __________ B. WING ______________	04/06/2020
NAME OF PROVIDER OR SUPPLIER	STREET ADDRESS, CITY, STATE, ZIP
INTEGRITY HOME CARE + HOSPICE	2960 N EASTGATE AVE, SPRINGFIELD, MO, 65803
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)
L0536
L0536	29559 Based on agency policy, clinical record review and interviews, the agency interdisciplinary group (IDG) failed to: - Ensure that each patient and the primary care giver(s) received education and training provided by the hospice as appropriate (L544); - Ensure all drugs and treatment necessary for the palliation and management of the terminal illness and related conditions necessary to meet the needs of the patient were available (L549); and - Ensure communication of accurate ongoing sharing of information between all disciplines providing care and services (L557). The cumulative effect of these practices has the potential to affect all patients receiving hospice services from this agency.
L0544
L0544	29559 Based on policy review, record review, and interviews, the provider failed to inform and educate the primary care giver (PCG) as appropriate in one of one record sampled (Patient/Record #1). The PCG was not informed of general inpatient care (GIP) or continuous care being available for unrelieved symptom control. The deficient practice has the potential of affecting all patients on service with the provider. Findings included: Review of the agency policy titled "ON-CALL/WEEKEND SERVICES, Policy No. H:2-040.1" showed in part the following: - The policy purpose is "To establish the process by which patients have access to hospice services 24 hours per day"; - "Patient care needs are the highest priority; therefore, weekend and evening staffing will be scheduled accordingly. Clinical personnel are expected to perform visits on an as-needed basis, including weekends"; - The on-call staff can be reached by calling the hospice number. After hours this number will be forwarded to the answering service. The answering service will pass every patient related call to the on-call nurse. - The on-call nurse will provide follow-up appropriate to the call: A. Call the patient/family/caregiver B. Visit the patient, if necessary C. Obtain physician (or other authorized independent practitioner) orders, as needed D. Arrange for other hospice services, as needed - The on-call nurse will document each patient/family interaction in a clinical note. - The on-call nurse will maintain a record of all patient contacts during on-call hours. - "It is the responsibility of the on-call nurse to determine if the need is emergent or non-emergent. This decision should be based upon the nurse's clinical judgement and critical thinking skills, a thorough nursing assessment over the phone, review of clinical record, and the current needs of the patient/family/caregiver in their course of hospice care. The following list is meant to guide the on-call nurse. It is not an exhaustive list, but includes many problems that may require a visit from the hospice nurse; and - Possible scenarios requiring emergent nursing visit includes uncontrolled pain, caller reports they have an urgent need, and duplicate calls concerning the same problem. Review of the agency policy titled "The Plan of Care" dated 11/22/2017 showed in part the following: - The purpose of the policy is to ensure that an individualized plan of care is completed that complies with accepted standards of care and regulatory issues. - A written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the Integrity Home Care + Hospice. - The care provided to the patient must be in accordance with the plan of care. - The plan of care will meet the documentation requirements of the physician-directed medical orders and the care planning process. - The plan of care will be based on the initial, comprehensive and ongoing comprehensive assessments performed by members of the interdisciplinary group and will be reviewed on a regular basis but no less than every fourteen (14) days. - The plan will focus on identified problems, goals, and interventions. - The patient and family/caregiver will be encouraged to participate in the development of and continued updating of the plan of care. - The plan of care will identify the patient ' s needs and services to meet those needs, including the management of pain and discomfort and symptom relief. It must state, in detail, the scope and frequency of services needed to meet the patient ' s and family/caregiver ' s needs. - Each patient will be monitored for his/her response to care or services provided against established patient goals and patient outcomes to evaluate progress toward goals. - The plan of care will be reviewed and revised as frequently as deemed necessary, but not less often than every 14 days, by the interdisciplinary group, with input from the attending physician, the patient, and the family/caregiver, based on ongoing comprehensive assessments of the patient and family/caregiver. Review of the plan of