Every finding on record at Compassus Milwaukee Metro

Based on record review and interview, the agency failed to assess for and provide Durable Medical Equipment (DME) and supplies to meet patient needs in 1 of 10 patient records reviewed (Patient #1). Findings Include: --- Review of agency policy titled “Individualized Plan of Care” dated 10/17/2025 revealed “2. Content of Plan of Care: b. Interventions to manage pain and other symptoms: ii. Non-pharmacological interventions, including supply and DME needs. F. Medical supplies and appliances/DME needed to support patient care needs. i. All DME.” Review of agency policy titled “Hospice Drugs, Biologicals, Medical Supplies and DME” dated 10/17/2025 revealed “4. Orders for drugs, biologicals, medical supplies, and DME will be documented by an appropriately licensed team members. 11. Medical Equipment and Supplies c. Medical supplies required for comfort of the patient or the palliation of the terminal illness or related conditions will be provided by Compassus.” Record review of Patient #1 Discharge Summary dated 09/07/2025 revealed in part, “Patient #1 goal to be comfort… Hospice will see patient at home. They will order hospital bed. I talked to both patient and husband and all in agreement with hospice.” Record review of Patient #1’s “Hospice Certification and Plan of Care” dated 09/7/2025 to 12/05/2025 revealed “DME and Supplies: None.” Record review of Patient #1’s “Hospice Registered (RN) Start of Care” home visit dated 09/7/2025 at 1:50 PM revealed “Musculoskeletal Assessment: Decreased strength, fatigue, gait/ambulation disturbance. Mobility Assessment: Transfers bed to chair with maximum assistance. Gait/Balance: Decreased muscle coordination, complete bedbound status. Equipment/supplies in good working order: Yes. Genitourinary Assessment: Incontinence. Protective Devices used: Diapers, under pads. Supplies: Delivered none.”  Record review of Patient #1’s “Subsequent RN Visit” dated 09/08/2025 at 12:26 PM revealed “Musculoskeletal Assessment: Decreased strength/weakness. Mobility Assessment: Bedbound. Requires total assistance for all Activities of Daily Living (ADLS). Equipment/supplies in good working order: Yes. Genitourinary Assessment: Incontinence. Protective Devices used: Under pads, pull ups. Supplies: Delivered none.” Neither Hospice nurse home visit on 09/07/2025 and 09/08/2025 identified what type of equipment was being utilized in Patient #1’s home nor assessed what equipment and supplies were needed to meet Patient #1’s comfort needs. It was unclear as to whether the use of a hospital bed, wheelchair or any other medical equipment devices were assessed.  During an interview with Area Executive Clinical Operations (ACO) B on 12/02/2025 at 12:15 PM, when asked the agency protocol for supply and equipment needs and if any known issues for Patient #1, ACO B replied “On admission the nurse will go through what the patient wants and determines what is needed and order anything such as hospital beds or wheelchairs. There were no requests for additional supplies documented and no orders for DME or hospital bed. DME was not documented.” During an interview with Admission Nurse C on 12/03/2025 at 8:05 AM, when asked about the agency process on admission for equipment/supply needs and if any known issues for Patient #1, Admission Nurse C replied “Normally I order equipment right at the time of admission and offer right away because it would take time. Can take 4-6 hours if I order urgent. (For Patient #1) I don’t recall they wanted equipment. I didn’t have supplies with me, like briefs or anything in my car. We scheduled this admission last minute as patient had just been discharged from the hospital. Often equipment is already ordered pre-discharge but this wasn’t the case.” During an interview with Hospice Nurse D on 12/03/2025 at 8:57 AM, when asked about the agency process on admission for equipment/supply needs and if any known issues for Patient #1, Hospice Nurse D replied “I ask the patient if anything I can bring prior to the visit. Ask about all types of supplies like chux pads and gloves. I do carry a basic supply in the car and will provide at the visit if needed. Will suggest a hospital bed and oxygen at minimum.” Hospice Nurse D could not remember if there were issues with equipment needs.

Based on record review and interview the agency staff failed to ensure that patients received the right of effective symptom management in 1 of 10 medical records reviewed (Patient #1). --- 1. The agency staff failed to ensure that patients received effective pain and symptom management. See L512.

