Every finding on record at Bridge Hospice L.L.C.

Based on observation, interview and record review the agency failed to ensure the hospice staff followed accepted standards of practice to prevent the transmission of infections for 1 (Patient #3) of 4 patients observed during home visits.  Findings: --- Observation on 03/02/2026 at 2:30PM revealed S4Registered Nurse performed hand hygiene and applied gloves to her hands. With gloved hands, S4Registered Nurse positioned Patient #3 and removed Patient #3’s soiled bandage from her sacral wound, discarded the soiled bandage, and without removing her gloves or performing hand hygiene, S4 Registered Nurse reached into an open multiuse gauze packet and removed the clean gauze.  Further observation, revealed, S4 Registered Nurse then picked up a wound cleanser bottle and sprayed the clean gauze, with the same gloved hands. S4Registered Nurse then cleaned and measured Patient #3’s sacral wound.  S4 Registered Nurse then removed her gloves, performed hand hygiene and redressed Patient #3’s sacral wound.  After completion of wound care to Patient #3’s sacral wound, S4Registered Nurse removed Patient #3’s brief, repositioned Patient #3 to expose her left hip wound, removed her gloves and performed hand hygiene.  S4Registered Nurse then applied clean gloves, pushed the bed table to left side of the bed, with gloved hand and removed Patient #3’s soiled left hip dressing and discarded it.  With the same gloved hand, S4Registered Nurse reached in to the open multiple use gauze packet and removed the clean gauze, sprayed wound cleanser on the gauze, cleaned and measured the left hip wound, prepared clean dressing and redressed the wound. In an interview on 03/03/2026 at 4:00PM, S1Director of Nursing confirmed S4Registered Nurse should have changed her gloves and performed hand hygiene after removing the patient’s soiled dressing, before obtaining clean gauze and after cleaning the Patient #3’s wounds, prior to redressing the wounds.

Based on interview and record review the agency failed to ensure a registered nurse made an on-site visit to the patient's home no less frequently than every 14 days for 1(Patient #1) of 17 patients reviewed for hospice aide supervisory visits.  Findings: --- Patient #1Review of Patient #1's hospice plan of care for certification period 12/11/2025 to 3/10/2026 revealed Patient #1 was to receive hospice aide services three - five days a week.   Review of Patient #1's record revealed the hospice aide provided services in part: 12/12/2025, 12/15/2025 – 12,19/2025, 12/22/2025, 12/23/2025, 12/26/2025, 12/29/2025 – 12/31/2025, 01/02/2026, 01/05/2026, 01/07/2026, 01/12/2026, 01/14/2026, 01/16/2026, 01/19/2026, 01/21/2026, 01/23/2026, 01/26/2026, 01/28/2026, 01/30/2026, 02/02/2026, 02/04/2026, 02/06/2026, 02/09/2026, 02/11/2026, 02/13/2026, 02/16/2026, 02/18/2026, 02/20/2026, 02/23/2026, 02/25/2026, and 02/27,2026. Further review revealed no documented evidence the registered nurse performed an on-site hospice aide supervisory visit.    In interview on 03/02/2026 at 1:28PM, S2Director of Nursing indicated hospice aide supervisory visits were not completed on-site every 14 days.  S2Director of Nursing further indicated she was not aware hospice aide supervisory visits were required to be on-site, that it was the agency’s standard practice to conduct the supervisory visits via telephone call.

Based on interview and record review, the agency failed to ensure volunteers provided administrative and/or direct patient care service, which equaled 5 percent or greater of the total patient care hours of all hospice contract and employed staff. Findings: --- Review of the agency's volunteer binder revealed the percentage of volunteer hours for December 2025 was 4.12%, for November 2025 was 1.1%, for October 2025 was 1.24%, for September 2025 was 2.98% and for August 2025 was 3.23%. Review of the agency’s quarterly Volunteer Hour Report revealed the third quarter of 2025 total patient care hours were 2875.70, the total volunteer hours were 104.92, and the percent of volunteer hours for the quarter was 3.52; the fourth quarter of 2025 total patient care hours were 3,151.70, the total volunteer hours were 72, and the percent of volunteer hours was 2.23.  Further review revealed the total patient care hours provided for 2025 were10853.63, the total volunteer hours for 2025 was 451.92, percent of volunteer hours for 2025 was 4.16. In an interview on 03/04/2026 at 1:22PM, S1Administrator stated the agency did not have 5% or greater involvement of hospice volunteers for 2025 as required.  S1Administrator confirmed the total percentage for 2025 was 4.16 percent.