care will be documented in the clinical record. Revision dates will be noted on the plan of care. - As needed, the patient and family/caregiver will receive written instructions regarding treatments or aspects of care that will be the responsibility of the patient and family/caregiver to provide or follow through with. PATIENT/RECORD #1: Review of the patient's plan of care showed: - The patient was admitted to hospice service on 11/21/2019 for "CHRONIC OBSTRUCTIVE PULMONARY DISEASE" and "UNSPECIFIED SEVERE PROTEIN MALNUTRITION"; - A pain medication order dated 11/22/2019 for "OXYCODONE ORAL 10 MG (milligrams)1 TAB EVERY 4 HOURS PRN (as needed): BACK PAIN"; and - A pain medication order dated 12/19/2019 for "MORPHINE CONCENTRATE (AKA ROXANOL) ORAL 20 MG/ML (milliliter) 0.5 ML EVERY 2 HOURS PRN" During an interview on 03/31/2020 at 12:44 PM with the family, primary caregiver (PCG) of the patient, stated the following: - On 03/29/2020 the patient ran out of the only pain medication that was effective for the patient's pain; - He/she contacted the on-call nurses four times for a refill when the patient had just a couple tablets left and was informed that no refill was available because the refill was not due; - He/she was informed by two separate on-call nurses that if the pain was severe enough that he/she should send the patient to the hospital for pain management, and that the patient's hospice benefit would be stopped; - The patient ran out of medication on the evening of 03/29/2010 and was in severe pain, "11 out of 10 pain" that was so bad it was making the patient nauseated. The patient refused to go to the hospital because the patient feared the COVID-19 virus. - When asked if he/she informed the on-call nurses that the patient's pain was uncontrolled, he/she stated that when she called (RN-B) the first and second time, the patient still had a couple tablets of Oxycodone left. The third time he/she spoke with RN-A and the only time he/she spoke with RN-A, he/she was told that (the patient) was in pain and out of Oxycodone. - When asked if he/she was informed by the on-call nurses that the patient could have continuous care or general inpatient care (GIP) for uncontrolled pain, he/she responded "that's the first time I've ever heard of that, no". Review of a coordination note dated 03/29/2020 at 5:59 PM by RN-A showed in part the following: "1701- (PCG) RETURNED CALL TO PERSONAL PHONE. PCG VERY UPSET REGARDING TREATMENT OF (THE PATIENT). CONCERNED ABOUT WHAT TO DO ABOUT (THE PATIENT'S) PAIN WHEN MEDICATION RUNS OUT. EXPLAINED THAT (THE PATIENT) HAS ROXANOL (LIQUID MORPHINE) FOR BREAKTHROUGH PAIN. PCG REPORTS MORPHINE DOES NOT WORK. ADVISED PCG THAT IF PAIN GETS OUT OF CONTROL, AND (PCG) FEELS THAT TAKING PT TO THE HOSPITAL IS THE ONLY OPTION, THAT IS (THE PCG's) DECISION. HOWEVER, PATIENT MAY COME OFF HOSPICE." Review of all available on-call communication notes showed entries by the on-call nurses, RN-A and RN-B on 03/29/2020 at 4:05 PM, 4:24 PM, 5:01 PM, 5:59 PM, and 6:09 PM. During an interview with On-call RN-B on 04/02/2020 at 12:15 PM, he/she stated the following: - Received two or three phone calls from the patient's family/primary caregiver (PCG) on 03/29/2020 requesting refills of the pain medication Oxycodone; - He/she contacted the physician and the physician would not refill the medication because it was not time, the patient was using the medication more than prescribed; - Instructed the family (PCG) to use the PRN morphine since the Oxycodone was not going to be refilled early; - The PCG stated that the Morphine was not effective for the patient's pain, and the Oxycodone was effective; - The PCG was instructed that if the pain was unbearable, the patient should go to the hospital emergency room for treatment; and - When asked if continuous care or general inpatient care (GIP) was discussed with the patient or PCG, On-call RN-B stated "I don't think so". During an interview with On-call RN-A on 04/02/2020 at 2:20 PM, he/she stated the following: - Received one phone call from the patient's family/primary caregiver (PCG) the evening of 03/29/2020 requesting a refill of the pain medication Oxycodone; - The PCG stated that he/she had called multiple times for a Oxycodone refill; - He/she contacted RN-B about the situation and was informed the physician would not refill the medication because it was not time, the patient was using the medication more than prescribed; - Instructed the family (PCG) to use the PRN morphine since the Oxycodone was not going to be refilled early; - The PCG was upset that the Oxycodone would not be refilled, and stated that the Morphine does not work; - The PCG repeatedly asked "what should I do?". The PCG was instructed to use the available Morphine and that if the pain was unbearable, the patient should go to the hospital; and - When asked if continuous care or general inpatient care was discussed with the patient or PCG, On-call RN-A stated "not sure what you are talking about".
