Survey Report for 341596

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	341596	A. BUILDING __________ B. WING ______________	10/30/2019
NAME OF PROVIDER OR SUPPLIER	STREET ADDRESS, CITY, STATE, ZIP
AMEDISYS HOSPICE CARE	56 THREE HUNTS DRIVE BUILDING 3, PEMBROKE, NC, 28372
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)
L0501
L0501	28783 Based on review of complaint log, policy review, policy review, caregiver interview and staff interview the agency failed to document and investigate complaint for 1 of 1 patient [#1]. The findings include: "Policy: RI-006A ... Effective Date 1/1/06 ... Topic: Patient Grievances and Complaints ... Date(s) Revised: 02/2017 ... Purpose ... To Ensure that appropriate action will be taken to address all patient/caregiver complaints ... To provide a mechanism for receiving, reviewing, and resolving patient/caregiver complaints ... A grievance is a formal or informal written or verbal complaint that is made to any hospice employee ... The agency will maintain records of grievances/complaints and their outcomes ..." Review of the complaint log on 10/28/19 revealed no evidence that the agency received a complaint regarding Patient #1. Interview with the caregiver for Patient #1 conducted on 10/29/19 at 7:08 p.m. to 7:35 p.m. revealed, "I called and left messages for __________ [Name of Director of Clinical Operations] to call me about what had happened, but she never called me back until I called corporate ... When I talked to __________ [Name of Director of Clinical Operations] she said they should have handled things differently. But she never talked with anyone to investigate what happened, so that she could put measures in place so that this doesn't happen to someone else." Interview conducted with the Director of Clinical Operations on 10/30/19 at 1:12 p.m. revealed, "No, I did not receive a complaint ... ________ [Name of Caregiver of Patient #1] called my AVP [Area Vice President] ... I never got a complaint form, so I don't know what was written ... She told ________ [Name of AVP] that she was not pleased with the care that _________ [Name of Patient #1] received when she was dying ... She felt like more could have been done ... ________ [Name of AVP] asked me to reach out to her [caregiver] and check on her ... She told me she was upset about how _______ [Name of Patient #1] had passed and she did not want that to happen to her husband ... I did tell her that she could call me at any time ... I went back and looked at who was on call ... I don't have that documented anywhere."
L0512
L0512	28783 Based on clinical record review, caregiver and staff interviews the agency failed to manage the patient's pain and symptoms related to the terminal diagnosis and related conditions; and failed to ensure that what mattered to the patient regarding pain control and comfort was provided for 1 of 1 patient [#1]. Findings included: Patient #1 was a 72-year-old admitted to Hospice on 7/23/19. The patient had a terminal diagnosis of Malignant Neoplasm of Unspecified Part of Left Bronchus or Lung [Cancer of the lungs] which had spread to the brain. A review of the physician's orders/plan of care [POC] for the certification period 7/23/19 to 10/20/19 revealed SN [skilled nursing] was ordered. The SN visit frequency was 1 time per week for 1 week, 1 time per week every 2 weeks for 11 weeks and 3 PRN [as needed] visits for symptom management. SN orders included, "PULSE OX [pulse oximeter/used to measure oxygen level] PRN SX [symptom] MANAGEMENT ... NOTIFY MD IF BELOW 80% [notify doctor if oxygen level below 80%] ... HOSPICE RN [registered nurse] TO EVALUATE PATIENT, DISEASE PROCESS, SYMPTOMS, AND OTHER CONDITIONS ... HOSPICE NURSE TO OBSERVE AND ASSESS NEUROLOGICAL STATUS TO IDENTIFY CHANGES AND INTERVENE TO MINIMIZE COMPLICATIONS ... SKILLED NURSE TO REPORT SIGNIFICANT CHANGES IN STATUS TO PHYSICIAN FOR EARLY INTERVENTION ... HOSPICE NURSE TO ASSESS EFFECTIVENESS OF CARDIOPULMONARY SYMPTOM RELIEF MEASURES INCLUDING OXYGEN TREATMENT AND COMFORT MODALITIES ..." Medications on the POC for the certification period 7/23/19 to 10/20/19 included the following: -Ativan 1 tablet every 6 hours PRN [as needed] "Reason ... ANXIETY/AGITATION ... Instructions ... TAKE 1 TABLET BY MOUTH EVERY 6 HOURS AS NEEDED FOR ANXIETY OR TERMINAL AGITATION ..." -Levsin 1 tablet every 6 hours "Reason ... TERMINAL SECRETIONS ... Instructions ... TAKE 1 TABLET BY MOUTH EVERY 6 HOURS AS NEEDED FOR EXCESSIVE ORAL SECRETIONS ..." -Morphine Concentrate 20 milligrams/milliliter 0.25 to 1 ml [milliliter] "Reason ... PAIN/SOB [shortness of breath] ... Instructions ... TAKE 0.25 TO 1 ML EVERY 1 TO 2 HOURS AS NEEDED FOR PAIN OR SOB ..." The start of care visit was conducted by a registered nurse, #1E on 7/23/19. The Election of Benefit Statement was signed on 7/23/19 by Patient #1 and #1E. The Election of Benefit revealed, "Hospice Philosophy ... I acknowledge that I have been given a full explanation and have an understanding of the purpose of hospice care. Hospice care is to relieve pain and other symptoms related to my terminal illness and related conditions ... The focus of hospice care is to provide comfort and support to both me and my family/caregivers ... Right to choose an attending physician ... I do not wish to choose an attending physician and understand that the hospice medical director or designee will provide any physician services required by my plan of care ... I acknowledge that my choice for an attending physician is ... ______ [Name of Hospice Agency Medical Director] ..." The "PATIENT/ FAMILY INFORMED CONSENT" was signed on 7/23/19 by Patient #1 and #1E. The consent revealed, "I choose to receive hospice care from ______ [Name of Hospice Agency] ... and acknowledge and agree to the following ... I acknowledge receipt of the Patient information Booklet that contains written information on the topics listed below ... Topics discussed included ... Procedure for filing a grievance or complaint ... Medication and treatment