Based on record review and interview, the agency staff failed to ensure that patients received effective pain and symptom management in 1 of 10 patient records reviewed (Patient #1). --- Findings include: In a letter submitted to the State Agency, the complainant stated ";During the informative meeting on6/2/2023, we were told that a ";Comfort" package of medication would be sent to our home, and weshould receive them by the end of the week. It is the policy to have these medications on hand so thatwhen the time comes, he/she would have what is needed for pain and anxiety." Review of Patient #1s medical record revealed Patient #1 was admitted to the agency on 6/2/2023 with a primary diagnosis of kidney cancer with metastases (cancer had spread to other part of the body.) Secondary diagnoses included atherosclerotic heart disease, chronic kidney disease and atrial fibrillation. Review of Patient #1s ";Hospice RN (Registered Nurse) Start of Care dated 6/2/2023 revealed a Comprehensive Pain Assessment was completed with the results as follows: Pain was an active problem for the patient. Location of patients pain was lower extremities and described as aching/throbbing and was continuous. Further review revealed that the frequency of patients pain was all the time and medications/positioning helped. Weight bearing, activity, movement, exercise made the pain worse. The effects of pain on patients quality of life were an inability to enjoy activities/hobbies, patients functional status and mobility. Patient/caregiver barriers to effective pain management were fear of drug side effects. Review of Patient #1s ";Hospice RN Start of Care" dated 6/2/2023 revealed a Respiratory Assessment was completed with the results as follows: Patient had abnormal respiratory findings of abnormal breath sounds, cough, and sputum. Further review revealed patient had shortness of breath with treatments of opioids, other medication and oxygen. Review of Patient #1s ";Hospice RN Start of Care" dated 6/2/2023 revealed the nurses narrative in part, ";Patient has dizziness at times, c/o (complains of) SOB (shortness of breath) with exertion more at noc (night). Lung sounds wheezes with inspiration (breathing in). Chronic wet cough with thick sputum. Dizzy with periods of long-standing movement, no falls. Noted +4 pitting edema (swelling) to both feet. Abdomen is distended, semi-firm. Generalized weakness from six months ago." Further review of Patient #1s ";Hospice RN Start of Care" dated 6/2/2023 revealed, ";Goals not met: 1. Patient/Caregiver verbalizes proper use of comfort kit. Exception code: not applicable to clients POC (Plan of Care.) A comfort kit/pack of medications include Hyoscyamine (to decrease respiratory sections), Lorazepam (to relieve anxiety/restlessness) and Morphine (to relieve pain, shortness of breath, anxiety.) Review of Patient #1s medication profile revealed Patient #1 was prescribed Percocet (opioid pain reliever) 5 mg (milligrams)– 325 mg, 1 tablet every 4 hours as needed for pain, on discharge from the hospital on 6/2/2023. Further review revealed Tylenol Extra Strength (pain reliever) 500 mg tablet, 2 tablets twice daily. Review of Patient #1s ";Hospice RN Subsequent Visit" dated 6/8/2023 at 9:34 a.m. revealed in part, ";Patient has only been taking Percocet 1-2 times a day. Patient states it doesnt help much. Writer encouraged to take it more frequently and regularly to stay on top of the pain. Patient states he/she has SOB with activity and sometimes at night. Patient uses intermittent O2 (oxygen) when SOB." Further review revealed that medications were reviewed for effectiveness and no changes were made to the medications and no new symptoms of disease were reported. There was no documentation of comfort medications in the home or education on the use of them for symptom reduction. Review of Patient #1s ";Hospice RN Subsequent Visit" dated 6/13/2023 at 10:54 a.m. revealed in part, ";Spouse had called and stated patient has had a bad day yesterday and since last Friday (6/9/2023). Patient is sleeping 22+ hours a day and having difficulty walking and following commands. Patient was weaker but no falls. Appetite is still poor. Patient losing weight. No edema. Percocet reordered and comfort meds ordered." Further review revealed patient rated pain at a 3 with no pattern to the pain. Patient reported pain effecting appetite and mobility. Breakthrough medication for pain was needed greater than 3 times per day. The following comfort medications were ordered on 6/13/2023: Hyoscyamine Sulfate (to decrease respiratory secretions) 0.125mg tablets give 1 tablet sublingual (under the tongue) every 4 hours as needed for access secretions; Lorazepam (antianxiety) 0.5 mg tablet give 1 tablet by mouth or sublingual every 1 hour for anxiety/restlessness; Morphine (narcotic pain reliever) Concentrate 100mg/5ml (milliliters) oral solution give 0.25 - 1 ml every hour as needed for pain/SOB/anxiety 0.25mg for mild symptoms, 0.5ml for moderate symptoms, 1ml for severe symptoms. Review of Patient #1s ";Hospice LPN (Licensed Practical Nurse) Subsequent Visit" dated 6/19/2023 (Monday) at 3:10 p.m. revealed in part, ";In home for routine LPN visit. Arrived to find patient in bed resting. O2 at 3LPM (Liters per Minute). Audible secretions. Lung sounds are coarse and wet. No oral intake today. Patient is lethargic. Minimally responds to writer and less responsive as visit continues. An as needed Percocet was given 45 minutes prior to my arrival. Using accessory muscles less as visit continued. Local fill to be done for Percocet as family is now out of it. Family does not have comfort meds (medications) yet. Call placed to DCS to do a local fill for the comfort meds. Discussed meds with spouse and administration of meds. Updated DCS (Director of Clinical