Survey Report for 741755

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	741755	A. BUILDING __________ B. WING ______________	10/02/2019
NAME OF PROVIDER OR SUPPLIER	STREET ADDRESS, CITY, STATE, ZIP
IPR HEALTHCARE SYSTEM INC	8830 INTERCHANGE DRIVE, HOUSTON, TX, 77054
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)
L0509
L0509	26943 Based on record review and interview, the agency failed to document receipt of a complaint, investigate and document all components of a complaint investigation for 1 of 4 patients (#3) whose records were reviewed, in that: Patient #3's clinical record contained documentation that Patient #3's daughter (#100) complained that Patient #3 was being overmedicated by Patient #3's spouse #102. The agency failed to document on the agency's complaint log book receipt of the complaint, its investigation, and all steps taken to resolve the complaint. The failure of the agency to ensure the investigation and documentation of all components of complaints received, could potentially result in concerns related to client care not being addressed or investigated and harm being caused to agency patients. The agency's 4 sampled clients could be affected by this failure Findings include: Record review of the agency's complaint log binder revealed the agency documented that they have not received any complaints for 2019. Record review of intake #155011 revealed the following: "(Patient #3) has chronic obstructive pulmonary disease and was placed on hospice care with (Agency). There were concerns about (Patient #3) being overmedicated and hospice staff instructing (Spouse #102) to continue to give (Patient #3) medications. (Patient #3) had become bed bound and mostly unresponsive so hospice staff notified (Patient #3's) children to prepare her funeral. Prior to hospice staff notifying (Patient #3's) children about her condition, (Patient #3) had been fine shortly before. Hospice staff were instructing (Spouse #102) to give (Patient #3) morphine and multiple medications, every 2 to 4 hours, which they listed on a piece of cardstock for (Spouse #102). The hospice (LVN #60) was the one writing the orders for the medications, which a doctor has said an LVN cannot do. The hospice nurse was (RN #61) ... (Patient #3's) doctor, who only wants her to be given blood pressure medication as needed ... prior to the hospice agency being fired (Spouse #102) called the hospice agency and said (Patient #3) was agitated so they had (Spouse 102) give her more morphine and the next morning he was giving her more pills. (Patient #3) had not been agitated and had hardly moved for 8 hours. (Patient #3) now is alert and walking around. There are concerns about (Spouse #102) and his ability to even care for himself, let alone be able to administer (Patient #3's) medications ..." Patient #3 Record review of discharged Patient #3's clinical record (CR) revealed Patient #3 was admitted to hospice on 6/08/19 and the terminal diagnosis listed was end stage chronic obstructive pulmonary disease and related diagnoses of hypertension, anxiety disorder and gastroesophageal reflux disease. Record review of MSW #55's Psychosocial Visit Record dated 9/12/19 which reads in part, "Caregiver Information ... Patient is showing remarkable decline. Recently had CC care due to unmanaged s/s of agitation and falls ... The patient's family are not involved with the patient's care at all. The patient's Spouse (#102) is elderly and has some significant problems related to increased drinking and possibly changes in his cognitive status. The care of the Patient is very stressful for the Spouse (#102) ... Care Plan ... The Spouse (#102) was asked if he has any special request for the Patient or himself. He indicated that he did not. Spouse (#102) encouraged not to drink while this patient is transitioning as she has no one to help gauge her problem issues except for him. Even though there is a Daughter (#100) who resides on the same property. The Nursing staff indicates that the patient's adult children will not come to assist in the Patient's care. Spouse (#102) verbalized understanding." Record review of the following Progress Notes signed by LVN #60 revealed the following: - 9/13/19 (1:30 a.m.) - "Patient's husband called SN at 1:30 a.m., very upset, states that she (Patient #3) is very agitated and trying to get out of bed, states he gave her v 0.25 mg pre filled syringe of morphine about 1 ½ hours ago and he doesn't know what to do. Instructed him to give her another 0.25 pre - filled syringe of morphine, he was concerned that would be too much, explained that she also has 0.5 mg morphine pre - filled syringe ordered, that with what he gave her and what I'm telling him to give will equal that so it will not be too much - verbalized understanding. Instructed him that if this does not calm her and she continues to be agitated to try to get out of bed to call me. He called me back at 2 