Survey Report for 261679

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	261679	A. BUILDING __________ B. WING ______________	01/06/2021
NAME OF PROVIDER OR SUPPLIER	STREET ADDRESS, CITY, STATE, ZIP
SOLACE HOSPICE CARE, LLC	14010 MANCHESTER ROAD, MANCHESTER, MO, 63011
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)
L0517
L0517	38507 Based on policy review, review of RN-A's written statement, record review, medication dispensing record review, and interview, the agency failed to ensure the rights of the patient were protected when the patient's right to be free of misappropriation of property was violated. The patient's narcotic medication was found to be misappropriated in one (Record/Patient #1) out of two records reviewed. This deficient practice has the potential to affect the protection of patient rights in all the agency's patients. Findings included: Review of the agency's policy titled, "PAT.06 Patient Rights and Responsibilities," dated 2016, showed, in part, the following: - The hospice protects and promotes the rights of each individual under it's care; and - The hospice respects the patient's rights and notifies the patient of their rights and responsibilities. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice on 09/24/2020 with a terminal diagnosis of breast cancer with metastasis to the lung and liver (spreading cancer). The patient lived in his/her adult child's home. He/she was cared for by the daughter and granddaughter. The patient required assistance with ambulation and personal care. At times, the patient had complaints of pain in the abdomen, chest, and back. During the course of the complaint survey, it was found that RN-A (registered nurse A), patient #1's case manager, had picked up all the patient's medications from the pharmacy except one time. The patient's daughter/caregiver was interviewed and stated that the morphine IR and liquid concentrate were only delivered one time at the start of care, 09/24/2020, and they were delivered by the pharmacy. RN-A then delivered all the medications after that to the home except the morphine (strong, narcotic pain medication) IR (immediate release), ER (extended release), and liquid concentrate. (The morphine IR that was in the home delivered by the pharmacy at the start of care, came up missing later in the episode.) RN-A was the only nurse to make nurse visits to the home except one as needed visit by another RN. The hospice aide also made visits for bathing. The hospice aide is not involved with medications. Review of the initial comprehensive assessment showed: - A skilled nurse initial assessment dated 09/24/2020 was completed by RN-A. (The clinical director verified that RN-A did the actual visit and verified from the EMR (electronic medical record) that RN-D, the admission nurse, audited the note and signed it as completed. The clinical director thought that was all right); - The documentation showed the patient had a current pain level of 2 out of a scale of 0-10 (0 being no pain, and 10 being the worst pain imaginable) and worst pain of 8. The location of the pain was the "mid-upper gastric pain/abdominal pain/left chest/back pain". The pain description was aching, gnawing, radiating, sharp, shooting, sore, and weakness. Frequency was intermittent. Breakthrough pain medication in the last 24 hours was given three to four times. The medication that controlled the pain was not documented; - The visit summary on the 09/24/2020 assessment showed that the patient's pain was well controlled with morphine IR (a fast acting strong, narcotic pain medication) every four hours as needed at this time; - The patient did not have morphine IR in the home at the time of the visit. The medication was delivered that evening by the pharmacy. So, the patient would not have been able to use it until the evening of 09/24/2020; and - RN-A's documentation was inconsistent with the facts. During an interview on 12/31/2020 at 2:40 PM, RN-A stated that: - He/she completed the skilled nurse initial assessment on 09/24/2020; -Tramadol (mild pain reliever) was in the home (not documented in the visit note or on physician orders); - Morphine IR 15 mg was given to the patient during the visit to help his/her pain; - (Read him/her the chart narrative