Survey Report for 331515

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	331515	A. BUILDING __________ B. WING ______________	10/21/2021
NAME OF PROVIDER OR SUPPLIER	STREET ADDRESS, CITY, STATE, ZIP
HOSPICE OF JEFFERSON CO/PALLIATIVE CARE OF JEFFERS	1398 GOTHAM STREET, WATERTOWN, NY, 13601
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)
L0512
L0512	34489 Based on 4 record reviews of patient's who reside in the hospice residence and staff interviews, it was determined for one (1) patient (patient # 5) the agency failed to ensure that the patient received effective pain and symptom management resulting in a significant change in condition and hospitalization. Evidence was as follows: Patient # 5 was admitted to the hospice residence on 06/18/21 with a terminal diagnosis of cirrhosis of the liver with portal hypertension, and additional diagnoses of coronary artery disease, congestive heart failure, hypertension, and chronic kidney disease. The 09/02/21 interdisciplinary group (IDG) report included documentation of discussion of the patient's symptoms including intermittent paranoia and hallucinations, itching of the skin, pain to feet and legs, and ascites with abdominal girth measurement of 159 cm (62.2 inches) on 08/24/21. The patient had multiple medications ordered for symptom management and behavior management including: - quetiapine 50 mg twice daily for neurological imbalance - Trazadone 100 mg at bedtime for sleep - Ativan 1 mg three times a day for anxiety, agitation - dexamethasone 8 mg daily for restlessness, itching - Zofran 4 mg every 4 hours as needed (PRN) for nausea - hydroxyzine 50 mg every 6 hours PRN for itching - Lactulose 10 grams/15 ml every 48 hours for neurological imbalance - Neurontin 300 mg at bedtime for pain - midodrine 15 mg three times daily for orthostatic hypotension - torsemide (diuretic) 20 mg daily for fluid imbalance - spironolactone (diuretic)100 mg daily for fluid imbalance - morphine solution 0.25 to 1 ml, initial dose 0.25 ml every 2 hours PRN for pain or difficulty breathing - hyoscyamine 0.125 mg sublingual every four hours PRN for terminal secretions On 09/15/21, the day shift the hospice RN failed to provide any personal care or medications ordered and necessary to control patient's symptoms of paranoia and hallucinations for an entire 8 hour shift, resulting in the patient developing symptoms of extreme distress and psychosis. On 09/15/21, the day shift hospice RN documented between 7:00 am and 2 pm that the patient was asleep and it was unsafe to administer any medications to the patient. This resulted in the patient not receiving the eight (8) medications scheduled at 8 am the medications included: - quetiapine - an anti-psychotic drug used to decrease hallucinations ordered 2 times a day - dexamethasone for restlessness ordered once a day - midodrine used to treat low blood pressure ordered 3 times a day - nicotine patch to be changed once a day for 14 days - spirolactone a diuretic ordered once a day to treat edema for people with cirrhosis of the liver - Tamsulosin ordered twice a day to relax the muscles of the prostate and bladder - torsemide a second water pill ordered once a day to treat edema The medication administration progress note indicates "not administered" for these 8 am medications as patient asleep [patient lethargic]. The RN also failed to perform a bed bath using Selsun Blue body wash ordered daily which may have made the patient less lethargic and encouraged him to take the scheduled medications. At 12:00 pm the patient had midodrine and Tamsulosin ordered that were not administered for the reason [excessive lethargy] At 2:00 pm the RN documented lorazepam 1 mg ordered 3 times a day not administered again for excessive lethargy. At 4:00 pm the