Survey Report for 261662

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	261662	A. BUILDING __________ B. WING ______________	06/07/2021
NAME OF PROVIDER OR SUPPLIER	STREET ADDRESS, CITY, STATE, ZIP
HAVEN HOSPICE	850 NORTH 25TH STREET, OZARK, MO, 65721
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See reverse for further instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation
LABORATORY DIRECTOR’S OR PROVIDER/SUPPLIER REPRESENTATIVE’S SIGNATURE		TITLE	(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
(X4) ID PREFIX TAG	SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY SHOULD BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)
L0500
L0500	34028 Based on policy review, record review, grievance file review and interview, the hospice provider failed to ensure that patients received effective pain management and symptom control in one (Patient #1) of five records reviewed (L512) by failing to consistently and accurately count controlled substances in the home resulting in the patient being without consistent pain medication. Due to this systemic failure, there was the potential for ineffective pain management and symptom control in three additional records (Records #2, #4, and #5). The severity of this deficient practice resulted in the inability of the hospice to ensure effective pain management and symptom control to all hospice patients.
L0512
L0512	34028 Based on policy review, record review, grievance file review and interview, the hospice provider failed to ensure that patients received effective pain management and symptom control in one (Patient #1) of five records reviewed by failing to conduct accurate, consistent, controlled substance counts in the home resulting in the patient being without consistent pain medication. In addition, the agency failed to conduct controlled substance counts on all visits in three other records reviewed (Records #2, #4, and #5) which could result in ineffective pain management and symptom control. Findings included: Review of agency undated policy titled, "Patient's Rights/Responsibilities," showed the patients had the right to receive effective pain management and symptom control for conditions related to terminal illness. Review of agency policy dated 01/01/2015 and titled, "Pain Management," showed unrelieved pain has a tremendous negative impact on quality of life. Pain is a multidimensional phenomenon, composed of not only nociceptive and neuropathic components, but psychological, spiritual, and existential determinants as well. Nearly all pain can be relieved with the expert use of common medications administered by non-invasive routes. Careful assessment and frequent reassessment are the keys to effective, targeted treatments. Addiction is extraordinarily rare in this setting and fears of creating addiction should not be a concern in prescribing opioids in doses sufficient to control pain. Procedure: - The skilled nurse will perform a pain assessment during each home visit. The pain assessment will be documented; - the interdisciplinary hospice team, composed not only of physicians and nurses, but social workers, pastoral care workers, and psychologists, focuses on recognizing and addressing these non-biologic aspects of pain; - All other interdisciplinary members will ask the patient whether they are experiencing pain and will document positive results. The skilled nurse will be contacted with reports of pain that are not consistent with the patient's history and any report of pain over a pain scale of "5"; - The skilled nurse will contact the attending physician and/or medical director/designee to report unresolved pain issues including new site, increase in pain or other symptoms; - the skilled nurse will contact the patient within 24 hours of any change in the pain treatment regime and will make a home visit to the patient within 48 hours of the change unless refused by the patient; and - The interdisciplinary team will discuss pain issues to determine other causal factors and possible non-pharmacologic treatment measures to employ. Review of agency policy dated 01/1/2015 and titled, "Medication - Controlled Substance/Drug Safety and Disposal," showed it is the ethical responsibility to inform and assist the patient or the patient's family of their responsibility in safely storing of all drugs and the disposing of unused drugs including controlled substances/drugs. In the event that medications discrepancies exist with controlled substances, the agency Interdisciplinary Team (IDT) or nurse may facilitate a change in the patient's medication management system to a cautionary method, which may involve, counts of controlled substances on hand each visit to maintain closer regulation. