Every finding on record at Carolinas Palliative Care and Hospice Network, Inc.

Based on agency policy, clinical record review, and staff interviews, the agency failed to notify the physician of a laboratory result for 1 of 1 patient with symptoms of a urinary tract infection. (patient #11) Findings included: --- A policy, Hospice Coordination of Patient Care (reviewed 01/23/24), received on 10/22/24 at approximately 3:00 PM from the Accreditation Coordinator stated, ";Staff provides the physician... Outcomes of Service and care." Patient #11 was admitted on 11/13/23 with a diagnosis of Alzheimers Disease. The plan of care for 02/11/24-05/10/24 included orders for skilled nurse visits 2 times a week and 3 PRN (as needed) and an order dated 02/22/24 for a urinalysis. The urinalysis was obtained 02/22/24. A review of the clinical record revealed no communication with the physician of the results of the urinalysis. An interview conducted on 10/22/24 at approximately 10:15 AM the Accreditation Coordinator revealed that there is no documentation of communication with the doctor and the expectation is to communicate all lab results with the physician.

Based on policy review, complaint report, clinical record review, and staff interview, the agency failed to document complaint resolution for 1 of 2 patients that voiced a concern (#1). Findings included: --- A policy, ";Hospice Complaint Resolution (dated 12/31/22) was provided by the Director of Accreditation on 8/15/23 at 2:47 p.m. The policy stated, ";Hospice will provide for a prompt response and, if possible, and equitable resolution of complaints." Patient #1 was admitted on 7/21/23 with diagnoses of Parkinsons disease, peripheral vascular disease, type 2 diabetes, and acquired absence of unspecified foot (toe amputation). The Plan of Care (POC) for 7/21/23-10/18/23 included orders for skilled nursing one time for one week, then twice weekly. The POC also included orders for wound care to the left foot—cleanse with wound cleanser, apply skin barrier, cover with adhesive foam dressing, change twice weekly; and wound care to a venous stasis ulcer right foot 2nd toe-- cleanse with wound cleanser, apply skin barrier, cover with adhesive foam dressing, change twice weekly. A complaint report dated 8/2/23 was provided by the agency. The complaint stated, ";Daughter [daughters name] report to triage RN they are upset of how hospice handled her fathers wound that appears to be infected; she reports hospice had not properly assessed and offered a solution to assist with the wound." The clinical operations manager returned the call to the daughter. The daughter reported concern related to wound care and delay in transportation. There was no evidence that the concerns related to the wound were addressed. An interview with RN #3 on 8/15/23 at 10:15 a.m. revealed when spoke with the patient caregiver, the immediate concern was related to the transportation to the inpatient hospice. RN #3 confirmed transportation was addressed in the complaint follow-up, but the wound care concern was not documented. An interview with the clinical manager on 8/15/23 at 2:55 p.m. confirmed the follow-up to the wound care concerns should have been included in the complaint investigation.

Based on clinical record review, and staff interview, the agency failed to provide interventions for constipation for 1 of 4 patients (#2). Findings included: --- Patient #2 was admitted on 6/28/23 with a diagnosis of Alzheimer's Disease. The Plan of Care (POC) for 6/28/23-9/25/23 included orders for skilled nursing visits twice on day one, then daily. The POC included a goal that the ";Patient will have an effective bowel program for the remainder of certification period." The POC also included orders for Dulcolax suppository 10 mg daily as needed for constipation and Natural Senna Laxative 8.6 mg tablets daily as needed for constipation. On 6/29/23, the RN conducted an assessment. The RN noted the ";Family reported patient has not had nutritional intake for days and has not had BM [bowel movement] in 12 days; suppository administered..." On 6/30/23, the RN visit note stated, ";Last BM was 2 weeks ago. No positive result from the suppository given by the admissions nurse." There was no evidence of further follow-up on the constipation. An interview with RN #3 on 8/15/23 at 11:46 a.m. confirmed there was no evidence of follow-up on the constipation.

