Failure to Administer Hospice Comfort Medications to Actively Dying Resident
Penalty
Summary
The deficiency involves the facility’s failure to timely transcribe and administer hospice physician comfort-medication orders for a resident who was actively dying and on hospice services. Facility policies on pain management and medication administration required prompt recognition and assessment of pain, implementation and carrying out of physician orders, and timely administration of medications, with documentation of any reason for not administering medications. The resident had diagnoses including Neurocognitive Disorder with Lewy Bodies, unspecified dementia, anxiety disorder, adult failure to thrive, and was on hospice services with a Do Not Resuscitate status. A quarterly MDS showed the resident was cognitively intact but required moderate to maximal assistance with activities of daily living. On the morning in question, the hospice nurse arrived at approximately 10:30 AM after being contacted by the resident’s daughter about a change in condition. The hospice nurse assessed the resident and documented that the resident had an expected very short life expectancy of days to one week, was near death, used non-verbal indicators of pain, had labored tachypnea at 32 breaths per minute, tachycardic and irregular heart rate at 132 beats per minute, warm and clammy skin, and no oral intake for two days. The hospice nurse determined the resident was actively dying and obtained physician orders for Morphine Sulfate, Ativan (Lorazepam), and Hyoscyamine, with scheduled and PRN dosing for comfort and secretion control. These written orders were faxed to the facility and pharmacy at 11:26 AM, marked urgent. The hospice nurse reported giving verbal orders and specific instructions to the LPN on duty to obtain the medications from the facility’s emergency stock and administer them immediately. Despite these orders and instructions, the medical record and Medication Administration Record showed no evidence that the comfort medications were transcribed into the resident’s MAR or administered at any time before the resident’s death that afternoon. Nurse’s notes by the LPN at 2:02 PM documented elevated heart rate, rapid respirations, lack of eating or drinking, and that the hospice nurse had evaluated the resident and stated the resident was actively dying, but there was no documentation of comfort-medication administration or ongoing monitoring after the hospice visit. The resident’s daughter reported observing her mother with altered mental status, faint moaning, rapid shallow breathing, pale and moist skin, and appearing in distress earlier that morning, and stated that during her absence from approximately midday until about 2:00 PM, a family friend at the bedside did not see staff assess or medicate the resident. Upon her return, the daughter questioned the LPN about the lack of Morphine or other medications and was told the medications were awaiting pharmacy delivery; the hospice nurse later informed the daughter that the medications could have been taken from the facility’s emergency stock. The former DON confirmed that Morphine, Lorazepam, and Hyoscyamine were maintained in emergency stock and could have been used immediately. The DON verified there was no evidence the ordered medications were administered, and the hospice nurse stated that the failure to administer comfort medications caused harm and, in her professional judgment, caused the resident to die in agony.
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