that showed the patient's pain was controlled on the current regimen and did not show that a dose was given.) - RN-A then retracted the earlier statement that she gave the medication and stated, "I got in a hurry and charted wrong. I guess I didn't give it to him/her. It wasn't there yet." - Later in the interview RN-A stated that the reason he/she took over delivery of the patient's medications was because the first delivery from the pharmacy came in the evening of 09/24/2020 and the daughter did not want it delivered in the evening; -RN-A could not have given the patient the medication or known the morphine IR was controlling the pain because the morphine was a new medication for the patient; and was not available yet. Review of the printed dispensing record for patient #1 from PH-A (pharmacy A) showed morphine dispensed 09/24/2020 through 12/14/2020 the following number of times and total quantities for each type of morphine: - Morphine SO4 20 milligrams (MG) per milliner (ML) three times for a total of 90 mls; - Morphine SO4 IR 15 mg tablets four times for a total of 165 tablets; - Morphine SO4 IR 30 mg tablets eight times for a total of 460 tablets; and - Morphine SO4 ER 15 mg tablets one time for a total of 15 tablets. During an interview with the daughter/caregiver on 01/05/2021 at 9:54 AM, she stated that: - The patient left the hospital on 09/22/2020 and first went to his/her own home and stayed with a son; - The patient had his/her lungs drained at the hospital and was at first in pain but by the time she arrived at daughter's house on 09/24/2020, the patient denied pain and was not taking anything for the pain; - He/she was unsure if the Tramadol was filled or not since the patient went to the son's house first; - When the patient came to her home on 09/24/2020, he/she was up walking around and feeling better; - The only time morphine IR and morphine liquid was delivered to the home was when the pharmacy brought it on 09/24/2020; - RN-A said he/she would deliver the medications after that because the pharmacy delivered them 09/24/2020 late in the evening; - She preferred to have them delivered during the day and RN-A indicated this was the preferred way to get the medication; - When RN-A brought the medications, they were never in a pharmacy bag; - The medications she brought were the patient's routine medications, not medications for pain; and - RN-A told her that he/she would do the pill box, ordering, and handling of all medications. (The patient's other daughter was on the three-way call and corroborated all that her sister stated.) During an interview on 12/30/2020 at 9:55 AM, the administrator stated that: - On 12/14/2020, the agency received a call from the patient's family questioning the medications received from PH-A; - A medication dispensing record was obtained from PH-A for the agency and the family; - After the family reviewed the medication dispensing record they informed the agency that they had only received the first delivery of morphine from the pharmacy and none since 09/24/2020; - The patient has only received two doses of morphine during the episode and is resistant to taking pain medications; and - The patient controls pain with Tylenol and gabapentin (medication used to control nerve pain). RN-A is likely the person responsible for the missing narcotics due to: - Interviews with reliable sources showing the patient's pain level and use of narcotics varies greatly from RN-A's documentation; and - The many inconsistencies in RN-A's interview, written statement, and clinical record documentation.
L0536
L0536	38507 Based on policy review, review of pharmacy prescription dispensing record, RN-A's written statement 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 the IDG designated registered nurse was providing coordination of care and continuous assessment of the patient/family (L540) - Ensure there was an individualized written plan of care for each patient (L545) - Ensure that the IDG maintained responsibility for directing, coordinating, and supervising the care and services provided (L554) The cumulative effect of these systemic practices resulted in the inability of the hospice to provide effective care planning and IDG oversight to meet the needs of all hospice patients.