L0549
L0549	29559 Based on policy review, record review, and interviews, the provider failed to have medications or treatments available to palliate and manage the patient's pain needs in one of one record sampled (Patient/Record #1). The patient's medication regimen was not effective for the patient for adequate control. Only one of the three prescribed pain medications was effective for the patient, and the patient ran out of that medication from overuse, resulting in the patient having uncontrolled pain. The deficient practice has the potential of affecting all patients on service with the provider. Findings included: Review of the agency policy titled "INTERDISCIPLINARY GROUP COORDINATION OF CARE Policy No. H:2-035.1" showed in part the following: - The purpose is to "ensure the coordination of services for each patient"; - The hospice interdisciplinary group will retain professional management responsibilities for the provision of services, including inpatient care, and will insure that services are furnished in a safe and effective manner. - The type and scope of services provided by the interdisciplinary group will be based upon comprehensive and ongoing assessments regarding the needs of the patient and family/caregiver and the comprehensive plan of care that defines patient and family/caregiver problems, goals, and interventions. The exact combination of services and the level of care will be unique to each patient and family/caregiver unit and will change as the needs of the patient and family/caregiver evolve over the course of their involvement with hospice. - It will be the responsibility of the Case Manager to facilitate communication about changes in the patient's status between interdisciplinary group members and the patient's attending physician; - Integrity Home Care + Hospice personnel will communicate changes in a timely manner via telephone, one-to-one meetings, interdisciplinary group meetings, and home visits. Documentation of all communications will be included in the clinical record on a communication note, interdisciplinary group meeting form, and/or clinical note. Documentation will include the date and time of the communication, individuals involved with the communication, information discussed, and the outcome of the communication. - When the patient requires services from the interdisciplinary group, the Case Manager will be responsible for cooperative care planning to assure goals, interventions, and outcomes are palliative in nature. - Written evidence of care coordination will be found in the plan of care and/or inter-disciplinary team meeting forms in the patient's clinical record, and will involve the hospice patient's attending physician. - Continuity of care will be maintained throughout the patient's course with hospice. Exchange of information between hospice staff and contracted providers will be documented in the clinical record. - The interdisciplinary group will provide ongoing support for patient and family/caregivers. - Core hospice services (nursing, social work, physician, and counselors) will be available 24 hours a day, seven (7) days a week, as will be drugs, biologicals, and medical supplies. Other services may be available as needed and will include hospice aide, homemaker, therapies, and volunteer and bereavement services. Review of the agency policy titled "ONGOING COMPREHENSIVE ASSESSMENTS Policy No. H:2-047.1" showed in part the following: - The policy purpose is to "provide guidelines for assessments of patients during ongoing care" - The scope and intensity of ongoing hospice patient assessments will be determined by the patient's