next shift began work and the licensed practical nurse (LPN) documented administration of the patient's midodrine, and the following medication needed for symptom management: - 4:45 pm - morphine 20 mg/1 ml patient states he is in a lot of pain. - 4:46 pm - Haloperidol 0.5 mg as needed for comfort - 5:32 pm - morphine .25 ml 1 time dose per the RN from day shift. for no reason - 6:00 pm - morphine 20 mg/1 ml given to patient for pain - 8:50 pm - morphine 20 mg/1 ml given to patient for comfort also given at that time was Haloperidol .5 mg At an undisclosed time, the evening LPN documented in the narrative note patient resting in bed, patient responds to verbal cues and wanted to talk to someone, the LPN documented that she listened for a while then had a volunteer come and sit with the patient who was alert and talking for over 2 hours. At 10:05 pm, the LPN documented the patient's call light was sounding and when she entered the patient's room the call bell was on the floor and pulled out of the wall. The LPN plugged the cord back into the wall the patient grabbed the her arm and started "yelling/growling and jerking me back and forth". A second LPN came into the room while the patient still had the LPN's arm, when the first LPN turned to look at the doorway, the patient kicked her in the head. The second LPN was able to distract the patient, and the first LPN was able to get to safety. The second LPN attempted to calm the patient and asked what the patient would like them (the hospice) to do? The patient yelled "Kill her Kill her". After a few other clear words the patient's speech became gibberish, but he continued to yell and throw objects at the door. Sometime between 10:05 pm and 11:00 pm the on-call RN arrived to assess the patient situation and give direction to the LPN. The LPN was directed to continue to provide as needed medications for symptom management of pain and behavior. At 11:45 pm the night shift LPN arrived and continued to administer as needed medications for symptom management, and documented with the assistance of the on-call RN the patient was settled in bed for the night. On 09/16/21 from 12:00 am to 6:15 am, the LPN documented providing the patient with as needed medication. At 4:25 am the LPN documented the patient was displaying the same growling and yelling behaviors so he was medicated as ordered with some relief At 6:15 am the patient was resting comfortably in bed. No agitation noted. On 09/16/21, at 8:00 am the patient became agitated, combative, got out of bed, started banging on the door of the room swearing and yelling. The RN on duty called the ambulance, and specifically "pushed the panic button" which brings the police department to the residence. The patient was transported to the hospital. On 10/06/21 at 9:30 am the surveyor interviewed the LPN assigned to the patient on the evening shift. The LPN stated the shift prior the RN did not medicate the patient at all and prior to that staff had been medicating the patient regularly to keep the patient at a therapeutic level. On 10/06/21 at 3:15 pm the surveyor interviewed the day shift RN assigned to provide care on 09/15/21. The RN stated that the patient was sleeping and not arousable and there was no way to give medications. The HN stated catheter care was provided. The RN provided no further explanation of the lack of care. On 10/14/21 at 8:30 am the surveyor interviewed an individual who was present in the hospice residence on 09/15/21 who stated they overheard the day shift RN state "I didn't touch him all, it was almost negligence." Failure to ensure that the patient's right to receive effective pain and symptom management for conditions related to the terminal illness resulted in the inability to control behaviors and manage symptoms.