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice services on 03/20/2018 with a terminal diagnosis of unspecified severe protein-calorie malnutrition, weakness, pneumonia due to other specified infections and shortness of breath. Review of the nursing documentation showed that: -On 05/22/2019 the patient was taking fentanyl 12 mcg per hour to be changed every 72 hours. The pharmacy delivered 3 patches to the patient on 05/22/2019; -On 05/24/2019 RN C documented he/she put a fentanyl patch on the resident with a count of "2 patches" left (patch should be changed on 05/27/2019). The resident had pain right knee and left ankle and lower legs; -On 05/28/2019 RN C documented two fentanyl patches counted (which would be incorrect if patient got his/her patch changed as ordered on 05/27/2019. Patient complained of pain in bilateral lower extremities (BLE). The patient's granddaughter changed the fentanyl patch this morning; -On 05/29/2019 the nurse practitioner documented that the patient complains of generalized pain that is not well controlled by her current patch and tramadol. The patient appears uncomfortable; -On 05/29/2019 RN A documented the patient has three fentanyl patches left. Review of pharmacy packing and delivery slips do not show any other patches being delivered between 05/22/2019 to 05/29/2019. The patient has pain BLE; -On 06/07/2019 RN C documented the patient had zero fentanyl patches left, refill ordered. The patient rated his/her pain a nine on scale of one to ten. The patient's fentanyl was supposed be changed by the family the day before but that did not occur. RN C changed the patient's fentanyl patch and gave the patient and one half of a tramadol; -On 06/11/2019 (fentanyl patch should have been changed on 06/10/2019) LPN D documents the patient had zero fentanyl patches, the patient had pain in BLE. The patient declined using any oral pain medication. The LPN called the pharmacy for a refill on the fentanyl patches. The patches were to arrive in the evening and the patient's granddaughter would put the patch on the patient; -On 06/12/2019 the pharmacy packing slip showed fentanyl 75 mcg count five patches were delivered to the patient; (Patient is actually taking 12 mcg.) -On 06/14/2019 LPN D documented that the patient had pain and the granddaughter reported the fentanyl patches arrived on 06/13/2019 and she applied a patch on the patient. LPN D failed to document fentanyl patch count, what mcg patch the patient was wearing, where the patient's fentanyl patch was placed. The patient refused to take any oral medication to help with pain; -On 06/15/2019 at 5:18 PM RN B received a call from the patient's care giver who said the patient continued to be very sleepy since her fentanyl patch (75 mcg) was replaced on 6/13/2019. The patient had been off the fentanyl patches for approximately five days before the new (75 mcg) patch was restarted. RN B asked reason the patient had been without a patch for five days and the patient's caregiver said because they had not received a refill. She said the patient's current fentanyl patch was larger than the previous fentanyl patch and the patient seemed very sleepy. SN informed the patient that the change in pharmacy (agency was using a new pharmacy) could make the fentanyl patch larger and the patient would have to readjust to the dosage since the patient had been off the fentanyl patch for five days; -On 06/15/2019 at 9:00 PM an unsigned interdisciplinary note showed the skilled nurse (SN) missed a phone call from the patient's granddaughter. The skilled nurse was on vacation but she called the granddaughter back. The granddaughter reported the patient's fentanyl patches that were actually delivered on 06/12/2019 Wednesday night, were a lot bigger in size. The granddaughter did not put the patch on 06/12/2019 because she wanted to get clarification from the agency. The granddaughter stated that on 06/13/2019 she called the agency, and got clarification and was told yes, they were the right patches and to put it on the patient. The next evening the patient was not talking right. SN advised the granddaughter to take the patch off. The SN looked through all orders and patient chart and did not find any changes in the patient's fentanyl patch dosage. Patient had been on fentanyl 12 mcg patch; - On 06/15/2019 at 9:00 PM, RN B documented that he/she received a call from patient's primary nurse RN C. RN C notified RN B that the patient was given fentanyl 75 mcg patch and should only be on a 12 mcg patch. The fentanyl 75 mcg patch was applied on 06/13/2019; -On 06/15/2019 at 9:25 PM, RN B made a home visit to see the patient. The fentanyl patch had been removed. The patient remained peaceful and resting comfortably during the observation; -On 06/16/2019 at 11:05 AM, RN B received a call from the patient's care giver who stated the patient was complaining of a lot of pain in her left foot and he/she was going to take the patient to the hospital; -On 06/16/2019 at 12:31 PM, RN B received a second call from the patient's care giver stating hospice needs to come assess the patient; -NO in person nursing note for 06/16/2019 visit after call from patient's caregiver; -On 06/17/2019 at 9:10 AM, RN C documented the patient had pain in his/her right foot and ankle. RN C was called by the patient's caregiver to come make a visit. The patient was very confused and lethargic. RN C contacted the patient's doctor and Narcan (a medication used to block opiates) was ordered. RN C administered Narcan. The patient became more alert, but confused and agitated. - From 6/17/2019 to time of death on 6/20/2019 (4 days) the patient did not have any pain medication. (Per interview with the care giver, after RN C administered