procedure including the patient's right to pain management & medication safety ... Hospice Philosophy: I understand that hospice provides palliative, not curative care, to meet the physical emotional and spiritual needs of the patient and family. I understand that hospice focuses on the relief of pain and symptoms ... My attending physician is:________ [Name of Medical Director] ... Hospice Services: I understand hospice services will be provided by the Hospice Interdisciplinary team, my chosen attending physician and providers contracted by Hospice. The Hospice Interdisciplinary team consist of nurse, physicians ... home health aides ... Hospice services are available on a scheduled and as needed basis, twenty-four hours a day, seven days a week ... Patient and Family Role with Hospice ... I ... understand that the hospice team is not intended to take the place of the family, but rather to support the primary caregiver and family in caring for the patient ..." A document dated 7/23/19 and titled "WHAT MATTERS TO ME" included the name of Patient #1. The document indicated that what mattered to Patient #1 was "Pain Free ... Comfort ... Staying home ..." Interview with #1E conducted on 10/29/19 at 4:04 p.m. revealed, "I asked [asked what mattered] the patient and the caregiver ... This [What Matters to Me Document] is kind of a guide for the plan of care ... This [Pain Free, Comfort, Staying home] was the patient's wishes." Interview confirmed it was the patient's wishes to be pain free, comfortable and to remain home. Hospice Aide was ordered after the start of care. Hospice Aide services began the week of 8/4/19. A Hospice Aide visit was conducted by #4E on 8/16/19 at 12:27 p.m. to 1:39 p.m. The Hospice IDG [interdisciplinary group] Comprehensive Assessment and Plan of Care Update Report for Patient #1 indicated an IDG meeting was conducted on 8/16/19. There was no indication in the Hospice IDG meeting notes that the patient's caregiver called [8/16/19] regarding a decline in the patient's condition and a need for a SN visit. Review of the IDG Meeting Agenda revealed the meeting was held on 8/16/19 at "1:45-1745." Signatures of those in attendance included, the Medical Director, the Business Office Specialist/Scheduler [#3E], Director of Clinical Operations, and the RN Case Manager [#5E] for Patient #1. There was not a signature noted for the Clinical Manager [#8E], who was present, as reported by the Director of Clinical Operations on 10/30/19 at approximately 2:30 p.m. Client Episode Coordination Notes Report revealed a call was placed by the caregiver of Patient #1 on 8/16/19 at 5:07 p.m. The coordination note revealed, "... CG [caregiver] ... REPORTS THAT PATIENT HAS HAD A SIGNIFICANT CHANGE SINCE YESTERDAY ... INCREASED AGITATION ... REQUESTS NURSE VISIT ... CALL TO ON CALL NURSE _______ [Name of #2E] ... RN WHO WILL MAKE VISIT ..." SN visit notes revealed #2E conducted a visit to Patient #1 on 8/16/19 at 6:21 p.m. to 7:17 p.m. #2E documented, "INDICATE REASON FOR VISIT AND PROBLEMS/CONCERNS REPORTED ... DECLINE IN STATUS ... WAS CURRENT NEUROLOGIC/EMOTIONAL/COGNITIVE STATUS ASSESSED ... YES ... CURRENT NEUROLOGIC/EMOTIONAL/COGNITIVE STATUS ... DETERIORATING ... ABNORMAL NEUROLOGIC FINDINGS ... HEADACHE ... SEIZURES ... PATIENT'S MENTAL STATUS ... ORIENTED TO PERSON ... RESTLESS ... AGITATED ... LETHARGIC ... DOES DROWSINESS SIGNIFICANTLY AFFECT THE PATIENT ... YES ... DROWSINESS SCORE ... 0-10 ... 10 ... DROWSINESS SCORE REPORTED BY ... CAREGIVER ... PATIENT REPORTED GOAL DROWSINESS SCORE ... 0-10 ... 5 ... WHAT IS WORST LEVEL IN THE LAST 24 HOURS FOR DROWSINESS ... 10 ... WAS PAIN/COMFORT ASSESSED ... YES ... PATIENT'S RESPONSE: *ARE YOU UNCOMFORTABLE BECAUSE OF PAIN ... NO ... PAIN REPORTED BY ... CAREGIVER-ASSISTED ... IS PATIENT UNDER 18 OR NOT ABLE TO ANSWER ... PATIENT UNABLE TO VERBALIZE ... WAS A DETAILED PAIN ASSESSMENT COMPLETED ... YES ... FREQUENCY OF PAIN INTERFERING WITH PATIENT'S ACTIVITY OR MOVEMENT ... ALL OF THE TIME ... HOW DOES THE PATIENT DESCRIBE THE CHARACTER OF PAIN ... ACHING ... INDICATE DURATION OF PATIENT'S PAIN ... CONTINUOUS ... WERE MEDICATIONS RECONCILED DURING THIS VISIT ... YES ... PROVIDE DETAIL OF RECONCILIATION ... PT ONLY TAKING COMFORT MEDICATIONS ... IS PATIENT ABLE TO SELF-ADMINISTER MEDICATIONS ... NO ... PERSON(S) AUTHORIZED TO ADMINISTER MEDICATION ... CAREGIVER ... REASON FOR VISIT ... PATIENT CARE DUE TO UNEXPECTED STATUS CHANGE ... NARRATIVE ... PRN VISIT DUE TO CAREGIVER COMPLAINT OF A DECLINE IN STATUS ... THE CAREGIVER STATES THAT PATIENT HAS STARTED CHOKING WITH JUST SIPS OF WATER AND STATING THAT IT WAS DIFFICULT FOR HER TO SWALLOW. THIS RN NOTICED A LUMP IN THE THROAT THAT WAS NOT THERE LAST WEEK PER CAREGIVER. WHEN ASKED PATIENT IS SHE IN PAIN SHE STATES NOT REALLY. SPEECH IS VERY FAINT AND VERY SLOW. DIFFICULT FOR THIS RN TO UNDERSTAND. CAREGIVER STATES THAT PATIENT WAS HAVING A COMPLETE CONVERSATION YESTERDAY SO THIS IS A MAJOR DECLINE. CAREGIVER STATES SHE LEAVES A COOL RAG ON HER HEAD BECAUSE OF PAIN ... EDUCATED CAREGIVER ON ADMINISTRATION OF COMFORT MEDS [medications] AT THIS TIME ... DUE TO RAPID DECLINE I ANTICIPATE PATIENT IS ACTIVELY DYING. INCREASING VISITS TO DAILY ..." Interview with the caregiver for Patient #1 conducted on 10/29/19 at 7:08 p.m. to 7:35 p.m. revealed, "It [patient's decline] started Friday [8/16/19] ... I originally called at 10 a.m. ... I spoke with ________ [Name of #3E] ... I'm pretty sure it was ________ [Name of #3E] ... The aide [#4E] came that day [8/16/19] ... when she got there that day [8/16/19] she called the office and told them she [Patient #1] had declined ... When the aide called, her regular nurse ... ________ [Name of #5E] was in the office at the time ... She [#5E] had no clue as to what was going on ... She [#5E] would have come but no one told her what was going on ... I called back at 5:00 [p.m. 8/16/19] because no one had come all day [8/16/19] ... I think they didn't realize how fast things were going ... _________ [Name of #6E] was on call that night [8/16/19] but she couldn't come because they had her doing an admission, so they sent __________ [Name of #2E] ... __________ [Name of #2E] came sometime after 6 [p.m.] ... When __________ [Name of #2E] left, she [Patient #1] had calmed down ..." Interview with #5E conducted on 10/30/19 at 9:54 a.m. revealed, "Yes I was in the office when the aide called on Friday [8/16/19] ... That Friday was our meeting for IDG's [interdisciplinary group meetings] ... I was in this office between 1 and 1:30 [p.m.] and I was here until the meeting was over around 4 or 5 o'clock ... The only thing that _____ [Name of Clinical Manager] said to me that day was that she [Patient #1] would get a visit on Saturday [8/17/19] ... The notes in the IDG notes are based on my last visit with the patient ... I was in ______ [Name of City] that morning [8/16/19] but no one called me to ask me to go ... She lived between ______ [Name of City] and ______ [Name of City], so I could have seen her [Patient #1] ..." Interview conducted with #4E on 10/30/19 at 9:58 a.m. to 10:23 a.m. revealed, "... Yes, I remember ______ [Name of Patient #1] ... That Friday [8/16/19] when I got there ________ [Name of caregiver for Patient #1] was a little bit edgy. She was telling me that the night before she had a bad night. When I got there, she told me she had called the office around 10 or 11 [a.m. on 8/16/19] to tell them that ______ [Name of Patient #1] was declining ... I got up and looked at the patient ... She was just laying there ... I thought she had already passed ... I went out of the room and called ________ [Name of Hospice Agency] ... ________ [Name of #3E] answered the phone and my exact words was ________ [Name of caregiver for Patient #1] stated that she called the office about 10 or 11 and she said that there was a serious decline from the night before ... ______ [Name of #3E] told me to hold on ... _____ [Name of Director of Clinical Operations] gets on the phone ... I told her that ________ [Name of Patient #1] needed a nurse out there and she [caregiver for Patient #1] said that she had called earlier ... _____ [Name of Director of Clinical Operations] told me to hold on ... ______ [Name of #3E] gets back on the phone and tell me that ______ [Name of Clinical Manager] said there will be no nurse coming out today because they don't have nobody to send out there ... I got off the phone and told her that they said that they don't have a nurse to come out today ... I apologized. She said to me would I get you in trouble if I told them I need a nurse right now, I told her no ma'am. She then stated she would wait until 5:00 o'clock ... maybe the on-call nurse would come out ... ________ [Name of RN/#5E] told me that no one ever told her that her patient was declining, and she said she was in the office that day [8/16/19] for IDG." Interview with Interview with the Business Office Specialist/Scheduler [#3E] conducted on 10/30/19 at 12:08 p.m. revealed, "I ... work in the office ... I answer the phones and do scheduling ... I'm over the CNA'S with their schedules ... I remember her [caregiver for Patient #1] calling [8/16/19] ... I'm not sure that I talked to her ... I talked with the aide [#4E] ... She [#4E] was calling because _____ [Name of Patient #1] needed a nursing visit ... ________ [Name of the Director of Clinical Operations] asked me if I was talking to ________ [Name of Hospice Aide/#4E] on the phone, and she said ... she wanted to talk to her ... I got back on the phone with _______ [Name of Hospice Aide/#4E] and told her that _________ [Name of Clinical Manager/#8E] said that we did not have a RN to send out at the moment ... She said it would be tomorrow [8/17/19] when she got a nursing visit ..." Interview with the Clinical Manager [#8E] conducted 10/30//19 at 12:25 p.m. to 12:34 p.m. revealed, "... Coordination notes should be put in when a family calls requesting a visit ... We call the primary nurse to let them know that they need to go see the patient right away ... There are times that those calls don't get documented ... It's not an official process but it's one that we strive for in our office ... Every interaction should be documented ... Yes, she [caregiver of Patient #1] called that day [8/16/19] ... I don't recall saying that we were short staff ... I know the practice is to notify the primary nurse ... that is what I would have done ... If I didn't document, it ... I can't argue with __________ [Name of #5E] that I called her [#5E]." Interview conducted on 10/30/19 at 12:37 p.m. with the RN [#2E] who conducted the visit on the evening of 8/16/19 revealed, "I educated her [caregiver] on how to administer the Morphine. She gave her a dose while I was there ... I was on-call ... triage must have called me to make the visit [8/16/19] ... At that point I felt she needed daily visits, just to keep an eye on them." Interviews confirmed the hospice agency failed to provide effective pain management and symptom control in a timely manner for Patient #1 on 8/16/19. A scheduled SN visit was conducted on 8/17/19 at 1:02 p.m. by #9E. #9E documented, "... Narrative ... PT ... VITALS WNL [within normal limits] BUT PT ACTIVELY DECLINING ... NO SIGNS AND SYMPTOMS OF PAIN ... NO P.O. [oral/by mouth] INTAKE ... NO URINARY OUTPUT SO FAR THIS DAY ... BED BOUND ... DEPENDENT ON CG [caregiver] ... DAILY VISITS CONTINUED DUE TO ACTIVE DECLINE ... ENCOURAGE CG TO CALL AS NEEDED ..." Client Episode Coordination Notes Report revealed #10E, a registered nurse made an entry on 8/17/19 at 9:49 p.m. Review of the entry [8/17/19 at 9:49 p.m.] revealed, "NAME OF CALLER _____ [Name of caregiver for Patient #1] ... PURPOSE OF CALL ... PROBLEM/CONCERN IDENTIFIED ... O2 85% PULSE 116, PT LETHARGIC, NO ORAL INTAKE TODAY ... ACTION TAKEN: EMOTIONAL SUPPORT PROVIDED ... COMFORT MEDS REVIEWED ... END OF LIFE SIGNS AND SYMPTOMS REVIEWED ... SN VISIT MADE: DECLINED ... _____ [Name of caregiver for Patient #1] DECLINED VISIT ... STATES SHE