L0698
L0698	34489 Based on record review and interviews with the Chief Executive Officer (CEO), Director of Patient Care (DPC), Hospice Residence Manager (RNNM) and nursing staff it was determined the hospice failed to maintain accurate records and investigate discrepancies of controlled drugs for 1 of 4 patients (Patient # 7 ) in the hospice residence. Evidence was as follows: On 10/04/21 the surveyor requested any incident reports from the hospice including medication errors from the CEO. A folder was provided with two fall reports. On 10/06/21 at 8:35 AM, the surveyor interviewed the residence RNNM regarding controlled drug records, viewed the locked cabinets, and reviewed the count sheets and related forms. The RNNM stated each patient in the residence had their own supply of medications and controlled drugs were locked in narcotic cabinets. There were two cabinets, one for each side of the unit. Staff members counted all medications and signed off at the end of each shift prior to handing off the keys and leaving the building. The RNNM stated everything was disposed of when the patient died. Patient # 7 was admitted to the hospice on 02/26/21 with a terminal diagnosis of endometrial cancer, and was transferred to the hospice residence on 09/21/21. The September 2021 Controlled Medication Inventory included documentation of the patient's medications brought in from home and included Ativan 0.5 mg tablets with a count of 17 tablets on 09/21/21. The next entry on the form was on 09/24/21 with 4 tablets administered and 13 tablets remaining. On 09/29/21 the quantity remaining was 12 and a notation on the form indicating the original count was incorrect and there were 12 tablets remaining. This entry was initialed by the RNNM and DPC. The September 2021 Shift Count of Ativan 0.5 mg showed a count of 13 tablets from 09/24/21 11 PM to 7 AM shift to 09/29/21 on the 3-11 PM when the count was 12 tablets. A review of patient # 7's record showed the last time the patient had received Ativan was on 09/24/21 at 10:40 PM when 2 mg (4 tablets) were administered for an active seizure. On 10/06/21 at 3:15 PM the surveyor interviewed the RNNM who stated when the medication was discovered missing she reported it to the DPC and the resource nurse as she had never had a discrepancy come up before. They went through the record and no Ativan had been given, they then interviewed the family and came to the conclusion the count had been incorrect when the medication was brought in from the patient's home. On 10/07/21 at 10:00 AM, during record reviews the DPC stated when the Ativan count was discovered to be wrong, an investigation was done and it was determined the medication was counted wrong when it was brought in by the family. When asked why all the staff members had counted the same incorrect number of pills for 5 days prior, the DPC did not have an answer and agreed she did not know what had happened to the pill. There was no written investigation provided prior to leaving the facility. On 10/12/21 the DPC emailed a medication incident and discrepancy investigation report dated 10/11/21. This report stated the lorazepam (Ativan) count was lacking one pill, no doses had been given to the patient during the previous shift and it was later noted that one of the nurses found a pill on the counter that was identified to be lorazepam. The report included an email from this nurse dated 10/04/21, 5 days after the pill came up missing. On 10/13/21 at 8:28 AM, the surveyor interviewed the staff member who discovered the pill who stated the medication was thought to be dropped from another patient who staff had destroyed medications after the patient's death. When asked about destruction of medications, the staff member stated the policy was that a registered nurse and another nurse were supposed to count and dispose of medications, however on the off shifts it may be licensed practical nurses who do this. She said she did not think the medication had belonged to Patient #7 as it was 5 days since the medication came up missing and the counter had been cleaned and floor swept. The LPN stated this was reported to the DPC and RNNM. On 10/14/21 at 8:30 AM, the nurse who counted the medications at the beginning of the day shift on 09/29/21 stated the Ativan tablets were counted with the night nurse and there were 13 tablets in the vial. The nurse was asked by the RNNM who was also working the shift to count for both sides of the floor which was not the usual practice and stated the RNNM gave medications to the patient and this nurse did not enter the cabinet during the shift. The nurse stated when the shift ended the keys were handed off to the RNNM without counting, and later the nurse received a call from the RNNM asking what happened to the other Ativan. On 10/21/21 at 10:19 AM, the surveyors interviewed the CEO, DPC and RNNM on site and reviewed additional information. The DPC stated policies and procedures for narcotics had not been reviewed or updated since 2012-2018 depending on the policy and the DPC was actively working on updating them. The DPC stated she was aware of the need to track medications, ensure variances are investigated, and the need to report them and the facility had not been compliant with regulations. The RNNM submitted a copy of the Medication Variance Tracking Form form for the dates of 05/15/21 to present. The form included several entries for Roxanol (morphine liquid) with excesses or shortfalls of up to 6.5 ml. The form included prescription numbers instead of medical record numbers as directed on the form, making tracking very difficult. The DPC stated the form needed to be updated and the process changed. Failure to ensure agency procedures are followed and are consistent with state and federal requirements has the potential for medication diversion and possible patient harm.