Services) that daily visits seem appropriate." This was now 6 days since the comfort medications were ordered. Review of Patient #1s ";Medical Social Worker PRN (as needed) Visit" dated 6/19/2023 at 5:02 p.m. revealed in part, ";The MSW informed spouse that the DCS sent the medications over to pharmacy and we are just waiting for doctor to sign the orders. The MSW asked spouse to call pharmacy by 6:00 p.m. to see if orders were signed and if they werent to contact hospice. The patient will have daily SNV (Skilled Nurse Visits) due to change in condition and decline." Review of Patient #1s ";Client Coordination Note" dated 6/19/2023, no time noted, revealed in part, ";Phone Conversations: Morphine (narcotic pain and symptom reliever), Lorazepam (anti-anxiety) and Hyoscyamine (relieves sections) orders sent to pharmacy. Family members angry that they had to wait for the comfort meds due to technological issues with the doctors PIN (personal identification number) number. Issue resolved and family able to pick up medication." Patient #1 passed away on 6/21/2023 at 4:00 a.m. Comfort medications were ordered on 6/13/2023. The patient did not receive comfort medications until 6/19/2023. The patient was without comfort medications until the last two days of life. An interview was conducted with DCS RN A and ACO (Area Executive of Clinical Operations) RN B on 8/29/2023 at 1:20 p.m. When asked why there was such a delay in the comfort medication for Patient #1 ACO RN B explained that Patient #1 did not want comfort medications on admission; that there are no standing orders for them and each patient is assessed for the need for them. This writer explained that no documentation was found in Patient #1s record that Patient #1 declined comfort medications on admission. ACO RN B then referred to the agencys investigation of the incident and the written explanation from the admitting nurse which stated ";At the time of admit, they didnt want comfort meds in the home they felt didnt need them at that time." This information was not documented in the medical record. When asked what the expectation is of delivery time of comfort medications DCS RN A stated that it was usually 4 hours. When asked why there was a 6-day delay in Patient #1 receiving the comfort meds, ACO RN B stated that the physician (who is also the Medical Director) was unable to log in to the electronic medical record system to sign the orders. The physician worked with the software company to get the problem solved. ACO RN B also stated that the pharmacy would not accept a verbal order from the physician for the medications and the physician had to reach out to the Associate Medical Director to electronically sign the orders because the software company was unable to fix the problem in a timely manner.

It is required that each patient’s individualized written plan of care: Identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review, document review and interview. In 4 of 19 (21%) records the agency did not ensure documentation of all updates and current care to include interventions and goals for the patients. The agency policy "C9 Written Interdisciplinary Plan of Care" (revision date 01/20/2020] states in part, "The interdisciplinary group will ensure the provision of care and services according to the plan of care and that the plan of care reflects updated patient and family/caregiver needs as determined in updated comprehensive assessments." Clinical Record 6: The patient was admitted 03/31/2023 with CHF (congestive heart failure)/COPD (chronic obstructive pulmonary disease) and multiple wounds. A nursing visit note on 04/13/2023 documented the patient had a cough and a request for orders. Orders were written for Robitussin (for cough) 5mg/5ml every 4 hours as needed for cough. The IDG (interdisciplinary group) meeting documentation on 04/25/2023 did not document any update for the patient's respiratory status or comfort related to the cough. Clinical Record 11: The patient was admitted 10/09/2022 with COPD. A nursing clinical note on 01/09/2023 documented a foley catheter was inserted for clear, yellow return. The plan of care was not updated with any interventions or goals for the catheter as of the patient's date of death, 01/22/2023. Clinical Record 10: The patient was admitted 11/17/2022 with Alzheimer's and Dementia and has a foley catheter. On 11/28/2022 Cipro was started for a UTI (urinary tract infection). The IDG meeting documented an update to the plan of care on 12/06/2022 stating "no medication change". The meeting documentation did note one infection but what infection was unclear and there was no update documented if the infection improved or not. There were no interventions documented specific to the new UTI. Clinical Record 13: The patient was admitted 03/01/2023 with prostate cancer, HTN (hypertension), DM (diabetes). On 04/27/2023 a prn (as needed) nursing visit was made, the patient had increased coughing and sputum; Robitussin cough medicine was started. IDG meeting on 04/11/2023 documented "no medication changes", (medication was changed) and no update regarding the patient's cough status. On 05/02/2023 a prn nursing visit was made as the patient felt unwell. The blood sugar reading was found to be "high", the patient had blurred vision and it is documented that the glipizide was restarted. The IDG meeting on 05/09/2023 documented "no change in medications" and there was no mention of the high blood sugar or how the patient was tolerating. There was no evidence of a change or update to intervention or goals related to the cough or change in blood sugar status. Interview with the Director of Clinical Services and the Regional Clinical Director who stated that a current process improvement project is in place for updated interdisciplinary group meetings.

