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
341523 A. BUILDING __________
B. WING ______________ 		09/11/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
TRANSITIONS LIFECARE 250 HOSPICE CIRCLE, RALEIGH, NC, 27607
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)
L0719      
37615 Based on review of agency reports, clinical record review and staff interviews, the inpatient hospice did not maintain patient safety by failing to address potential and real safety threats for 1 of 1 patient that was receiving inpatient hospice services and documented as an elopement risk upon admission (#1). This tag is cross-referred to L725. Findings include: L725-Based on review of agency reports, clinical record review, and staff interviews the agency failed to prevent an elopement in 1 of 3 patients (#1).
L0725      
37615 Based on review of agency reports, clinical record review and staff interview the agency failed to prevent an elopement in 1 of 3 patients (#1). Immediate jeopardy was identified beginning 8/28/20 and was abated on 9/11/20 with an acceptable allegation allegation of compliance. Findings include: Patient #1 was admitted on 4/7/20 with diagnoses of malignant neoplasm of occipital lobe (brain tumor), generalized idiopathic epilepsy (seizures), type 1 diabetes, essential hypertension, and chronic obstructive pulmonary disease (COPD-a lung disease). On 8/23/20 patient #1 was admitted to the hospice home for general inpatient care due to increased anxiety/agitation. The on-call triage nurse received a call from the patient's daughter on 8/23/20 at approximately 10:29 a.m. The triage note stated, "pt [patient] is hallucinating as well as threatening to leave and go to Virginia. Pt has had medication this am and is calm now; Instructed dtr [daughter] to give medications in middle of the night; every 6 hours. Dtr wanted Hospice to know Pt is threatening to leave; declined nurse visit." On 8/23/20 at 5:00 p.m. the on-call triage nurse received another call from the patient's daughter. The triage note stated, "At the time of the call patient was packing up her things threatening to leave. Requested an SNV [skilled nurse visit]." The nurse conducted a visit at 6:07 p.m. The clinical note stated, "Dtr expresses concern for pt's safety as she is still ambulatory, smokes, and refuses medications." The patient was admitted to the hospice house on the evening of 8/23/20. The inpatient unit transfer note by RN #2 documented patient as an elopement risk. The note also revealed patient was full weight bearing and required 1 person assist. On 8/24/20 at 6:12 a.m., the admission RN (RN #2) stated in the clinical note, "Pt is an elopement risk as she was threatening to leave her daughters house during an episode of severe agitation per daughter's report. Bed alarm engaged and door alarm/alert system has been placed to both patio door and room door. Pt has recently displayed significant symptoms and is at high risk of symptom reoccurrence." The 8/24/20 inpatient note did not address mobility. The inpatient unit note for 8/25/20 stated "poor endurance" and a "2 person assist". The clinical note for 8/26/20 at 5:54 a.m. stated, "Patient summoned staff to bedside multiple times within a two-hour period and appeared anxious and agitated, threatening to leave HHome [hospice home] and setting off bed alarm x 1 also requiring x 2 each PRN [as needed] doses of PO [by mouth] Haldol [antipsychotic medication]. X 1 PRN dose of PO Ativan was given for anxiety. The clinical note for 8/27/20 at 5:58 a.m. stated, "Pt experienced severe episode of agitation yelling out, attempting to scratch and hit staff, Pt unable to coordinate movement during episode." The inpatient unit note for 8/27/20 did not address mobility status. The clinical note for 8/27/20 at 8:35 p.m. stated, "pt agitated, confused and boughts [sic] of paranoia." The 8/28/20 clinical note stated, the "Pt able to stand unsteady during episodes of agitation ..." The clinical note for 8/28/20 by RN #3 stated, "Entering her room it was empty, all doors/closet/bathroom was searched but pt was not in room at this time. Pt wheelchair was pointed to door, chair alarm was with wheelchair with the node attached to the base, foley bag [urinary catheter drainage bag] on floor and pt cell phone on floor. Doors to the patio were open. Search was ongoing until pt was found behind hospice building on the other side of a fence in neighboring yard. The fence was closed in and unable to go around. I had to climb the fence to reach the pt. Pt was lying in the grass and pushing herself to a seated position as I approached. I asked the Pt if she was alright and did she hurt anywhere. Pt stated "I am fine, I am safe. Its ok you won't get into trouble. I am safe. My husband is coming to get me." Again asked the pt if she was hurt and pt states 'No, No I don't hurt anywhere." I assessed the pt as much as she would allow. No c/o pain