Every finding on record at Eureka Springs Hospital Hospice, LLC

Based on clinical record review, staff interview, and policy review, the hospice failed to ensure that all patient and family complaints were identified, documented, investigated, and incorporated into the Quality Assessment and Performance Improvement (QAPI) program in two (#7 and #10) of ten clinical records reviewed. Specifically, the hospice failed to recognize and process complaints received through multiple avenues, failed to investigate complaints in accordance with its policy, and failed to evaluate the effectiveness of a Performance Improvement Project (PIP) implemented to address complaint management. These deficient practices had the potential to affect all hospice patients and families who voiced concerns regarding the quality of care and services provided. --- Review of the hospice policy titled Grievance Procedure, Patient/Caregiver Complaints, Policy Number: 1.002, stated that staff members would make every attempt to resolve complaints immediately, when possible, and report all complaints/grievances and actions taken to the Executive Administrator/Executive Director within 24 hours of receipt. The policy further required the Executive Administrator/Executive Director  to interview the patient, representative, involved staff, or other individuals as appropriate; conduct an investigation and analysis; take appropriate action to resolve the issue; and follow up with patient and/or complainant no later than 30 days after the complaint was filed, documenting the outcome in the hospice information system. The hospice submitted documentation of a Performance Improvement Project (PIP) related to complaint management that was in effect at the time a complaint was received. Despite implementation of the PIP, the complaint was not adequately investigated, demonstrating the interventions were ineffective in preventing recurrence. Review of clinical record #7, with a start of care date of 01/28/2026, revealed a patient diagnosed with Cerebrovascular Disease. Review of the client’s coordination notes dated 02/02/2026 (Registered Nurse), 02/03/2026 (Registered Nurse), 02/03/2026 (Social Worker), and 02/05/2026 (Registered Nurse) documented complaints from the patient’s son regarding a lack of communication; however, the entries did not include specific details regarding the nature of the complaint. Review of the “General Event Information” revealed the complaint was entered into the complaint system on 02/12/2026 as “lack of communication,” again without specific details. The complaint report stated, “No documentation of family contact or update noted.” The record contained no evidence that additional investigative activities were conducted, including interviews with involved staff or the complainant, no documented findings of analysis, no corrective actions, and no documentation that follow-up was completed with the patient or family. During an interview, Personnel #2 stated the patient’s son complained that hospice staff never contacted him following visits to provide updates regarding his mother’s condition and that staff had failed to communicate with him regarding her care. Despite this information, the complaint report did not reflect that these concerns were investigated or that the complainant was notified of the outcome. Review of clinical record #10, with a start of care date of 04/02/2026, revealed a patient diagnosed with Unspecified Severe Protein-Calorie Malnutrition. Review of the “Change of Designated Hospice” form, completed by the patient’s wife on 04/30/2026, documented the reason for transferring hospice services as “lack of communication leading to insufficient attention.” Despite the expressed dissatisfaction with hospice services, there was no evidence the hospice recognized the statement as a complaint or grievance. Review of the complaint log and grievance records revealed the concern was not entered into the complaint tracking system, no investigation was initiated, and there was no documentation of findings, corrective actions, or follow-up with the patient’s wife. During an interview conducted on 06/12/2026 at 2:30 p.m., Agency Personnel #2 confirmed that the identified complaints were not processed in accordance with the hospice’s Complaint/Grievance Policy. Agency Personnel #2 further confirmed the complaints were not documented, investigated, or followed through to resolution as required by the agency's policy and the Hospice Conditions of Participation.