prognosis, diagnoses, condition, desire for care, response to previous care, and the care setting. - The hospice nurse to assess pain, secondary symptoms, current treatment related to the identified symptoms, the patient ' s response to treatment, vital signs, breath sounds, skin integrity, functional status, safety/home environment, patient and family/caregiver support, compliance with treatments and medication regimen, and the need for an alternative setting or level of care. - Based on the assessments, the plan of care including problems, needs, goals, and outcomes will be reviewed and updated by the interdisciplinary group members responsible for the case. - Based upon the findings of the assessment, change/verbal orders will be generated and forwarded to the physician (or other authorized independent practitioner) as needed. - The physician will be notified to verify any changes in medications, including over-the-counter medications, and treatment/interventions PATIENT/RECORD #1: Review of the patient's plan of care showed: - The patient was admitted to hospice service on 11/21/2019 for "CHRONIC OBSTRUCTIVE PULMONARY DISEASE" and "UNSPECIFIED SEVERE PROTEIN MALNUTRITION"; - A pain medication order dated 11/22/2019 for "OXYCODONE ORAL 10 MG (milligrams)1 TAB EVERY 4 HOURS PRN (as needed): BACK PAIN"; and - A pain medication order dated 12/19/2019 for "MORPHINE CONCENTRATE (AKA ROXANOL) ORAL 20 MG/ML (milliliter) 0.5 ML EVERY 2 HOURS PRN" During an interview on 03/31/2020 at 12:44 PM with the family, primary caregiver (PCG) of the patient, stated the following: - On 03/29/2020 the patient ran out of the only pain medication that was effective for the patient's pain; - He/she contacted the on-call nurses four times for a refill when the patient had just a couple tablets left and was informed that no refill was available because the refill was not due; - He/she was informed by two separate on-call nurses that if the pain was severe enough that he/she should send the patient to the hospital for pain management, and that the patient's hospice benefit would be stopped; - The patient ran out of medication on the evening of 03/29/2010 and was in severe pain, "11 out of 10 pain" that was so bad it was making the patient nauseated. The patient refused to go to the hospital because the patient feared the COVID-19 virus; - When asked if he/she informed the on-call nurses that the patient's pain was uncontrolled, he/she stated that when she called (RN-B) the first and second time, the patient still had a couple tablets of Oxycodone left. The third time he/she spoke with RN-A and the only time he/spoke with RN-A, he/she was told that (the patient) was in pain and out of Oxycodone. - When asked if he/she was informed by the on-call nurses that the patient could have continuous care or general inpatient care (GIP) for uncontrolled pain, he/she responded "that's the first time I've ever heard of that, no". Review of all available on-call communication notes showed entries by the on-call nurses, RN-A and RN-B on 03/29/2020 at 4:05 PM, 4:24 PM, 5:01 PM, 5:59 PM, and 6:09 PM. During an interview with On-call RN-B on 04/02/2020 at 12:15 PM, he/she stated the following: - Received two or three phone calls from the patient's family/primary caregiver (PCG) on 03/29/2020 requesting refills of the pain medication Oxycodone; - He/she contacted the physician and the hospice physician would not refill the medication because it was not time, the patient was using the medication more than prescribed; - Instructed the family (PCG) to use the PRN morphine since the Oxycodone was not going to be refilled early; - The PCG stated