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
491500 A. BUILDING __________
B. WING ______________ 		12/12/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
CAPITAL HOSPICE 2900 TELESTAR COURT, FALLS CHURCH, VA, 22042
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)
L0520      
27661 Based on staff interview, document review and clinical record review it was determined the agency failed to provide safe care as ordered by a physician. Specifically the agency failed to conduct a complete comprehensive assessment of the patient to include the Intravenous (IV) medication (Morphine) the patient was receiving at the time of admission to the inpatient unit. (refer to G524) During the course of the survey it was determined the agency staff failed to assess the patient's IV medication (Morphine) that was not connected to an infusion pump allowing all the contents to infuse into the patient in a short period of time. The agency also failed to maintain clinical notes that contained documentation of all care provided. Specifically, the notes for a critical incident were not documented in a patient's clinical record. (refer to G671) A finding of Immediate Jeopardy was identified on December 11, 2019 at 12:40 PM after the surveyor consulted with the Office ofLicensure and Certification (OLC) and reviewed by the OLC management staff. On December 11, 2019 at 12:50 PM, agency staff were notified of the Immediate Jeopardy and a Plan of Removal was requested. On December 12, 2019, the survey team received the agency's Plan of Removal. The plan consisted of training/testing of staff; competency testing for documentation standards, Scope of Practice and Assessment standards. All staff will have completed the required testing material prior to providing any direct patient care. Disciplinary actions have been taken for staff involved in the incident and policy/protocol changes for direct admits to the inpatient unit have been instituted. All education had been completed by the exit conference and a revised policy has been institued to reflect no patients on an exisiting infusion will be received at any inpatient units unless the infusion is running through a hospice approved pump. After confirming the plan for removal of the Immediate Jeopardy had been completed by the agency, the Immediate Jeopardy was abated on December 12, 2019 at 2:20PM.
L0524      
27661 Based on staff member interview and clinical record review, it was determined the agency's staff member failed to perform a complete comprehensive assessment on one (1) of five (5) patients in the survey sample. Specifically, professional staff member failed to assess and document in the clinical record that patient #1 was receiving Intravenous (IV) fliuds that contained Morphine for pain that may have resulted in a medication error/overdose (patient #1). The findings were: A review of the electronic clinical record on 12/11/19 with staff member #1 and the Quality Nurse (staff member #4) assisting with the review revealed that patient #1 was admitted to the inpatient hospice unit on 11/03/19. The RN (staff member #6) documented the first contact with the patient at 2:15 PM on 11/03/19. Staff member #6 documented the reason for the contact was a head to toe assessment. The clinical note failed to contain information related to the Morphine drip or the IV access site. staff member #6 documented three additional contacts with the patient, one at 3:30 PM, one at 5:30 PM and one at 6:30 PM. The clinical notes for the three (3) additional contacts failed to mention the Morphine drip, IV access site, or any problems with the patient to include a suspected drug overdose. The patient expired that evening, 11/3/19. A physician (staff member #10) assessed the patient on 11/03/19, and documented on the form, MD/NP (medical doctor/nurse practitioner) Initial Consultation. The physician documented under the heading of, history of present illness for Patient #1 and read in part, was started on a Morphine drip at 1 mg/hr due to pain behavior. A decision was made to transfer to the IPU (in-patient unit) for management of pain and respiratory secretions. It was further documented that the EMS (emergency medical services) driver reported the patient showed signs of pain during transport. Staff member #10 also documented under the heading of, assessment and plan, the following and read in part, previously on a Morphine drip at 1 mg/hr (hour), will d/c (discontinue) drip and will start on 4 mg IV q (every) 4 hours atc (around the clock). The clinical note from the physician failed to contain documentation of the status of the IV Morphine at the time of the assessment