L0540
L0540	38507 Based on record review, registered nurse job description review, and interviews, the agency failed to ensure the designated registered nurse (RN) provided coordination of care and accurate continuous assessments when the RN reported false information about the patient's pain and narcotic pain medication use, in one (Record/Patient #1) of two records reviewed. This deficient practice has the potential to adversely affect the safe and appropriate care of all the agency's patients. Findings included: Review of the registered nurse job description dated 2006, showed, in part, the following. The RN: - Uses the case management approach and acts as the coordinator of the interdisciplinary team (IDT) in order to maintain the proper linkages with a continuum of care; and - Informs the attending physician, medical director, and other personnel of changes in the patient's needs and outcomes of interventions. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice on 09/24/2020 with a terminal diagnosis of breast cancer with metastasis to the lung and liver (spreading cancer). The patient lived in his/her adult child's home. He/she was cared for by the daughter and granddaughter. The patient required assistance with ambulation and personal care. At times, the patient had complaints of pain in the abdomen, chest, and back. Review of the initial comprehensive assessment dated 09/24/2020 completed by RN-A showed: - The patient had a current pain level of 2 out of a scale of 0-10 (0 being no pain, and 10 being the worst pain imaginable) and worst pain of 8. The location of the pain was the "mid-upper gastric pain/abdominal pain/left chest/back pain". The pain description was aching, gnawing, radiating, sharp, shooting, sore, and weakness. Frequency was intermittent. Breakthrough pain medication in the last 24 hours was given three to four times. The medication that controlled the pain was not documented; and - The visit summary on the 09/24/2020 assessment showed that the patient's pain was well controlled with morphine IR (a fast acting strong, narcotic pain medication) every four hours as needed at this time. (Note: The morphine had not yet been delivered to the patient's home until the evening of 09/24/2020 by the pharmacy.) Review of the interdisciplinary team (IDT) meeting notes showed the following: - On 09/30/2020, the physical status of the patient reported by RN-A, showed the patient pain was well controlled with morphine IR 15 mg every four hours as needed at this time (Per interview, the patient's daughter stated that the patient was not having a problem with pain during this time.) - On 10/14/2020, the physical status of the patient showed the patient had been complaining of increased abdominal pain that radiates to her back and worsens with coughing/deep breaths. The physician was called and updated and new orders were received for morphine contin (extended release morphine that is used on a regular daily basis for control of chronic pain). The IDT note goes on to say that the patient is tolerating the medication well and symptom relief noted at this time; and - On 10/28/2020, the RN reported that the physician was updated and a new order for morphine immediate release 30 mg orally every fours as needed received and resulted in significantly improved pain and cough. (There was no mention of the morphine extended release in the IDT notes or nursing assessment notes after the 10/14/2020 IDT note but the patient medication sheet showed it was discontinued on 10/14/2020 and it was only dispensed one time from the pharmacy.) Review of RN-A's written statement dated 01/05/2021 regarding the care of Patient #1, showed in part, the following: - "During my time with the patient, multiple reports of increased/continued pain and coughing/dyspnea were made by family/patient/and hospice aide to me, which I also assessed during my nursing visits at times as well"; and -"When these reports were made, I notified the physician and new medication orders/changes were received, ordered from the pharmacy, and delivered to the home by myself...." During an interview with the daughter/caregiver on 01/05/2021 at 9:54 AM, she stated that: - The patient left the hospital on 09/22/2020 and first went to his/her own home and stayed with a son; - The patient had his/her lungs drained at the hospital and was at first in pain but by the time she arrived at the daughter's house on 09/24/2020, the patient denied pain and was not taking anything for pain; - The patient may have had Tramadol at the son's house but did not have any pain medication when he/she came to daughter's house; - When the patient came to her home on 09/24/2020, he/she was up walking around and feeling better; - No morphine was received in the home during the episode of care except for the first delivery by the pharmacy on 09/24/2020; and - After a bad reaction to the morphine IR given one time by the daughter on 10/31/2020 and morphine liquid given one time by the as needed nurse on 11/08/2020, the daughter stated, "We will never give him/her morphine again!" (The patient's other daughter was on the three-way call and corroborated all that her sister stated.) During an interview on 01/04/2021 at 3:40 PM, hospice aide A (HA-A) stated that: - The patient would sometimes mention he/she was in a little pain; - He/she never saw the family give the patient pain medication; and - The family would sometimes decline an aide visit as the patient "was not feeling well" but the family was not specific what was wrong with the patient. Review of RN-A's assessments and written statement compared to the daughter's interview and the hospice aide interview, showed inconsistencies in the patient's pain level and use of pain medication. RN-A, designated as the registered nurse member of the IDT, failed to give accurate assessments of the patient's needs to the IDT.
