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
341507 A. BUILDING __________
B. WING ______________ 		07/26/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
DUKE HOSPICE 4023 NORTH ROXBORO ROAD, DURHAM, NC, 27704
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      
41345 Based on policy and procedure, clinical record review, and staff interview the agency failed to provide effective pain management/symptom control for 1 of 3 discharged patients (#1). Findings include: A policy, "Pain Management", revised 08/2019 was received from Employee #1 on 07/26/21 at 10:56 a.m. The policy stated, "all patients have the right to appropriate pain assessment and management ...". Patient #1 had a SOC (start of care) of 02/25/2021and included diagnoses of malignant neoplasm of upper lobe left bronchus or lung, secondary and unspecified malignant neoplasm of intrathoracic lymph nodes, gram negative sepsis, severe sepsis with septic shock and, pneumonia. Plan of care for 02/25/21 to 05/25/21 included orders for skilled nursing visits as follows: 1 time a week for 1 week, and 2 times a week for 12 weeks with 4 as needed visits. Review of the agency on call report for 04/18/2021 revealed Patient #1 caregiver called on call services at 4:36 a.m. on 04/18/21 with report of Patient #1 having chest pain the report stated- she has pain medication that she can give every hour and said he is still in a lot of distress; she is not sure what to do. Review of the case communication note (on all report) for 04/18/2021 at 6:35 a.m. revealed a message was received from the caregiver stating Patient #1 was having chest pain and a call was returned by RN (Registered Nurse) __________ and stated she gave him morphine 5mg (milligrams) and repeated it in less than 3 minutes and then called hospice, at the time a the call the patient was feeling much better, the nurse advised to increase the oxygen level for 3 lpm (liters per minute) to 3.5 lpm and to stack pillows together to elevate his head of bead. Further review of the record revealed another case communication note (on call report) was dated for 04/18/2021 with no time recorded with the following notation- received call from caregiver of Patient #1 asking if it is okay to give patient more pain meds- call return she states she gave morphine 5mg 45 minutes ago but he still has some pain-RN advised to go ahead and medicate him and to call if no pain relief in an hours' time. No documentation was noted in the record that a visit was conducted to assess the patient. Staff Interview with Employee #3 was conducted on 07/26/21 at 2:09 p.m. and revealed, "that is a good question, I usually try to triage to see if we can help by phone, she never complained that the pain management was not working and she didn't request a visit, I should have done a visit". An Interview was conducted with the Clinical Manager on 07/26/21 at 2:52 p.m. and revealed, "yes, he should have made a visit".