including a description of the bag of Morphine, if Morphine was infusing, the amount in the bag or the status of the IV access site. The initial consultation documented by the physician also included a note stating, I was alerted by nursing staff member that they found the Morphine bag empty even though it was initially clamped by EMS (emergency medical services) staff member. The note further addressed who the physician contacted and stated,will gather more information. The time of the initial consult indicated the time the form was generated was on 11/03/19 at 2:30 PM to 3:00 PM. Based on interviews and a time line of events provided by the Chief Performance and Compliance Officer (staff member #3) in a email to the OLC (Office of Licensure and Certification) regarding the suspected overdose of Morphine occurred between 2:45 pm and 3:00 pm. The emailed time line indicated the physician documented the assessment after the overdose had occurred. The exact time the consult was done by staff member #10 could not be determined. In an interview with the Chief Performance and Compliance Officer (staff member #3) on 12/11/19 at 11:45 AM the Chief Performance and Compliance Officer stated, there does not appear to be a comprehensive assessment of the patient from the Doctor on down to the CNA (certified nursing assistant). An interview with the RN (Resgistered Nurse) staff member #6, who was involved in the case could not be conducted due to the current employment status of that employee. An interview with the charge nurse the night of the incident, staff member #7, was conducted by phone on 12/12/19 at 11:05 AM. Staff member #7 stated knowing the patient was approved for admission the day prior and the next thing the staff member #7 knew was the CNA came, told what happened. "I went to med (medication) room and talked to the nurse". staff member #7 reports asking the nurse (staff member #6) what was the concentration of the Morphine and the nurse did not know, the nurse was asked how much was in the bag and the nurse stated, I do not know. The charge nurse said the nurse (staff member #6) was told to stop what was being done and call the MD (Medical Director) for an order of Narcan (opioid antagonist indicated for the emergency treatment of known or suspected opioid overdose). The patient (#1) was given two (2) doses of Narcan before the family requested them to stop. According to staff member #7, the first person to notice the bag of Morphine was empty was the CNA (staff member #5) when the CNA and the RN (staff member #6) went in to the patient's room together. An interview with the physician (staff member #10) was conducted on 12/12/19 at 1:05 PM. staff member #10 stated, the first thing noted during the assessment of Patient #1 was the face, breathing, skin with a lot of bruising, can't remember an IV. The physician stated, "Thought the patient was going to die within the hour" and the need to call the spouse right away. The physician reports going immediately to call spouse and unable to reach the wife so a voice mail was left. staff member #10 further reported, it was a quick assessment, do not usually get patients on a drip, wrote a script for Morphine as soon as staff member #10 left the room and handed it to the nurse then left the facility The time line of events and the amount/dose of Morphine was submitted by email to the Office of Licensure and Certification (OLC) on 11/21/19 by staff member member #3. According to the written time line of events, the hospice agency's review of the incident revealed at 2:20 PM (1420), the nurse (staff member #6) noted the bag of Morphine to be full and at 3:00 PM (1500), the bag was noted to be empty. An interview with staff member #2 on 12/11/19 revealed, the hospice agency had received a "verbal report" (from the transport company) that approximately 92 mg (of Morphine) was left in the bag at the time of arrival at the inpatient unit. A review of the hospital discharge record revealed a bag of Morphine 100 mg in dextrose 5% /100 ml infusion at a rate of 1mg per hour was started at 11:15 on 11/03/19 at the hospital. The order was discontinued at 3:46 PM on the hospital records (after the patient arrived at the hospice facility). The discharge summary from the hospital states, start on Morphine drip per family request for comfort care, however Morphine was not listed under medications on the discharge summary medication list. Failure of clinical staff member to complete a comprehensive assessment of the patient resulted in a bag of IV Morphine, reported to be approximately 92 mg, infused in the patient over a short time span (approximately 40 minutes).