L0545
L0545	38507 Based on policy review, clinical record review, and interviews, the agency failed to ensure the interdisciplinary group (IDG) developed an individualized written plan of care for each patient that reflected interventions needed for the palliation and management of the terminal illness and related conditions in two (Records/Patients #1 and #2) of two patient records reviewed. This deficient practice has the potential to adversely affect the care and services provided to all the agency's patients. Findings included: Review of the agency's policy titled, "COC63 Plan of Care," dated 2016, showed, in part, the following: - It is the policy of hospice that a written individualized interdisciplinary team care plan be established and maintained for each individual admitted to hospice and the care provided to the individual will be in accordance with the plan of care; - The plan of care will include all services necessary for palliation and management of the terminal illness and related conditions; and - The plan of care will include orders for specific hospice services and disciplines, treatments, procedures and interventions to manage pain and symptoms. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice on 09/24/2020 with a terminal diagnosis of breast cancer with metastasis to the lung and liver (spreading cancer). The patient lived in his/her adult child's home. He/she was cared for by the daughter and granddaughter. The patient required assistance with ambulation and personal care. At times, the patient had complaints of pain in the abdomen, chest, and back. Review of the IDG meeting notes and care plans dated 09/30/2020, 10/14/2020,10/28/2020, 11/11/2020, 11/25/2020, and 12/09/2020 showed the visit frequency remained two times per week for 12 weeks through out the episode of care. Review of the skilled nurse visit notes from 09/24/2020 through 12/12/2020 completed by registered nurse A (RN-A) and one visit made by the as needed nurse showed the following: - Two weeks had two visits and both of those were due to an extra as needed visit being done; - Seven weeks had one visit documented per week; and - Two weeks had no visit documented. - The week of 10/18/2020 showed no documentation for why there was no visit and the week of 12/06/2020 showed missed visit communication notes showing that the visits were declined; and, - The IDG failed to ensure the care provided to the individual was in accordance with the plan of care and included all services necessary for palliation and management of the patient. During an interview on 01/05/2021 at 9:54 AM, the patient's daughter stated that: - RN-A only made a visit to the patient one time per week, usually on Wednesday; - He/she never came on a scheduled visit two times a week; and - "I was surprised to see a nurse come two times a week after RN-A quit coming. I didn't know RN-A was supposed to come two times." RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice on 11/06/2020 with a terminal diagnosis of lung cancer with metastasis to the spine and brain (spreading cancer). The patient lived in his/her home. He/she was cared for by the family. The patient required assistance with all activities of daily living and was bedbound. Review of the clinical record showed: - A physician order dated 11/09/2020 to cleanse the wound with wound cleanser and apply foam dressing to the wound as needed. The order failed to specify what wound this was referring to: and - The care plan from the IDT meeting dated 11/11/2020 failed to show specific wound care interventions that included the above order. Review of the interdisciplinary team (IDG) notes which include the care plans, showed the following: - 11/25/2020-The skilled nurse summary showed that a pressure ulcer (breakdown of the skin that is caused from pressure on an underlying bony process) was forming on the left outer knee. On 11/27/2020, the care plan was updated under skin integrity to include: Assess need for adaptive devices for mitigation of skin breakdown including inflation devices, gel, wraps, etc as ordered and instruct patient/family/caregiver in skin care and signs and symptoms of breakdown; - The care plan failed to show individualized treatments or devices used for the left outer knee wound; - 12/09/2020- The skilled nurse summary showed pressure ulcer outer knee measurement 2 cm by 2 cm (centimeter), closed and pink covered by Alleyvn (foam dressing). Left lower extremity has 5 cm by 3 cm stasis ulcer (a breakdown of the skin (ulcer) caused by fluid build-up in the skin from poor vein function) purple and closed. Covered with Alleyvn. Right outer lower extremity stasis wound 3.25 cm by 3 cm closed and purple, covered with Alleyvn; - Review of the care plan included with the 12/09/2020 IDG notes failed to show an update with the new wounds assessed and Alleyvn for treatment; - 12/23/2020- The skilled nurse summary showed left leg wound measures 5 cm by 3 cm, skin no longer intact