that the Morphine was not effective for the patient's pain, and the Oxycodone was effective; - The PCG was instructed that if the pain was unbearable, the patient should go to the hospital emergency room for treatment. During an interview with On-call RN-A on 04/02/2020 at 2:20 PM, he/she stated the following: - Received one phone call from the patient's family/primary caregiver (PCG) the evening of 03/29/2020 requesting a refill of the pain medication Oxycodone; - The PCG stated that he/she had called multiple times for a Oxycodone refill; - He/she contacted RN-B about the situation earlier and was informed the physician would not refill the medication because it was not time, the patient was using the medication more than prescribed; - Instructed the family (PCG) to use the PRN morphine since the Oxycodone was not going to be refilled early; - The PCG was upset that the Oxycodone would not be refilled, and stated that the Morphine does not work; and - The PCG repeatedly asked "what should I do". The PCG was instructed to use the available Morphine and that if the pain was unbearable, the patient should go to the hospital. Review of the case coordination notes showed on 03/29/20 RN-B documented "1624 RECEIVED MESSAGE FROM PCG REQUESTING CALL BACK REGARDING MEDICATION REFILL, REPORTS (PCG) HAS CALLED 3 TIMES. 1628- RETURNED CALL TO (PCG). THE PCG REPORTS PATIENT RECEIVED ONLY A PARTIAL FILL OF 30 MG OXYCODONE EARLIER THIS WEEK AND (THE PATIENT) ONLY HAS THREE TABLETS LEFT." PCG DOES REPORT PATIENT HAS TAKEN SOME EXTRAS DUE TO INCREASED PAIN AND PCG REPORTS AND CALLS ABOUT EXTRA DOSES. THIS NURSE COULD NOT FIND ANY DOCUMENTATION OF EXTRA DOSES BEING TAKEN. PATIENT CAREGIVER REQUESTING A REFILL TODAY AS PATIENT ONLY HAS ENOUGH FOR 9 HOURS AND WILL NOT GET THROUGH THE NIGHT. ADVISE PATIENT CAREGIVER THAT PATIENT DOES HAVE ROXANOL AS WELL FOR PAIN. PCG DOES REPORT THAT PATIENT FEELS THIS MEDICATION IS NOT EFFECTIVE IN PAIN CONTROL. (PCG) REPORTS ONLY THE OXYCODONE FEELS EFFECTIVE AT THIS TIME. ADVISE THIS NURSE WILL CALL (The Hospice Physician) AND REQUEST A REFILL BUT THERE IS NO GUARANTEE THAT THE PHYSICIAN WILL CALL IN A REFILL AS THIS IS NOT THE FIRST TIME THE PATIENT HAS REQUESTED A REFILL BEFORE REFILL DATE. CALL (The Hospice Physician) AND UPDATED ON CURRENT STATUS OF PRESCRIPTION. EXPLAINED TO CALL (The Hospice Physician) THAT PHYSICIAN DID ORDER A REFILL ON THE 23RD AND PATIENT ONLY HAS THREE TABLETS LEFT. PATIENT SHOULD HAVE A 10 1/2 DAY SUPPLY AND IT IS ONLY DAY 6. PHYSICIAN DECLINED TO REFILL MEDICATION AT THIS TIME AND WILL ONLY REFILL ON EXPECTED REFILL DATE. RETURN CALL TO PCG AND UPDATED ON CONVERSATION WITH PHYSICIAN. PCG WAS VERY UPSET THAT II WILL NOT BE CALLED IN TODAY AS PATIENT DOES ONLY HAVE 3 TABS LEFT. (The PCG)WANTS TO KNOW WHAT (He/she) IS SUPPOSED TO DO. ADVISED (The PCG) THAT (The Patient) DOES STILL HAVE THE ROXANOL FOR BREAKTHROUGH PAIN AS WELL AS THE LONG-ACTING MORPHINE FOR TWICE A DAY AND IT SHOULD BE ABLE TO BE USED FOR PAIN CONTROL THIS TIME. AGAIN PCG ASKED HOW HOSPICE COULD DO THIS BECAUSE IT'S SHOULDN'T BE ALLOWED. PCG BECAME VERY UPSET WITH THIS NURSE . Review of the case coordination notes showed on 03/29/20 RN-A documented "1701- RETURNED CALL. PCG VERY UPSET REGARDING TREATMENT OF (THE PATIENT). CONCERNED ABOUT WHAT TO DO ABOUT HER PAIN WHEN HER MEDICATION RUNS OUT. EXPLAINED THAT (THE PATIENT) HAS ROXANOL (LIQUID MORPHINE) FOR BREAKTHROUGH PAIN. PCG REPORTS MORPHINE DOES NOT WORK. ADVISED PCG THAT IF PAIN GETS OUT OF CONTROL, AND (PCG) FEELS THAT TAKING PT TO THE HOSPITAL IS THE ONLY OPTION, THAT IS (PCG) DECISION. HOWEVER, PATIENT MAY COME OFF HOSPICE."
