Survey Report for 741593

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	741593	A. BUILDING __________ B. WING ______________	09/09/2020
NAME OF PROVIDER OR SUPPLIER	STREET ADDRESS, CITY, STATE, ZIP
SERENE MEADOWS HOSPICE LLC	1140 E WEST PIONEER PKWY SUITE E, ARLINGTON, TX, 76013
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)
L0591
L0591	30245 Based on record review and interviews, the hospice's nursing services failed to ensure that the nursing needs of the patient were met as identified in updated assessments. In 1 (#1) of 1 patient clinical record reviewed where the registered nurse had identified that the patient had staples in the left hip and the patient had developed a wound to the right outer ankle, the nurse failed to meet the nursing needs of the patient. The failure of the registered nurse to ensure that the nursing needs of Patient #1 were met resulted in staples remaining in Patient #1's left hip, 3 months post-surgical hip repair, and an identified wound that did not receive intervention. Findings Include: The agency had a policy titled "Patient Reassessment," labeled PE.4 with a revision date of 11/01/2013. The policy read in part: "Purpose - to establish criteria for reassessment of the patient and family receiving hospice care. Policy - Hospice Interdisciplinary Team will update and revise the Comprehensive Health Assessment, in collaboration with the attending physician, that identifies patient and family needs, identification of services including the management of discomfort, symptom relief, the scope and frequency of services, the patient's progress towards desired outcomes, as well as a reassessment of the patient's response to care...Procedure 1. Patient will be assessed by the nurse at every nursing visit and by appropriate disciplines according to the patient needs...4. The reassessment will be discussed with the patient's physician as appropriate. Assessment information related to the non-terminal diagnosis will be reported to the responsible physician. The agency had a policy titled "Interdisciplinary Team, Coordination of Care and Services," labeled TX.8 with a revision date of 01/15/2009. The policy read in part; "Purpose - to describe the process by which the Interdisciplinary Team (IDT) ensures the monitoring and coordination of the patient/family's specific needs and problems. Policy - the agency will designate and Interdisciplinary Team, who, in consultation with the patient's attending physician, work together to meet the physical, medical, psychosocial, emotional, and spiritual needs of the hospice patients and families facing terminal illness and bereavement...The IDT will include...1. A doctor of medicine or osteopathy (who is employed or under contract with the hospice), 2. A registered nurse...A registered nurse, who is a member of the IDT, will be designated to provide coordination of care and will ensure continuous assessment of each patient's/family's needs, and implementation of the IDT plans of care....Procedure: 1. Plan of Care 1.1 All hospice care and services furnished to patient/families will follow and individualized written POC established by the hospice IDT in collaboration with the attending physician, the patient or representative, and the primary caregiver in accordance with the patient's needs...3. Coordination of Services. 3.1 Include, at least, the RN (registered nurse), Physician, Social Worker, and Counselor... 3.2 Develop, coordinate, supervise, and evaluate the care and services provided to patients and families, regardless of their treatment setting. Ensure that the care and services are provided in accordance with the POC (Plan of Care). Ensure that the care and services provided are based on all assessments of the patient/family needs....3.5. Oversight of POC by the Medical Director...3.7 Provide for and ensure the ongoing sharing of information between all disciplines providing care and services..." Patient#1: Patient#1's clinical record contained a document titled, "Hospice Initial Plan of Care/Physician Orders" dated 2/26/2020 and signed by Employee B, a registered nurse. The Plan of Care listed Senile Degeneration of the Brain as the terminal diagnosis with Cerebral Vascular Accident, Frequent Falls, and Chronic Obstructive Pulmonary Disease as secondary conditions. The initial Plan of Care was signed by the agency's Medical Director as the hospice physician and as the attending physician. NURSING VISITS Patient#1's clinical record contained the start of care initial assessment conducted by Employee B on 2/26/2020. Employee B documented that Patient#1's skin had fair skin turgor, skin was pale, warm, and dry. Patient#1 had a skilled nurse visit conducted on 4/15/2020 by Employee A, a registered nurse. Employee A documented that Patient#1 complained of left hip pain after a fall in the bedroom; x-rays indicated that Patient#1 had a left hip fracture; and Patient#1 was transferred to the hospital for surgical intervention. Patient#1's clinical record contained a document titled "Initial Nursing Assessment, part of the Comprehensive Assessment" that a was comprehensive assessment conducted on 5/7/2020 by Employee B, three weeks after Patient#1 had been hospitalized for a hip fracture. Employee B documented that the old surgical site was not assessed because