Survey Report for 741640

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	741640	A. BUILDING __________ B. WING ______________	06/29/2021
NAME OF PROVIDER OR SUPPLIER	STREET ADDRESS, CITY, STATE, ZIP
REMARKABLE HOSPICE	1645 GREENS PRAIRIE RD SUITE 401B, COLLEGE STATION, TX, 77845
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)
L0505
L0505	34717 Based on interview and record review, the hospice failed to respect a patient's right to have his or her person treated with respect, consideration and recognition of his or her individuality and personal needs in 1 of 1 records reviewed, (Patient #1) in that: 1) The agency failed to send an on-call nurse to assess Patient #1's changing condition within a reasonable amount of time after multiple requests from a family member was made. 2) The agency failed to ensure ordered pain medications were available to Patient #1 in a timely manner. This failure placed Patient #1 at risk for delay in treatment, increased pain, harm, the inability for the hospice to detect and monitor patient problems including decline in status and unmet care needs. Findings Include: Review of the clinical record for Patient #1 revealed a start of care date of 05/11/2021 with a diagnosis of Malignant Neoplasm of Bone and Articular Cartilage, Multiple Myeloma, Unspecified Dementia with Behavioral Disturbance, Major Depressive Disorder and Anxiety Disorder. Review of the plan of care for the time period 05/11/20201 through 08/08/2021 revealed medication orders: Lorazepam 0.5mg tablet. Reason: Anxiety/agitation, Instructions: Administer one tablet by mouth every four hours as needed for anxiety/agitation. Morphine Concentrate 100mg/5ml (20mg/ml) oral solution. Reason: Pain/SOB (shortness of breath), Instructions: Administer 0.5 ml SL (sublingual) every hour as needed for Pain/SOB. Review of the clinical record for Patient #1 revealed documentation entitled "Visit Note Report", dated 05/11/2021, which read in part "PT (Patient) was admitted to (Facility- Identifier D) on 3/29/21 after family became dissatisfied with care in Austin. Since being admitted to (Facility) PT has been hospitalized twice d/t (due to) injury. First one on 4/4/21 for right clavicle injury and the most recent on 5/2/21 for fracture to distal left humeral shaft that is currently in a temporary splint. Facility and PT welcome visits from the following disciplines: RN X2WK and PRN (as needed) Symptom Management." Review of the clinical record for Patientt #1 revealed documentation entitled "Client Coordination Note Report", dated 05/15/2021 at 1031 AM. The document read in part, "This nurse received a phone call from LVN (Identifier C) at Facility (Identifier D) regarding patient (Patient #1). LVN states that the patient's brother (Identifier G) is upset no prn (as needed) medications are available at the facility. LVN further states that the patient has an order for Morphine and Lorazepam, however no medications have been received by the facility. This nurse then assured LVN scripts would be sent over to facility pharmacy for delivery today." The documentation was entered by RN (Identifier B). Review of the clinical record for Patient #1 revealed documentation entitled "Client Coordination Note Report", dated 05/15/2021 at 1106 AM. The document read in part, "This nurse received a phone call from brother (Identifier G). Brother to patient stating that he is very upset that medications are not at the facility to help keep his brother (Patient #1) comfortable and he would like to know who dropped the ball on this. This nurse apologized to (Identifier G) and ensured (assured) him medications have been sent into the pharmacy for STAT (immediate) delivery. (Identifier G) stated he wanted a better explanation of why the medications were not there if the facility had an order for them. This nurse did not find anything in the chart indicating why medication had not been ordered. This nurse then called facility (Identifier D) and spoke with LVN (Identifier C). New order for increase in Tramadol given to LVN. This nurse asked LVN if something happened this morning to exacerbate patient's pain as from previous notes pain appears to be controlled. LVN then told this nurse that this morning facility staff was getting patient up from the bed when they felt something pop. Patient began complaining of increased pain, asked to be left in bed. When this nurse asked where the pop was located LVN reported the facility staff stated they were unsure." The documentation was entered by RN B. Review of the patient record revealed no documentation that a visit was conducted on 05/15/2021 by the RN to assess Client #1 after a report of possible injury and change in the patient's pain level. An Interview was conducted on 06/28/2021 with the Administrator at 1:35 p.m. Surveyor reviewed the plan of care for Patient #1 with the Administrator. Surveyor asked why Morphine and Lorazepam was not provided for Patient #1 as ordered. Administrator stated they are not ordered from the facility pharmacy until they are needed. Surveyor requested documentation that an RN visit was conducted on 05/15/2021 for Patient #1 after receiving multiple calls for reports of uncontrolled pain. Administrator stated "No. RN (Identifier B) relied on the Facility (Identifier D) nurse's assessment who advised that a hospice skilled nurse visit was not needed. Administrator stated RN had multiple patients to see that day. Administrator stated the client's brother (Identifier G) called approximately 17 times on 05/15/2021 and was very irate and cursing. Administrator acknowledged RN (Identifier B) should have made a skilled nurse visit to assess the patient for change in condition and acknowledged ordered pain medications should have been available for Patient #1. A Telephone Interview was conducted on 06/28/2021 with RN (Identifier B) at 3:30 p.m. The RN B discussed what occurred on 05/15/2021 regarding Patient #1. RN B stated she was the on-call nurse on 05/15/2021. RN B stated she notified the physician of the patient's increased pain and obtained an order to increase his dosage of Tramadol while the facility was waiting for Morphine to arrive. RN B confirmed she did not visit Patient #1 to assess for a change in condition. RN B stated "I should have gone. I had multiple patients in crisis that day and one actively dying." RN B stated she felt the patients that had nursing care were less of a priority on that day. Review of the agency's policies and procedures revealed a policy entitled "ONGOING COMPREHENSIVE ASSESSMENTS, Policy No. PCC.331.1, Revised May 2020", which read in part "Ongoing comprehensive assessment should focus on: A. Patient's and family caregiver's response to care. B. Changes in patient condition, level of deterioration. E. Change in patient's and family/caregiver's perceived needs." Review of the agency's policies and procedures revealed a policy entitled," RIGHTS/RESPONSIBILITIES, Policy No. RI.201.1", which read in part "The patient will be informed during the initial assessment visit, in advance of furnishing care of: L. The right to pain management and symptom control. Patient and family/caregiver responsibilities will be explained upon admission and as needed. The patient and family/caregiver are responsible for: B. Reporting unexpected changes in patient's condition. C. Providing feedback regarding services, needs and expectations, asking questions regarding care and services."