L0557
L0557	29559 Based on policy review, record review, and interviews, the hospice on-call nurses failed to coordinate/inform the hospice physician that the pain medications available to the patient were ineffective and that the patient was having uncontrolled pain in one of one record sampled (Patient/Record #1). The patient's medication regimen was not effective for the patient for adequate control. Only one of the three prescribed pain medications was effective for the patient, and the patient ran out of that medication from overuse, resulting in the patient having uncontrolled pain. The deficient practice has the potential of affecting all patients on service with the provider. Findings included: Review of the agency policy titled "INTERDISCIPLINARY GROUP COORDINATION OF CARE Policy No. H:2-035.1" showed in part the following: - The purpose is to "ensure the coordination of services for each patient"; - The hospice interdisciplinary group will retain professional management responsibilities for the provision of services, including inpatient care, and will insure that services are furnished in a safe and effective manner. - The type and scope of services provided by the interdisciplinary group will be based upon comprehensive and ongoing assessments regarding the needs of the patient and family/caregiver and the comprehensive plan of care that defines patient and family/caregiver problems, goals, and interventions. The exact combination of services and the level of care will be unique to each patient and family/caregiver unit and will change as the needs of the patient and family/caregiver evolve over the course of their involvement with hospice. - It will be the responsibility of the Case Manager to facilitate communication about changes in the patient's status between interdisciplinary group members and the patient's attending physician; - Integrity Home Care + Hospice personnel will communicate changes in a timely manner via telephone, one-to-one meetings, interdisciplinary group meetings, and home visits. Documentation of all communications will be included in the clinical record on a communication note, interdisciplinary group meeting form, and/or clinical note. Documentation will include the date and time of the communication, individuals involved with the communication, information discussed, and the outcome of the communication. - When the patient requires services from the interdisciplinary group, the Case Manager will be responsible for cooperative care planning to assure goals, interventions, and outcomes are palliative in nature. - Written evidence of care coordination will be found in the plan of care and/or inter-disciplinary team meeting forms in the patient's clinical record, and will involve the hospice patient's attending physician. - Continuity of care will be maintained throughout the patient's course with hospice. Exchange of information between hospice staff and contracted providers will be documented in the clinical record. - The interdisciplinary group will provide ongoing support for patient and family/caregivers. - Core hospice services (nursing, social work, physician, and counselors) will be available 24 hours a day, seven (7) days a week, as will be drugs, biologicals, and medical supplies. Other services may be available as needed and will include hospice aide, homemaker, therapies, and volunteer and bereavement services. Review of the agency policy titled "ONGOING COMPREHENSIVE ASSESSMENTS Policy No. H:2-047.1" showed in part the following: - The policy purpose is to "provide guidelines for assessments of patients during ongoing care" - The scope and intensity of ongoing hospice patient assessments will be determined by the patient's prognosis, diagnoses, condition, desire for care, response to previous care, and the care setting. - The hospice nurse to assess pain, secondary symptoms, current treatment related to the identified symptoms, the patient ' s response to treatment, vital