Every finding on record at Adventa Hospice, LLC.

Based on observation, staff interviews, and review of agency policy and procedures, it was determined that the Certified Nursing Aide (CNA) AA failed to follow standard precautions to prevent the transmission of infectious by using dirty glove to apply barrier cream during bed bath for one patient (P) (P#16) of 19 sampled patients. --- The Findings include: Review of the policy titled, ";Hand Hygiene," Policy: PCP-001, review date 6/20/23 revealed, ";Change gloves during patient care if moving from a contaminated body site to a clean body site." During a home visit with P#16 on 3/19/2024 at 10:42 a.m., observed CNA AA perform complete bed bath care to P#16. During the bathing procedure, P#16 had a bowel movement. CNA AA wiped patients bottom with wet wipes, changed left handed glove and failed to change the right-hand glove. CNA AA used the left-hand glove to get barrier cream, squeezed it in right hand dirty glove and applied it to rub the bottom area of P#16. On 3/19/2024 at 10:58 a.m., an interview was conducted with CNA AA who confirmed that she did not change the right-hand dirty glove, and that she applied barrier cream to P#16s bottom with right hand dirty glove. CNA AA revealed that she changed gloves many times and she was confused that she did not change the right-hand dirty glove before she applied the barrier cream to P#16s bottom during the bathing procedure. During an interview on 3/19/2024 at 3:20 p.m., the Director of Nursing (DON), acknowledged that the CNA AA did not follow acceptable standards for infection control to prevent transmission of infectious diseases by using the dirty glove to apply barrier cream to P#16s bottom.

Based on observation, record review, staff interviews, and review of agency policy and procedures, it was determined that the agency failed to shampoo patients hair each visit according to the care plan for one patient (P) (P#16) of 19 sampled patients. --- The Findings include: Review of the policy titled, ";Hospice Plan of Care," Policy: AA-005, last reviewed 09/28/23 reveals ";Changes in the patients POC are based on reassessment data and significant changes. A significant change is defined as a change in frequency or level of care. Changes in the patients condition will be reflected in the patients ongoing POC and shall be made in writing by the Clinical Manager or the Registered Nurse overseeing that patients care. Verbal orders must be recorded in accordance with the agency policy and included in the POC. Changes in the patients condition must be documented in the medical record (in either written or electronic format) on an ongoing basis and at the interdisciplinary team (IDT) meeting. All Plan of Care Documents will be signed by the appropriate hospice staff members." . Review of the document titled, ";Aide Care Plan Report," effective date of current Aide Care Plan: 3/18/24, reveals personal care with shampoo every visit. On 3/19/2024 at 9:45 a.m., observed Certified Nurse Aide (CNA) AA perform complete bed bath to P#16. CNA AA failed to shampoo patients hair according to aide care plan report. On 3/19/2024 at 10:58 a.m., an interview was conducted with CNA AA, who confirmed that she did not shampoo patients hair, because she shampoos patients hair once a week on every Thursdays. On 3/19/2024 at 3:00 p.m., an interview was conducted with the Director of Nursing (DON), who stated that the aide was to perform activities of daily living, including grooming, and hair shampoo according to plan of care and per agency policy and procedures. DON also said that the agency would conduct in-service training for the hospice staff immediately.