Based on clinical record review and staff interview, the hospice failed to ensure timely assessment, follow-up, and coordination of care in response to a significant change in the patient’s condition in one (#10) of ten clinical records reviewed. This deficient practice placed all hospice patients at risk for delayed recognition of clinical deterioration, inadequate symptom assessment and management, delayed implementation of appropriate interventions, unmanaged pain, and failure to meet patient and family care needs. --- Review of clinical record #10, with a start of care date of 04/02/2026, revealed a patient diagnosed with Unspecified Severe Protein-Calorie Malnutrition.Documentation revealed that on 04/22/2026 at 11:39 p.m., the patient’s wife contacted the hospice triage line reporting that the patient was experiencing chest pain unlike anything he had experienced previously. Triage staff reviewed the patient’s medications, instructed the wife to administer a dose of morphine, and documented that the wife requested a nursing visit.Further documentation revealed that a hospice nurse contacted the family by telephone on 04/22/2026 at 11:53 p.m. The nurse documented that the patient’s pain increased with deep breaths and was localized to the right anterior chest. The nurse instructed the wife to reposition the patient onto his left side, wait 30 minutes and administer additional dose of morphine if the pain had not subsided. The nurse documented a follow-up telephone call approximately 30 minutes later, at which time the wife reported the patient’s pain had decreased to a tolerable level. Despite the report of new-onset chest pain, the family’s request for a nursing visit, and continued telephone assessment, there was no evidence that an in-person nursing assessment was performed.Documentation further revealed that the next scheduled nursing visit on 04/24/2026 was missed due to a documented staff emergency/illness. There was no evidence that an alternate nursing visit or follow-up assessment was arranged.The next documented nursing visit occurred on 04/28/2026. The visit note contained no documentation addressing the patient’s previously reported chest pain, the triage contacts on 04/22/2026, the missed visit on 04/24/2026, or an evaluation of the patient’s response to the interventions provided by telephone.Documentation further revealed that on 04/30/2026, the family requested transfer to another hospice, citing “lack of communication leading to insufficient attention.”   During an interview conducted on 06/12/2026 at 2:30 p.m., Agency Personnel #2 confirmed that the agency failed to ensure timely nursing assessment, appropriate follow-up, continuity of care, and effective communication in response to a significant change in the patient’s condition.

Based on clinical record review and staff interview, the Skilled Nurse (SN) failed to include Oxygen on the patient's "Medications" list (a section of the Agency's care plan containing the medication profile) in 4 (#4. #15, #16, and #18) of 14 (#1, #2, #3, #4, #8, #9, #10, #12, #14, #15, #16, #17, #18, and #19) clinical records reviewed of patients utilizing oxygen. This deficient practice presented a potential risk to patients currently requiring Oxygen therapy by delaying pertinent information to the attending Physician regarding the patients individualized medication regimen. Findings follow: --- Review of clinical record #4 with a start of care of 03/29/24 revealed a patient with a diagnosis of Congestive Heart Failure. Review of a document titled "Vital Signs Report" revealed the patient utilized oxygen on 03/29/24, 03/31/24, and 04/04/24. Review of a document titled "Client Medication Report" failed to include oxygen on the patient's list of current medications. Review of clinical record #15 with a start of care of 10/21/23 revealed a patient with a diagnosis of Metastatic Liver Cancer. Review of a document titled "Vital Signs Report" revealed the patient utilized oxygen on 10/24/23, 10/29/23, 11/01/23, 11/03/23, and 11/04/23. Review of a document titled "Client Medication Report" failed to include oxygen on the patient's list of current medications. Review of clinical record #16 with a start of care of 12/11/23 revealed a patient with a diagnosis of Moderate Protein Calorie Malnutrition. Review of a document titled "Vital Signs Report" revealed the patient utilized oxygen on 12/25/23 and 12/27/23. Review of a document titled "Client Medication Report" failed to include oxygen on the patient's list of current medications. Review of clinical record #18 with a start of care of 11/17/23 revealed a patient with a diagnosis of Bone Cancer. Review of a document titled "Client Coordination Note Report" and dated 11/27/23 revealed ";DR. DUNN HAS ORDERED CONTINOUS O2 (oxygen) AT 2 L (liters) NASAL CANNULA". Review of a document titled "Client Coordination Note Report" and dated 12/03/23 revealed patient ";BREATHING ON CONTINOUS OXYGEN VIA MASK AT 2 LPM (liters per minute)". Review of a document titled "Client Medication Report" failed to include oxygen on the patient's list of current medications. An interview on 04/05/24 at 11:10 AM with Agency Personnel #1 confirmed the failure to include oxygen on the patient's current list of medications.

