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
341545 A. BUILDING __________
B. WING ______________ 		12/07/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
CRAVEN COUNTY HOSPICE 2818 NEUSE BLVD, NEW BERN, NC, 28560
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)
L0557      
44098 Based on policy review, clinical record review, and employee interview, the agency failed to provide an accurate medication list to the skilled nursing facility during a respite stay for 1 of 3 patients (Patient #2). Findings included: Policy H:2-030.1 titled The Plan of Care was received from the Employee #1, the Clinical Manager, on 12/07/21 at 1:54 PM and revealed, "The Case Manager (or admitting registered nurse) will then notify the attending physician ...of the initial assessment findings, the identification of patient needs and the recommended services to meet those needs. The plan of care will be reviewed prior to care being delivered ...Care provided to the patient will be in accordance with the plan of care." Policy H:2-014.1 titled Physician Services-Attending Physician Role was received from Employee #1, the Agency Director, on 12/07/21 at 11:54 PM and revealed, "Communication between the attending physician and other members of the interdisciplinary group will be ongoing and documented in the hospice clinical record ...The plan of care will be developed by the hospice registered nurse, the patient and family/caregiver, attending physician, and the hospice Medical Director after the initial assessment is performed and prior to start of care." Patient #2 was a transfer from another hospice agency and was admitted on 09/03/21 with a principal diagnosis of Alzheimer's disease. Hospice Certification and Plan of Care from 09/03/21 to 10/04/21 revealed orders for skilled nursing 1 time per week for 9 weeks, social work 1 time to evaluate and assess for emotional support and community resources, and chaplain 1 time for assessment of spiritual needs. Hospice admission narrative note of 09/03/21 revealed, "Medications reviewed with husband/CG (caregiver), profiled with [name of pharmacy], and no meds (medications) ordered at this time. [Patient #2's spouse's name] states he does not use any medications previously ordered and that [Patient #2] takes no medications on a daily basis." Medications on the Hospice Certification and Plan of Care from 09/30/21 to 10/04/21 include the following: acetaminophen 650 milligram suppository per rectum every 6 hours as needed for fever; bisacodyl 10 milligram suppository insert 1 suppository per rectum daily as needed for constipations [sic] if no BM (bowel movement) 3 days; haloperidol 2milligrams per milliliter, give 0.5 milliliter sublingual every 6 hours as needed for agitation, hyoscyamine 0.125 milligram tablet every 4 hours as needed for excess secretions; ibuprofen 600 milligram tablet, take 1 tablet by mouth every 8 hours as needed for pain; lorazepam 0.5 milligrams every 6 hours as needed for anxiety; methocarbamol 500 milligram tablet by mouth three times daily; morphine concentrate 20 milligrams per milliliter solution, take 0.25 milliliters by mouth every hour as needed for pain or shortness of breath; prochlorperazine maleate 10 milligrams by mouth every 6 hours as needed for nausea/vomiting; quetiapine 25 milligram tablet by mouth two times daily The agency coordinated a respite stay for Patient #2 from 09/20/21 to 09/27/21 with a contracted skilled nursing facility. The NC Medicaid Long Term Care FL2 Form which contains the admitting orders was provided to the skilled nursing facility prior to the respite stay and included the aforementioned medications. The Medication Administration Record from the skilled nursing facility for dates 09/01/21 to 09/30/21 revealed that Patient #2 received the following medications during the respite stay: quetiapine 15 total doses received 09/20/21 through 09/27/21 methocarbamol 23 total doses received 09/20/21 through 09/27/21 lorazepam 7 total doses received 09/20/21 through 09/25/21 and 09/27/21 haloperidol 5 total doses received 09/20/21 through 09/23/21 and 09/27/21 ibuprofen 1 total dose received 09/23/21 A PRN (as needed) On-Call SN (skilled nursing) visit note of 09/27/21 revealed, "Patient's husband called to report patient had returned from [name of skilled nursing facility] and had multiple wounds and medications. SN arrived and found patient on the floor in the living room. Husband reports patient was brought into the house in a wheelchair and placed on the couch. Patient then fell off of couch and crawled across floor ...Patient noted to have multiple skin tears on bilateral calves and right elbow. +3 bilateral lower leg and pedal edema noted with weeping coming from wound on back of left leg. Patient also noted to have multiple bruises on left arm. Patient was seen on Friday where +1 edema was noted at ankles and 1 small, nickel sized blister was noted on back of right knee and skin tear to right elbow was noted. Patient was able to ambulate through her home before going to the facility and had to have maximum assistance getting into bed at this time ..." In an interview on 12/07/21 at approximately 1:00 PM, Employee #2, the Clinical Manager, stated, "Medication review should be done every visit ...when he [Patient #2's spouse] said that he was not giving the medication, they should not have been a medication list." In an interview on 12/07/21 at 2:38 PM, Employee #4, the Medical Director, stated, "The assumption is that the medications are assisting in keeping the patient in a stable state. If she [Patient #2] was in a stable state without taking the medications but they were still on her list, that would be a problem." In an interview on 12/07/21 at 4:35 PM, Employee #3, the Registered Nurse Case Manager, stated, "The medications profiled were received from the previous hospice's paperwork. I may have mentioned it [Patient #2's spouse was not giving her any medication on a regular basis] in report but I did not specifically seek out a doctor ...I did call and speak to the facility nurse to give report [prior to respite stay] ...I did tell her [the skilled nursing facility nurse] that she [Patient #2] wasn't taking any medications and the nurse said, 'oh I remember her' ...Now, I know that I should go to the doctor and discuss the medications, as needed ones as well, if I don't believe they're appropriate."