KNOWS DEATH IS NEAR AND JUST WANTED REASSURANCE THAT SHE IS DOING EVERYTHING CORRECT ... ENCOURAGED TO CALL 24/7 FOR ANY NEEDS OR CONCERNS ..." Client Episode Coordination Notes Report revealed #10E made another entry on 8/18/19 at 12:56 a.m. Review of the entry [8/18/19 at 12:56 a.m.] revealed, "NAME OF CALLER _____ [Name of caregiver for Patient #1] ... PURPOSE OF CALL ... PROBLEM/CONCERN IDENTIFIED ... PT CONTINUES TO DECLINE. PULSE 138 O2 [oxygen] IN THE 70S ... ACTION TAKEN: REVIEWED END OF LIFE AND WHAT TO EXPECT. ENCOURAGED TO CALL 24/7 WITH ANY NEEDS OR CONCERNS ... SN VISIT MADE: ______ [Name of RN #6E] ... COMMENTS: FAMILY REPORTS THEY HAVE BEEN GIVING 1ML OF MORPHINE EVERY HOUR ALONG WITH ATIVAN 1MG Q 6 [1 milligram every 6 hours] WITH NO SYMPTOM RELIEF ..." Interview with the caregiver for Patient #1 conducted on 10/29/19 at 7:08 p.m. to 7:35 p.m. revealed, "When I called that night [8/17/19] I told them her heart rate was up and her oxygen was dropping. There was no oxygen in the home for her and she had lung cancer. I asked the nurse if I should put my husband's oxygen on her, she said not to because at this point it may agitate her more. I never declined a visit. I know I repeatedly said I needed somebody to help me. The nurse taking the call was trying to get someone to come out. She could hear her moaning. She was moaning all night. No one ever came. When I saw that no one was coming I started videoing her. I called back around 7:00 the next morning [8/18/19] because she started to have seizures. They told me to put the secretion medicine in her mouth to help with the foaming. I didn't know how to administer the secretion medicine. When ________ [Name of RN #6E] came she [Patient #1] was taking her last breath." The caregiver of Patient #1 called and left a message on 10/30/19 at 8:48 a.m. to clarify what happened when she called on 8/17/19. She indicated the very first call [8/17/19 at 9:49 p.m.], she called to make sure the dosage of Morphine 1 milliliter was right. She confirmed that she declined the nurse visit [8/17/19 at 9:49 p.m.]. She indicated that the second time she called [8/18/19 at 12:56 a.m.] she requested a nurse to come out to visit." Interview conducted on 10/30/19 at 11:04 a.m. with #6E revealed, "I spoke to ______ [Name of Caregiver] when I got the call it was around 1:00 a.m. [8/18/19] ... We [caregiver of patient #1 and #6E] talked about her comfort medications ... I know she had Morphine and I think she had Ativan ... I messaged the doctor [Medical Director] and I didn't get a response back ... No, I didn't call him ... I always text ... I let her know that I would see her 1st thing in the morning and if she needed anything to call back ... I believe I texted Dr. _______ [Name of Medical Director] ... If I'm not mistaken ... she was maxed out on the amount of medication [Morphine] we could give ... I'm not sure why I didn't go out because I didn't document the call ... I told her [caregiver for Patient #1] that as soon as he messaged me back, I would call her to let her know it there were any changes ..." Interview with #10E conducted on 10/30/19 at 11:13 a.m. to 11:15 a.m. revealed, "I work for _________ [Name of Hospice Agency] I am the after-hours coordinator ... she [caregiver of Patient #1] told me that she did not want a visit when she called [8/17/19 at 9:49 p.m.] ... She called me again at 12:56 a.m. [8/18/19] ... She only called me twice ... ________ [Name of #6E] was supposed to make the visit ... The nurse is to call the patient and let them know what time they will be there." Interview confirmed the hospice agency failed to provide effective pain management and symptom control for Patient #1. The agency also, failed to ensure that what mattered to Patient #1, to be pain free and comfortable, was achieved.
L0554
L0554	28783 Based on clinical record review, policy review, caregiver and staff interviews the Hospice agency failed to coordinate nursing visits in a timely manner for 1 of 1 patient requesting a nursing visit [#1]; failed to coordinate with the Medical Director for 1 of 1 patient [#1] in need of pain and symptom relief; and failed to coordinate needed support to the caregiver in the hours proceeding the patient's death for 1 of 1 patient [#1]. Findings included: "Policy: TX-012 ... Effective Date 1/1/06 ... Topic: Core Services-Nursing Service ... Date Revised ... 10/2018 ... Applicable Services ... Hospice ... Nursing services ensure that the nursing needs of the patient are met as identified in the initial, comprehensive, and updated assessments ... Operational Guidelines ... 1. The primary registered nurse is the case manager. The case manager will be designated in the hospice patient POC [plan of care]. The Case management includes ... d. Coordination of services given by other health care providers ... and ensure continuous assessment of the patient's/family's needs and the implementation of the POC ... e. Documentation of all activities and findings ... g. the observation and assessment of signs and symptoms and the reporting to the physician of reactions to treatments, including drugs and changes in the patient's physical or emotional condition ..." Patient #1 was a 72-year-old, admitted to Hospice on 7/23/19. The patient had a terminal diagnosis of Malignant Neoplasm of Unspecified Part of Left Bronchus or Lung [Cancer of the lungs] which had spread to the brain. A review of the physician's orders/plan of care [POC] for the certification period 7/23/19 to 10/20/19 revealed SN [skilled nursing] was ordered. The SN visit frequency was 1 time per week for 1 week, 1 time per week every 2 weeks for 11 weeks and 3 PRN [as needed] visits for symptom management. SN orders included, "PULSE OX [pulse oximeter/used to measure oxygen level] PRN SX [symptom] MANAGEMENT ... NOTIFY MD IF BELOW 80% [notify doctor if oxygen level below 80%] ... HOSPICE RN [registered nurse] TO EVALUATE PATIENT, DISEASE PROCESS, SYMPTOMS, AND OTHER CONDITIONS ... HOSPICE NURSE TO OBSERVE AND