signs, breath sounds, skin integrity, functional status, safety/home environment, patient and family/caregiver support, compliance with treatments and medication regimen, and the need for an alternative setting or level of care. - Based on the assessments, the plan of care including problems, needs, goals, and outcomes will be reviewed and updated by the interdisciplinary group members responsible for the case. - Based upon the findings of the assessment, change/verbal orders will be generated and forwarded to the physician (or other authorized independent practitioner) as needed. - The physician will be notified to verify any changes in medications, including over-the-counter medications, and treatment/interventions PATIENT/RECORD #1: Review of the patient's plan of care showed: - The patient was admitted to hospice service on 11/21/2019 for "CHRONIC OBSTRUCTIVE PULMONARY DISEASE" and "UNSPECIFIED SEVERE PROTEIN MALNUTRITION"; - A pain medication order dated 11/22/2019 for "OXYCODONE ORAL 10 MG (milligrams)1 TAB EVERY 4 HOURS PRN (as needed): BACK PAIN"; and - A pain medication order dated 12/19/2019 for "MORPHINE CONCENTRATE (AKA ROXANOL) ORAL 20 MG/ML (milliliter) 0.5 ML EVERY 2 HOURS PRN". During an interview on 03/31/2020 at 12:44 PM with the family, primary caregiver (PCG) of the patient, stated the following: - On 03/29/2020 the patient ran out of the only pain medication that was effective for the patient's pain; - He/she contacted the on-call nurses four times for a refill when the patient had just a couple tablets left and was informed that no refill was available because the refill was not due; - He/she was informed by two separate on-call nurses that if the pain was severe enough that he/she should send the patient to the hospital for pain management, and that the patient's hospice benefit would be stopped; - The patient ran out of medication the evening on 03/29/2010 and was in severe pain, "11 out of 10 pain" that was so bad it was making the patient nauseated. The patient refused to go to the hospital because the patient feared the COVID-19 virus; - When asked if he/she informed the on-call nurses that the patient's pain was uncontrolled, he/she stated that when she called (RN-B) the first and second time, the patient still had a couple tablets of Oxycodone left. The third time he/she spoke with RN-A and the only time he/spoke with RN-A, and he/she was told that (the patient) was in pain and out of Oxycodone. - When asked if he/she was informed by the on-call nurses that the patient could have continuous care or general inpatient care (GIP) for uncontrolled pain, he/she responded "that's the first time I've ever heard of that, no". Review of all available on-call communication notes showed entries by the on-call nurses, RN-A and RN-B on 03/29/2020 at 4:05 PM, 4:24 PM, 5:01 PM, 5:59 PM, and 6:09 PM. Review of the case coordination notes showed on 03/29/20 RN-B documented "1624 RECEIVED MESSAGE FROM PCG REQUESTING CALL BACK REGARDING MEDICATION REFILL, REPORTS (PCG) HAS CALLED 3 TIMES. 1628- RETURNED CALL TO (PCG). THE PCG REPORTS PATIENT RECEIVED ONLY A PARTIAL FILL OF 30 MG OXYCODONE EARLIER THIS WEEK AND (THE PATIENT) ONLY HAS THREE TABLETS LEFT." PCG DOES REPORT PATIENT HAS TAKEN SOME EXTRAS DUE TO INCREASED PAIN AND PCG REPORTS AND CALLS ABOUT EXTRA DOSES. THIS NURSE COULD NOT FIND ANY DOCUMENTATION OF EXTRA DOSES BEING TAKEN. PATIENT CAREGIVER REQUESTING A REFILL TODAY AS PATIENT ONLY HAS ENOUGH FOR 9 HOURS AND WILL NOT GET THROUGH THE NIGHT. ADVISE PATIENT CAREGIVER THAT PATIENT DOES HAVE ROXANOL AS WELL FOR PAIN. PCG DOES REPORT THAT PATIENT FEELS THIS MEDICATION IS NOT EFFECTIVE IN PAIN CONTROL. (PCG) REPORTS ONLY THE OXYCODONE FEELS EFFECTIVE AT THIS TIME. ADVISED THIS NURSE WILL CALL (The Hospice Physician) AND REQUEST A REFILL BUT THERE IS NO GUARANTEE THAT THE PHYSICIAN WILL CALL IN A REFILL AS THIS IS NOT THE FIRST TIME THE PATIENT HAS REQUESTED A REFILL BEFORE REFILL DATE. CALLED (The Hospice