a.m. and said she is resting now." - 9/16/19 (10:45 a.m.) - "(LVN #60) met (RN #61) at patient's home to discuss patient comfort care. Patient did not have her oxygen on but was put on by RN. The Daughter (#100) was very rude, abrasive, when we attempted to answer her questions she would interrupt and not let you answer, was demanding to know why her mom was being medicated. Tried to explain that she is hallucinating, has had falls, has increased pain and anxiety but the Daughter (#100) stated she does not. The RN was telling them what Hospice guidelines are, exactly what we have done to treat their mother then the Son (#101) became hostile, was leaning towards her and pointing his finger in her face. The situation became very tense. They stated we should be cleaning the home and why are we allowing a 90 year-old to provide her care. Attempted to explain that he has done everything we ask of him to do correctly, that he keeps a record of any medications he gives her, that all medications are counted at each SN visit and their [sic] has been no discrepancies and stays in contact with the LVN/SN for any questions. Also tried to explain that SN did speak to Daughter (#100) to inquire if she/any of her siblings or grandchildren could offer him assistance but was told they work and at this point in her career she can not miss work. We were told they will be taking her to a Dr. (doctor) that specializes in Hospice and will notify us of what their decision is. " - 9/16/19 (4:30 p.m.) - "(LVN #60 and RN #61) arrived at patient's home. As we were walking into patients [sic] bedroom patient almost fell but fell backward onto her hospital bed. Patient asked her husband who was in the kitchen but their [sic] was no one [their]. The Son (#101) and Daughter (#100) arrived, when I told the Daughter (#100) she almost fell and was seeing someone who was not their [sic] she raised her voice and said she (Patient #3) did not. The (Agency) binder was not in the home. Daughter (#100) and Son (#101) stated the binder/all documentation, all medications have been taken and will be investigated. (RN #61) had patient's Son (#101) sign all necessary forms to discharge patient from (Agency). As we were leaving patient's Daughter (#100) stated this is her property and we are not allowed on her property at any time." Interview on 10/2/19 at 2:16 p.m., Surveyor asked Supervising Nurse #52 regarding Patient #3. Supervising Nurse #52 stated Patient #3 was a readmitted to their agency for hospice services. She revealed that Patient #3's Son (#101) has medical power of attorney over her and that Patient #3's children were not involved directly with her care. Supervising Nurse #52 stated that Patient #3 was of sound mind and was the one who signed the admission paperworks from the first and second admission. Supervising Nurse #52 stated that Patient #3 has a Daughter (#100) that lives in a home which is walking distance from Patient #3 but that there had been tension between Patient #3's children and Patient #3's Spouse (#102) due to personal issues that happened in the past. Supervising Nurse #52 stated she has only seen Patient #3's Daughter (#100) once even if she lives in the same property. She stated that Daughter (#100) thinks we should clean Patient #3's house. Supervising Nurse #52 stated that that there had been increased tension as well because Patient #3's children thought that Patient #3's Spouse (#102) was drinking again. Supervising Nurse #52 stated that when Patient #3 was falling and hallucinating, the hospice decided to do eight hours of continuous comfort care and because they believed Patient #3 going through terminal transition. She stated that Patient #3's Spouse (#102) told them that Patient #3's children did not want Patient #3 to be medicated. Supervising Nurse #52 revealed that they went over all of Patient #3's medications with her Spouse (#102) and he did fine. Surveyor asked if there were issues with Patient #3's Spouse (#102)'s ability to take care of Patient #3. Supervising Nurse #52 stated, "No" and that Patient #3's Spouse (#102) followed their instructions with no issues and that he calls the agency for anything related to Patient #3's care. Supervising Nurse #52 stated on Sunday 9/15/19, they could not get a hold of Patient #3 by telephone. She stated then asked RN #61 and LVN #60 to check on Patient #3 the following day, Monday 9/16/19. Supervising Nurse #52 stated that was when the RN #61 and LVN #60 reported to her incident when they were confronted by Patient #3's children (#100 and #101) in the home and that they could not find the agency's agency binder and Patient #3's medications because it was taken by Patient #3's children. She stated that later in the afternoon the same day, the nurses went back again for Son #101 to sign the hospice revocation. She stated that Patient #3 cried when hospice was revoked and when LVN #60 was told not to come back to