Survey Report for 671774

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	671774	A. BUILDING __________ B. WING ______________	04/14/2022
NAME OF PROVIDER OR SUPPLIER	STREET ADDRESS, CITY, STATE, ZIP
HARBOR HOSPICE OF SOUTHEAST HOUSTON LP	11990 KIRBY DRIVE, HOUSTON, TX, 77045
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)
L0651
L0651	32043 Based on observation, interview and record review, administrator failed in the responsibility of managing the daily operations of the agency in that: Adm did not make sure that the cleaning product used by external contractor used cannot cause discomfort to agency ' s patients. Adm did not promptly address problem identified in nursing care provided to patients #1. Adm did not make sure that LVN2 received general orientation upon hire. This failed practice has the potential to harm the patients due to inadequate administrative supervision that may result in poor care delivery and negative patient outcomes. Findings Include: Review of administrator ' s job description revealed responsibilities that read in part: "Is responsible for organizing and directing the agency ' s ongoing function of the hospice program." "Has overall responsibility for employing qualified, competent staff through recruiting, hiring, supervising, counseling, and firing when necessary." "Is responsible for negotiating, supervising, and evaluating contracts with outside agencies and services." Cleaning Product: Interview with FM2 during visit to the patient #2 ' s room on 4/12/22 at 11:45 am with Adm and DON, FM2 stated the following: Patient #2 was previously in room 11 on the east side of the building. When he came to visit patient #2 on 4/9/22, there were work crew power washing the outside pavement and wall of the building. When he entered the building, there was a strong chlorine odor in the hallway and the odor was even stronger when he entered the patient ' s room. He spoke with a member of the work crew who informed him that they were using a solution of 90% bleach and 10% water and had sprayed the solution on the ground and around the air-conditioning unit to remove stains and prevent mold. He (FM2) complained to the DON and insisted that the patient be moved into another room and the patient was then moved to room 12. During this interview, the cleaning crew was seen outside through the window starting the above cleaning on the west side of the building. During unit walk through with Adm and DON on 4/12/22 at 12:48 pm, a strong, irritating chlorine odor was perceived in the hallway. Adm then instructed the DON to tell the work crew to stop the work. Review of agency ' s active census revealed that the agency had 2 patients with respiratory diseases and 2 with stroke. During interview 4/13/22 at 2:32 pm with Adm and DON, Adm stated that bleach was part of chemicals in the agency ' s MSDS, but they only used premixed bleach products. Adm acknowledged that bleach fume was an irritant and could be harmful to patients with compromised respiratory system. Adm was asked why she did not ensure that the contractor would not use products that may be harmful to the patients. Adm stated that the contractor was hired by the corporate office. Patient Care: During visit to Patient #1 ' s room on 4/12/22 at 12:50 pm with Adm and DON, patient was found lying in bed supine and tilted to the left with head-of-bed at approximately 30 degrees. Patient #1 was eating with his fingers with the food plate on his chest, and a pitcher of water by his right hip on the bed. On entrance into the room, Adm raised the head-of-bed up a little and said to the patient "You need to be up some more". Patient #1 stated the following: Agency staff gave him food without giving him a fork to eat. He wanted to go back home because he got better care with the hospice home care than he was receiving at the IPU. Review of patient #1 ' s CR showed that the patient was admitted to hospice on with primary diagnosis of COPD. Review of the POC for the benefit period 3/10/22 - 5/8/22 showed functional limitations as bowel/bladder incontinent and legally blind. During interview on 4/12/22 at 1:22 pm with Adm, she acknowledged that how patient #1 was found eating his lunch above was unacceptable, and she would look into it. During follow-up interview with Adm on 4/13/22 at 1:07 pm, she stated that she had not had time to investigate who served patient #1 food as stated above. Orientation: Review of PR of LVN2 revealed a hire date of 4/6/20. further review of that new employee orientation was completed a year later on 3/24/21. During interview on 4/14/22 at 2:33 pm with HR Coordinator, she stated that administration was required to send the staff for new employee orientation upon hire, but administration did not send the staff and it was not done until March of 2021. During interview on 4/14/22 at 3:12 pm with Adm, she stated that LVN2 received job specific training but general orientation was not provided because "there was too much going on at the time." Adm stated that newly hired employees were required to go through the general orientation and the job specific orientation. Adm acknowledged that newly hired staff were taught agency ' s policies and procedures during the new employee orientation.