ASSESS NEUROLOGICAL STATUS TO IDENTIFY CHANGES AND INTERVENE TO MINIMIZE COMPLICATIONS ... SKILLED NURSE TO REPORT SIGNIFICANT CHANGES IN STATUS TO PHYSICIAN FOR EARLY INTERVENTION ... HOSPICE NURSE TO ASSESS EFFECTIVENESS OF CARDIOPULMONARY SYMPTOM RELIEF MEASURES INCLUDING OXYGEN TREATMENT AND COMFORT MODALITIES ..." Medications on the POC for the certification period 7/23/19 to 10/20/19 included the following: -Ativan 1 tablet every 6 hours PRN [as needed] "Reason ... ANXIETY/AGITATION ... Instructions ... TAKE 1 TABLET BY MOUTH EVERY 6 HOURS AS NEEDED FOR ANXIETY OR TERMINAL AGITATION ..." -Levsin 1 tablet every 6 hours "Reason ... TERMINAL SECRETIONS ... Instructions ... TAKE 1 TABLET BY MOUTH EVERY 6 HOURS AS NEEDED FOR EXCESSIVE ORAL SECRETIONS ..." -Morphine Concentrate 20 milligrams/milliliter 0.25 to 1 ml [milliliter] "Reason ... PAIN/SOB [shortness of breath] ... Instructions ... TAKE 0.25 TO 1 ML EVERY 1 TO 2 HOURS AS NEEDED FOR PAIN OR SOB ..." The start of care visit was conducted by a registered nurse, #1E on 7/23/19. The Election of Benefit Statement was signed on 7/23/19 by Patient #1 and #1E. The Election of Benefit revealed, "Hospice Philosophy ... I acknowledge that I have been given a full explanation and have an understanding of the purpose of hospice care. Hospice care is to relieve pain and other symptoms related to my terminal illness and related conditions ... The focus of hospice care is to provide comfort and support to both me and my family/caregivers ... Right to choose an attending physician ... I do not wish to choose an attending physician and understand that the hospice medical director or designee will provide any physician services required by my plan of care ... I acknowledge that my choice for an attending physician is ... ______ [Name of Hospice Agency Medical Director] ..." The "PATIENT/ FAMILY INFORMED CONSENT" was signed on 7/23/19 by Patient #1 and #1E. The consent revealed, "I choose to receive hospice care from ______ [Name of Hospice Agency] ... and acknowledge and agree to the following ... I acknowledge receipt of the Patient information Booklet that contains written information on the topics listed below ... Topics discussed included ... Procedure for filing a grievance or complaint ... Medication and treatment procedure including the patient's right to pain management & medication safety ... Hospice Philosophy: I understand that hospice provides palliative, not curative care, to meet the physical emotional and spiritual needs of the patient and family. I understand that hospice focuses on the relief of pain and symptoms ... My attending physician is:________ [Name of Medical Director] ... Hospice Services: I understand hospice services will be provided by the Hospice Interdisciplinary team, my chosen attending physician and providers contracted by Hospice. The Hospice Interdisciplinary team consist of nurse, physicians ... home health aides ... Hospice services are available on a scheduled and as needed basis, twenty-four hours a day, seven days a week ... Patient and Family Role with Hospice ... I ... understand that the hospice team is not intended to take the place of the family, but rather to support the primary caregiver and family in caring for the patient ..." Hospice Aide was ordered after the start of care. Hospice Aide services began the week of 8/4/19. A Hospice Aide visit was conducted by #4E on 8/16/19 at 12:27 p.m. to 1:39 p.m. The Hospice IDG [interdisciplinary group] Comprehensive Assessment and Plan of Care Update Report for Patient #1 indicated an IDG meeting was conducted on 8/16/19. There was no indication in the Hospice IDG meeting notes that the IDG coordinated care to ensure that the patient received a skilled nursing visit in response to a call from the caregiver the morning of 8/16/19 reporting a decline in the patient's condition. Review of the IDG Meeting Agenda revealed the meeting was held on 8/16/19 at "1:45-1745." Signatures of those in attendance included, the Medical Director, the Business Office Specialist/Scheduler [#3E], Director of Clinical Operations, and the RN Case Manager [#5E] for Patient #1. There was not a signature noted for the Clinical Manager [#8E], who was present, as reported by the Director of Clinical Operations on 10/30/19 at approximately 2:30 p.m. Review of the clinical record revealed no documentation to indicate that the caregiver of Patient #1 called the Hospice agency the morning of 8/16/19. Client Episode Coordination Notes Report revealed a call was placed by the caregiver of Patient #1 on 8/16/19 at 5:07 p.m. The coordination note revealed, "... CG [caregiver] ... REPORTS THAT PATIENT HAS HAD A SIGNIFICANT CHANGE SINCE YESTERDAY ... INCREASED AGITATION ... REQUESTS NURSE VISIT ... CALL TO ON CALL NURSE _______ [Name of #2E] ... RN WHO WILL MAKE VISIT ..." SN visit notes revealed #2E conducted a visit to Patient #1 on 8/16/19 at 6:21 p.m. to 7:17 p.m. #2E documented, "INDICATE REASON FOR VISIT AND PROBLEMS/CONCERNS REPORTED ... DECLINE IN STATUS ... WAS CURRENT NEUROLOGIC/EMOTIONAL/COGNITIVE STATUS ASSESSED ... YES ... CURRENT NEUROLOGIC/EMOTIONAL/COGNITIVE STATUS ... DETERIORATING ... ABNORMAL NEUROLOGIC FINDINGS ... HEADACHE ... SEIZURES ... PATIENT'S MENTAL STATUS ... ORIENTED TO PERSON ... RESTLESS ... AGITATED ... LETHARGIC ... DOES DROWSINESS SIGNIFICANTLY AFFECT THE PATIENT ... YES ... DROWSINESS SCORE ... 0-10 ... 10 ... DROWSINESS SCORE REPORTED BY ... CAREGIVER ... PATIENT REPORTED GOAL DROWSINESS SCORE ... 0-10 ... 5 ... WHAT IS WORST LEVEL IN THE LAST 24 HOURS FOR DROWSINESS ... 