Patient#1 was at the table eating breakfast. Employee B documented that a verbal report was given to (Employee A, a registered nurse) to assess the old surgical site at the next visit. Employee A's first visit after Patient#1 returned to services was on 5/19/2020, 12 days after Patient#1 returned to the hospice's services. Employee A, a registered nurse, conducted skilled nurse visits on 5/19/2020 and 5/26/2020. Employee A documented that Patient#1 had "No skin issues" at the visits conducted on 5/19/2020 and 5/26/2020. Employee A failed to assess the left hip surgical site. Patient#1's clinical record contained a hospital discharge summary dated 6/2/2020 through 6/4/2020. The hospital discharge summary indicated that Patient#1 had been hospitalized for a Transient Ischemic Attack. Employee B, a registered nurse, conducted a skilled nurse visit on 6/8/2020, after Patient#1 had been discharged from the hospital. Employee B documented that Patient#1's skin was warm, dry, and fair. Employee B documented that Patient#1 was not cooperative during the skilled nurse visit. Employee B did not document an assessment of Patient#1's left hip surgical site. Employee A, a registered nurse, conducted a skilled nurse visit on 6/11/2020. Employee A documented that Patient#1 had staples in left hip from hip fracture surgery. Employee A failed to notify the physician. Employee A conducted a skilled nurse visit on 6/18/2020. Employee A failed to assess Patient#1's left hip staple site. Employee A conducted a skilled nurse visit on 6/23/2020. Employee A failed to assess Patient#1's left hip staple site. Employee A documented that Patient#1 had Unstageable eschar to the right outer heel that measured 2.5 by 2.0 cm (centimeter). Employee A failed to notify the physician. Employee B conducted a skilled nurse visit on 7/1/2020. Employee B did not document an assessment of Patient#1's staple site and right outer heel. Employee B conducted a skilled nurse visit on 7/8/2020. Employee B documented the presence of a pressure ulcer but did not document an assessment of Patient#1's left hip staple site. Employee A documented on a nursing note on 7/14/2020 that the house manager called and stated that Patient#1 had seizures. Employee A documented arrival to the group home and "told (unreadable) and sent pt (patient) to hospital via ambulance." Employee A failed to ensure the nursing needs of Patient #1 were met when Employee A failed to notify the physician that staples remained in Patient#1's left hip from a left hip fracture repair that had occurred in April 2020 and failed to notify the physician that Patient#1 had a wound with eschar to the right outer heel. IDT Patient#1's clinical record contained documentation of IDT meetings. The meeting occurred on the following dates: -5/11/2020 - return to services 3 weeks post-surgery for left hip fracture repair. Skilled nurse visits once a week. -5/25/2020 -Skilled nurse visits once a week. -6/22/2020 - Skilled nurse visits once a week. Employee A documented on 6/11/2020 that Patient#1 had staples in the left hip that were from a left hip fracture surgical repair in April 2020. Employee A failed to ensure that Patient #1's nursing needs were met when Employee A failed to notify the physician that Patient #1 had staples in the left hip 2 months after left hip surgery. -7/6/2020 - Skilled nurse visits once a week. Employee A failed to ensure that Patient#1's nursing needs were met when Employee A failed to notify the physician that Patient #1 had developed a wound with eschar to the right outer heel. Employee A failed to ensure Patient #1's nursing needs were met when Employee A failed to follow the policies of the hospice. The policy titled "Interdisciplinary Team, Coordination of Care and Services" indicated that a registered nurse that was a member of the IDT, would be designated to provide coordination of care and would ensure continuous assessment of each patient's needs. Employee A failed to ensure Patient #1's nursing needs were met when Employee A failed to follow the policy titled "Patient Reassessment' which indicated that the nurse would assess the patient at every nursing visit and that the reassessment would be discussed with the patient's physician as appropriate and that information related to the non-terminal diagnosis would be reported to the responsible physician. The hospice's Medical Director was designated as the hospice physician and the attending physician per the Initial Plan of Care. The hospice provided the surveyor with documentation of their investigation. The document was unsigned. The hospice's documentation indicated that the agency discovered that Patient #1 had staples on July 15, 2020 after Patient #1 had been hospitalized. The hospice documented that the agency audited the skilled nursing notes and discovered that Employee A had documented that Patient #1 had staples in the left hip. The hospice documented that the agency received Patient #1 back on services on 5/7/2020, 23 days after Patient #1 had hip surgery. The hospice documented that staples should be removed 7 - 14 days post surgery. The surveyor had an interview on 9/9/2020 at approximately 11:10 a.m. with Employee C, the Administrator. Employee C told the surveyor that the hospice knew that there was an issue with the staples.