Narcan to the patient, the patient would cry and yell out in pain if touched or moved). Review of the RN undated investigation notes completed by the administrator showed the following: -The agency staff entered the patient's medication into the electronic medical record (EMR) incorrectly; -The field nurses failed to complete a medication profile reconciliation; -The patient's normal field nurse (RN C) found the agency staff had entered the patient's current medication order into the EMR incorrectly but failed to notify the physician, pharmacy or any of the interdisciplinary team (IDG) team; -RN A failed to make a visit to the patient's home after family called multiple times concerned about the patient's fentanyl patches. During an interview on 06/02/2021 at 12:45 PM, RN C said the following: -She was the patient's case manager for eight months; -He/she went on vacation when the incident occurred; -On 06/15/2019 he/she called the patient's family back and discovered the patient had been given 75 mcg fentanyl patch rather than her normally ordered fentanyl 12 mcg patch; -He/she told the patient's care giver to remove the fentanyl 75 mcg patch and called the office to have a RN make a visit; -He/she seen the patient at the patient's home on 06/17/2019 and the patient would wake up and call him/her "brat" which is something that was normal for the patient to do; -The patient had pain in his/her lower extremities; -On 06/17/2019 he/she contacted the patient's doctor because the family was upset that the fentanyl patch was causing lingering side effects. The doctor ordered Narcan to be administered. He/she administered the Narcan to the patient; -The patient did not show any "major changes" after he/she administered the Narcan; -He/she believed RN B destroyed the patient's fentanyl patches as the patient did not have any fentanyl patches in the home; -The patient had Tylenol and tramadol for pain but the patient did not like to take oral medication. The patient's family did not want the patient to be on any other pain medication; -The patient was declining prior to being administered the increased dosage of fentanyl; -He/she tried to count fentanyl patches when doing visits but can't remember if counted them every time; -He/she should have reconciled all patient medications every fourteen days before IDG and if any medication changes; -The patient ran out of fentanyl 12 mcg patches when I went on vacation; -The patient should have not been without any fentanyl patches for any length of time. During an interview on 06/02/2021 at 1:30 PM, RN B said the following: -He/she was the on call nurse for the agency; -On 06/15/ 2019 he/she went to the patient's house because RN C called him/her and reported the patient was given six times the amount of fentanyl he/she was previously ordered; -The patient was small and 75 mcg of fentanyl was too big for him/her; -When he/she got to the patient's house the patient's family member had already removed the fentanyl 75 mcg patch; -He/she did complete an assessment but he/she can't find the documentation; -The old EMR would delete documentation sometimes; -The patient had already been showing signs of decline prior to this incident; -The patient did not have pin point pupils and was able to joke with him/her, the patient's oxygen level was a little low and he/she put oxygen on the patient; -I instructed the family members to only give tramadol for pain as he/she had too much opiates in his/her system; -He/she can't recall if he/she called the doctor; -He/she took the patient's four fentanyl 75 mcg patches out of the patient's home and brought them for the administrator to see and destroy; -He/she should have destroyed the fentanyl patches in the patent's home but the administrator wanted to see them; -He/she made a note and attached a picture of the fentanyl patches to the note. That note is missing from the patient's medical record. During an interview on 06/02/2021 at 3:34 PM, RN A said the following: -The patient's family member called concerned about his/her fentanyl patches looking different; -He/she did not check the EMR or make an in home visit to check on the patient; -He/she wishes he/she would have checked the EMR and made a home visit to check medication labels. During an interview on 06/02/2021 at 3:40 PM, LPN D said the following: -He/she was a float nurse for the agency; -He/she did not check patient patches and dosages when he/she made home visits; -He/she did not normally reconcile medications; -He/she seen the patient on 06/14/2019 and the patient had no major changes. During an interview on 06/03/2021 at 11:00 AM, the patient's care giver said the following: -The patient went without his/her ordered fentanyl patches because the agency was changing pharmacies and they could not get a refill; -The agency gave the patient the wrong dosage of fentanyl patch; -He/she removed the patient's fentanyl 75 mcg patch because the patient's primary nurse RN C told him/her to and the patient was having side effects from being overdosed; -After RN C administered Narcan to the patient, the patient would cry and yell out in pain if touched or moved; -He/she and the patient did not want the patient to be in pain. During an interview on 