10 ... WAS PAIN/COMFORT ASSESSED ... YES ... PATIENT'S RESPONSE: *ARE YOU UNCOMFORTABLE BECAUSE OF PAIN ... NO ... PAIN REPORTED BY ... CAREGIVER-ASSISTED ... IS PATIENT UNDER 18 OR NOT ABLE TO ANSWER ... PATIENT UNABLE TO VERBALIZE ... WAS A DETAILED PAIN ASSESSMENT COMPLETED ... YES ... FREQUENCY OF PAIN INTERFERING WITH PATIENT'S ACTIVITY OR MOVEMENT ... ALL OF THE TIME ... HOW DOES THE PATIENT DESCRIBE THE CHARACTER OF PAIN ... ACHING ... INDICATE DURATION OF PATIENT'S PAIN ... CONTINUOUS ... WERE MEDICATIONS RECONCILED DURING THIS VISIT ... YES ... PROVIDE DETAIL OF RECONCILIATION ... PT ONLY TAKING COMFORT MEDICATIONS ... IS PATIENT ABLE TO SELF-ADMINISTER MEDICATIONS ... NO ... PERSON(S) AUTHORIZED TO ADMINISTER MEDICATION ... CAREGIVER ... REASON FOR VISIT ... PATIENT CARE DUE TO UNEXPECTED STATUS CHANGE ... NARRATIVE ... PRN VISIT DUE TO CAREGIVER COMPLAINT OF A DECLINE IN STATUS ... THE CAREGIVER STATES THAT PATIENT HAS STARTED CHOKING WITH JUST SIPS OF WATER AND STATING THAT IT WAS DIFFICULT FOR HER TO SWALLOW. THIS RN NOTICED A LUMP IN THE THROAT THAT WAS NOT THERE LAST WEEK PER CAREGIVER. WHEN ASKED PATIENT IS SHE IN PAIN SHE STATES NOT REALLY. SPEECH IS VERY FAINT AND VERY SLOW. DIFFICULT FOR THIS RN TO UNDERSTAND. CAREGIVER STATES THAT PATIENT WAS HAVING A COMPLETE CONVERSATION YESTERDAY SO THIS IS A MAJOR DECLINE. CAREGIVER STATES SHE LEAVES A COOL RAG ON HER HEAD BECAUSE OF PAIN ... EDUCATED CAREGIVER ON ADMINISTRATION OF COMFORT MEDS [medications] AT THIS TIME ... DUE TO RAPID DECLINE I ANTICIPATE PATIENT IS ACTIVELY DYING. INCREASING VISITS TO DAILY ..." Interview with the caregiver for Patient #1 conducted on 10/29/19 at 7:08 p.m. to 7:35 p.m. revealed, "It [patient's decline] started Friday [8/16/19] ... I originally called at 10 a.m. ... I spoke with ________ [Name of #3E] ... I'm pretty sure it was ________ [Name of #3E] ... The aide [#4E] came that day [8/16/19] ... when she got there that day [8/16/19] she called the office and told them she [Patient #1] had declined ... When the aide called, her regular nurse _______ [Name of #5E] was in the office at the time ... She [#5E] had no clue as to what was going on ... She [#5E] would have come but no one told her what was going on ... I called back at 5:00 [p.m. 8/16/19] because no one had come all day [8/16/19] ... I think they didn't realize how fast things were going ... _________ [Name of #6E] was on call that night [8/16/19] but she couldn't come because they had her doing an admission, so they sent __________ [Name of #2E] ... __________ [Name of #2E] came sometime after 6 [p.m.] ... When __________ [Name of #2E] left, she [Patient #1] had calmed down ..." Interview with #5E conducted on 10/30/19 at 9:54 a.m. revealed, "Yes I was in the office when the aide called on Friday [8/16/19] ... That Friday was our meeting for IDG's [interdisciplinary group meetings] ... I was in this office between 1 and 1:30 [p.m.] and I was here until the meeting was over around 4 or 5 o'clock ... The only thing that _____ [Name of Clinical Manager] said to me that day was that she [Patient #1] would get a visit on Saturday [8/17/19] ... The notes in the IDG notes are based on my last visit with the patient ... I was in ________ [Name of City] that morning [8/16/19] but no one called me to ask me to go ... I could have seen her [Patient #1] ..." Interview conducted with #4E on 10/30/19 at 9:58 a.m. to 10:23 a.m. revealed, "... Yes, I remember ______ [Name of Patient #1] ... That Friday [8/16/19] when I got there ________ [Name of caregiver for Patient #1] was a little bit edgy. She was telling me that the night before she had a bad night. When I got there, she told me she had called the office around 10 or 11 [a.m. on 8/16/19] to tell them that ______ [Name of Patient #1] was declining ... I got up and looked at the patient ... She was just laying there ... I thought she had already passed ... I went out of the room and called ________ [Name of Hospice Agency] ... ________ [Name of #3E] answered the phone and my exact words was ________ [Name of caregiver for Patient #1] stated that she called the office about 10 or 11 and she said that there was a serious decline from the night before ... ______ [Name of #3E] told me to hold on ... _____ [Name of Director of Clinical Operations] gets on the phone ... I told her that ________ [Name of Patient #1] needed a nurse out there and she [caregiver for Patient #1] said that she had called earlier ... _____ [Name of Director of Clinical Operations] told me to hold on ... ______ [Name of #3E] gets back on the phone and tell me that ______ [Name of Clinical Manager/#8E] said there will be no nurse coming out today because they don't have nobody to send out there ... I got off the phone and told her that they said that they don't have a nurse to come out today ... I apologized. She said to me would I get you in trouble if I told them I need a nurse right now, I told her no ma'am. She then stated she would wait until 5:00 o'clock [p.m.] ... maybe the on-call nurse would come out ... ________ [Name of RN/#5E] told me that no one ever told her that her patient was declining, and she [#5E] said she was in the office that day [8/16/19] for IDG." Interview with the Business Office Specialist/Scheduler [#3E] conducted on 10/30/19 at 12:08 p.m. revealed, "... I work in the office ... I answer the phones and do scheduling ... I'm over the CNA'S with their schedules ... I remember her [caregiver of Patient #1] calling [8/16/19] ... I'm not sure that I talked to her ... I talked with the aide [#4E] ... She [#4E] was calling because _____ [Name of Patient #1] needed a nursing visit ... ________ [Name of the Director of Clinical Operations] asked me if I was talking to ________ [Name of Hospice Aide/#4E] on the phone, and she said ... she wanted to talk to her ... I got back on the phone with _______ [Name of Hospice Aide/#4E] and told her that _________ [Name of Clinical Manager/#8E] said that we did not have a RN to send out at the moment ... She said it would be tomorrow [8/17/19] when she got a nursing visit ..." Interview with the Clinical Manager [#8E] conducted 10/30/19 at 12:25 p.m. to 12:34 p.m. revealed, "... Coordination notes should be put in when a family calls requesting a visit ... We call the primary nurse to let them know that they need to go see the patient right away ... There are times that those calls don't get documented ... It's not an official process but