and necrosis (dead tissue) present in a 2 cm by 4 cm area, right leg 6 cm by 4 cm stasis ulcer with 3 cm by 2 cm necrotic area with odor and left foot with one plus edema (swelling); and - Review of the care plan included with the 12/23/2020 IDG notes failed to show an individualized treatment plan for the wounds or ordered wound care. Review of the skilled nursing assessment notes dated 12/21/2020 showed that the wounds are worsening and becoming necrotic. The wounds were dressed by the registered nurse (RN). Wounds were cleaned with soap and water, medihoney (a medical grade honey gel for wound treatment) applied and covered with Alleyvn. The record failed to show a physician order for the new wound dressing and the IDG note and care plan failed to show an update for the new treatment. During an interview on 01/06/2021 at 2:25 PM, the administrator stated that; - The patient had wounds from the beginning of care and the RN should have been documenting from the beginning; - The care plans should have included wound care since the start of care; - The patient had chronic wounds on legs and the patient left them covered all the time; - He/she looked at the patient's electronic medical record (EMR) and there were no new physician orders after mid-November 2020 and there was no order for the medihoney dressing; - The agency was told by a consultant that the care plans were not individualized enough; and - The EMR only allows use of the preprogrammed assessments and interventions and they cannot type freehand information on the care plans.
L0554
L0554	38507 Based on policy review, record review, review of the pharmacy dispensing record, and interviews, the agency failed to ensure that the interdisciplinary group (IDG) maintained responsibility for direction, coordinating, and supervising the care and services provided when the registered nurse documented false reports of increasing pain which resulted in numerous pharmacy refills of narcotics over an eleven week period of care in one (Record/Patient #1) out of two records reviewed. This deficient practice has the potential to adversely affect the integrity of care to all the agency's patients. Findings included: Review of the agency's policy title, "COC.44 Interdisciplinary (IDT) Conferences," dated 2016, showed, in part, the following. IDT conferences include: - Evaluating current services for their effectiveness; - Evaluating pharmacotherapeutic effectiveness of symptom and pain management and outcomes; - Oversight of the plan of care by the medical director; and - The information discussed and the adjustments in the treatment plan and/or suggestions for resolution to the identified problem/concern areas will be documented on the appropriate forms, including the team conference form. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice on 09/24/2020 with a terminal diagnosis of breast cancer with metastasis to the lung and liver (spreading cancer). The patient lived in his/her adult child's home. He/she was cared for by the daughter and granddaughter. The patient required assistance with ambulation and personal care. At times, the patient had complaints of pain in the abdomen, chest, and back. Review of the interdisciplinary team (IDT) meeting notes showed the following: - On 09/30/2020, the physical status of the patient reported by RN-A, showed the patient pain well controlled with morphine IR 15 mg every four hours as needed at this time (Per interview, the patient's daughter stated that the patient was not having a problem with pain during this time.) The physician note showed a concise history of the patient's cancer and that the patient was recently hospitalized with severe dyspnea with left sided pleural effusion on 09/16/2020 and underwent a thoracentesis. The patient's breast cancer apparently metastasized to liver and lung. The physician note failed to address the patients current pain status or treatment. The note failed to show documentation of IDT discussion; - On 10/14/2020, the physical status reported by RN-A showed the patient had been complaining of increased abdominal pain that radiates to her back and worsens with coughing/deep breaths. The physician was called and updated and new orders were received for morphine contin (extended release morphine that is used on a regular daily basis for control of chronic pain). The IDT note goes on to say that the patient is tolerating the medication well and symptom relief noted at this time. There failed to be physician or IDT discussion documented; - On 10/28/2020, the RN reported that the physician was updated and a new order for morphine immediate release 30 mg orally every four hours as needed received and resulted in significantly improved pain and cough. (There was no mention of the morphine extended release in the IDT notes or assessments but the patient medication sheet showed it was discontinued on 10/14/2020 and it was only dispensed one time from the pharmacy.) There failed to be