06/03/2021 at 2:00 PM the administrator said the following: -He/she never found documentation of the fentanyl medication destruction for the patient; -He/she did not remember destroying fentanyl patches for the patient; -He/she would expect his/her staff to assure the fentanyl patches and all controlled substances be destroyed at the patient's home; -He/she could not find any IDG coordination for the patient or incident; -He/she would expect the staff to contact the physician on how to manage the patient's pain after the fentanyl patch was removed. During an interview on 06/03/2021 at 3:00 PM the administrator stated that they would expect a controlled substance count to be documented on each nursing visit. During an interview on 06/03/2021 at 4:15 PM the hospice physician said the following: -He/she vaguely remembered the patient and the incident; -He/she would have ordered Narcan to reverse any side effects the increased fentanyl patch may have been having on the patient; -He/she cannot remember being notified of the medication error but obviously was notified on the date he/she ordered Narcan; -He/she did not feel the increased fentanyl dosage contributed to the patient passing away; -The fentanyl patch had been removed and the Narcan would have resolved any remaining issues the opiates may have been causing. 42078 PATIENT/RECORD #2: Review of the clinical record showed the patient was admitted on 07/12/2019 with a terminal diagnosis of chronic obstructive pulmonary disease (a type of obstructive lung disease characterized by long-term breathing problems and poor airflow). The patient resided in his/her own home with the care of his/her child who lived nearby. Review of the medication profile showed that the patient had multiple controlled substances in the home for symptom management including Ativan (an antianxiety medication), Norco (an opioid pain medication), and morphine (an opioid pain medication). The nursing visits dated 05/07/2021, 05/10/2021, 05/11/2021, 05/12/2021, 05/14/2021, 05/18/2021, 5/21/2021, and 05/28/2021 failed to contain documentation of controlled substance counts performed according to agency policy. During an interview on 06/03/2021 at 3:00 PM the administrator stated that they would expect a controlled substance count to be documented on each nursing visit. PATIENT/RECORD #4: Review of the clinical record showed the patient was admitted to hospice services on 10/28/2020 with a terminal diagnosis of chronic obstructive pulmonary disease (is a type of obstructive lung disease characterized by long-term breathing problems and poor airflow), and secondary diagnoses of chronic diastolic congestive heart failure (the heart is unable to pump sufficiently to meet the bodies tissues' needs), chronic atrial fibrillation (a rapid, irregular heart rhythm that can cause a stroke or heart failure), Alzheimer's disease (an irreversible, progressive brain disorder that slowly destroys memory and thinking skills), and insulin dependent diabetes. The patient resided in his/her own home with the care of their child. Review of the medication profile showed that the patient had one controlled substance in the home, tramadol (an opioid pain medication used to treat mild to moderate pain). The nursing visits dated 05/25/2021, 05/28/2021, and 06/01/2021 failed to contain documentation of the controlled substance counts performed according to agency policy. During an interview on 06/03/2021 at 3:00 PM the administrator stated that they would expect a controlled substance count to be documented on each nursing visit. RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to hospice services on 01/29/2019 with a terminal diagnosis of heart failure (a condition in which the heart is unable to pump sufficiently to maintain blood flow to meet the body tissues' needs for metabolism). The patient died in his/her home on 12/12/2019. Review of the medication profile showed that the patient had multiple controlled substances in the home for symptom management including hydrocodone/acetaminophen (a combination drug containing an opioid used to treat severe pain), morphine (an opioid used to treat severe pain), and lorazepam (a benzodiazepam used to treat anxiety, insomnia, and panic attacks). The nursing visits during the last month of life showed, the visits dated 12/07/2019, 12/08/2019, 12/09/2019, 12/10/2019 failed to contain documentation of controlled substance counts performed according to agency policy. During an interview on 06/03/2021 at 3:00 PM the administrator stated that they would expect a controlled substance count to be documented on each nursing visit.
L0536
L0536	34028 Based on policy review, record review, and interview, the agency failed to meet the requirements for the Condition of Participation: §418.56 Interdisciplinary group (IDG), care planning, and coordination of services when the hospice failed to ensure that the IDG maintained responsibility for directing, coordinating, and supervising the care and services provided (L554) in one of five records reviewed. The cumulative effect of this deficient practice resulted in the failure of the agency to provide care planning, coordination, and IDG oversight to meet the needs of all hospice patients.