It is required that each patient’s individualized written plan of care: Drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review, document review and interview. In 5 of 19 (26%) records in which interdisciplinary group team updates were documented, the agency did not ensure accurate documentation of medication changes. The agency policy "C9 Written interdisciplinary Plan of Care" [revision date 01/20/2020] states in part, "The content of the plan includes at minimum: an identification of the services to be provided, including management of symptoms, treatments, drugs, biologicals and management of other symptoms." Clinical Record 2: The patient was admitted 04/21/2023 with the following medications ordered: Eliquis 5mg po daily and Aspirin 325mg po daily. There were no anticoagulant/bleeding precautions documented on the plan of care dated 04/21/2023 - 07/14/2023. Clinical Record 7: The patient was admitted 02/23/2023 with COPD (chronic obstructive pulmonary disease)/CHF (congestive heart failure) and increasing respiratory distress. The nursing visit note on 05/10/2023 documented a new order was received for Buspar (for anxiety), no dose or administration frequency was documented. The nursing visit note on 05/17/2023 documented the family report of improvement with using Buspar. The updated plan of care on 05/23/2023 does not include the medication Buspar on the medication profile. Clinical Record 10: The patient was admitted 11/17/2022 with Alzheimer's and Dementia and has a foley catheter. On 11/28/2022 an order for Cipro was started for a UTI (urinary tract infection). The IDG updated plan of care on 12/06/2022 documented no medication change and the plan was not updated for the change documented on the comprehensive nursing assessments. Clinical Record 11: The patient was admitted 10/09/2022 with COPD. The plan of care after 10/09/2022 documented oxygen at 4L continuously but each nursing assessment after 10/10/2022 documented that the patient was using 6L per nasal cannula. None of the updated plans of care documented the oxygen at 6 liters of flow as of the patient's date of death, 01/22/2023. Clinical Record 13: The patient was admitted 03/01/2023 with prostate CA (cancer), HTN (hypertension), DM (diabetes). On 04/27/2023 a prn (as needed) visit was made. The patient had increased coughing and sputum; Robitussin cough medicine was started. IDG (interdisciplinary group) meeting on 04/11/2023 documented "no medication changes" (medication was changed). On 05/02/2023 a prn nursing visit was made as the patient felt unwell, a blood sugar reading of "high" and the patient had blurred vision. It was documented that the glipizide was restarted. The IDG meeting 05/09/2023 documented "no change in medications" and there was no mention of the high blood sugar or how patient was tolerating the symptoms. There was no evidence documented of updates from the changes documented in the nurse's comprehensive assessment. Interview with the Director of Clinical Services and the Regional Clinical Director stated that there is a process improvement in place for interdisciplinary group meetings.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as: Safe handling of equipment in the patient’s care environment if it is likely to have been contaminated with body fluids. This standard was not met as evidenced by interview and observation. In 1 of 4 (25%) observed home visits the agency did not ensure that all equipment was sanitized to prevent possible contamination with body fluids. Home Visit 3: During the observed visit on 06/06/2023 at noon with the registered nurse, it was noted that the nurse measured the MAC (mid-arm circumference) with a retractable tape measure and following the measurement on the patient skin, retracted the tape measure without cleaning, exposing the inside of the casing to any possible contamination. During equipment cleaning the retractable tape measure was re-pulled out of the casing, cleaned and retracted into the contaminated casing. The Director of Clinical Services stated, on interview, that it should have been cleaned prior to retraction.