Patient #3's home especially because LVN #60 had been her nurse for a long time. Supervising Nurse #52 stated they did not observe Patient #3's Spouse (#102) to be intoxicated or having alcohol in the home and although the home is a bit cluttered, it was a lot better from the first time they admitted Patient #3 to the agency. Surveyor asked why the agency did not document the receipt of the complaint and document all components of their investigation to resolve the complaint. Supervising Nurse #52 stated the reason it was not documented on the complaint log was because they did not feel it was a complaint because Patient #3's Daughter (#100) did not call to make a complaint. Supervising Nurse #52 stated they felt it was more of an issue between Patient #3's children and Patient #3's Spouse (#102). At 3:05 p.m., Supervising Nurse #52 revealed they could not dispose Patient #3's medications because Patient #3's Daughter (#100) has them. She stated that she still feels it was an issue between family members and that it was not a complaint because Patient #3's Spouse (#102) followed instructions given to him and there was no medication discrepancy. Supervising Nurse #52 stated that Alternate Administrator also spoke with Patient #3's Son (#101) (MPOA) and he did not reveal to him in any way that there was a complaint. Interview on 10/2/19 at 3:11 p.m., Surveyor asked RN #61 about Patient #3. RN #61 revealed that she started seeing Patient #3 around August 2019 and that she did not know that there are been personal issues between Patient #3's children against Patient #3's Spouse (#102) until 9/12/19. RN #61 stated that Patient #3's Son (#101) was contacted about the continuous (comfort) care provided to Patient #3 on 9/12/19 due to the patient's recent falls, hallucinations, agitation and no longer able to follow instructions. RN #61 stated that when the followed up Monday morning (9/16/19), she met Patient #3's Son (#101) and Daughter (#100) who came over and was condescending and pointing a finger on her face. RN #61 stated that they were saying that Patient #3 was being overmedicated and that they were not cleaning patient's house. RN #61 stated she tried to explain to them but Patient #3's children were not willing to listen and told her they were going to take Patient #3 for a doctor's appointment. RN #61 stated went see Supervising Nurse #52 and also notified Alternate Administrator about the situation. RN #61 stated there having issues with Patient #3's Spouse (#102) giving the medication to Patient #3. RN #61 stated that she did not see Patient #3's Spouse (#102) to be unfit in taking care of Patient #3. She stated although Patient #3's Spouse (#102) is 90 years old, he was able to verbalize instructions given to him, able to return demonstrate instructions with the preparation of the medications, and she feel confident about him taking care of Patient #3. RN #61 stated that Patient #3 was administering her own medications not until they initiated continuous care. RN #61 stated that Patient #3 was feeling depressed about the conflict between her Spouse (#102) and children, however she was just happy that her children were there to see her. Interview on 10/2/19 at 3:33 p.m., Alternate Administrator revealed that he had a conversation with Patient #3's Son (#101) (MPOA) said they were just leaving the doctor's office, that he was worried about Patient #3. Alternate Administrator stated Patient #3's Son (#101) told him everything was okay and they wanted a second opinion for Patient #3. Alternate Administrator stated Patient #3's Son (#101) wanted to continue hospice services with their agency but later Patient #3's Daughter (#100) called and spoke to RN #61 that they will be revoking hospice for Patient #3. Surveyor asked why there was no documentation on the agency's complaint log book regarding receipt of the complaint and the agency's effort to resolve the complaint from Patient #3's family members. Alternate Administrator stated that there was no evidence that Patient #3 was being overmedicated and because Patient #3's Son (#101) said they were going to continue with their service. Alternate Administrator stated that it came out of nowhere when Patient #3's children came to confront their nurses about the medication. Alternate Administrator stated he was just very concerned that they did not have all of Patient #3's medications to properly dispose of it. Alternate Administrator stated that from his conversation with Patient #3's Son (#101), it seemed like everything was okay and that Patient #3's Son (#101) clearly stated to him he wanted for the nurse to see Patient #3 since he lives far from Patient #3. Surveyor asked if he documented his conversation with Patient #3's Son (#101), Alternate Administrator stated he did not and that that he now understands the need to document this on their complaint log. Record review of the agency's written policy on