L0554
L0554	34028 Based on agency policy, agency record review, and interview the agency failed to ensure that the interdisciplinary group maintains responsibility for directing,coordinating, and supervising the care and services provided in one (Patient/Record #1) of five records reviewed. The severity of this deficient practice has the potential to affect the care, treatment, and services of all patients served by the agency. Findings included: Review of agency policy dated 01/01/2015 and titled, "Interdisciplinary (IDT) Conferences)," showed the staff will participate in Interdisciplinary Team conferences to provide for an interdisciplinary approach to providing care for all agency patients. - All disciplines providing services to a patient will be involved interdisciplinary conferences; - Each staff member will be responsible for discussing appropriate issues/concerns with other disciplines involved in the patient's care and planning for future care and services, including patient progress, patient education, care/treatment changes, scheduling needs; - The information discussed and the adjustments in the treatment plan and/or suggestions for resolutions to the identified problem/concern areas will be documented on the appropriate forms; and - Routine IDT conferences include: * Identifying obstacles to and solutions for access of care issues; * Developing, reviewing and modifying patient/family plans of care, as appropriate, considering changes in patient's clinical status, social, cultural and physical environments that may present obstacles to effective interventions and the special needs of the patient; * Oversight of plan of care by the medical director; * Evaluating current services for their effectiveness; and * Evaluating pharmacotherapeutic effectiveness of symptom and pain management and outcomes. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice services on 03/20/2018 with a terminal diagnosis of unspecified severe protein-calorie malnutrition, weakness, pneumonia due to other specified infections and shortness of breath. Review of the nursing documentation showed that: -On 05/22/2019 the patient was taking fentanyl 12 mcg per hour to be changed every 72 hours. The pharmacy delivered 3 patches to the patient on 05/22/2019; -On 05/29/2019 the nurse practitioner documented that the patient complains of generalized pain that is not well controlled by her current patch and tramadol. The patient appears uncomfortable; -On 06/07/2019 RN C documented the patient had zero fentanyl patches left, refill ordered. The patient rated his/her pain a nine on scale of one to ten. The patient's fentanyl was supposed be changed by the family the day before but that did not occur. RN C changed the patient's fentanyl patch and gave the patient and one half of a tramadol; -On 06/11/2019 (fentanyl patch should have been changed on 06/10/2019) LPN D documents the patient had zero fentanyl patches, the patient had pain in BLE. The patient declined using any oral pain medication. The LPN called the pharmacy for a refill on the fentanyl patches. The patches were to arrive in the evening and the patient's granddaughter would put the patch on the patient; -On 06/12/2019 the pharmacy packing slip showed fentanyl 75 mcg count five patches were delivered to the patient; (Patient is actually taking 12 mcg.) -On 06/14/2019 LPN D documented that the patient had pain and the granddaughter reported the fentanyl patches arrived on 06/13/2019 and she applied a patch on the patient. LPN D failed to document fentanyl patch count, what mcg patch the patient was wearing, where the patient's fentanyl patch was placed. The patient refused to take any oral medication to help with pain; -On 06/15/2019 at 5:18 PM RN B received a call from the patient's care giver who said the patient continued to be very sleepy since her fentanyl patch (75 mcg) was replaced on 6/13/2019. The patient had been off the fentanyl patches for approximately five days before the new (75 mcg) patch was restarted. RN B asked reason the patient had been without a patch for five days and the patient's caregiver said because they had not received a refill. She said the patient's current fentanyl patch was larger than the previous fentanyl patch and the patient seemed very sleepy. SN informed the patient that the change in pharmacy (agency was using a new pharmacy) could make the fentanyl patch larger and the patient would have to readjust to the dosage since the patient had been off the fentanyl patch for five days; -On 06/15/2019 at 9:00 PM an unsigned interdisciplinary note showed the skilled nurse (SN) missed a phone call from the patient's granddaughter. The skilled nurse was on vacation but she called the granddaughter back. The granddaughter reported the patient's fentanyl patches that were actually delivered on 06/12/2019 Wednesday night, were a lot bigger in size. The granddaughter did not put the patch on 06/12/2019 because she wanted to get clarification from the agency. The granddaughter stated that on 06/13/2019 she called the agency, and got clarification and was told yes, they were the right patches and to put it on the patient. The next evening the patient was not talking right. SN advised the granddaughter to take the patch off. The SN looked through all orders and patient chart and did not find any changes in the the patient's fentanyl patch dosage. Patient had been on Fentanyl 12 mcg patch; - On 06/15/2019 at 9:00 PM, RN B