It is required that consistent with current professional standards of practice, licensed professionals actively participate in the coordination of all aspects of patient care including: Conducting ongoing interdisciplinary comprehensive assessments; and developing and evaluating the plan of care. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 19 (5%) records reviewed in which a social worker was accepted and requested, the agency did not ensure that the social worker coordinated with the family or team to provide an assessment and participate in development of a plan of care for the holistic care of the patient. The agency policy "C9 Written Interdisciplinary Plan of Care" [revision date 01/20/2020] states in part, "The care plan is the discipline-specific aspects of the plan of care, which inform the team about the different approaches to the patient holistic needs." Clinical Record 12: The patient was admitted 10/31/2022 with congestive heart failure, kidney disease and diabetes. The initial plan of care dated 10/31/2022 - 01/28/2023 ordered MSW 1 month 1, effective 11/1/2022. The social worker documented on 11/08/2022, "Unable to get ahold of family". (This was day 9). The other disciplines (RN, Chaplain and aide) are visiting regularly and document many family members are participating, the patient resides in an assisted living facility. The IDG (interdisciplinary group) meetings on 11/07/2022, 11/21/2022, 12/05/2022, 12/20/2022 and 01/03/2023 documented the social worker hasn't visited yet. There was no documentation evident to coordinate a visit with the social worker or for care plan development with respect to the patient/family needs with social work. The Regional Clinical Director stated, on interview that a social worker was covering from another agency and the follow through that was attempted was not documented in the record.

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 4 of 13 (31%) records in which a hospice aide was accepted, the agency did not ensure specific written instructions were developed for the aide assignments, thus leaving the aides to make decisions outside of the aide's scope of practice. Clinical Record 2: The aide plan of care developed on 04/25/2023 did not document instruction of the use of off-load boots bilaterally as identified in the nursing visit note on 04/22/2023 to be used related to pressure ulcers on both heels. Clinical Record 12: The aide plan developed on 10/31/2022 with an assigned task of "shower first visit weekly" did not include direction for the Kerlix dressing on the left lower extremity, if it should be covered during the shower, removed or what to do to protect it. Clinical Record 14: The aide plan developed on 05/05/2023 and updated 05/18/2023 did not include directions for the Hoyer Lift that was delivered and instructed on 05/17/2023. The bath type ordered was a "shower on the 2nd visit". Additionally, the patient had multiple dressings starting 05/15/2023 (3 on the back, and one each on the left buttock, coccyx, and left thigh). There was no instruction documented for the aide with respect to what to do if the dressings were saturated, or falls off, or if the dressings required covering during a shower. Clinical Record 17: The aide plan was developed on 10/06/2021 with no updates since that date. The assigned tasks were for bed bath every visit and shower every visit with no decision-maker for this task; the patient's diagnoses were Colon Cancer and forgetfulness. The Director of Clinical Services and the Regional Clinical Director stated, on interview, that "we have been meeting and educating on Aide Care Plans and have a current process improvement plan in place."