physician or IDT discussion documented; - On 12/09/2020, the physician documentation showed the same note documented as the 09/30/2020 IDT note and added "the patient with peripheral edema to bilateral thighs most likely c/w lymphedema." There failed to be physician documentation of the patient's pain level or current treatment. On this date, the patient had been on morphine sulfate IR 30 mg (milligrams) one to two tablets every four hours as needed. From 11/02/2020 to 12/02/2020 it had been refilled five times (about one time per week) for a total of 300 tablets (verified by pharmacy dispensing record); - The morphine IR 30 mg given to the patient would have averaged about 10 tablets per day or 300 mg (milligrams); and - None of the IDT notes for this patient showed a discussion of the patient's pain and current pain regimen, any suggestions for a change of medication, or a change in the treatment for the on-going and worsening pain described by RN-A. During an interview on 01/06/2021 at 9:15 AM, the clinical director stated that: - During IDT meetings the patient's pain was discussed and RN-A said the current regimen was good; - RN-A "was telling us in IDT that the patient was in that much pain and needed all that pain medication"; and - Discussions were not documented in the patient record during IDT due to problems with virtual meetings and a glitch in the software that causes disconnections.
L0664
L0664	38507 Based on policy review, review of pharmacy prescription dispensing record, record review, and interview, the agency failed to meet the requirements for the Condition of Participation: §418.102 Medical Director, when the hospice failed to ensure the medical director provided responsible care for the medical component of the hospice's patient care program. (L669) Due to the serious nature of this citation, the standard level deficiency was deemed justifiable to raise this citation to a condition level. The cumulative effect of this systemic practice resulted in the hospice failing to provide sufficient medical oversight to meet the needs of all hospice patients.
L0669
L0669	38507 Based on policy review, record review, review of pharmacy dispensing record, and interviews, the agency failed to ensure the medical director maintained responsibility for the medical component of the hospice patient's care in one (Record/Patient #1) of two records reviewed. This deficient practice has the potential to adversely affect the medical care of all the agency's patients. Review of the agency's policy titled, "MED.05 Physician Services," dated 02/21/19, showed, in part, the hospice medical director and physician employees in conjunction with patient's attending physician, are responsible for the palliation and management of the terminal illness and conditions related to the terminal illness. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice on 09/24/2020 with a terminal diagnosis of breast cancer with metastasis to the lung and liver (spreading cancer). The patient lived in his/her adult child's home. He/she was cared for by the daughter and granddaughter. The patient required assistance with ambulation and personal care. At times, the patient had complaints of pain in the abdomen, chest, and back. Review of the interdisciplinary team (IDT) meeting notes showed the following: - On 09/30/2020, the physical status of the patient reported by RN-A, showed the patient pain well controlled with morphine IR 15 mg every four hours as needed at this time (The patient's daughter stated that the patient was not having a problem with pain during this time.) The physician note showed a concise history of the patient's cancer and that the patient was recently hospitalized with severe dyspnea with left sided pleural effusion on 09/16/2020 and underwent a thoracentesis. The patient's breast cancer apparently metastasized to liver and lung. The physician note failed to address the patients current pain status or treatment. The note failed to show documentation of IDT discussion; - On 10/14/2020, the physical status of the patient showed the patient had been complaining of increased abdominal pain that radiates to her back and worsens with coughing/deep breaths. The physician was called and updated and new orders were received for morphine contin (extended release morphine that is used on a regular daily basis for control of chronic pain). The IDT note goes on to say that the patient is tolerating the medication well and symptom relief noted at this time. There failed to be physician or IDT discussion documented; - On 10/28/2020, the RN reported that the physician was updated and a new order for morphine immediate release 30 mg orally every fours as needed received and resulted in significantly improved pain and cough. (There was no mention of the morphine extended release in the IDT notes or assessments but the patient medication sheet showed it was discontinued on 10/14/2020 and it was only dispensed one time from the