Complaint Investigation Report

Regarding the allegation: Failure to communicate resident change of condition to hospice in a timely manner

It was alleged that facility staff failed to communicate R1’s change of condition in a timely manner as it related to R1’s aggression and behavioral challenges. As a result of R1’s behavioral challenges, it was alleged that the facility assisted R1 with the self-administration of medication without prior approval or against what was prescribed by hospice. Interviews conducted with a hospice representative noted that they often felt they received updates regarding R1’s progression during their regularly scheduled visits. It was at that point, per the interviews and record review of hospice nursing notes, that hospice was notified of R1’s behavioral changes. Interviews with facility nursing staff confirmed that staff may wait to provide updates to an outside agency if they knew they were visiting the facility regularly.

A review of the facility’s ‘Service Plan Conference Sheet’ dated 11/4/2021 indicated that a conversation was had regarding R1’s agitation and behaviors. As a result of that care plan meeting, a medication change was made to address R1’s agitation. Records review indicated that R1’s ‘as needed’ medication (PRN) for Seroquel was discontinued on 11/05/2021, and a routine Lorazepam (Ativan) was prescribed twice a day. The LPA reviewed hospice nursing notes from 11/08/2021. Records from the 11/08/2021 visit indicated that facility staff communicated to a hospice representative that they had called in a ‘stat delivery’ for Seroquel over the weekend due to R1’s behaviors (Saturday, 11/06/2021 or Sunday 11/07/2021). An interview with the hospice representative and hospice nursing notes revealed that hospice reminded facility staff that the Seroquel had been discontinued. The LPA reviewed the physician’s orders and confirmed that the facility had received a written order from R1's hospice to discontinue the Seroquel, and to start Lorazepam (Ativan) twice a day. The LPA reviewed R1’s electronic medication administration record (eMAR) and observed that there were no logged entries indicating that the Seroquel was administered on 11/06/2021, 11/07/2021, or 11/08/2021. However, the dates following the 11/08/2021 date were notated as ‘discontinued’.

The LPA reviewed hospice nursing notes from a 11/24/2021 visit. Records from the 11/24/2021 visit indicated that facility staff informed the hospice representative that the staff had assisted R1 with the self-administration of an additional PRN Seroquel every night prior to the 11/24 visit to R1 due to increased agitation. This allegedly was not reported to hospice nor R1’s responsible party until the hospice representative went to the facility on 11/24/2021. The LPA reviewed R1’s electronic medication administration record (eMAR) and observed that there were no entries indicating that R1 was assisted with the self-administration of PRN Seroquel from 11/17/2021 – 11/28/2021. However, the dates following the 11/28/2021 date were notated as ‘discontinued’.