Every finding on record at Area Agency on Aging of Western Arkansas, Inc.

Based on clinical record review and staff interview, it was determined the agency failed to ensure the individualized plan of care included essential Foley catheter management parameters for one (#2) of five (#2, #5, #7, #12, and #14) clinical records reviewed with catheter orders. Specifically, the plan of care did not include the catheter size (French), balloon inflation volume, or clear clinical indications for catheter changes. This deficient practice has the potential to affect all patients on census with indwelling catheter orders. Lack of clearly defined catheter specifications and change criteria increases the risk of preventable complications, including urethral trauma, balloon-related injury, obstruction, and catheter-associated urinary tract infection (CAUTI). Findings follow: --- A review of Clinical Record #2, with a start of care date of 02/26/25, revealed a patient admitted with a diagnosis of Follicular Lymphoma. Review of the “Hospice Plan of Care” for the certification period 01/11/2026 through 03/11/2026 included an order stating: “Change Foley catheter around the 1st of the month and PRN (as needed). Use Coude catheter”. Further review determined the catheter order was incomplete. The plan of care failed to specify the catheter size (French), balloon inflation volume, and detailed clinical indications for catheter changes, resulting in a lack of clear, individualized direction for safe catheter management.During an interview on February 12, 2026, at 3:30 PM, Agency Personnel #1 confirmed that the current plan of care did not include specific, complete, and individualized Foley catheter management orders.

Based on clinical record review, home health aide visit documentation, and staff interview, it was determined that the hospice aide failed to provide care in accordance with the written individualized plan of care for one (#3) of fourteen (#1-#14) patients receiving hospice aide services. Specifically, assigned personal care tasks and supportive services outlined in the interdisciplinary plan of care were not completed as ordered and were not documented as refused, deferred, or modified with appropriate clinical justification. This practice does not ensure that care is delivered consistent with the patient’s assessed needs and the established hospice plan of care. Failure of the hospice aide to follow the written plan of care has the potential to affect all patients receiving aide services. This deficient practice places patients at risk for unmet personal care needs, compromised comfort and dignity, and potential adverse outcomes related to hygiene, skin integrity, and overall safety. Findings follow: --- A review of Clinical Record #3, with a start of care date of 05/22/24, revealed a patient admitted with a diagnosis of Alzheimer’s Disease. Review of the “Hospice Plan of Care” for the certification period 01/11/2026 through 03/11/2026 included an order for hospice aide services: “4 wk 9 wk (four times a week for nine weeks); Beginning during week of 1/12/2026-Ending on 3/12/2026.” The plan of care assigned the hospice aide the following interventions: ambulate with assistance only; assist with meal preparation, meal setup, and feeding; document bowel movements; provide incontinent care; change linens; clean the bathroom following patient care; clean the patient’s living area; clean the kitchen after meal preparation; perform patient laundry; make the bed; assist with dressing, showering, foot care, nail care, shampooing, and shaving; implement fall and standard precautions; and report pain to the nurse. Review of hospice aide visit notes revealed documentation of completed tasks limited to laundry, assistance with transfers, and housekeeping. The documentation did not reflect completion of the full scope of assigned personal care and supportive interventions as outlined in the individualized plan of care.During an interview on February 12, 2026, at 3:30 PM, Agency Personnel #1 that the hospice aide did not consistently complete and/or document all interventions as outlined in the patient’s written plan of care.

Based on clinical record review and staff interview, it was determined the Registered Nurse (RN) failed to ensure that written instructions for hospice aide (HA) services were individualized and reflective of each patient’s specific care needs for two (#5 and #11) of fourteen (#1–#14) patients receiving HA services. Specifically, review of the hospice aide care orders revealed that, while the frequency of visits was identified, the plan of care did not include patient-specific tasks, personal care instructions, or detailed interventions to guide aide service delivery. The absence of individualized written instructions does not ensure that hospice aide services are provided in accordance with the patient’s assessed needs and the interdisciplinary plan of care. This deficient practice has the potential to affect all patients currently receiving hospice aide services. Without clearly defined, individualized care instructions, patients are at risk for inconsistent service delivery and potentially unsafe or inappropriate personal care practices, including bathing. Findings follow: --- A review of Clinical Record #5, with a start of care date of 08/02/24, revealed a patient admitted with a diagnosis of Diffuse Large B-Cell Lymphoma. Review of the “Hospice Plan of Care” for the certification period 01/12/2026 through 03/12/2026 included hospice aide service orders stating: “Aide; 2 wk 12 wk (two visits per week for twelve weeks); 1 wk 1 wk (one visit per week for one week) with service dates identified as beginning the week of 08/06/2024 through 10/30/2024. While the frequency and duration of visits were documented, the plan of care did not include specific, patient-centered tasks or interventions to guide hospice aide service delivery.A review of Clinical Record #11, with a start of care date of 04/23/25, revealed a patient admitted with a diagnosis of Chronic Obstructive Pulmonary Disease with Lower Respiratory Infection. Review of the “Hospice Plan of Care” for the certification period 04/23/2025 through 06/21/2025 included hospice aide service orders stating: “1 d 1 d (one visit per day for one day)”and “Aide; 2 wk 8 wk (two visits per week for eight weeks) with service dates identified as beginning the week of 04/27/2025 through 06/21/2025. While the frequency and duration of visits were documented, the plan of care did not include specific, patient-centered tasks or interventions to guide hospice aide service delivery.During an interview on February 12, 2026, at 3:30 PM, Agency Personnel #1 confirmed that the hospice aide plans of care did not include specific, complete, or individualized instructions to direct care.