pharmacy.) There failed to be physician or IDT discussion documented; - On 12/09/2020, the physician documentation showed the same note as 09/30/2020 IDT note and added the patient with peripheral edema to bilateral thighs most likely c/w lymphedema. There failed to be physician documentation of the patient's pain level or current treatment. On this date, the patient had been on morphine sulfate IR 30 mg (milligrams) one to two tablets every four hours as needed since 11/04/2020 . From 11/02/2020 to 12/02/2020 it had been refilled five times (about one time per week) for a total of 300 tablets (see pharmacy dispensing record); - The morphine IR 30 mg given to the patient would have averaged about 10 tablets per day or 300 mg (milligrams); and - None of the IDT notes for this patient showed a discussion of the patient's pain and current pain regimen, any suggestions for a change of medication, or a change in the treatment for the on-going and worsening pain described by RN-A. During an interview on 12/31/2020 at 2:20 PM, the clinical director stated that: - The oncologist is no longer following the patient since he/she was on hospice; and - The medical director is the patient's primary care physician now. During an interview on 01/04/2021 at 2:15 PM, the medical director stated that: - He/she was the primary physician for the patient; - During the interview, the medical director read his/her note from the IDT meeting dated 09/30/2020. He/she then stated that the patient "definitely had a reason to take a pain medication." Referring to the patient's diagnosis; - He/she was unable to remember the patient; - He/she had not met the patient and does not do home visits. The nurse practitioner does the home visits; - He/she is on call 24 hours per day/7 days a week and receives calls from the hospice staff numerous times per day and cannot recall specific conversations about this patient; and - Does not document the calls. "I think the nurses document these calls." During an interview on 01/06/2021 at 9:15 AM, the clinical director stated that: - During IDT meetings the patient's pain was discussed and RN-A said the current regimen was good; - RN-A "was telling us in IDT that the patient was in that much pain and needed all that pain medication"; and - Discussions were not documented in the patient record during IDT due to problems with virtual meetings and a glitch in the software that causes disconnections.
L0798
L0798	38507 Based on policy review, Missouri State regulation review, record review, and interviews, the agency failed to comply with all applicable State laws and regulations when the agency failed to follow the State of Missouri regulation: 19 CSR 30-35.010 2.H.5 Hospice Program Operations-Medications in one (Record/Patient #1) out of two records reviewed. This deficient practice has the potential to adversely affect medication safety for all the agency's patients. Findings included: Review of the agency's policy titled, "COC.58 Medication-Guidelines for Possession of Drugs," dated 2016, showed, in part, the following: -Documentation of each medication transported by a nurse will be made in the patient's medical record; - A separate log will be kept recording the drugs transported to patients; and - The log will maintained by individual nurses and will be submitted weekly. Review of the agency's policy titled, "COC.56 Medication Delivery," dated 2016, showed when medications are delivered to the patient's residence by hospice staff, the date, patient name, medication name and strength, quantity indicated on the prescription container, and signatures of the hospice staff member and the receiver shall be documented. Review of the Missouri State Regulation 19 CSR 30-35.010 2.H.5 Hospice Program Operations-Medications showed when controlled substance medications are delivered to the patient's residence by hospice staff, the date, patient name, medication name and strength, quantity indicated on the prescription container, and signatures of the hospice staff member and the receiver shall be documented. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice on 09/24/2020 with a terminal diagnosis of breast cancer with metastasis to the lung and liver (spreading cancer). The patient lived in his/her adult child's home. He/she was cared for by the daughter and granddaughter. The patient required assistance with ambulation and personal care. At times, the patient had complaints of pain in the abdomen, chest, and back. Review of the patient's clinical record failed to show documentation of drug delivery to the patient's home. During an interview on 01/06/2021 at 9:45 AM, the administrator stated that: - The staff always got signatures at the pharmacy when they picked medication up but not at the home; and - The agency was aware it was in their policy to get a signature at the patient's home but thought it was good enough that nurses documented they dropped off the medications and had a pharmacy signature.