Every finding on record at Aaa of Western Ark Inc Mena Hospice

Based on a review of clinical records and staff interviews, it was determined that the agency failed to supervise and assess the quality of care and services through on-site Supervisory Aide Visits (SAV) every 14 days in two (#8 and #10) of thirteen (#1-#13) clinical records reviewed with Hospice Aide (HA) services. This lack of supervision by the RN had the potential to place all patients receiving HA services at risk for adverse outcomes due to possible delays in the discovery of noncompliance with the Plan of Care by the HA or possible changes in the needs of the patient and family.  Findings follow: --- A review of clinical record #8, with a start of care (SOC) date of 04/09/24, revealed a patient diagnosed with Chronic Obstructive Pulmonary Disease. Review of a document titled "Hospice Current Plan of Care" with a certification period from 04/04/2025 to 06/02/2025, revealed orders for a Hospice Aide (HA). Supervisory aide visits conducted 04/02/25 and 04/23/25 (7 days past the required 14-day time frame).A review of clinical record #10, with a SOC date of 11/01/24, revealed a patient diagnosed with Hypertensive Heart Disease with Heart Failure. Review of a document titled "Hospice Plan of Care" with a certification period from 11/01/2024 to 01/29/25, revealed orders for a HA. Supervisory aide visits conducted on 12/17/24 and 01/02/25 (2 days past the required 14-day time frame).During an interview on 01/09/25 at 10:00 AM, Agency Personnel #1 and #2 confirmed the Registered Nurse failed to perform Supervisory Aide Visits every fourteen days as required.

Based on clinical record review and staff interview, it was determined the Agency failed to ensure a process was in place for checking all medications for actual or potential drug interactions in 7 (#1, #3, #5, #6, #9, #10 and #11) of 7 (#1, #3, #5, #6, #9, #10 and #11) clinical records of patients currently utilizing oxygen. This failed practice by the Agency presented a risk to all patients on census currently requiring oxygen therapy as the failure to conduct a complete medication review potentially prevented the Interdisciplinary Team from making informed decisions regarding the patient's medication regimen. Findings follow: --- A. Review of clinical record #1, with a start of care (SOC) of 11/04/22, revealed a patient with a diagnosis of Neurocognitive Disorder with Lewy Bodies. A document titled "Patient Medication List" revealed "oxygen, 2 Liter, Nasal, Daily, as needed for shortness of breath/comfort". A document titled "Medication Screenings" revealed no documentation to indicate oxygen had been checked for actual or potential drug interactions. B. Review of clinical record #3, with a SOC of 08/12/22, revealed a patient with a diagnosis of Heart Failure. A document titled "Patient Medication List" revealed "oxygen, 4 Liter, Nasal, continuous". A document titled "Medication Screenings" revealed no documentation to indicate oxygen had been checked for actual or potential drug interactions. C. Review of clinical record #5, with a SOC of 07/25/22, revealed a patient with a diagnosis of Hypertensive Heart Disease with Heart Failure. A document titled "Patient Medication List" revealed "oxygen, 2 Liters/Minute, Nasal, Daily, as needed for dyspnea". A document titled "Medication Screenings" revealed no documentation to indicate oxygen had been checked for actual or potential drug interactions. D. Review of clinical record #6, with a SOC of 08/10/22, revealed a patient with a diagnosis of End Stage Renal Disease. A document titled "Patient Medication List" revealed "Oxygen, 2 Liter, Nasal, Daily, as needed for difficulty breathing". A document titled "Medication Screenings" revealed no documentation to indicate oxygen had been checked for actual or potential drug interactions. E. Review of clinical record #9, with a SOC of 10/06/22, revealed a patient with a diagnosis of Chronic Obstructive Pulmonary Disease. A document titled "Patient Medication List" revealed "Oxygen, 4 Liter, Nasal, continuous". A document titled "Medication Screenings" revealed no documentation to indicate oxygen had been checked for actual or potential drug interactions. F. Review of clinical record #10, with a SOC of 12/03/21, revealed a patient with a diagnosis of Chronic Obstructive Pulmonary Disease. A document titled "Patient Medication List" revealed "Oxygen, 2 Liter, Nasal, Daily, as needed for shortness of breath". A document titled "Medication Screenings" revealed no documentation to indicate oxygen had been checked for actual or potential drug interactions. G. Review of clinical record #11, with a SOC of 10/26/22, revealed a patient with a diagnosis of Malignant Neoplasm of Cardia. A document titled "Patient Medication List" revealed "Oxygen, 2 Liter, Nasal, continuous". A document titled "Medication Screenings" revealed no documentation to indicate oxygen had been checked for actual or potential drug interactions. H. An interview on 12/07/22 at 9:30 AM with Agency Personnel #2 and #3 confirmed oxygen had not been checked for actual or potential drug interactions.

Based on clinical record review and staff interview, it was determined the Registered Nurse (RN) failed to supervise and assess the quality of care and services through supervisory aide visits (SAV) every 14 days in 2 (#8 and #9) of 4 (#3, #5, #8 and #9) current patients records reviewed with Hospice Aide (HA) services. This lack of supervision by the RN had the potential to place all patients receiving HA services at risk for adverse outcomes due to possible delays in the discovery of noncompliance with the Plan of Care by the HA or possible changes in the needs of the patient and family. Findings follow: --- Review of clinical record #8, with a start of care (SOC) of 10/03/22 and a diagnosis of Alzheimer's revealed orders for HA services two times per week. HA services began on 10/04/22. The RN documented on a form titled, "HSN Visit" first SAV conducted on 10/20/22 (2 days late). Review of clinical record #9, with a SOC of 10/06/22 and a diagnosis of Chronic Obstructive Pulmonary Disease revealed orders for HA services two time per week. The RN documented on a form titled, "HSN Visit" SAVs conducted on 10/24/22 and 11/08/22 (1 day late). An interview on 12/08/22 at 10:00 AM with Agency Personnel #2 and #4 confirmed the late SAVs.