L0721
L0721	32043 Based on observation, interview and record review, agency failed to ensure that staffing for all services reflected its volume of patients, their acuity, and the level of intensity of services needed to ensure that POC outcomes were achieved and negative outcomes were avoided for 3 of 3 patients reviewed (patients #1, #2 & #3) in that adequate nursing care was not provided to the patients as follows: Patient #1 was observed lying in one position for several hours, interview with the patient and documentation also showed that agency staff did not turn the patient ordered. Patients #2 & #3's wounds on admission deteriorated and the patients also developed other ulcers while in the agency's care. The patients' FMs ascertained that the patients were not being turned as necessary by agency staff. This failed practice impacted the above patients resulting in deteriorating skin condition. This failed practice also has the potential for harm resulting from inadequate care due to poor staffing. Findings Include: Patient #1 Interview with the patient during visit to the patient's room on 4/12/22 at 12:50 pm with Adm and DON, patient was found lying in bed supine and tilted to the left with HOB at approximately 30 degrees. patient #1 was eating with his fingers from a plate with food resting on his chest, and there was a pitcher of water on the bed by his right hip. Upon entrance into the room, Adm raised the HOB higher and said to the patient "You need to be up some more". Patient #1 responded that Agency staff gave him food without giving him a fork to eat. He wanted to go back home because he got better care with the hospice home care than he was receiving at the in-patient unit. The hospice home-care came twice a week and the hospice aide came five times a week to give him bath. He did not get enough food in IPU. He had not been re-positioned since morning. During follow-up visit to patient #1 on 4/12/22 at 3:20 pm with RN 1, hha2 and DON, the patient was laying in the same position as noted at 12:50 pm. patient #1 stated that no staff had come to turn him. The staff (RN 1, hha2 and DON) attempted to reposition the patient and could not. RN 1 stated that they needed more help to turn the patient. When asked how they had been repositioning the patient if three employees could not turn the patient, RN 1 stated that they usually got more people to assist with turning the patient. RN 1 also stated that patient #1 had a right hip fracture and did not want to be turned on his right side because he was in pain when turned to the right side. RN 1 was asked if she realized that the patient could be re-positioned as needed with pillows and wedges to prevent the patient from laying in one position for a long time. RN 1 stated that they used pillows and wedges to re-position the patient. The only pillow observed in the room was the pillow under the patient's head. RN 1 checked the closet and acknowledged there were no other pillows in the room. RN 1 stated that the pillows were probably removed from the room. RN 1 added that she did not know why the pillows were removed from the room. When RN 1 was asked if she realized that the pillows that were used for any patient should remain in the patient's room until discharge to prevent cross contamination, RN 1 did not respond. Review of patient #1's CR showed that the patient was admitted to hospice on 11/20/19 with primary diagnosis of COPD. Review of the POC for the benefit period 3/10/22 - 5/8/22 showed functional limitations the patient was incontinent of bowel/bladder and legally blind. Safety measures included skin breakdown prevention. Orders /Treatments included: SN to assess skin and follow inpatient wound care protocol per wound stage. Aide to turn patient every 2 hours. Further review of CR showed that patient #1 was transferred to IPU for symptoms exacerbation on 4/10/22 at 6:40 pm. IDT POC completed in IPU on 4/12/22 included aide's intervention to turn patient every 2 hours. Review of RN comprehensive assessment completed of 4/11/22 at 4:53 am showed that the patient had redness in his buttocks and back and stage I ulcers in right buttock and anterior left thigh. Review of shift running document showed that patient was not turned from the time of admission until 4/11/22 at 9:55 am with the aide documenting that patient refused to be turned. Further review of the shift running document showed documentation by hha1 on 4/12/22 that patient #1 was re-positioned at 11:35 am on his left side; 1:30 pm & 3:40 pm patient remained on his left side because patient refused to be turned. During interview on 4/14/22 at 1:30 pm with hha1, she stated the following: During meal time, dietary staff usually place the food tray in the patient rooms, the aides then set-up the food on the bedside table for the patient to eat and also feed patients that cannot feed themselves. She did not know how patient #1 got his food on 4/12/22 because she was busy assisting another patient to feed. She usually re-positioned the patient every 2 hours. It was difficult for aides to get help from the nurses, sometimes they called for help to turn the patients and they cannot get help from the nurses. She had reported the problem with getting assistance for patient care to the Adm and DON on