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 ______________	04/22/2020
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)
L0587
L0587	29559 Based on clinical record review, policy review, and staff interview the hospice provider agency failed to ensure that a patient's needs were met based on an updated assessment. This deficiency example was identified at an immediate jeopardy level (L591). The administrator was verbally informed of the preliminary survey findings identified at an immediate jeopardy (IJ) level and also informed in writing on 04/22/2020 with an IJ template. The findings were confirmed as IJ after CMS review. The effect of this deficient practices has the potential to affect nursing services for all patients on service with the agency.
L0591
L0591	29559 Based on policy review, record review, and interviews the hospice provider failed to ensure nursing care and services met the needs of a patient as identified in an updated assessment in one of one record reviewed (Patient/Record #1). Patient #1 had changes in assessment after being burned while smoking and wearing oxygen. The hospice nurse failed to follow agency policy, notify the physician of the changes, or recognize the incident as emergent. The patient expired as a results of the injuries. The deficiency example was identified at an immediate jeopardy level. The deficiency has the potential to affect all patients on service with the agency. 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. 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. Review of the agency policy titled "HOSPICE NURSING CARE" showed in part the following: - The purpose of the policy is to specify the role of the nurse in hospice care. - Nursing services will be provided in accordance with accepted standards of practice by or under the supervision of a registered nurse. The hospice nurse (registered nurse or licensed practical/vocational nurse) will be a member of the interdisciplinary group. The hospice nurse will play a key role in easing physical and psychosocial symptoms and initiating communication with the interdisciplinary group to establish the plan of care. - A hospice registered nurse will be assigned as the Case Manager for each patient and family/caregiver, and his/her duties will be enumerated in a job description. Duties will include the responsibility for coordination of care and fostering communication between the patient and the interdisciplinary group. The Case Manager will assure that components of the plan of care are established and implemented by the interdisciplinary group. The Case Manager will determine the scope and frequency of services needed based on acuity and patient and family/caregiver needs. - The hospice registered nurse performs the initial assessment and participates in the comprehensive assessment and ongoing updates of the comprehensive assessments to assess the impact of the terminal diagnosis on the patient ' s physical, functional, psychosocial and environmental needs and activities of daily living. - The hospice nurse will participate in developing and implementing the plan of care and will report the condition of patient and family/caregiver to the attending physician, Medical Director and interdisciplinary group on a regular basis, as well as changes in the plan of care. - The hospice nurse will manage discomfort and provide symptom relief, prepare clinical and progress notes that demonstrate progress toward established goals. - The hospice nurse will provide specialized hospice training to other staff, family/caregivers to insure adequate care, direct provision of nursing care will be based on hospice nursing standards and clearly defined treatment protocols, and assess the patient and family/caregiver response to care. - The hospice nurse will ensure communication of information to appropriate team members. - A hospice nurse will be available on a 24-hour basis to meet the physical, psychosocial, spiritual, and practical needs of patients and families/caregivers admitted to the Integrity Home Care + Hospice. PATIENT/RECORD #1: Review of the patient's hospice record showed: - The patient was admitted to hospice on 02/17/2020 with primary diagnosis of chronic obstructive pulmonary disease (COPD), with co-morbidities of respiratory failure, CHF, weakness, and obesity. The hospice nurse was routinely visiting the patient twice weekly. The hospice plan of care showed Morphine liquid every four hours as needed for pain and shortness of breath, and Ativan routinely for anxiety. The patient was on routine steroids and inhalers for COPD. The narrative by the physician noted that the patient had multiple suicide attempts and anxiety. The patient was on oxygen at 2LPM (liters per minute) and "still continued to smoke". Baseline comprehensive assessment on 02/17/2020 showed that the patient's oxygen saturation was 91% with O2 (oxygen) at 8LPM (liters per minute). The patient was alert and orientated to person and place. The respiratory assessment showed dyspnea on exertion and rest, crackles and wheezes in lungs. Review of the 02/18/2020 hospice nurse assessment showed that the patient's oxygen saturation was 90% on O2 (oxygen) at 7LPM. Integumentary (skin) assessment red lower extremities. Respiratory assessment showed dyspnea (no assessment of lung sounds such as crackles or wheezes). Review of the 02/21/2020 hospice nurse assessment showed oxygen saturation 93% on 4LPM,, no problems in skin assessment, dyspnea (No crackles or wheezes assessed), "breathing even and unlabored". Review of the 02/25/2020 hospice nurse