HospitalInspections.org

Based on interview and record review, the facility failed to ensure implementation of the pain management plan of care for 1 (#2) of 4 patients, resulting in less than optimal outcomes. Findings include:

On 12/2/24 at 1700, phone interview with patient #2's sister revealed that the patient had excruciating pain that was not managed during the end of her life. The sister had agreed to signing on to hospice in the hospital, provided that the Physician Pain Management Consultant FF continue to follow the patient for the pain management plan of care due to success in pain management for patient #2. This had not been done. The patient's sister was a physician with hospice experience.

Medical record review revealed that patient #2 was 64-year-old female admitted to the hospital on 6/8/24 for pain crisis of abdominal and back pain related to metastatic colon cancer (initially diagnosed 1/18/23). She had pathologic vertebral fractures and wounds which required interventions. The patient was placed on multiple pain medications, including a continuous intravenous solution of Dilaudid. The plan was to get pain under control then transfer to hospice.

Continued medical record review revealed that on 6/21/24 at 1505, the patient was signed on to inpatient hospice. The hospice nurse met with the sister to clarify that hospice in the hospital was for the patient who required symptom management that could not be managed in less than acute care setting. The hospital and hospice agency had an agreement that clarified that hospital staff provided direct patient care with the oversight of the hospice staff/agency.

The medical record documented that patient's representative (sister) requested the Pain Management/Palliative Care Physician FF to be on board to continue to manage the patient's pain. The Hospice Nurse HH documented in the "Hospice Inpatient Admission Coordination Note dated 6/21/24 at 1420" to consult this physician if needed and Attending Physician CC agreed. The patient was transferred from the oncology unit (8 South) to the medical unit with hospice patients (6 Center) on 6/21/24 at 2245.

Review of pain level scores revealed that on on 6/21/24 at 2245 the patient's pain score was 0-none (0-10 pain scale). On 6/22/24 at 1545, patient #2's pain had spiked up to 7-severe, medications were adjusted. On 6/22/24 at 1733 patient's pain level was 5-moderate. Medications continued to be adjusted by the Attending Physician CC and Physician Assistant DD (PA). No other pain levels were recorded after the level 5. Medications were adjusted and the patient expired at 1926.

On 12/4/24 at approximately 1230, interview with Physician CC revealed that he was the attending physician (internal medicine/geriatrics), but not a hospice/palliative care physician. He stated that he and his PA have taken care of end of life patients with input from the hospice team. The requested Pain Management/Palliative Care Physician FF had not continued to follow and manage the patient's pain. The patient's right to develop and implement the pain management plan of care had not been honored.