It is required that a hospice aide provides services: Ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 4 of 13 (31%) records in which a hospice aide was accepted, the agency did not ensure that the aides documented the assigned tasks as ordered by the interdisciplinary team. Clinical Record 5: The aide plan of care (POC) assigned on 04/25/2023 with no further updates, the task of "bath (shower) 2nd visit" with an aide visit frequency of two times a week. The week beginning 05/14/2023 with aide visits completed 05/16/2023 and 05/18/2023, a bed bath was documented at each visit; a bed bath was not assigned on the POC. The aide also documented on both dates in the section "Nurse notified", "nothing to report". The aide visit on 06/01/2023 (the first visit of the week), documented a bed bath and, in the section, "Nurse notified", "nothing to report." NOTE: No bath was ordered the first visit of the week and the only bath type assigned on the POC was a shower. Clinical Record 9: The aide POC developed 01/16/2023 included the assigned task of "shower 2nd visit of the week". The week beginning 01/15/2023 with aide visits documented on 01/17/2023 and 01/19/2023 and the next week, first visit on 01/24/2023, a shower was documented as provided on each visit. Showers were provided the first and second visit of each week, rather than on the 2nd visit of each week. Clinical Record 14: The aide POC developed on 05/05/2023 and updated 05/18/2023 ordered an aide visit frequency of 5 times a week. The bath type assigned was a shower on the second visit. The week of 05/07/2023 the second visit was on 05/09/2023 documented that a bath was "not required". The week of 05/14/2023 the second visit was on 05/16/2023 documented that a bath was "not required". The week of 05/21/2023 the second visit was on 05/23/2023 documented that a bath was "not required". Additionally, on 05/11/2023 (the 4th visit of the week) a bed bath was documented; the only bath type assigned was a shower. The aide visit on 05/30/2023 (1st visit of the week) a bed bath was documented. Both notes documented 'Y' (yes) to "communicated with other disciplines", but there was no coordination note about approval for a bed bath was evidenced. Clinical Record 15: The aide POC developed on 05/01/2023 included the following assigned tasks: sponge bath the first and third visits and shower the second and fourth visits of the week. The aide visit frequency was four times a week. The first week with the first visit on 05/01/2023, a shower was documented (sponge was ordered), the second visit 05/02/2023, no bath was provided and documented "not required" (a shower was the assigned task). The second week the first visit on 05/08/2023 documented a shower and a sponge bath (a sponge bath was assigned). The second visit on 05/09/2023 documented a sponge bath was provided (a shower was the assigned task). The fourth visit on 05/12/2023 documented a sponge bath was provided (a shower was the assigned task). The Director of Clinical Services and Regional Clinical Director stated, on interview, that the tasks documented did not match the tasks assigned and that a process improvement plan is in place for this.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. Each patient’s record includes, at a minimum: Physician orders. This standard was not met as evidenced by clinical record review and interview. In 5 of 16 (31%) records which included the need for additional written orders, the agency did not ensure that the orders were written or correctly written to include location of dressings. Clinical Record 2: The patient was admitted 04/21/2023 with end-stage multiple sclerosis and stage IV pressure areas. A physician order written 04/24/2023 stated: "Rinse with wound cleanser, pat dry, pack with normal saline-soaked gauze, cover with island dressing and change M-W-F." The order does not identify the wound location. This patient has bilateral openings on heels, the left outer knee, ischial and rectal wounds. The clinical notes identified the packing was being used for the left ischium wound but the order lacked this detail. Clinical Record 7: The patient was admitted 02/23/2023 with COPD (chronic obstructive pulmonary disease)/CHF (congestive heart failure) and increasing respiratory distress. The nursing visit note on 05/10/2023 documented a new order received for Buspar, there was no dose or administration frequency documented. The nursing visit note on 05/17/2023 documented the family reports improvement with using Buspar. There was no documented order for Buspar as of the date of review, 06/05/2023. Clinical Record 9: The patient was admitted 01/13/2023 with CHF/DM (diabetes mellitus). A physician order written 01/16/2023 stated: "Cleanse wound and apply border dressing one time a week." There was no wound location for dressing on the order. The clinical assessment documented the location as the left elbow skin tear with serosanguinous drainage. Clinical Record 11: The patient was admitted 10/09/2022 with COPD. A physician order written 01/13/2023 stated: "Clean with soap and water, pat dry and apply Neosporin or Medi-honey. Cover with gauze and change daily." There was no wound location for dressing identified. Additionally, on 01/10/2022 the nursing visit note documented that patient was on oxygen at 6 Liters. There was no order evidenced in the record, as of the patient's date of death on 01/22/2023, for 6 L of oxygen. The initial plan of care on 10/09/2022 documented oxygen at 4 L and that continued on the plans of care developed up to the patient's death 01/22/2023. Also, on 01/09/2023 the nursing visit note documented that a foley catheter was inserted. There was no evidence in the record of an order for insertion of a foley catheter as of the patient's death 01/22/2023. Clinical Record 12: The patient was admitted 10/31/2022 with CHF, kidney failure and diabetes. A physician order written 12/02/2022 stated: "Cleanse wound and surrounding area with normal saline spray, pat dry with gauze pad, apply Santyl, secure with kerlix tape. Avoid tape adhesive on skin." This order was absent a location of the wound and frequency of dressing change. Additionally there was no order for the dressing changed performed from 10/31/2022 - 12/02/2022: "Cleanse left lower leg with normal saline, apply Medi-honey dressing, cover with bordered dressing and change twice a week." Interview with Director of Clinical Services and Regional Clinical Director who stated that the software entry of wound orders looks like the location is included but it is not and the education continues for this.