documented that he/she received a call from patient's primary nurse RN C. RN C notified RN B that the patient was given fentanyl 75 mcg patch and should only be on a 12 mcg patch. The Fentanyl 75 mcg patch was applied on 06/13/2019; -On 06/15/2019 at 9:25 PM, RN B made a home visit to see the patient. The fentanyl patch had been removed. The patient remained peaceful and resting comfortably during the observation; -On 06/16/2019 at 11:05 AM, RN B received a call from the patient's care giver who stated the patient was complaining of a lot of pain in her left foot and he/she was going to take the patient to the hospital; -On 06/16/2019 at 12:31 PM, RN B received a second call from the patient's care giver stating hospice needs to come assess the patient; -NO in person nursing note for 06/16/2019 visit after call from patient's caregiver; -On 06/17/2019 at 9:10 AM, RN C documented the patient had pain in his/her right foot and ankle. RN C was called by the the patient's caregiver to come make a visit. The patient was very confused and lethargic. RN C contacted the patient's doctor and Narcan (a medication used to block opiates) was ordered. RN C administered Narcan. The patient became more alert, but confused and agitated. - From 6/17/2019 to time of death on 6/20/2019 (4 days) the patient did not have any pain medication. (Per interview with the care giver, after RN C administered Narcan to the patient, the patient would cry and yell out in pain if touched or moved). Review of the RN undated investigation notes completed by the administrator showed the following: -The agency staff entered the patient's medication into the electronic medical record (EMR) incorrectly; -The field nurses failed to complete a medication profile reconciliation; -The patient's normal field nurse (RN C) found the agency staff had entered the patient's current medication order into the EMR incorrectly but failed to notify the physician, pharmacy or any of the interdisciplinary team (IDG) team; -RN A failed to make a visit to the patient's home after family called multiple times concerned about the patient's fentanyl patches. Review of the patient's medical record showed there was no documentation that IDG met or discussed any of the above information. During an interview on 06/02/2021 at 12:45 PM, RN C said the following: -She was the patient's case manager for eight months; -He/she went on vacation when the incident occurred; -On 06/15/2019 he/she called the patient's family back and discovered the patient had been given 75 mcg fentanyl patch rather than her normally ordered fentanyl 12 mcg patch; -He/she told the patient's care giver to remove the fentanyl 75 mcg patch and called the office to have a RN make a visit; -He/she seen the patient at the patient's home on 06/17/2019 and the patient would wake up and call him/her "brat" which is something that was normal for the patient to do; -The patient had pain in his/her lower extremities; -On 06/17/2019 he/she contacted the patient's doctor because the family was upset that the fentanyl patch was causing lingering side affects. The doctor ordered Narcan to be administered. He/she administered the Narcan to the patient; -The patient did not show any "major changes" after he/she administered the Narcan; -He/she believed RN B destroyed the patient's fentanyl patches as the patient did not have any fentanyl patches in the home; -The patient had Tylenol and tramadol for pain but the patient did not like to take oral medication. The patient's family did not want the patient to be on any other pain medication; -The patient was declining prior to being administered the increased dosage of fentanyl; -He/she tried to count fentanyl patches when doing visits but can't remember if counted them every time; -He/she should have reconciled all patient medications every fourteen days before IDG and if any medication changes; -The patient ran out of fentanyl 12 mcg patches when I went on vacation; -The patient should have not been without any fentanyl patches for any length of time. During an interview on 06/02/2021 at 1:30 PM, RN B said the following: -He/she was the on call nurse for the agency; -On 06/15/ 2019 he/she went to the patient's house because RN C called him/her and reported the patient was given six times the amount of fentanyl he/she was previously ordered; -The patient was small and 75 mcg of fentanyl was too big for him/her; -When he/she got to the patient's house the patient's family member had already removed the fentanyl 75 mcg patch; -He/she did complete an assessment but he/she can't find the documentation; -The old EMR would delete documentation sometimes; -The patient had already been showing signs of decline prior to this incident; -The patient did not have pin point pupils and was able to joke with him/her, the patient's oxygen level was a little low and he/she put oxygen on the patient; -I instructed the family members to only give tramadol for pain as he/she had too much opiates in his/her system; -He/she can't recall if he/she called the doctor; -He/she took the patient's four fentanyl 75 mcg patches out of the patient's home and brought them for the administrator to see and destroy; -He/she should have destroyed the fentanyl patches in the patent's home but the administrator wanted to see them; -He/she made a note and attached a picture of the fentanyl patches to the note. That note is missing form the patient's medical record. During an interview