Based on clinical record review, and staff interview, the agency failed to communicate an extended wait time for transport for 1 of 1 patients reviewed that had a planned transfer to the hospice inpatient unit (#1). Findings included: --- Patient #1 was admitted on 7/21/23 with diagnoses of Parkinsons disease, peripheral vascular disease, type 2 diabetes, and acquired absence of unspecified foot (had toe amputation). The Plan of Care (POC) for 7/21/23-10/18/23 included orders for skilled nursing one time for one week, then twice weekly. The POC also included orders for wound care to the left foot. On 8/1/23 at 8:49 p.m., the patients caregiver called the on-call nurse to report the patients left foot wound had maggots present in the wound. The on-call nurse notified the nurse practitioner (NP) and received new orders for wound care. The NP also stated he could transfer to the hospice inpatient unit if the patient/caregiver desired. At 9:55 p.m., the caregiver called the on-call nurse again and stated that they wanted a nurse to make a visit the next day. The caregiver also confirmed the patient ";would likely be agreeable to transferring to the IPU [inpatient unit] tomorrow by the just does not want to go tonight." On 8/2/23, a nurse visit was conducted. The patient/caregiver agreed to go to the inpatient unit. The triage nurse arranged non-emergent transport to the inpatient unit at approximately 11:41 a.m. The updated coordination note from 8/2/23 at 12:00 p.m. stated, ";EMS called back and cancelled and gave another number to call to arrange this [non-emergent transport]. They are saying closer to 5pm to transport. TN [this nurse-triage nurse] emailing team to update." A Complaint Report revealed on 8/2/23 at 4:40 p.m. the clinical operations manager returned a call to the patients caregiver. The caregiver voiced concerns regarding a ";a delay in transporting" the patient to the inpatient hospice unit. There was no evidence that the patient or caregiver was notified that non-emergent triage would be approximately 5 hours. An interview with triage nurse #2 on 8/15/23 at 10:40 a.m. revealed she told the visiting nurse that transport would be approximately 5:00 p.m. An interview with the visiting nurse, RN #5, was conducted on 8/15/23 at 11:00 a.m. revealed she had left the patients home when she was notified of the approximate time for transport. She confirmed that she did not call the patient/caregiver and notify them of the expected time of transport.

Based on policy and procedure review, clinical record review, observation, and patient/caregiver interviews, the agency failed to review all current medications for 1 of 2 skilled nursing virtual home visits conducted (#12). Findings include: A policy, "Hospice Medication Reconciliation", approved 05/14/2021 was received from the clinical operations manager on 12/07/21 at approximately 12:33 p.m. The policy stated, " ...at the time of assessment the registered nurse will create and document a complete list of medications that patient is taking, including dose, route, and frequency ..." Patient #12 was admitted on 11/14/21 with the following diagnoses: malignant neoplasm of lower lobe, left lung, secondary malignant neoplasm of brain, chronic respiratory failure, depression, and anxiety disorder: skilled nursing 3 times a week for start of care week, then 2 times a week with 3 as needed visits. A virtual home visit was conducted on 12/07/21 at 10:00 a.m. with the registered nurse. A review of current medications was conducted with the patient/caregiver during the home visit. The medication profile provided by the agency did not include the following medication: PreserVision ( supplement for eyes) 2 tablets daily by mouth. Interview with the patient/caregiver on 12/07/21 at 10:32 a.m. confirmed he has been taking this medication since October of this year.

Based on agency policy review, clinical record review and staff interviews the agency failed to follow the Plan of Care [POC] related to wound care for 1 of 1 patient with a wound [#5]; obtaining an INR [international normalized ratio] for 1 of 1 patient [#10]; failed to administer a blood pressure medication for blood pressure outside the given parameter for 1 of 3 patients [#11] in the hospice home; to prefilling a medi-planner for 1 of 1 patient [#13]. The findings included: The policy, Hospice IDG [interdisciplinary group] Care Planning Process [10/22/21,] was provided by employee # on 12/8/21. The policy stated, " ...The plan of care specified the care and services necessary to meet the patient and family-specific needs ..." 1. Patient # 5 had a Start of Care [SOC] date of 11/6/21 and a terminal diagnosis of Merkel Cell Carcinoma of Right Lower Limb, Including Hip, Secondary Malignant Neoplasm of Other Specified Sites and Human Immunodeficiency Virus. A review of the Plan of Care [POC] for the certification period 11/6/21 to 2/3/22 revealed an order for SN [skilled nurse] 1 time for SOC [Start of Care] week, effective 11/7/21- times a week, effective 11/14/21-2 times a week, 3 PRN [as needed] for pain, dyspnea, anxiety, falls, wound care or decline and "Hospice nurse to provide education related to pressure ulcer care. Hospice nurse to perform pressure ulcer care as follows to SDTI [suspected deep tissue injury] to left buttock: Cleanse with wound cleanser, apply Calazime and leave open to air 3 times a day and PRN incontinence. May instruct caregiver to perform wound care in SN absence. Hospice nurse to provide education related to right groin biopsy site. Hospice nurse/patient to perform wound care as follows: cleanse with wound cleanser. Cover with wet to dry normal saline gauze and abd pad, secure with tape using clean technique. Wound care to be performed 2 times a day and PRN for dislodgement, excessive drainage or if it becomes soiled. May instruct caregiver to perform wound care in SN absence. "A review of the SOC visit completed by RN # 7 on 11/7/21 revealed 2 areas of skin breakdown: Wound 1- Right biopsy site and 2-Left buttock unstageable DTI [deep tissue injury]. A review of the SOC visit revealed the RN did not measure the wounds nor did she complete any wound care in accordance with the POC. A review of the clinical record revealed the following: A routine visit was completed by RN # 7 on 12/3/21. A review of the clinical record revealed the RN did not do the wound care on wound 1 or 2 in accordance with the POC. 2. Patient # 10 had a Start of Care [SOC] date of 11/15/21 and a terminal diagnosis of Other Sequelae of Cerebral Infarction. A review of the Plan of Care [POC] for the certification period 11/15/21 to 2/12/21 revealed orders for SN [skilled nursing] 2 times a week and 3 PRN [as needed] for pain, SOB [shortness of breath] and to assess change and decline. A review of the POC update order dated 11/27/21 revealed the following order, "Skilled nurse to obtain INR [international normalized ratio] lab Monday 11/29/21. A review of the clinical record revealed no SN visit was made on 11/29/21 and the lab was not obtained. A SN visit was made on 11/30/21 and the INR was obtained during that visit. During an interview with employee # 1 on 12/8/21 employee # 1 stated, "We did not see the patient on 11/29/21, the nurse was sick. She saw the patient on 11/30/21 and obtained the INR during that visit." 3. Patient # 11 had a Start of Care [SOC] date of 8/20/21 and a terminal diagnosis of Alzheimer ' s Disease. A review of the clinical record revealed Patient # 11 was admitted to _____ Hospice Home on 10/21/21 and remained at the hospice home on 12/7/21. A review of the Hospice IDG [interdisciplinary group] Comprehensive Assessment Plan of Care Update Report revealed the following medication order, "Clonidine HCL 0.1 mg [used for hypertension] take if SBP [systolic blood pressure] is greater than 175 or DBP [diastolic blood pressure] is greater than 105." A review of the vital sign report revealed the following blood pressures 11/4/21-143/106, 11/7/21-154/113, 11/8/21-149/108, 11/11/21- 149/112, 11/12/21-143/108, 11/13/21-159/123, 11/14/21-154/119, 11/16/21-166/112, 11/18/21-155/115. Further review of the clinical record revealed the Clonidine was not administered in accordance with the POC. An interview was conducted with RN # 1 on 12/8/21. During the interview employee # 1 confirmed the medication was not administered in accordance with the POC. 4. Patient # 13 had a Start of Care [SOC] date of 8/13/21 and a terminal diagnosis of Parkinson ' s Disease [a disorder of the central nervous system]. A review of the Plan of Care [POC] for the certification period 11/11/21 to 2/8/22 revealed orders for SN [skilled nursing] 2 times per week and 3 PRN [as needed] for symptom management/assess changes and "skilled nurse to prefill medi-planner every week." A review of the clinical record revealed Patient # 15 received nursing visits on 11/12/21, 11/16/21, 11/19/21, 11/23/21,11/26/21, 11/30/21, 12/3/21, 12/7/21 by RN #3. Further review of the clinical record revealed the RN documented " ...Pill-planner filled by spouse ..." During an interview with employee # 1 on 12/8/21, employee # 1 confirmed the POC was no followed related to the prefilling of the medi-planner.

