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
671684 A. BUILDING __________
B. WING ______________ 		08/20/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
TRADITIONS HEALTH 17070 RED OAK DRIVE STE 105, HOUSTON, TX, 77090
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)
L0543      
38432 Based on record review and interview, the hospice agency failed to ensure all care and services furnished to 1 of 3 patients reviewed (#3) followed an individualized written plan of care established by the Hospice Interdisciplinary Group (IDG) for 1 of 3 (Patient #3) patients reviewed in that: The hospice nurse failed to ensure medication was administered at the dosage ordered in the patient's individualized written plan of care established by the IDG for Patient #3. Failure to ensure medication was administered at the dosage ordered in the patient's individualized written plan of care established by the IDG for Patient #3 resulted in the patient receiving medication at a higher dose than ordered and could have contributed to the patient's declined health and hospitalization. Findings include: Record review of complaint intake #181177 read in part: "........ON 01/16/2020, RN #53 PROCEEDED TO ADMINISTER A 500 MG BOTTLE OF MORPHINE EVEN AFTER PATIENT DECLINED TO TAKE THE MEDICATION DETAILING A DRUG-INDUCED SEIZURE EXPERIENCED A MONTH PRIOR AFTER TAKING 0.2 GRAMS OF MORPHINE. THE NURSE RUSHED OUT OF THE HOME AFTER ADMINISTERING THE MEDIATION, LEAVING PATIENT UNCONSCIOUS. 911 WAS CALLED BY FAMILY AFTER THEY WERE UNABLE TO WAKE HER. IT TOOK OVER 45 MINUTES FOR EMS TO GET A RESPONSE BEFORE TRANSFERRING HER TO .... HOSPITAL. PATIENT WAS TRANSFERRED ...... FOR FURTHER TREATMENT AND SHE WAS HOSPITALIZED FOR OVER FOUR WEEKS. THE PATIENT CLAIMS THE INCIDENT LEFT HER WITH RANGE OF PROBLEMS INCLUDING DIFFICULTY WALKING, DIFFICULTY TALKING, HEARING LOSS, AND MEMORY LOSS......" Patient #3 Record review of Patient #3's Clinical Record (CR) revealed a Start of Care (SOC) on 01/10/2020, and a primary diagnosis of Human Immunodeficiency Virus (HIV). The Hospice Certification and Plan of Care (POC) signed and dated by physician Identifier #56 for the benefit period 01/10/2020 - 04/08/2020 showed following medications Orders: 1. Acetaminophen Rectal 650 mg amount/frequency:1 every 4 hours for pain or fever 2. Asper creme (lidocaine) 4% Topical amount/frequency: 1 every 72 hours/PRN 3. Bisacodyl Rectal (stool softener) 10 mg amount/frequency: 1 daily 4. Lorazepam oral 0.5 mg amount/frequency: 1 every 4 hours PRN for anxiety 5. Metoprolol tartrate oral 25 mg amount/frequency: 1 daily 6. Morphine oral 100/5 ml amount/frequency: 0.25 for pain or shortness of breath (SOB) 7. Robitussin cough and cold CF oral 5-10 mg/5 ml amount/frequency: 2 every 6 hours. Record review of the skilled nurse visit on 01/16/2020, signed by the RN Identifier #53, indicated, the nurse administered and documented, "Roxanol (Morphine) 0.5 ml SL at 1000 a.m., for redness/excoriation to open vaginal lesions causing increased pain and burning, pain rated 7/10." Physician ordered, "morphine oral 100mg/5 ml, 0.25 every 4 hours for pain and SOB." Further review of clinical record indicated patient #3 was admitted to the hospital seeking aggressive treatment on 01/16/2020 same day the skilled nurse Identifier #53 administered the medication. Record review of the internal investigation documentation and email correspondence between the agency's Alternate Supervising Nurse #57 and skilled nurse #53 also revealed that skilled nurse #53 administered double the dose of Morphine ordered. Interview with the agency's Vice President of Hospice Clinical Services and Compliance / #51 on 08/20/2020 at 12:56 p.m., she was asked to provide the Physician's order for 0.5 ml of Morphine, that skilled nurse #53 administered, for review. The Vice President of Hospice clinical services and compliance / #51 looked through the clinical records and said, "I cannot find the order. May be the skilled nurse got a supplemental order from the physician and forgot to enter it. I cannot say. The nurse is no longer working for us (the hospice)." Record review of agency's policy titled "MEDICATION ADMINISTRATION", HCL/PC. 16 revised 050119, page 3 of 4 read in part: "......Medications are administered as per Agency's Clinical Procedure Manual and per physician orders......."