Every finding on record at Baptist Memorial Home Care & Hospice

Based on policy review, medical record review and interview, the facility failed to ensure an initial bereavement assessment was performed for 2 of 10 (Patient #6 and #8) sampled active patients. The findings included: 1. Review of the facility's "BEREAVEMENT ASSESSMENT" policy (Revised 3/1/21) revealed, "...The Social Worker or designee will complete a Bereavement Risk Assessment within 5 days of admission to hospice..." 2. Medical record review for Patient #6 revealed a Start of Care (SOC) date of 1/31/2024. Review of the 2/1/2024 Social Work initial assessment revealed no documentation of an initial Bereavement Risk Assessment. 3. Medical record review for Patient #8 revealed a SOC date of 11/6/2023. Review of the 11/10/2023 Social Work initial assessment revealed no documentation of an initial Bereavement Risk Assessment. In an interview on 4/16/2024 at 1:32 PM, the interim Executive Director verified there was no documentation of an initial Bereavement Risk Assessment for Patient #6 and Patient #8.

Based on policy review, medical record review and interview, the facility failed to ensure nurses documented wound measurements per facility policy for 2 of 3 (Patient #1 and #8) sampled patients with wounds. The findings included: 1. Review of the facilitys ";WOUND ASSESSMENT, DOCUMENTATION AND PHOTOGRAPHY" policy (revised 3/1/21) revealed, ";...Wound measurements (weekly) including the length, depth, and width of the wound in centimeters..." 2. Medical record review for Patient #1 revealed a certification period of 1/25/2024 through 4/23/2024. Patient #1 was documented as having a wound to the coccyx at the beginning of the certification period. Review of weekly Skilled Nurse (SN) notes beginning 1/25/2024 through 4/14/2024 revealed no weekly wound measurements were performed the weeks of 1/28/2024, 2/4/2024, 2/18/2024, 3/3/2024, 3/10/2024, 3/17/2024 and 3/31/2024. 3. Medical record review for Patient #8 revealed a certification period of 2/4/2024 through 5/3/2024. Patient #8 was documented as having a sacral, right buttock and left buttock wound at the beginning of the certification period. Review of weekly SN notes beginning 2/4/2024 through 4/13/2024 revealed no weekly wound measurements were performed the weeks of 2/4/2024, 2/18/2024, 3/10/2024, 3/31/2024, and 4/7/2024. In an interview on 4/16/2024 at 1:20 PM, the interim Executive Director stated, ";...they should measure once a week. If the caregiver or patient refuses, they should get an order..."

Based on policy review, medical record review and interview, the facility failed to ensure aide supervisory visits were performed at least every 14 days for 1 of 7 (Patient #8) sampled patients receiving aide visits. The findings included: 1. Review of the facility's "HOSPICE AIDE SUPERVISION" policy (revised 11/1/22) revealed, "...Hospice Aide Supervisory Requirement...Tennessee...At least every 14 days with or without aide present..." 2. Medical record review for Patient #8 revealed a certification period of 2/4/2024 through 5/3/2024. Review of aide orders revealed aide visits were to be conducted 2 times weekly through the end of the certification period. Review of aide supervisory visits beginning 2/4/2024 through 4/15/2024 revealed an aide supervisory visit was conducted on 2/16/2024, then no supervisory visit until 3/5/2024. Further review revealed an aide supervisory visit was conducted on 3/28/2024, then no supervisory visit conducted as of 4/15/2024. In an interview on 4/16/2024 at 1:45 PM, the facilitys interim Executive Director verified the aide supervisory visits were not conducted every 14 days.