Resolution of Patient Conflicts, Grievances or Complaints reads in part, "Purpose: I. To establish a procedure and ensure the patient's/caregiver's and or guardian's right to voice conflicts, file a complaint, and provide and to make recommendations for resolutions of conflicts without fear of retaliation, coercion, discrimination, reprisal or unreasonable interruption of care ... Policy: I. The Agency will receive, document, address and resolve conflicts that involve complaints made by a patient, a patient's family or guardian, or a patient's health care provider. II. The Agency will provide a written statement that informs the client of the complaint procedure at time of admission ... Procedure: I. The Agency will investigate complaints made by a patient, a patient's family or guardian, or a patient's health care provider regarding: A. Treatment or care that was furnished by Agency. B. Treatment or care that Agency failed to furnish ... IV. The Agency will document the receipt of the complaint and initiate a complaint investigation within ten (10) calendar days. Management will be informed of complaint. A. If the grievance is due to perceived discrimination, the Civil Rights Coordinator will be informed, as well. B. Documentation will include, but not be limited to, the name and address of the person filing, the nature of the complaint, and the remedy/relief the person is seeking. V. The Agency will complete the investigation and documentation within thirty (30) days after the receipt of the complaint, unless Agency has and documents reasonable cause for the delay ... VI. The Agency will involve the patient/caregiver and/or the patient's physician as appropriate to reach a resolution ... X. All actions taken and follow - up performed will be documented on a complaint form, as well as reported to the management staff ... XIV. A summary report of grievances/complaints and their outcomes will be submitted quarterly to the governing body/owner. This information is included in the QAPI annual report. XV. The Administrator of the Agency has ultimate responsibility for resolution of patient complaints."
L0521
L0521	26943 Based on interview and record review, the hospice failed to document in the comprehensive assessment for 1 of 4 patients (#3), the complete physical, psychosocial, emotional, and spiritual care needs related to management of the terminal illness in that: Patient #3's comprehensive assessment failed to include the psychosocial and emotional assessment completed by the Medical Social Worker (MSW). This failure put the psychosocial and emotional needs of Patient #3 and the family at risk of not being met and or resolved during their end of life care. The agency's 4 sampled patients could be affected by this failure. Findings include: Patient #3 Record review of discharged Patient #3's clinical record (CR) revealed Patient #3 was admitted to hospice on 6/08/19 and the terminal diagnosis listed was End stage chronic obstructive pulmonary disease and related diagnoses of Hypertension, Anxiety disorder and Gastroesophageal reflux disease. Record review of the Hospice Initial Plan of Care/Physician's Orders signed by MD revealed the following orders reads in part: - Nurse to evaluate/monitor/assess needs two times per - Social Worker to counsel/assess psychosocial/social related to illness/assess/financial/refer as appropriate. - Chaplain/counselor assess spiritual needs. Record review of Patient #3's CR showed an Initial Nursing Assessment was completed on 6/8/19 by Supervising Nurse #52. The CR did not contain documentation that psychosocial and emotional assessment was completed by MSW #55 as part of the initial comprehensive assessment. There was also no documentation if Patient #3 refused services from MSW #55. Interview on 10/02/19 at 2:16 p.m., Surveyor asked Supervising Nurse #52 for MSW #55's psychosocial and emotional assessment as part of Patient #3's initial comprehensive assessment. Supervising Nurse #52 stated that she believes Patient #3 refused chaplain services, but she will look into the MSW assessment. Interview on 10/02/19 at 4:45 p.m., Supervising Nurse #52 stated that Patient #3 refused services from MSW #55 but it was not documented on the clinical record. Record review of the agency's written policy on Initial Patient Assessments/Patient Admission reads in part, "Purpose: To identify patient needs and assess the patient's residence as a basis for planning individualized, outcome - oriented care. Policy ...The IDT, in consultation with the patient's attending physician, will perform and make available to each patient admitted, a patient - specific Comprehensive Health Assessment, no later than five (5) calendar days after the election of hospice care. The Comprehensive Health Assessment will identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice the hospice patient's well - being, comfort, and dignity throughout the dying process."