Based on clinical record review and staff interview, it was determined that the agency failed to ensure discharge summaries were completed and transmitted to the attending physician, as required, for three (#5, #10, and #13) of eleven (#4–#14) clinical records reviewed for patients who were discharged. This deficient practice resulted in incomplete documentation of the patient’s condition at discharge, services provided, medication reconciliation, and follow-up or transfer information. Additionally, the absence of a completed and transmitted discharge summary prevented the attending physician from being informed of the patient’s status at the time of discharge. This practice has the potential to impede effective care coordination and continuity of services for all patients who are discharged or who revoke the election of hospice care, as well as their family members. Findings follow: --- A review of Clinical Record #5, with a start of care date of 08/02/24, revealed a patient admitted with a diagnosis of Diffuse Large B-Cell Lymphoma. Documentation indicated the patient expired at home on 08/26/24 and was discharged from hospice services. The clinical record lacked evidence that a discharge summary was completed. Additionally, there was no documentation to support that a discharge summary was transmitted to the patient’s attending physician, as required.A review of Clinical Record #10, with a start of care date of 03/27/25, revealed a patient admitted with a diagnosis of Hypertensive Heart and Chronic Kidney Disease with Stage 5 Chronic Kidney Disease and End Stage Renal Disease. Documentation indicated the patient expired at home on 03/27/25 and was discharged from hospice services. The clinical record lacked evidence that a discharge summary was completed. Additionally, there was no documentation to support that a discharge summary was transmitted to the patient’s attending physician, as required.A review of Clinical Record #13, with a start of care date of 01/31/25, revealed a patient admitted with a diagnosis of Hypertensive Heart and Chronic Kidney Disease with Heart Failure and Stage 1 through Stage 4 Chronic Kidney Disease. Documentation indicated the patient expired at home on 03/14/25 and was discharged from hospice services. The clinical record lacked evidence that a discharge summary was completed. Additionally, there was no documentation to support that a discharge summary was transmitted to the patient’s attending physician, as required.During an interview on February 12, 2026, at 3:30 PM, Agency Personnel #1 confirmed the failure of the Agency to complete discharge summaries as required.

Based on review of clinical records and staff interview, the Skilled Nurse (SN) failed to include oxygen on the patient's medication list in 1 (#5) of 5 (#1-#5) records reviewed and failed to have a process to review patient medications for drug interactions, duplicate drug therapy or contraindications in 1 (#5) of 5 (#1-#5) records reviewed. This deficient practice presented a potential risk to all patients on census as a 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 #5, with a start of care (SOC) 12/14/22, and a diagnosis of Cancer of the Esophagus revealed the following: 1) On a document titled "HSN LPN Visit-12/16/2022 1:40PM" the LPN (Licensed Practical Nurse) documented "o2 (oxygen) ordered for comfort and decreased Spo2 (oxygen saturation)". 2) On a document titled "HSN LPN Visit-12/16/2022 1:40PM" oxygen listed under "DME (durable medical equipment) and Supplies" 3) On a document titled "HSN LPN Visit-12/16/2022 1:40PM" oxygen not listed under medications. 4) On a document titled "HSC Visit-12/21/2022 4:30PM" the SC (Spiritual Counselor) documented "now on O2". 5) On a document titled "Medication Screenings" there (a section of the Agency's Care Plan containing the medication profile) was no documentation to indicate oxygen had been checked for actual or potential drug interactions. B. During a staff interview on 01/11/3 at 12:40 PM Agency Personnel #1 confirmed oxygen was not included on medication profile and not checked for actual or potential interactions for patient #5.