assessment showed the patient's oxygen saturation was 90% on 4LPM, nasal cannula. The nurse documented respirations were "even and unlabored". The nurse did not assess a thready pulse quality (as found on 03/10/2020) or wheezes in the patient's lungs (as found on 03/10/2020). Review of the 03/03/2020 hospice nurse assessment showed that no vital signs were documented/assessed for the patient. The skin assessment showed "no problems in integumentary". The respiratory assessment showed dyspnea (no assessment of wheezes or crackles documented). No assessment of a thready pulse quality was documented (as found on 03/10/2020). Review of the 03/06/2020 hospice nurse assessment showed the patient's oxygen saturation 93% on 4LPM. "breathing is even and unlabored" SOB (short of breath) on occasion. No assessment of a thready pulse quality was documented (as found on 03/10/2020). Review of the hospice on-call nurse assessment by RN-A on 03/10/2010 at 6:29 AM showed the following: - The nurse visited the patient from 5:57 AM to 6:29 AM; - The patient's oxygen saturation was 67% on 4LPM. (This was a change in assessment from the baseline recent previous assessments); - The nurse assessed the patient's pulse as "thready" (This was the first instance of a thready pulse assessment during the hospice admission); - "Patient smoking with oxygen on face black", " Pain "3" generalized and the location was the patient's nose. "Changes to integumentary assessment? "NO". (There was no further assessment to the extent of the skin injuries caused by the patient's burns); - The pulmonary assessment showed wheezing upper right, right middle, and lower left. (This was a change in assessment from the previous recent assessments); - The nurse documented that he/she communicated with " RN, supervisor", no narrative about the communication; and - There was no communication to the hospice physician regarding the patient's incident or change in condition. Review of long-term care facility (skilled nursing facility = SNF) nurse's notes showed the following: - On 3/10/2020, at 7:27 A.M., a nurse documented that around 4:00 A.M. to 4:15 A.M., the resident lit a cigarette with his/her nasal cannula and oxygen on. The resident stated, "I tried to put it out". The residents face was black and ashy with his/her facial hair singed. The resident was alert, breathing, and sitting on the side of his/her bed. Staff replaced the resident nasal cannula and the resident's oxygen saturation (percentage of hemoglobin binding sites in the bloodstream occupied by oxygen) level was at 54 percent (normal level is 90 percent or greater). The physician was contacted (no time noted or directive from physician noted) and the resident's oxygen was turned up to six to seven liters and his/her oxygen saturation was at 69 percent. Staff attempted to wipe the black ash off the resident's face and the resident stated his/her face was sore. The resident swallowing was assessed by giving the resident water. The resident had no coughing or complaints of discomfort or pain. Hospice arrived around 6:00 A.M. Staff completed 15-minute checks and attempted to have resident on one-on-one care, but staff was limited. Staff asked hospice to provide a one-on-one sitter; -On 3/10/2020, at 9:17 A.M., a nurse documented the resident was alert and responded with a nod or shake of his/her head. The resident's respirations were labored at rest. The resident stood in a tri-pod stance while sitting in his/her chair. The resident's oxygen was at 4 liters via nasal cannula. The resident's nose had thick yellow phlegm making inside of nose unable to be visualized. The resident had blisters on his/her upper lip and right eye. The residents face was blackened and scorched in appearance. Hospice was contacted and a message was left. The resident's oxygen saturation was at 46 percent at four liters of oxygen. Review of the patient's skin observation dated 3/10/2020, at 9:17 A.M., showed the resident had a scorched face, blisters on his/her upper lip and right eye area, chapped lips, and abdominal bruising. Review of the EMS records showed the paramedics assessed the patient upon arrival at the long-term care facility: - The incoming report from the long-term care facility staff was that the patient had an oxygen saturation of "46% on 4L" (four liters per minute by nasal cannula); - Upon arrival the patient was "belaboring to breathe"; - "The patient had obvious burns, blisters around (his/her) eyes and mouth"; and - The patient had "hypoxia and was placed on a 15LNRB" (a non-rebreather high flow oxygen mask). Review of the emergency room hospital records from 03/10/2020 showed the following: - The patient's admission diagnosis was "Burn of unspecified degree of nose (septum), burn of mouth and pharynx, and dyspnea"; - The patient's final diagnosis was acute respiratory failure, hypoxia, burn of second degree of nose (septum), burn of left eyelid and periocular area, burn of right eyelid and periocular area, burns involving less than 10% of body surface, chronic obstructive pulmonary disease (COPD); - "The cause of the injury was exposure to smoke, fire and flames, explosion of explosive materials"; - The patient was activated as a "level 1 trauma" (highest category) due to smoking while on oxygen; - The nursing facility staff called EMS (emergency medical services) " because the patient was hypoxic"; - The physician's physical exam showed "blistering to the face, in the nares, and eyelids"; - The physician assessed the patient with gasping respirations on admission to the emergency room; - The hospital