Based on clinical record review, agency documentation and staff interview it was determined the Interdisciplinary Group (IDG) failed to update an individualized Plan of Care (POC) which included patient specific scope and frequency of visits to be provided by each discipline including the Hospice Chaplain, Home Health Aide (HHA) , Skilled Nurse (SN), and/or Social Worker (SW) in 7 (#2, #5, #6, #9, #10, #11, and #14) out of 19 (#1-#19) clinical records reviewed, This lack of individualized and updated POC could result in unmet needs and lack of patient specific care for all patients on current census. Findings follow: --- 1. Review of clinical record #2 with a start of care of 03/15/24 revealed a patient with a diagnosis of Alzheimers. Review of a document titled ";Hospice IDG Comprehensive Assessment and Plan of Care Update Report" with a meeting date of 04/03/24 failed to include Chaplain, HHA, SN, or SW visit frequency. 2. Review of clinical record #5 with a start of care of 03/12/24 revealed a patient with a diagnosis of Parkinsons Disease. Review of a document titled ";Hospice IDG Comprehensive Assessment and Plan of Care Update Report" with a meeting date of 03/27/24 failed to include Chaplain, HHA or SN visit frequency. 3. Review of clinical record #6 with a start of care of 03/17/24 revealed a patient with a diagnosis of Cerebrovascular Disease. Review of a document titled ";Hospice IDG Comprehensive Assessment and Plan of Care Update Report" with a meeting date of 04/03/24 failed to include Chaplain, SN or SW visit frequency. 4. Review of clinical record #9 with a start of care of 03/08/24 revealed a patient with a diagnosis of Congestive Heart Failure. Review of a document titled ";Hospice IDG Comprehensive Assessment and Plan of Care Update Report" with a meeting date of 03/27/24 failed to include Chaplain visit frequency. 5. Review of clinical record #10 with a start of care of 03/01/24 revealed a patient with a diagnosis of Cerebrovascular Disease. Review of a document titled ";Hospice IDG Comprehensive Assessment and Plan of Care Update Report" with a meeting date of 03/13/24 failed to include Chaplain visit frequency. Review of a document titled ";Hospice IDG Comprehensive Assessment and Plan of Care Update Report" with a meeting date of 03/27/24 failed to include Chaplain or SN visit frequency. 6. Review of clinical record #11 with a start of care of 01/20/24 revealed a patient with a diagnosis of Heart Failure. Review of a document titled ";Hospice IDG Comprehensive Assessment and Plan of Care Update Report" with a meeting date of 03/27/24 failed to include Chaplain, HHA, or SN visit frequency. 7. Review of clinical record #14 with a start of care of 03/01/24 revealed a patient with a diagnosis of Hypertensive Heart Disease with Heart Failure. Review of a document titled ";Hospice IDG Comprehensive Assessment and Plan of Care Update Report" with a meeting date of 03/20/24 failed to include Chaplain, HHA, or SN visit frequency. 8. Agency Personnel #1 submitted additional documentation on 04/04/24 at 4:40 PM. Review of a document titled ";Hospice IDG Details" revealed ";Care plan updates and changes are to be addressed in the IDG notes by each discipline. This documentation will reflect changes since the last IDG meeting or since the last visit (if the specific discipline has not had contact with the patient since the last IDG meeting and/or this is the first IDG meeting)". Reports visit frequencies included on POC update only if there has been a change in frequency since the last IDG meeting. 9. An interview on 04/05/24 at 11:10 AM with Agency Personnel #1 confirmed the failure to include the specific scope and frequency of visits on the patients POC updates.