many occasions. During interview on 4/12/22 at 1:22 pm with Adm, she acknowledged that how patient #1 was found having his lunch above was unacceptable, and she would look into it. During follow-up interview with Adm on 4/13/22 at 1:07 pm, she stated that she had not had time to investigate who served the patient #1 the above lunch. Patient #2 Interview with the FM1 and FM 2 during visit to the patient's room on 4/12/22 at 11:45 am with Adm and DON, FM 2 stated the following: There were several problems with the care agency provided to the patient as follows: They had noted patient #2 with HOB down and the patient laying flat in bed on three occasions. He had picture and video evidence for two of the occasions. FM 2 showed surveyor a picture of patient laying flat in bed which the FM 2 said was taken by another FM the Monday after the patient was admitted to the facility. FM 2 also showed two video clips of the patient, one of the videos showed the patient in respiratory distress with heavy crackles in the breath sound and in the other video the patient's breath sound was clearer. FM 2 stated that the first video was how patient #2 sounded when he walked into the room on 4/9/22 and found the patient laying flat in bed, and the second video was after he called the nurse and the patient was suctioned by the nurse. FM 2 further stated that patient was transferred from hospital to hospice after hospitalization for stroke. FM 2 stated that patient #2 came to the agency with some redness in the sacrum. FM 2 explained that patient #2 had been in the facility for 12 days and the patient had sores in bilateral heels and elbows, and the auricle of the right ear. FM 2 showed surveyor the patient's heels with bandages wrapped around them, and small dark red area in the auricle of right ear. FM 2 stated that he had to tell the agency staff to elevate the patient's legs on a pillow to prevent further pressure on the patient's heels. FM 2 stated that one or two FMs visited the patient daily and stayed 4-6 hours with the patient. FM1 and FM 2 stated that agency staff never came to reposition the patient unless a FM asked them (agency staffs). FM 2 further stated that the agency usually has enough staff on duty but the employees just sit behind the desk on their computers. FM 2 further stated that he complained to Adm on 4/9/22 about the patient being left flat in bed. FM 2 added that the Adm said she would investigate the issue and let him know the outcome of her investigation in 48 hours, but he has not heard anything from the Adm. patient #2 was on continuous oxygen by nasal cannula. During follow-up interview on 4/14/22 at 9:53 am with FM 2, he stated that at least one FM arrived at patient bedside between 9 am - 12 pm and stayed with the patient for 4 - 6 hours. Review of patient #2's CR showed that the patient was admitted to hospice on 3/31/22 with primary diagnosis of cerebral infarction, unspecified. Review of the POC for the benefit period 3/31/22 - 6/28/22 showed functional limitations include bowel/bladder incontinent, endurance, speech, ambulation, and dyspnea with minimal exertion. Safety measures included fall precaution, oxygen precaution skin breakdown prevention, and aspiration precaution. Orders /Treatments include: SN to assess skin daily and follow inpatient wound care protocol per wound stage. Aide to turn patient every 2 hours. Review of RN initial comprehensive assessment completed of 3/31/22 showed one wound identified in left buttock, the wound was assessed as 7.5cm/3.0cm/0cm in size, yellow & dusky with eschar, slough, moist wound bed, redness/excoriation in surrounding skin with scant serosanguinous drainage. Review of the SN visit note on 4/7/22 showed that the patient still only had the above wound and the wound was assessed as 3.8 cm/2.6 cm/ 0 cm in size, with eschar, slough wound bed, yellow color with scant serosanguinous drainage, and redness in surrounding skin. Review of the SN visit note on 4/8/22, SN visit note showed significantly decline in the above wound. The wound was assessed as unstageable ulcer of right and left buttocks and sacrum 9cm/10cm/0cm in size; red, dusky & black color, macerated wound edges, redness in surrounding skin, and scant browning drainage with foul odor. In addition, the note revealed that the patient had developed a 5cm/4cm blister in the left inner foot heel and a 6cm/4cm blister in right outer foot heel. Review of Shift Running Document showed that the aides documented repositioning the patient every 2 hours. During interview on 4/12/22 at 1:22 pm with Adm and DON, Adm stated that patient ' s HOB can be flat and it is only required to be elevated if the patient was having a lot of secretion. Adm acknowledged that it was not acceptable for a patient on continuous oxygen should have the HOB flat. DON stated that patient #2's head-of-bed was not really flat, but was not just as high as the family wanted it. Patient #3 Review of patient #3's CR showed that the patient was admitted to hospice on 2/11/22 with primary diagnosis of Alzheimer ' s disease, unspecified. Review of the POC for the benefit period 2/11/22 - 5/11/22 showed functional limitations as bowel/bladder incontinent and dyspnea on minimal exertion. Safety measures include skin breakdown prevention. Orders /Treatments include: SN to perform wound care per wound care protocol. Aide to turn patient every 2 hours. Further review of CR showed that patient #3 was transferred to IPU for symptoms exacerbation on 3/22/22. IPU aide care plan include intervention to turn patient every 2 hours. Review of SN assessment completed by home-care RN4 on 3/22/22 prior to transfer to IPU showed that the patient had 5cm/4cm blister in the sacrum and 5cm/5cm blisters in bilateral heels. Review of SN comprehensive assessment completed in IPU on 3/22/22 showed wound assessment as follows: Left head scalp 1cm/0.8cm stage II wound, pink, no drainage. Left leg knee 1cm/0.9cm stage II wound, red with scant serous drainage. Medial buttocks coccyx 6.3cm/10cm stage II wound, red with scant serous drainage. Right arm elbow 4cm/1.2cm stage II skin tear, red with scant serous drainage. Right foot 0.8cm/0.6cm red dry scab. Right foot heel intact blister, no measurement Right head scalp 0.6cm/0.6cm dry pink stage II ulcer Right lower back lumbar area 1.3cm/0.8cm red skin tear with scant serous Review of the SN note dated 4/2/22 at 7:20 pm prior to patient discharge from IPU showed wound assessment with following wounds listed without measurement: Left foot heel pressure ulcer with suspected deep tissue injury, dusky color Medial buttocks coccyx stage II pressure ulcer, slough moist wound bed, macerated red/yellow, dusky & black color with serosanguinous drainage. Right elbow pink stage II skin tear Right foot heel purple intact blister Right lower back stage II skin tear, pink color, no drainage. Right medial buttocks stage II pressure ulcer, pink color, no drainage. Right upper buttocks stage II pressure ulcer, pink color, no drainage. Review of SN assessment completed by home-care RN 4 on 4/4/22 showed that the patient had 9.5cm/12cm ulcer in the sacrum, red color with scant serous drainage. 8.5cm/11cm ulcer in right heel, purple, macerated with scant serous drainage. 4cm/5cm/0cm large purple blister in left heel with no drainage, and 1cm blisters in bilateral elbows. During interview with RN 4 on 4/13/22 at 12:03 pm, she stated the following: She assessed patient #3 on 3/22/22 before the patient was sent to the inpatient unit. patient #3 only had blisters in the sacrum about 6cm in diameter, and bilateral heels approximately 4cm in diameter. The blister in the sacrum had a little opening in the center. When she assessed the patient on 4/4/22 after the patient returned to home-care, the blisters were open wounds and the wounds were larger in sizes and the patient also had wounds in the elbows about 1cm in size. Review of Shift Running Document showed that the aides documented repositioning the patient every 2 hours. During interview on 4/13/22 at 2:54 pm with Adm and DON, they were presented with the skin breakdown of patients #2 & #3. Adm stated that when patients are dying, it is expected that the patients would have skin breakdown. Adm acknowledged that imminent death is not a justification for skin breakdown. DON stated that the patients had multiple wounds due to protein deficiency because the patients were not eating. DON was asked if protein deficiency was part of patients diagnoses and if the issue was addressed by the IDT. DON stated that he did not know if protein deficiency was part of the diagnoses. DON also stated that the issue was not discussed by IDT. When asked if not frequently turning the patients can result in skin breakdown or worsening wounds, the DON stated that sometimes the patients refused to be turned. DON was asked what actions they took when a patient consistently refused re-positioning. DON stated that the patients have the right to refuse care. When asked how they supervised to make sure that the patients were turned every two hours, Adm stated that there was documentation that the patients were re-positioned every 2 hours. Review of agency's staffing matrix and nursing assignments from 3/22/22 - 4/13/22 showed that the agency had adequate number of staff on most of the days. The agency had some staffing shortage but not acute shortage to result in poor care. During interview on 4/14/22 at 11:38 am with Adm, she was presented with the above staffing mix and asked if the nursing duties assignment was responsible for the negative care outcomes. Adm stated the following: i) Each shift has two RNs; the charge nurse and the second nurse. The charge nurse was responsible for admissions, and the second RN completed patient assessments and performed all wound care. ii) The LVNs administered medications and the aides provided patients' ADLs. iii) patient assessments, wound care and baths were done by the morning shift for patients in even number rooms, and by the night shift for patients in odd number rooms. iv) The agency management had made a decision to hire two wound care nurses that will be responsible for wound care. Review of agency's policy titled "The Plan of Care, revised 05/2016, read in part: "A written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care." Review of agency's job description of the DON revealed responsibilities that read in part: "Is responsible for supervising the nursing staff, the home health aides, and on-call services." "Assures that a patient's plan of care is executed as written."