physician wrote "The staff at the skilled nursing facility did not believe they needed to call EMS, despite the burns and blisters to (the patient's) face, because the patient was on hospice"; - The patient received comfort medications Morphine (pain medication) and Ativan (anti-anxiety medication); and - The patient died in the hospital at 12:30 PM on 03/10/2020; During an interview with the skilled nursing facility night shift charge nurse on 04/16/2020 at 12:02 PM, he/she stated the following: - He/she called the hospice at approximately 4:30 AM on 03/10/2020 because patient #1 had burned him/herself while smoking a cigarette when wearing oxygen; - The patient had "oxygen saturation in the 50's; - The patient's baseline oxygen saturation was "90's"; - When asked what the patient's lung sounds and pulse quality where like, the nurse could not recall; - The patient's face was "burned", the patient's oxygen tubing (nasal cannula) was "melted"; - The hospice nurse was "reluctant" to come in, but "I convinced (him/her)" to come; - The hospice nurse arrived around 6:00 AM to assess the patient, - When asked if he/she communicated with the hospice nurse regarding the patient after the hospice nurse assessed the patient, the SNF nurse responded "yes (the hospice nurse) looked at (the patient) and acted like it was "no big deal", said (the patient's) sat (oxygen saturation) was 67%; and - "I asked (the hospice nurse) to sit with the patient, he/she said that he/she would have to call the supervisor about that and left". During an interview with the skilled nursing facility day shift charge nurse on 04/16/2020 at 4:00 PM, he/she stated the following: - He/she was informed by the night shift charge nurse on 03/10/2020 in shift report that patient #1 had burned him/herself while smoking a cigarette when wearing oxygen; - The night shift reported that patient last had oxygen saturation in the "60's"; - The patient's baseline oxygen saturation was "90's"; - The patient's face was "blackened" and covered in "soot"; - The hospice nurse left around 6 AM, and he/she did not speak to the hospice nurse after the nurse assessed the patient. The hospice nurse may have spoke to the (SNF) night shift nurse; and - When asked if he/she spoke to the hospice nurse after the hospice nurse left, or if anyone from the hospice called him/her to check up on the patient's condition, he/she responded "no". During an interview with the Hospice RN-A on 04/17/2020 at 10:00 AM, he/she stated the following: - He/she received a call form the answering service approximately 4:30 AM on 03/10/2020 to call the SNF about patient #1. - The SNF nurse reported that the patient had burned him/herself while smoking a cigarette when wearing oxygen, the patient's sats had dropped to the 50's; - He/she arrived to the facility around 6:00 AM, it was difficult to find the patient due to the facility layout; - The SNF night shift RN was giving report to the SNF day nurse when I arrived, the day nurse showed me to the patient's room, did not look at the patient with me and left; - The patient was naked, incontinent of stool, had blackened face, a oxygen saturation of approximately 67% on approximately 4 LPM of oxygen per nasal cannula, lung sounds were diminished; - When asked of the quality of the patient's pulse, he she could not recall; - When asked if the patient had pain, he/she responded "no" - When asked if the patient had blisters from the burn, he/she responded "no"; - When asked if the patient was provided any comfort medications, he/she responded "no"; - When asked if he/she reported the incident or the patient's condition to the hospice supervisor or hospice physician, he/she responded "no"; - When asked if he/she reviewed the patient's recent baseline assessments in the hospice electronic medical record (EMR), the nurse responded "no, I didn't have my computer, only the tablet"; - He/she did talk to the hospice manager and asked about a volunteer for sitting with the patient; and - When asked if the SNF nurse requested that he/she sit with the patient, he/she responded "no, the person who asked me about a sitter were (SNF) aides that were in the hallway outside of (the patient's) room". During an interview with the Hospice RN-B (manager of Hospice RN -A) on 04/17/2020 at 10:41 AM, he/she stated the following: - He/she received a call from the hospice RN-A in the AM on 03/10/2020 to ask about a volunteer for the patient; - When asked if RN-A informed him/her that the patient had a burned face, low oxygen saturations, alteration in lung sounds, and a thready pulse, he/she responded "no, the conversation was only about a volunteer"; and - When asked who was the first person to notify you of the patient's condition, RN-B responded that the SNF day nurse called him/her to inform that the patient was going to the emergency room. A review of the provider's quality assurance data of the event showed an incident summary. The summary stated in part the following: "(RN-A) received a call from facility where (Patient #1) resided at 0444 and stated that patient was trying to light a cigarette with (his/her) oxygen on and (his/her) face was black. Upon (RN-A's) assessment, patient face is black, patient's oxygen saturation was 67% on 4 L, respiratory rate was 28, heart was thready, hair to (face) and head were singed. Patient was not having difficulty swallowing or shortness of breath. Facility was going to do 15 minute checks and (RN-A) left. (RN-A) should have called the medical director right away, sent the patient to the hospital, and called the DCS on-call."