Physician) AND UPDATED ON CURRENT STATUS OF PRESCRIPTION. EXPLAINED TO (The Hospice Physician) THAT PHYSICIAN DID ORDER A REFILL ON THE 23RD AND PATIENT ONLY HAS THREE TABLETS LEFT. PATIENT SHOULD HAVE A 10 1/2 DAY SUPPLY AND IT IS ONLY DAY 6. PHYSICIAN DECLINED TO REFILL MEDICATION AT THIS TIME AND WILL ONLY REFILL ON EXPECTED REFILL DATE. RETURN CALL TO PCG AND UPDATED ON CONVERSATION WITH PHYSICIAN. PCG WAS VERY UPSET THAT II WILL NOT BE CALLED IN TODAY AS PATIENT DOES ONLY HAVE 3 TABS LEFT. (The PCG)WANTS TO KNOW WHAT (He/she) IS SUPPOSED TO DO. ADVISED (The PCG) THAT (The Patient) DOES STILL HAVE THE ROXANOL FOR BREAKTHROUGH PAIN AS WELL AS THE LONG-ACTING MORPHINE FOR TWICE A DAY AND IT SHOULD BE ABLE TO BE USED FOR PAIN CONTROL THIS TIME. AGAIN PCG ASKED HOW HOSPICE COULD DO THIS BECAUSE IT' SHOULDN'T BE ALLOWED. PCG BECAME VERY UPSET WITH THIS NURSE . Review of the case coordination notes showed on 03/29/20 RN-A documented "1701- RETURNED CALL. PCG VERY UPSET REGARDING TREATMENT OF (THE PATIENT). CONCERNED ABOUT WHAT TO DO ABOUT HER PAIN WHEN HER MEDICATION RUNS OUT. EXPLAINED THAT (THE PATIENT) HAS ROXANOL (LIQUID MORPHINE) FOR BREAKTHROUGH PAIN. PCG REPORTS MORPHINE DOES NOT WORK. ADVISED PCG THAT IF PAIN GETS OUT OF CONTROL, AND (PCG) FEELS THAT TAKING PT TO THE HOSPITAL IS THE ONLY OPTION, THAT IS (PCG) DECISION. HOWEVER, PATIENT MAY COME OFF HOSPICE." During an interview with On-call RN-B on 04/02/2020 at 12:15 PM, he/she stated the following: - Received two or three phone calls from the patient's family/primary caregiver (PCG) on 03/29/2020 requesting refills of the pain medication Oxycodone; - He/she contacted the physician and the hospice physician would not refill the medication because it was not time, the patient was using the medication more than prescribed; - Instructed the family (PCG) to use the PRN morphine since the Oxycodone was not going to be refilled early; - The PCG stated that the Morphine was not effective for the patient's pain, and the Oxycodone was effective; and - The PCG was instructed that if the pain was unbearable, the patient should go to the hospital emergency room for treatment. During an interview with On-call RN-A on 04/02/2020 at 2:20 PM, he/she stated the following: - Received one phone call from the patient's family/primary caregiver (PCG) the evening of 03/29/2020 requesting a refill of the pain medication Oxycodone; - The PCG stated that he/she had called multiple times for a Oxycodone refill; - He/she contacted the RN-B about the situation earlier and was informed the physician would not refill the medication because it was not time, the patient was using the medication more than prescribed; - Instructed the family (PCG) to use the PRN morphine since the Oxycodone was not going to be refilled early; - The PCG was upset that the Oxycodone would not be refilled, and stated that the Morphine does not work; - The PCG repeatedly asked "what should I do". The PCG was instructed to use the available Morphine and that if the pain was unbearable, the patient should go to the hospital. During an interview with the hospice physician on 04/02/2020, he/ she stated the following: - An on-call nurse called the weekend of 03/29/2020 for a refill of Oxycodone for the patient; - When asked if the on-call nurse informed him/her that the patient was out of the pain medication Oxycodone, he/she responded that they asked for a refill; - When asked if the on call nurse informed him/her that the patient would not take the available Morphine products because they were ineffective, he/she responded "no"; - When asked if a on-call nurse informed him/her that the patient was in uncontrolled pain, he/she responded "no"; and - When asked if he/she would have changed the medication regimen for the patient if he/she was aware that the patient did not respond to the available Morphine, was out of the only medication that was effective (Oxycodone), and was in "11 out of 10" pain, he/she responded "yes".