Every finding on record at Doctors Hospice Northshores, LLC

It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide; Ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. This standard was not met, as evidenced by clinical record review, document review, and interview. Agency policy #HR-038 "Supervision" stated in part, "Hospice Aide services will be supervised every fourteen (14) days." In 3 of 12 (25%) clinical records reviewed for patients who received Hospice Aide (HA) services, the agency did not ensure that the HA was supervised by the Registered Nurse (RN) no less frequently than every 14 days. Clinical Record 2: The patient elected hospice care on 07/10/2024. The plan of care (POC), effective 07/10/2024, ordered HA services one (1) time a week for one (1) week and then two (2( times a week. The HA documented visits completed as ordered from 07/12/2024 through 08/20/2024, beginning on 07/12/2024. The nursing assessment forms completed by the RN from 07/12/2024 through 08/20/2024 documented, “Were hospice aide and/or LPN supervisory functions performed indirectly or directly...No." A clinical record review revealed no evidence of HA supervisory visits from 07/12/2024 through 08/20/2024. Clinical Record 3: The patient elected hospice care on 04/10/2024. The plans of care, effective 04/10/2024 and 07/09/2024, ordered HA services two (2) times a week. The HA documented visits completed as ordered from 04/12/2024 through 08/26/2024, beginning on 04/12/2024. The nursing assessment forms completed by the RN from 04/12/2024 through 08/26/2024 documented, “Were hospice aide and/or LPN supervisory functions performed indirectly or directly...No." A clinical record review revealed no evidence of HA supervisory visits from 04/12/2024 through 08/26/2024. Clinical Record 5: The patient elected hospice care on 04/24/2024. The POC, effective 04/24/2024, ordered HA services one (1) time a week. The HA documented visits completed as ordered from 04/24/2024 through 07/19/2024, beginning on 04/24/2024. The nursing assessment forms completed by the RN from 04/24/2024 through 07/19/2024 documented, “Were hospice aide and/or LPN supervisory functions performed indirectly or directly...No." A clinical record review revealed no evidence of HA supervisory visits from 04/24/2024 through 07/19/2024. During a joint record review and interview on 08/27/2024, the Director of Operations (DOO) stated that the agency process was for aide supervision visits to be completed during nursing visits entered into the system as needing a supervisory visit. The DOO was unsure why the RN did not document the aide supervision.

Based on interview and record reviews, the hospice agency failed to ensure nursing services met the needs of the patients for 3 of 3 (#2, #6, #8) patients reviewed for pressure wounds. The agency failed to follow: 1.) Acceptable standards of practice for wound care specifically for complete wound assessments for Patient #8; 2.) Acceptable standards of practice for weekly wound measurements, including the size and stage, for Patients #2, #6 and #8. Findings: Review of the Louisiana State Board of Nursing Declaratory Statement Scope of Practice for Registered Nurses - Wound Care Management adapted 02/1999 revealed the following in part: Registered nurses render care that is directed towards the prevention and treatment of wounds. Wounds are a common health care challenge that often occur with or result from Chronic disorders such as impaired circulation and malnutrition. Nursing care of skin/wound conditions involves the identification, assessment, management, and ongoing evaluation of patients with alterations in skin/tissue integrity that includes but is not limited to draining wounds, pressure ulcers, and vascular ulcers, and conditions resulting from incontinence, surgical procedures, and/or trauma. Scope of Practice - The Louisiana State Board of Nursing recognizes that assessment, planning, intervention, teaching, evaluation, and supervision are the major responsibilities of the registered nurse in the practice setting. The registered nurse is responsible for performing a nursing assessment and physical examination for preventative and restorative nursing and for providing patient/family teaching. Recognizing that the physician must always prescribe wound care, the following roles are defined to delineate the scope of practice for each member of the nursing team members. The registered nurse initiates appropriate wound preventative measures, stages wounds and collaborates with the wound care team in the implementation and evaluation of nursing interventions as prescribed by an authorized prescriber. Review of the National Pressure Ulcer Advisory Panel Prevention and Treatment of Pressure Ulcers: Quick Reference Guide revealed, in part, the following: Pressure Ulcer Assessment 1. Assess the pressure ulcer initially and re-assess it at least weekly. 1.1. Document the results of all wound assessments. Assess and document physical characteristics including: location, Category/Stage, size, tissue type(s), color, peri-wound condition, wound edges, sinus tracts, undermining, tunneling, exudate, and odor. Patient #2 Review of the clinical record for Patient #2 revealed a start of care date of 03/03/2022. Review of the plan of care for the current certification period 03/03/2022 to 05/31/2022 revealed a diagnosis of Pressure Ulcer of Right Hip, Stage 3. Further review of the plan of care revealed orders for the following Frequency/Duration of Visits: SN 3wk1, 4wk1, 2wk11, 1wk1, 3 prn visits. Orders of Discipline and Treatment included the following: Hospice nurse to perform wound care to right posterior buttock. Utilizing clean technique- cleanse with wound cleanser, apply honey, and cover with foam border dressing. Change every 3 days and prn. Review of the SN visit wound documentation revealed visits were conducted on the following weeks during this current certification period: Week of 03/07/2022, 03/14/2022 and 03/28/2022 revealed there were no weekly completed wound assessments documented, to include measurements of Patient #2's wound. Patient #6 Review of the clinical record for Patient #6 revealed a start of care date of 03/06/2022. Review of the plan of care for the current certification period 03/06/2022 to 05/04/2022 revealed diagnoses which included Posterior Heel Left Pressure Ulcer Stage 2, Mid Coccyx Pressure Ulcer Stage 2, Lateral Anterior edge of Right foot Stage 2, and Left Lateral Proximal Planter Pressure Ulcer Stage 2. Further review of the plan of care revealed orders for the following Frequency/Duration of SN Visits: 7wk1, 2wk7, 1wk1, 3 prn visits. Orders of Discipline and Treatment included the following: Hospice nurse to perform wound care to sacrum and bilateral feet wound utilizing clean technique. Cleanse with wound cleaner, apply wound paste, and cover with border gauze. Change every day and prn. Review of the SN visit wound documentation revealed visits were conducted on the following weeks during this current certification period: Week of 03/21/2022 and 04/02/2022 revealed there was no documentation there were no weekly completed wound assessments to include measurements of Patient #6's wound. Patient #8 Review of the clinical record for Patient #8 revealed a start of care date of 01/11/2022. Review of the plan of care for the current certification period 01/11/2022 - 04/10/2022 revealed diagnoses which included Pressure Ulcer to Coccyx. Further review of the plan of care revealed orders for the following Frequency/Duration of SN Visits: 4wk1, 3wk1, 1wk11, 3 prn visits. Orders of Discipline and Treatment included the following: Clean wound to coccyx with wound cleanser and apply collagen to wound bed and cover with clear dressing. Apply ointment to edges every 3 days and prn until healed. Review of the SN visit wound documentation revealed wound care was done in the following weeks during this current certification period: Week of 01/10/2022, 01/24/2022, 01/31/2022, 02/07/2022 and 02/21/2022 revealed there was no documentation of complete weekly wound assessments to include location, Category/Stage, size, tissue type(s), color, peri-wound condition, wound edges, sinus tracts, undermining, tunneling, exudate, and/or odor of Patient #8's coccyx wound. An interview was conducted on 04/07/2022 at 11:00 a.m. with S1RCO. She reviewed Patient #2 and Patient #6's clinical record and confirmed on the weeks listed above there were no wound measurements documented. She reviewed of Patient #8's clinical record and confirmed there was no documentation to indicate a complete weekly assessment of the wound was obtained by the RN.