L0671      
27661 Based on staff interview and clinical record review it was determined the agency failed to ensure clinical records contained clinical notes for all care provided for one (1) of five (5) patients whose clinical record was reviewed in the survey sample. Specifically, the notes for a critical incident were not documented in the patient's clinical record, (patient #1). The findings were: The Chief Performance and Compliance Officer (staff member #3), sent written documentation by email to the Office of Licensure and Certification (OLC) on 11/21/19 to report a medication error in which Patient #1 was suspected of receiving approximately 92 mg of IV morphine over a short time span. The written documentation provided a time line of events in which the hospice in-patient unit admitted a patient who was recieving intravenous (IV) Morphine. The bag of Morphine was reported to be an almost full bag at the time of admission and was not on an IV infusion pump and was reported to have beem clamped off per the emergency transport company. Clinical record review revealed the following: A certified nursing assistant (CNA), staff member #5, documented in the clinical record the first contact with the patient was at 2:10 PM on 11/03/19 and recorded the patient's temperature, pulse and respirations. No further notes/narrative were included in the clinical note. Two additional contacts for that same day were documented in the record by the CNA, one at 4:20 PM and again at 6:00 PM. The registered nurse (RN) staff member #6 documented their first contact with the patient at 2:15 PM on 11/03/19 and documented the reason for the contact was a head to toe assessment. The clinical note failed to contain information related to the IV Morphine drip or the IV access site. Staff member #6 documented three additional contacts with the patient, one at 3:30 PM, one at 5:30 PM and one at 6:30 PM. The clinical notes for the three (3) additional contacts failed to mention the IV Morphine drip, the IV access site, or any problems with the patient. The RN failed to document finding the bag of morphine empty, providing Narcan (opioid antagonist indicated for the emergency treatment of known or suspected opioid overdose) to the patient that was given x two (2), removing the IV or pronouncing the death of patient as indicated in the time line of events provided to OLC(Office of Licensure and Certification) by staff member #3.. The only documentation in the record related to the patient's death was a discharge summary that was completed by an RN not involved in the patient's care. The nurse documented the patient's the time of death with a note that stated in part, "during RN, CNA, patient found no breathing, no blood pressure and no heart rate, pronounced at 2112 PM, family notified." Interviews with staff revealed the following: Staff member #3 was interviewed on 12/11/19 at 11:45 AM and stated, "No documentation is one of the most disconcerting things I have ever seen". An interview with the RN (registered nurse) staff member #6 involved in the case could not be conducted due to current employment status. An interview with the CNA, staff member #5 was conducted by phone on 12/12/19 at 10:30 AM. The CNA stated he/she went into the room to help transfer the patient, was told the IV was clamped and the paramedic handed me the bag to hang on the pole. Staff member #5 further stated, "If I'm not mistaken, he said it was morphine". The paramedic asked if "we had a pump and I told him no". The CNA stated the nurse found the bag empty when repositioned the patient and it was majority full when (patient) came in (to unit). None of the information staff member #5 reported in the interview was documented in the clinical record. An interview with the charge nurse working the night of the incident, staff member #7, was conducted by phone on 12/12/19 at 11:05 AM. The nurse stated knowing the patient was approved for admission the day prior and the next thing the nurse knew was the CNA came, told what happened. "I went to med (medication) room and talked to the nurse". Staff member #7 reports asking the nurse (staff member #6) what was the concentration of the morphine and the nurse did not know, the nurse was asked how much was in the bag and the nurse said I do not know. The charge nurse said the nurse (staff member #6) was told to stop what was being done and call the MD (Medical Director) for an order of Narcan. The patient (#1) was given two (2) doses of Narcan before the family requested them to stop. According to staff member #7, the first person to notice the bag of morphine was empty was the CNA (staff member #5) when the CNA and the RN (staff member #6) went in to the patients room together. Staff member #7 reported asking where the bag from the morphine was and being advised it was thrown away and had already been taken to the dumpster. The staff were never able to retrieve the empty bag. The only information provided above by staff member #7 that was documented in the clinical record was the order for Narcan and the documentation of doses given.