it's one that we strive for in our office ... Every interaction should be documented ... Yes, she [caregiver of Patient #1] called that day [8/16/19] ... I don't recall saying that we were short staff ... I know the practice is to notify the primary nurse ... that is what I would have done ... If I didn't document, it ... I can't argue with __________ [Name of #5E] that I called her [#5E]." Interview conducted on 10/30/19 at 12:37 p.m. with the RN [#2E] who conducted the visit on the evening of 8/16/19 revealed, "I educated her [caregiver] on how to administer the Morphine. She gave her a dose while I was there ... I was on-call ... triage must have called me to make the visit [8/16/19] ... At that point I felt she needed daily visits, just to keep an eye on them." Interviews confirmed the Hospice agency failed to coordinate a SN visit in a timely manner for Patient #1 on 8/16/19. A scheduled SN visit was conducted on 8/17/19 at 1:02 p.m. by #9E. #9E documented, "... Narrative ... PT ... VITALS WNL [within normal limits] BUT PT ACTIVELY DECLINING ... NO SIGNS AND SYMPTOMS OF PAIN ... NO P.O. [oral/by mouth] INTAKE ... NO URINARY OUTPUT SO FAR THIS DAY ... BED BOUND ... DEPENDENT ON CG [caregiver] ... DAILY VISITS CONTINUED DUE TO ACTIVE DECLINE ... ENCOURAGE CG TO CALL AS NEEDED ..." Client Episode Coordination Notes Report revealed #10E, a registered nurse made an entry on 8/17/19 at 9:49 p.m. Review of the entry [8/17/19 at 9:49 p.m.] revealed, "NAME OF CALLER _____ [Name of caregiver for Patient #1] ... PURPOSE OF CALL ... PROBLEM/CONCERN IDENTIFIED ... O2 85% PULSE 116, PT LETHARGIC, NO ORAL INTAKE TODAY ... ACTION TAKEN: EMOTIONAL SUPPORT PROVIDED ... COMFORT MEDS REVIEWED ... END OF LIFE SIGNS AND SYMPTOMS REVIEWED ... SN VISIT MADE: DECLINED ... _____ [Name of caregiver for Patient #1] DECLINED VISIT ... STATES SHE KNOWS DEATH IS NEAR AND JUST WANTED REASSURANCE THAT SHE IS DOING EVERYTHING CORRECT ... ENCOURAGED TO CALL 24/7 FOR ANY NEEDS OR CONCERNS ..." Client Episode Coordination Notes Report revealed #10E made another entry on 8/18/19 at 12:56 a.m. Review of the entry [8/18/19 at 12:56 a.m.] revealed, "NAME OF CALLER _____ [Name of caregiver for Patient #1] ... PURPOSE OF CALL ... PROBLEM/CONCERN IDENTIFIED ... PT CONTINUES TO DECLINE. PULSE 138 O2 [oxygen] IN THE 70S ... ACTION TAKEN: REVIEWED END OF LIFE AND WHAT TO EXPECT. ENCOURAGED TO CALL 24/7 WITH ANY NEEDS OR CONCERNS ... SN VISIT MADE: ______ [Name of RN #6E] ... COMMENTS: FAMILY REPORTS THEY HAVE BEEN GIVING 1ML OF MORPHINE EVERY HOUR ALONG WITH ATIVAN 1MG Q 6 [1 milligram every 6 hours] WITH NO SYMPTOM RELIEF ..." Interview with the caregiver for Patient #1 conducted on 10/29/19 at 7:08 p.m. to 7:35 p.m. revealed, "When I called that night [8/17/19] I told them her heart rate was up and her oxygen was dropping. There was no oxygen in the home for her and she had lung cancer. I asked the nurse if I should put my husband's oxygen on her, she said not to because at this point it may agitate her more. I never declined a visit. I know I repeatedly said I needed somebody to help me. The nurse taking the call was trying to get someone to come out. She could hear her moaning. She was moaning all night. No one ever came. When I saw that no one was coming I started videoing her. I called back around 7:00 the next morning [8/18/19] because she started to have seizures. They told me to put the secretion medicine in her mouth to help with the foaming. I didn't know how to administer the secretion medicine. When ________ [Name of RN #6E] came she [Patient #1] was taking her last breath." The caregiver of Patient #1 called and left a message on 10/30/19 at 8:48 a.m. to clarify what happened when she called on 8/17/19. She indicated the very first call [8/17/19 at 9:49 p.m.], she called to make sure the dosage of Morphine 1 milliliter was right. She confirmed that she declined the nurse visit [8/17/19 at 9:49 p.m.]. She indicated that the second time she called [8/18/19 at 12:56 a.m.] she requested a nurse to come out to visit." Interview conducted on 10/30/19 at 11:04 a.m. with #6E revealed, "I spoke to ______ [Name of Caregiver] when I got the call it was around 1:00 a.m. [8/18/19] ... We [caregiver of patient #1 and #6E] talked about her comfort medications ... I know she had Morphine and I think she had Ativan ... I messaged the doctor [Medical Director] and I didn't get a response back ... No, I didn't call him ... I always text ... I let her know that I would see her 1st thing in the morning and if she needed anything to call back ... I believe I texted Dr. _______ [Name of Medical Director] ... If I'm not mistaken ... she was maxed out on the amount of medication [Morphine] we could give ... I'm not sure why I didn't go out because I didn't document the call ... I told her [caregiver for Patient #1] that as soon as he messaged me back ... I would call her to let her know it there were any changes ..." Interviews confirmed #6E sent a text message to the Medical Director in the early morning hours and did not get a response back. #6E confirmed she did not attempt to call the Medical Director because she "always" text. Interview confirmed the Hospice agency failed to coordinate with the Medical Director concerning pain management for Patient #1. Interview further confirmed, that #6E did not conduct a visit to the home of Patient #1 when she received the call on 8/18/19 at around 1:00 a.m., leaving the dying patient and patient caregiver unsupported. Interview with the Clinical Manager [#8E] conducted 10/30//19 at 12:25 p.m. to 12:34 p.m. revealed, "I was the clinical manager on duty the weekend that she [Patient #1] passed [8/18/19] ... I received a call from the on-call nurse [#6E] saying that she kept getting calls about _________ [Name of Patient #1] and that she didn't want to keep going back and forth to the house ... I told her if she's calling, she needed to make the visit ... I know she [#6E] was asked to go Saturday ... I believe triaged called and asked."