Based on clinical record review and staff interviews the agency failed to update the Plan of Care [POC] with a new order for Amlodipine for 1 of 1 patient [#1]; failed to update the POC related to an order for wound care for 1 of 1 patient with a wound [#5]. The findings included: 1. Patient # 1 had a Start of Care [SOC] date of 11/9/21 and a terminal diagnosis of Chronic Diastolic [Congestive] Heart Failure. A review of the Plan of Care [POC] for the certification period 11/9/21 to 2/6/21 revealed orders for SN [skilled nursing] 3 times per week SOE [start of episode] week, effective 11/14/21 2 times a week; 3 PRN [ as needed] for pain, SOB [shortness of breath] and to assess changes. A review of the clinical record revealed the patient received a SN visit on 11/15/21. During the visit, RN # 4 documented, " ...DIL [daughter in law] reports BP [blood pressure] is higher at time 160s/80s [sic] during my visit. New order given by Dr. _______[name] to restart 5 mg Amlodipine [blood pressure medication] ..." Further review of the clinical record revealed no POC update order related to Amlodipine. During an interview with employee # 1 on 12/8/21 employee # 1 revealed RN # 4 "failed to write the order given by the physician." 2. Patient # 5 had a Start of Care [SOC] date of 11/6/21 and a terminal diagnosis of Merkel Cell Carcinoma of Right Lower Limb, Including Hip, Secondary Malignant Neoplasm of Other Specified Sites and Human Immunodeficiency Virus. A review of the Plan of Care [POC] for the certification period 11/6/21 to 2/3/22 revealed an order for SN [skilled nurse] 1 time for SOC [Start of Care] week, effective 11/7/21- times a week, effective 11/14/21-2 times a week, 3 PRN [as needed] for pain, dyspnea, anxiety, falls, wound care or decline. A review of the client coordination noted dated 11/20/21 revealed RN # 8 documented the following information, "TPC [telephone call] from cg [caregiver] ______ [name] reporting that area on patient ' s backside had opened up and was leaking profusely ...Advised that nurse would be dispatched to make a visit ..." Further review of the clinical record revealed RN # 7 made a PRN visit on 11/20/21. RN # 7 documented the following information, "PRN visit to perform wound care to right hip ...cleaned with wound cleanser, applied non adhesive pad, abd pad and secured with paper tape ..." Further review of the clinical record revealed the RN did not update the POC with the wound care order.