in any extremities when moved, no noted wounds/bruises. Abrasion to front of right shin noted. Pt pulled herself into a standing position by grabbing onto my uniform, pt was unable to be redirected to stay seated for a more through [sic] assessment before standing up. I asked pt it she fell and pt stated ''No I don't like snakes". I repeated my question and pt stated "No I didn't fall, I was tired and I wanted to sit down, but I hate snakes. I laid down but I am afraid of snakes." At this time Dr _____ [hospice physician] had reached the pt as well and helped keep her standing. Pt was unable to bare [sic] weight for long and required 2 person max assist to remain on her feet. Pt started to get upset and emotional at this time and was repeating that her husband was coming to get her. Pt became more and more agitated and was unable to be redirected or reassured. Pt continued to increase in agitation and screaming for her husband. Dr. _______and I were able to lift pt over fence to staff on other side of fence who placed pt in a wheelchair." An Interdisciplinary Group (IDG) meeting was held on 8/25/20. There was no evidence that elopement precautions [wandering away from home or facility] were discussed during the meeting. An interview with agency director on 9/11/20 at 9:00 a.m. confirmed there was no evidence of elopement precautions being discussed in the IDG meeting. A review of the "Team Care Plan" for 8/25/20 did not identify elopement as a specific problem. However, the Aide Care Plan portion of the "Team Care Plan" did include the intervention of "Elopement Precautions." The Elopement Precautions were started on 8/23/20. The Aide Care Plan review in IDG for 8/25/20 stated to "continue" goals and interventions. A review of the hospice aide notes revealed the intervention of "Elopement Precautions" for 8/23/20-8/28/20. The aides had marked Elopement Precautions as "IC" [Intervention Complete] for 8/24/20- 8/25/20, and "NA" [not applicable] for 8/26/20-8/27/20. The agency provided the "Initial Allegation Report" and the "Investigation" at approximately 1:30 pm. The "Initial Allegation Report" revealed the patient was last seen in her room and 3:50 p.m. and then noted to missing from the room on 8/28/20 at 4:00 p.m. The agency conducted a search for the patient and found her "in a field adjacent to the facility." The patient "had a small abrasion on her right shin and superficial scratches on her upper back." The "Investigation" report confirmed the patient was found at 4:17 p.m. The report also stated, "When _______ (patient name) first arrived at the hospice home, she was assessed to be an elopement/wanderer risk. Over the next few days she went from being a 1-person to 2-person assist, grew weaker, felt to be near end of life and no longer posing an elopement/wanderer risk." An interview with hospice aide #4 on 9/9/20 at 3:00 p.m. revealed the patient was able to stand the evening of admission to the hospice home. The patient was placed on Elopement Precautions the evening of admission. The Elopement Precautions included a worksheet to sign every hour as well as alarming the patient's interior and exterior room doors. An interview was conducted with RN #3 on 9/9/20 at 3:15 p.m. [the nurse on 8/28/20 during elopement]. The RN stated that patient had been weak that morning, but alert, oriented, and cooperative. The patient became confused and was given Seroquel [antipsychotic medication] and Haldol. The last time the nurse visualized the patient prior to the elopement was approximately 3:00 p.m. The RN stated the patient had no elopement precautions or elopement care plan. An interview was conducted with hospice aide #5 on 9/10 at 11:55 a.m. [aide that was working at the time of the elopement.] The aide stated the patient was weak and was a two person assist. The hospice aide stated she had taken the patient out to smoke around 3:50 p.m. When she walked by the room at approximately 4:00 p.m. she noticed the patient was gone and the exterior door was open. The patient had removed her chair alarm and disconnected the indwelling catheter from the drainage bag. She stated the patient was not an Elopement Risk despite it being on the aide care plan. An interview was conducted on 9/10/20 at 2:45 p.m. with RN #6. She was the RN on the night of 8/24/20. She stated that it had taken 3 people to transfer the patient that night. She confirmed that she discontinued the elopement precautions, but her documentation failed to save. When she re-documented, she did not include that she had discontinued the elopement precautions. An interview was conducted with the hospice physician on 9/4/20 at 2:00 p.m . The physician stated the patient was extremely agitated after the elopement. She stated she felt this was "terminal agitation" [this is a syndrome that can happen in the final stages of life and may include hallucinations, confusion, anxiety, aggression, etc]. Allegation