L0671
L0671	28783 Based on clinical record review, policy review, caregiver and staff interview the Hospice agency failed to document calls to the office and failed to document details of afterhours call for 1 of 1 patient requesting a nursing visit [#1]. The findings include: "Policy: LD-006 ... Effective Date 1/1/06 ... Topic: Hours of Operation and On Call Service ... Date Revised ... 12/2018 ... Applicable Services ... Hospice ... Operational Guidelines ... 2. Nursing resources will be made available for patient needs during routine office hours Monday through Friday, from 8:00am to 5:00pm ... The guidelines during business hours are as follows ... a. Telephone calls to the agency during office hours are answered by agency staff ... b. Call are routed according to the patient/caregiver needs. staff will listen to the client's request and/or concerns and forward to the appropriate staff member in order to meet the patient needs ... c ... Documentation will be made on the coordination note ... 7. An after hours care coordination telephone log sheet is to be completed and retained ... either written or electronic ... The after hours care coordination telephone log will have at a minimum the following information ... Action Taken and the time ... Time call resolved ..." "Policy: TX-012 ... Effective Date 1/1/06 ... Topic: Core Services-Nursing Service ... Date Revised ... 10/2018 ... Applicable Services ... Hospice ... Nursing services ensure that the nursing needs of the patient are met as identified in the initial, comprehensive, and updated assessments ... Operational Guidelines ... 1. The primary registered nurse is the case manager ... The Case management includes ... d. Coordination of services given by other health care providers ... and ensure continuous assessment of the patient's/family's needs and the implementation of the POC ... e. Documentation of all activities and findings ..." Patient #1 was a 72-year-old, admitted to Hospice on 7/23/19. The patient had a terminal diagnosis of Malignant Neoplasm of Unspecified Part of Left Bronchus or Lung [Cancer of the lungs] which had spread to the brain. A review of the physician's orders/plan of care [POC] for the certification period 7/23/19 to 10/20/19 revealed SN [skilled nursing] was ordered. The SN visit frequency was 1 time per week for 1 week, 1 time per week every 2 weeks for 11 weeks and 3 PRN [as needed] visits for symptom management. Hospice Aide was ordered after the start of care. Hospice Aide services began the week of 8/4/19. Review of the clinical record revealed no documentation to indicate that the caregiver of Patient #1 called the Hospice agency the morning of 8/16/19 requesting a nursing visit. A Hospice Aide visit was conducted by #4E on 8/16/19 at 12:27 p.m. to 1:39 p.m. There was no documentation in the Hospice Aide visit note that the Aide called the office to report a change in the patient's condition. Interview with the caregiver for Patient #1 conducted on 10/29/19 at 7:08 p.m. to 7:35 p.m. revealed, "It [patient's decline] started Friday [8/16/19] ... I originally called at 10 a.m. ... I spoke with ________ [Name of #3E] ... I'm pretty sure it was ________ [Name of #3E] ... The aide [#4E] came that day [8/16/19] ... when she got there that day [8/16/19] she called the office and told them she [Patient #1] had declined ..." Interview conducted with #4E on 10/30/19 at 9:58 a.m. to 10:23 a.m. revealed, "... When I got there, she [caregiver of Patient #1] told me she had called the office around 10 or 11 [a.m. on 8/16/19] to tell them that ______ [Name of Patient #1] was declining ... I ... called ________ [Name of Hospice Agency] ... ________ [Name of #3E] answered the phone and my exact words was ________ [Name of caregiver for Patient #1] stated that she called the office about 10 or 11 and she said that there was a serious decline from the night before ... ______ [Name of #3E] told me to hold on ... _____ [Name of Director of Clinical Operations] gets on the phone ... I told her that ________ [Name of Patient #1] needed a nurse out there and she [caregiver for Patient #1] said that she had called earlier ... _____ [Name of Director of Clinical Operations] told me to hold on ... ______ [Name of #3E] gets back on the phone and tell me that ______ [Name of Clinical Manager/#8E] said there will be no nurse coming out today because they don't have nobody to send out there ..." Interview with the Business Office Specialist/Scheduler [#3E] conducted on 10/30/19 at 12:08 p.m. revealed, "... I work in the office ... I answer the phones and do scheduling ... I'm over the CNA'S with their schedules ... I remember her [caregiver of Patient #1] calling [8/16/19] ... I'm not sure that I talked to her ... I talked with the aide [#4E] ... She [#4E] was calling because _____ [Name of Patient #1] needed a nursing visit [8/16/19] ..." Interview with the Clinical Manager [#8E] conducted 10/30/19 at 12:25 p.m. to 12:34 p.m. revealed, "... Coordination notes should be put in when a family calls requesting a visit ... We call the primary nurse to let them know that they need to go see the patient right away ... There are times that those calls don't get documented ... It's not an official process but it's one that we strive for in our office ... Every interaction should be documented ... Yes, she [caregiver of Patient #1] called that day [8/16/19] ... I don't recall saying that we were short staff ... I know the practice is to notify the primary nurse ... that is what I would have done ... If I didn't document, it ... I can't argue with __________ [Name of #5E] that I called her [#5E]." Interviews confirmed the Hospice agency failed to document the caregiver's request for a SN visit on 8/16/19. Client Episode Coordination Notes Report revealed #10E made another entry on 8/18/19 at 12:56 a.m. Review of the entry [8/18/19 at 12:56 a.m.] revealed, "NAME OF CALLER _____ [Name of caregiver for Patient #1] ... PURPOSE OF CALL ... PROBLEM/CONCERN IDENTIFIED ... PT CONTINUES TO DECLINE. PULSE 138 O2 [oxygen] IN THE 70S ... ACTION TAKEN: REVIEWED END OF LIFE AND WHAT TO EXPECT. ENCOURAGED TO CALL 24/7 WITH ANY NEEDS OR CONCERNS ... SN VISIT MADE: ______ [Name of RN #6E] ... COMMENTS: FAMILY REPORTS THEY HAVE BEEN GIVING 1ML OF MORPHINE EVERY HOUR ALONG WITH ATIVAN 1MG Q 6 [1 milligram every 6 hours] WITH NO SYMPTOM RELIEF ..." Interview with the caregiver for Patient #1 conducted on 10/29/19 at 7:08 p.m. to 7:35 p.m. revealed, "When I called that night [8/17/19] I told them her heart rate was up and her oxygen was dropping. There was no oxygen in the home for her and she had lung cancer. I asked the nurse if I should put my husband's oxygen on her, she said not to because at this point it may agitate her more. I never declined a visit. I know I repeatedly said I needed somebody to help me ... No one ever came ..." The caregiver of Patient #1 called and left a message on 10/30/19 at 8:48 a.m. to clarify what happened when she called on 8/17/19. She indicated the very first call [8/17/19 at 9:49 p.m.], she called to make sure the dosage of Morphine 1 milliliter was right. She confirmed that she declined the nurse visit [8/17/19 at 9:49 p.m.]. She indicated that the second time she called [8/18/19 at 12:56 a.m.] she requested a nurse to come out to visit." Interview conducted on 10/30/19 at 11:04 a.m. with #6E revealed, "I spoke to ______ [Name of Caregiver] when I got the call it was around 1:00 a.m. [8/18/19] ... We [caregiver of patient #1 and #6E] talked about her comfort medications ... I know she had Morphine and I think she had Ativan ... I messaged the doctor [Medical Director] and I didn't get a response back ... No, I didn't call him ... I always text ... I let her know that I would see her 1st thing in the morning and if she needed anything to call back ... I believe I texted Dr. _______ [Name of Medical Director] ... I'm not sure why I didn't go out because I didn't document the call ..." Interviews confirmed the Hospice agency failed to document content of the call between the caregiver of Patient #1 and #6E regarding request for SN visit on 8/18/19. Complaint Intake # NC 00156744/cmw