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
441582 A. BUILDING __________
B. WING ______________ 		11/19/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
TENNESSEE QUALITY CARE - HOSPICE 2879 HIGHWAY 45 BYPASS, JACKSON, TN, 38305
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)
L0513      
19001 Based on review of facility policy, hospice admission documents, nursing staff in-service documents, medical record review and interview, the facility failed to ensure the patient and family right to be involved in development of the plan of care for 1 of 3 (Patient #2) sampled patients. The findings included: 1. Review of the facility policy "Patient Rights and Responsibilities" revealed, "It shall be the policy of this company for all employees to honor and support patient rights and responsibilities during the course of providing care...During the Admission visit the Registered Nurse will provide the patient and/or caregiver with the Patient Rights and Responsibilities information...Each Patient has at least but not limited to the following rights:...to refuse treatment...the right to self-determination..." Review of the facility's Hospice admission document "Patient Services and Information guide revealed, "Page 4- Hospice Concept...Why Hospice?...Hospice considers your entire family, not just you, as the unit of care. You and your family will be included in the decision making process...Page 5- The Roles of Hospice staff...Registered Nurse- Coordinates the implementation of the hospice plan of care...Listens to and helps with any of your concerns or those of your caregiver and family about your daily activities...Supervises the care and services provided...Page 14- Your Rights- Respect and Consideration- You have the right to: Exercise your rights as a hospice patient...Your court-appointed representative or the legal representative you have selected ...may exercise these rights for you in the event that you are not competent or able to exercise them for yourself...Page 15- Decision Making- You have the right to: Be involved in developing your hospice plan of care; and to participate in changing the plan whenever possible...Be advised of any changes in your services or plan of care before the change is made...Have family involved in decision making as appropriate concerning your care, treatment and services..." Review of nursing staff in-service documents dated 11/12/2020 revealed, "Communication with Patient Caregivers: Caregiver contact for all patients is to be made weekly at a minimum, all contact attempts should be in your communication note within the patient chart...Communication is vital for our success." Medical record review for Patient #2 revealed an admission date of 10/15/2020 with diagnoses that included: Multiple sclerosis, Vesicointestinal fistula, Constipation, Pneumonitis and Sepsis. Review of the admission documents for Patient #2 revealed the patient's niece was identified as the primary caregiver for the patient and documented the niece agreed to do the following: "Participate with the hospice interdisciplinary group and the patient in the development of the patient's plan of care, Communicate the patient's needs and preferences..." On 10/15/2020, Patient #2's niece signed the acknowledgement of receipt of the Patient Services and Information Guide. Review of the Skilled nursing (admission) note dated 10/15/2020 revealed, "...Family request no anxiety, sleeping or depression meds [medications]..." Review of nursing communication notes dated 10/15/2020 through 11/9/2020 revealed no evidence the nurse contacted the family to inform them of Patient #2 status. On 11/3/2020, Xanax 0.25 milligrams twice daily was ordered.. There was no documentation the hospice notified the family of the new medication, or the reason for the medication. On 11/10/2020 Patient #2's niece called the hospice to speak with Nurse #1. Nurse #1 documented the following: Pt [patient] now transitioning 1 episode of coughing up blood required suctioning. Episode of vomiting bile and feces over the weekend. Increased lethargy, family worried that patient may be medicated and wish to discontinue Xanax..." On 11/11/2020 Nurse #1 documented, "Telephone call: Spoke with patient's niece today to discuss update...Niece still believes that facility [skilled nursing facility where patient resides] is over medicating patient. Informed niece during today's visit patient was lethargic but able to wake up during visit and respond to questions..." Patient #2 expired at the skilled nursing facility on 11/12/2020. In a confidential family telephone interview on 11/13/2020 at 3:15 PM, the family member said the admitting hospice nurse stated a nurse would visit Patient #2 twice per week and make weekly calls to the family with updates. The family member also stated Patient #2 was started on Xanax and the family was not informed by hospice. The family member stated they felt Patient #2 was over medicated and called a nurse on 11/10/2020 because Patient #2 had declined and was lethargic. The family member stated hospice did not keep them informed and only the social worker contacted the family by telephone. In an interview on 11/16/2020 at 11:25 AM, the Patient Care Coordinator (PCC) verified nursing staff should contact the family weekly with updates for patients who reside in skilled nursing facilities. She verified Nurse #1 did not document any attempts to reach the POA in the medical record. The surveyor asked why the Xanax was initiated for Patient #2. The PCC stated the skilled nursing facility staff reported to the hospice nurse that Patient #2 was agitated and restless. The PCC verified there was no documentation in the hospice record as to why the Xanax was started. She further verified there was no documentation the family/POA was notified about the plan of care change for Xanax twice daily. In a telephone interview on 11/17/2020 at 9:30 AM, Nurse #1 was asked about her note dated 11/10/2020, specifically how she knew Patient #2 had to be suctioned and vomited bile and feces over the weekend. Nurse #1 stated Patient #2's niece reported it to her in a telephone call 11/10/2020. She verified the skilled nursing facility staff did not contact her regarding Patient #2 s decline. She stated when the family visited Patient #2 on 11/10/2020 they noted the decline and called. When asked if she had contacted the family at any time prior to the call from Patient #2's niece on 11/10/2020, she stated she had tried to call the family but was unable to reach them. When asked if she documented her attempts to unsuccessfully reach the family in the medical record, she stated she did not. Nurse #1 stated, "I should document every attempt...I know..." In an interview with the Administrator on 11/17/2020 at 10:45 AM, she verified there was no specific policy on when and how to communicate with families. The Administrator stated it was her expectation that the nurses would contact families and document those attempts in the medical record. The Administrator stated they were looking at adding a communication requirement to the policy regarding patients who reside in skilled nursing facilities. The hospice staff failed to respect the patient/primary caregiver's right to be fully informed and participate in the development of the plan of care.