of Compliance 1. The plan of correcting the specific deficiency. The plan should address the processes that lead to the deficiency cited: Immediate Jeopardy was identified due to patient elopement from the hospice home. At 4:00 pm on 8/28/2020 the CNA rounded to Patient #1's room after previous visit in room at 3:50 pm. CNA found patio door open, the wheelchair empty and Patient #1 was not in the room. The patient had disconnected her chair alarm so that it wouldn't sound (Attached to her clothing). Hospice home staff dispatched to search the facility and outside the building. At 4:19 daughter notified of the elopement. At 4:22 pm the police department notified of the elopement. Patient #1 was located by staff member in a field adjacent to the facility at 4:17 pm. When patient #1 first arrived at hospice home, she was assessed to be an elopement/wanderer risk. Over the next few days she went from being a 1-person to 2-person assist, grew weaker, felt to be near end of life and no longer posing an elopement/wandering risk. Elopement precautions were discontinued. 2. The procedure for implementing the acceptable plan of correction for the specific deficiency cited: o After the physician assessed Patient #1 on 8/28/20 after the elopement, the patient was moved to a room without an exterior exit, and alarms were initiated from the room into the hallway of the hospice home. o Staff were informed of patient elopement risk on 8/28/20 o The wandering/elopement process was re-initiated immediately o The physician updated the patient's medication due to extreme agitation on 8/28/20 o Several staff members in addition to patients daughter were present with the patient following the elopement due to significant agitation, to help calm patient and ensure safety through the measures of medication administration and reengaging an alarm to the patients room and maintaining presence in the room. 2-3 HC personnel were with the patient until approximated 9pm to ensure safety and symptom management. Following this the patient was observed at least hourly, and was in her bed with the alarm on. o The agency updated the Elopement/Wandering clinical process guide and policy on 9/10/2020. The policy included: now using and area of the hospice home that could be secured as a first choice of patient location if they are assessed as an elopement risk (4 rooms at the end of C wing with badge only access), if this area is not available then the patient would be located in a room without a patio. o Effective 9/10/20 the following was implemented: · Agency now requires a physician order to initiate and discontinue elopement precautions and elopement precautions can only be DC'd if the patient is imminently dying. · Following an elopement episode , every 15 minute patient checks for the first 4 hrs are now implemented, following with every 1 hour checks. · All patients in the building are now assessed upon admission and daily for elopement risk. · All chair alarms have now been changed to chair "seat" alarms, the alarm will be activated when a patient gets up out of a chair and cannot be disconnected by the patient. · Room doorway alarms have been upgraded from motion alarms to sensor alarms (they are placed in the threshold of the door and make a loud noise when the patient steps on them to leave the room). · A check list has been created for the nurses to ensure that when someone is on elopement precautions that all of the process is followed-This check list is kept in their report tool and will be reviewed with oncoming staff. · The Wandering elopement problem in careplanning has been upgraded with more interventions available as check list items · Additional security options are being investigated to ensure the building safety. Estimates are being sought for various additional door locks and campus security. · Staff were educated following the changes to the policy and process for wandering and elopement, the process was reviewed in person with each team member by a team leader on 9/10/20. Any team members that were not available in person, were reviewed over the phone and acknowledged the education via email. 3. The monitoring procedure to ensure that the plan of correction is effective and that specific deficiency cited remains corrected and/or in compliance with the regulatory requirements; o Hospice home team leaders are currently auditing every chart, every day to ensure compliance with new protocols. They are also meeting with HC providers in the rooms of patients on elopement precautions and with the nurses daily, to ensure safety and protocols followed and to provide follow up on education provided o The Hospice home full time auditor will be reviewing charts of patients on elopement precautions to ensure all documentation is completed correctly 4. The title of the person responsible for implementing the acceptable plan of correction. o Hospice Home Director of Nursing