Based on record review and interview the agency failed to ensure the hospice aide followed infection control practices while showering a patient for 1 of 1 sampled patients (Patient #2) observed for care and services provided by the hospice aide in a total sample of 15. Findings: --- Review of Patient #2s Plan of Care for certification period of 01/28/2023 to 03/28/2023 revealed the hospice aide was to provide a shower every visit, three times a week. Observation on 03/15/2023 at 9:02 a.m. revealed S2Hospice Aide (HA) brought Patient #2 to the shower area, undressed Patient #2, transferred Patient #2 from the geri-chair (reclining wheelchair) with Patient #2s feet uncovered. S2HA then placed Patient #2 in the shower chair and proceeded to wash Patient #2s body then washed the patients feet and in between the patients toes. S2HA then without changing washcloths or rinsing the towel proceeded to wash Patient #2s perineal area. In an interview on 03/15/2023 at 9:20 a.m., S2HA stated she had a limited supply of linens; therefore, she was unable to use a separate wash cloth for Patient #2s perineal area. S2HA further stated she did not rinse the towel between washing Patients feet and toes, and washing Patient #2s perineal area. In an interview on 03/15/2023 at 3:42 p.m., S1Director of Nursing (DON) stated S2HA should have used a clean wash cloth when going from cleaning Patient #2s feet to cleaning Patient #2s perineal area. S1DON further stated if enough linen was not available the hospice aide should have at least rinsed the wash cloth between washing the patients feet to washing her perineal area.

Based on record review and interview the agency failed to ensure the registered nurse measured and assessed patient wounds for healing or failure to heal weekly for 2 of 4 sampled patients (Patient #9 and Patient #13) with wounds in a total sample of 15. Findings: --- Review of the Wound Ostomy and Continence Nurses Society's Guidelines revealed assessment and documentation of wound status, which includes comprehensive clinical data demonstrating evidence of progress in healing or failure to heal. Comprehensive wound assessment includes: dimensions and depth; presence, location and depth of any sinus tracts or undermining areas; status and characteristics of the wound bed; volume, color, and odor of exudates; evidence of infection in surrounding tissues. Further review revealed when recorded over time this information can be used to track the progress of wound healing. Patient #9 Review of Patient #9s Admit Nursing Visit Note dated 11/09/2022 revealed Patient #9 was admitted with SDTI (suspected deep tissue injury) to the coccyx measuring 2.5cm (centimeters by 0.9cm; and a stage 3 to the mid thoracic spine (back) measuring 2.4cm x 1.6cm x 1cm. Review of Patient #9s Plan of Care Order for certification period of 11/09/2022 to 02/06/2023 revealed Patient #9 had impaired skin integrity with an intervention, in part, was the nurse was to collaborate with facility wound care nurse regarding wound management. Review of Patient #9s Skilled Nursing Visit Notes dated 02/08/2023, 02/10/2023, 02/13/2023, 02/15/2023, 02/17/2023, 02/20/2023, 02/22/2023, and 02/24/2023 revealed no documentation of wounds present or wound measurements. Review of Patient #9s Skilled Nursing Visit Note dated 02/27/2023 revealed Patient #9 was noted to have an arterial ulcer. Further review revealed no documented evidence and the agency presented no documented evidence of Patient #9s wound assessment. Review of Patient #9s Skilled Nursing Visit Note dated 03/01/2023 revealed Patient #9 was noted to have a dressing to the right heel. Further review revealed no documented evidence and the agency presented no documented evidence of Patient #9s wound assessment. Review of Patient #9s Skilled Nursing Visit Note dated 03/03/2023 revealed no documentation of wounds present or wound measurements. In an interview on 03/15/2023 at 3:46 p.m., S1DON (Director of Nursing) stated staff confirmed Patient #9 current had a small wound to his back and heel. S1DON further stated the agency did not have weekly documentation of the wounds present on admission until now. Patient #13 Review of Patient #13s Skilled Nursing Visit Note dated 02/06/2023 revealed Patient #13 had wound to right foot, nursing home providing wound care. Further review revealed no documented evidence and the agency presented no documented evidence of wound location, measurements, or description of Patient #13s wound. Review of Patient #13s Skilled Nursing Visit Notes dated 02/07/2023, 02/14/2023, 02/21/2023, 02/28/2023, and 03/07/2023 revealed no documented evidence and the agency presented no documented evidence of wound location, measurements, or description of Patient #13s right foot wound. In an interview on 03/15/2023 at 3:43 p.m., S1DON stated upon speaking with all the nurses involved in Patient #13s care, no wound care measurements were obtained, nor was the wound assessed weekly.