Every finding on record at Agape Care Louisiana, LLC

It is required that each patient’s individualized written plan of care: includes all services necessary for the palliation and management of the terminal illness, including measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. In 12 of 19 (63%) clinical records reviewed, the agency did not ensure that the patient's plan of care included measurable outcomes anticipated from implementing and coordinating the plan of care. Clinical Record 1: The patient elected hospice care on 03/06/2024 with a primary diagnosis of chronic obstructive pulmonary disease (COPD). On admission the nursing comprehensive assessment documented "altered cardiopulmonary status." The POC documented the patient's goal "Patient exhibits reduction/relief of any cardiopulmonary symptoms." This goal did not document a measurable outcome. Clinical Record 2: The patient elected hospice care on 06/11/2024 with a primary diagnosis of diffuse traumatic brain injury (TBI) with (W) loss of consciousness (LOC) of unspecified (UNSP) duration sequela. On admission the nursing comprehensive assessment documented "Safety Needs." The POC documented the patient's goal "Pt/cg will verbalize, demonstrates understanding of proper safety measures." This goal did not document a measurable outcome. Clinical Record 3: The patient elected hospice care on 09/20/2023 with the diagnosis of encephalopathy Unspecified. On admission the nursing comprehensive assessment identified the patient's goal "a need for safety measures." The POC documented the patient's goal "Pt/cg verbalizes, demonstrates understanding of proper safety measures." This goal did not document a measurable outcome. Clinical Record 4: The patient elected hospice care on 03/07/2024 with the diagnosis of Alzheimer's Disease. On admission the nursing comprehensive assessment documented "Altered Nutrition/Hydration." The POC documented the patient's goal "Caregiver (Cg) verbalizes, understanding of need for adequate nutrition/hydration as tolerated." This goal did not document a measurable outcome. Clinical Record 5: The patient elected hospice care on 02/23/2024 with the diagnosis of unspecified cirrhosis of liver. On admission the nursing comprehensive assessment documented "Alteration in comfort pain." The POC documented the patient's goal "Pt/cg will verbalize, satisfaction with level of pain management." This goal did not document a measurable outcome. Clinical Record 6: The patient elected hospice care on 05/31/2024 with a diagnosis of heart failure. On admission the nursing comprehensive assessment identified the patient's goal "a need for safety measures." The POC documented the patient's goal "Pt/cg verbalizes, demonstrates understanding of proper safety measures." This goal did not document a measurable outcome. Clinical Record 14: The patient elected hospice care on 03/07/2024 with a diagnosis of cerebral atherosclerosis. On admission the nursing comprehensive assessment identified the patient's goal "a need for safety measures." The POC documented the patient's goal "Pt/cg verbalizes, demonstrates understanding of proper safety measures." This goal did not document a measurable outcome. Clinical Record 15: The patient elected hospice care on 03/07/2024 the diagnosis of malignant neoplasm of unspecified part of right bronchus or lung. On admission the nursing comprehensive assessment documented "Alteration in comfort pain." The POC documented the patient's goal "Pt/cg will verbalize, satisfaction with level of pain management." This goal did not document a measurable outcome. Clinical Record 16: The patient elected hospice care on 05/10/2023 with the diagnosis of cerebral atherosclerosis. On admission the nursing comprehensive assessment documented "Need for skilled teaching related to preservation of skin integrity." The POC documented the patient's goal "Pt/cg will verbalize/demonstrate what to look for in routine skin inspection." This goal did not document a measurable outcome. Clinical Record 17: The patient elected hospice care on 01/26/2024 with the diagnosis of Non-Hodgkin's Lymphoma. On admission the nursing comprehensive assessment documented "Alteration in comfort pain." The POC documented the patient's goal "Pt/cg will verbalize, satisfaction with level of pain management." This goal did not document a measurable outcome. Clinical Record 18: The patient elected hospice care on 12/21/2023 with the diagnosis of malignant neoplasm bronchus or lung. On admission the nursing comprehensive assessment documented "Alteration in comfort pain." The POC documented the patient's goal "Pt/cg will verbalize, satisfaction with level of pain management." This goal did not document a measurable outcome. Clinical Record 19: The patient elected hospice care on 03/07/2024 with a diagnosis of Alzheimer's Disease. On admission the nursing comprehensive assessment identified the patient's goal "a need for safety measures." The POC documented the patient's goal "Pt/cg verbalizes, demonstrates understanding of proper safety measures." This goal did not document a measurable outcome. During an interview and joint review of clinical records on 7/9/2024 and 7/10/2024, the Director of Operations confirmed that these records did not include measurable goals. There was no additional information or documentation provided.

Based on record review and interview the agency failed to ensure the registered nurse followed standards of practice for assessment and treatment of patients with head injuries for 1 (Patient #1) of 15 sampled patients reviewed for care and services. Findings: Review of the National Center for Biotechnology Information's Head Trauma (Nursing) Article revealed if head trauma is considered mild consider observing the patient for at least 4 to 6 hours if no imaging was obtained. Further review revealed nursing management included observing the patient's pupil size for signs of elevated intracranial pressure. Review also revealed nursing should seek help if the patient has unequal pupils or is unresponsive. Review of Medscape Drug Book revealed adverse effects of Lorazepam included, in part, sedation, drowsiness, confusion, and disorientation. Review of Patient #1's Skilled Nursing Visit Notes on 12/15/2021 and 12/17/2021 revealed Patient #1's pupils were equal. Review of Patient #1's Skilled Nursing Visit dated 12/19/2021 revealed an as needed (prn) visit was made due to a report of Patient #1's falling and hitting her head on the table in the hallway. Review of Patient #1's assessment revealed a new bruise to Patient #1's left eyebrow, and Patient #1's pupils were unequal. Further review of Patient #1's Skilled Nursing Visit revealed the patient had impaired movement to the left pupil. Further review revealed Lorazepam (antianxiety medication) was administered to Patient #1 due to restlessness and wandering. In an interview on 01/11/2022 at 1:57pm, S2Registered Nurse (RN) stated she was contacted while on call about Patient #1's fall. S2RN stated Patient #1 was found by staff in the hallway under an end table. S2RN stated Patient #1 had a new bruise on her forehead and one pupil was slower to react. S2RN stated she notified S3Previous Medical Director of the fall and was informed to monitor Patient #1's mental status, but she did not discuss with him the use of Lorazepam during the phone call. S2RN stated she administered Lorazepam to Patient #1 because she was restless. S2RN stated she did not want Patient #1 to fall again In an interview on 01/11/2022 at 3:12pm, S3Previous Medical Director stated he did not have recollection nor record if he was contacted regarding Patient #1 on 12/19/2021. S3Previous Medical Director also stated, after a potential head injury, he would not have recommended the administration of Lorazepam, as the medication can sedate the patient and hide signs and symptoms of head injury negative effects.