on 06/02/2021 at 3:34 PM, RN A said the following: -The patient's family member called concerned about his/her fentanyl patches looking different; -He/she did not check the EMR or make an in home visit to check on the patient; -He/she wishes he/she would have checked the EMR and made a home visit to check medication labels. During an interview on 06/02/2021 at 3:40 PM, LPN D said the following: -He/she was a float nurse for the agency; -He/she did not check patient patches and dosages when he/she made home visits; -He/she did not normally reconcile medications; -He/she seen the patient on 06/14/2019 and the patient had no major changes. During an interview on 06/03/2021 at 11:00 AM, the patient's care giver said the following: -The patient went without his/her ordered fentanyl patches because the agency was changing pharmacies and they could not get a refill; -The agency gave the patient the wrong dosage of fentanyl patch; -He/she removed the patient's fentanyl 75 mcg patch because the patient's primary nurse RN C told him/her to and the patient was having side effects from being overdosed; -After RN C administered Narcan to the patient, the patient would cry and yell out in pain if touched or moved; -He/she and the patient did not want the patient to be in pain. During an interview on 06/03/2021 at 2:00 PM the administrator said the following: -He/she never found documentation of the fentanyl medication destruction for the patient; -He/she did not remember destroying fentanyl patches for the patient; -He/she would expect his/her staff to assure the fentanyl patches and all controlled substances be destroyed at the patient's home; -He/she could not find any IDG coordination for the patient or incident; -He/she would expect the staff to contact the physician on how to manage the patient's pain after the fentanyl patch was removed. During an interview on 06/03/2021 at 2:00 PM the administrator said the following: -He/she could not find any IDG coordination for the patient or incident; -He/she would expect the staff to contact the physician on how to manage the patient's pain after the fentanyl patch was removed.
L0694
L0694	34028 Based on policy review, record review and interview, the agency failed to ensure disposal of controlled substance medications in the patient's home followed the agency written policies and procedures in one (Record/Patient #1) of five patient records reviewed. This deficient practice has the potential to allow miss-use of controlled substance medications when no longer needed by a hospice patient. Findings included: Review of agency policy dated 01/1/2015 and titled, "Medication - Controlled Substance/Drug Safety and Disposal," showed the following: -It is the ethical responsibility to inform and assist the patient or the patient's family of their responsibility in safely storing of all drugs and the disposing of unused drugs including controlled substances/drugs. In the event that medications discrepancies exist with controlled substances, the agency Interdisciplinary Team (IDT) or nurse may facilitate a change in the patient's medication management system to a cautionary method, which may involve, counts of controlled substances on hand each visit to maintain closer regulation; -A agency staff member may not physically participate in the disposal of the controlled substances/drugs unless specially allowed by state law; -If the agency staff member, other than a hospice aide witnesses the disposal of the controlled drugs/substances, the disposal will be documented in the clinical record and will include prescription number, substance/drug name, strength, quality, method of disposal, name of person disposing of the substance/drug, and name of additional witnesses. RECORD/PATIENT #1: The hospice registered nurse (RN)-B made a visit at the time of death of the patient. On 06/20/2019 RN-B documented medication disposal at the time of death included all medications and witnessed by the patient's adult child. RN B failed to document disposal of fentanyl (a narcotic prescription medication to treat sever pain) patches. During an interview on 06/02/2021 RN B said the following:-On 06/15/2019 he/she was called out to the patient's house because the patient had been given incorrect dose of fentanyl patches; -The patient was supposed to have fentanyl 12 micrograms (mcg) patch but was given fentanyl 75 mcg patch and was having side effects from the increased dosage of fentanyl; -The patient's family member had taken the fentanyl patch off of the patient and had four patches left; -He/she took the four patches from the patient's house and brought then to the administrator; -He/she would normally destroy narcotics in the house but the administrator wanted to see them; -He/she could not find the note that showed this transaction. Review of the pharmacy delivery and dispense record for the patient's fentanyl patches showed five patches were delivered to the patient's residents on 06/12/2021. During an interview on 06/03/2021 at 2:00 PM, the administrator said the following: -He/she never found documentation of destruction of the patient's fentanyl patches; -He/she did not recall RN B bringing the fentanyl patches back to the agency or destroying the patches; -He/she expected staff to destroy narcotic medication at the patient's home or have family destroy the medication; -He/she expected staff to document destruction of narcotic medication in the electronic medical record.