Based on clinical record review and staff interview, it was determined the Agency did not ensure all orders were complete and accurate in 3 ( #15, #16, and #18) of 14 (#1, #2, #3, #4, #8, #9, #10, #12, #14, #15, #16, #17, #18, and #19) clinical records reviewed of patients utilizing oxygen and 1 (#11) of 4 (#2, #5, #11, and #15) clinical records reviewed of patients requiring a urinary catheter. This failed practice could result in potential harm for all patients on census in that the agency did not obtain individual and specific orders to address the patient's specific needs. Findings follow: --- Review of clinical record #11 with a start of care of 01/20/24 revealed a patient with a diagnosis of Heart Failure. Review of a document titled ";HOSPICE CERTIFICATION AND PLAN OF CARE" with a certification period of 01/20/24 to 04/18/24 revealed an order for supplies ";CATHETER, CATHETER DRAIN BAG, CATHETER INSERTION KIT". Review of a document titled ";Order Number: 32824629" revealed an order date of 02/22/24 and an order description of ";CURITY NORMAL SALINE FLUSH FOLEY CATHETER WITH 30 ML (milliliters) EVERY 8 HOURS AS NEEDED". Review of a document titled ";Visit Note Report" and dated 03/19/24 revealed VISIT MADE DUE TO LEAKING CATHETER...........INSERTED 18FR CATHETER". There was no evidence of individualized orders for the insertion of an indwelling catheter to include the type and size of catheter to be inserted. Review of clinical record #15 with a start of care of 10/21/23 revealed a patient with a diagnosis of Metastatic Liver Cancer. Review of a document titled "Vital Signs Report" revealed the patient utilized oxygen on 10/24/23, 10/29/23, 11/01/23, 11/03/23, and 11/04/23. There was no evidence of individualized orders for oxygen to include the dosage or concentration, route of administration, or frequency of use. Review of clinical record #16 with a start of care of 12/11/23 revealed a patient with a diagnosis of Moderate Protein Calorie Malnutrition. Review of a document titled "Vital Signs Report" revealed the patient utilized oxygen on 12/25/23 and 12/27/23. Review of a document titled ";Order Number: 32190780" revealed an order date of 12/27/23 and an order description of ";OXYGEN SETUP AS NEEDED FOR SHORTNESS OF BREATH". There was no evidence of individualized orders for oxygen to include the dosage or concentration, route of administration, or frequency of use. Review of clinical record #18 with a start of care of 11/17/23 revealed a patient with a diagnosis of Bone Cancer. Review of a document titled "Client Coordination Note Report" and dated 11/27/23 revealed ";DR. DUNN HAS ORDERED CONTINOUS O2 (oxygen) AT 2 L (liters) NASAL CANNULA". Review of a document titled ";Order Number: 32018851" revealed an order date of 12/01/23 and an order description of ";OXYGEN SETUP AS NEEDED FOR SHORTNESS OF BREATH". Review of a document titled "Client Coordination Note Report" and dated 12/03/23 revealed patient ";BREATHING ON CONTINOUS OXYGEN VIA MASK AT 2 LPM (liters per minute)". There was no evidence of individualized orders for oxygen to include the dosage or concentration, route of administration, or frequency of use. An interview on 04/05/24 at 11:45 AM with Agency Personnel #1 confirmed the orders were not complete and accurate.

Based on clinical review home visit observation and interview of agency staff, it was determined the agency skilled nurse (SN) failed to follow standards of practice for infection control during wound care and dressing change in 1 (#13) out of 2 (#13 and #14) home visits for wound care observation. This failed practice had the potential to affect all patients currently on census receiving wound care. Findings follow: --- 1. Review of clinical record #13 with a start of care of 03/08/24 revealed a patient with a diagnosis of Moderate Protein Calorie Malnutrition. Review of a document titled ";HOSPICE CERTIFICATION AND PLAN OF CARE" and a certification period of 03/08/24 to 06/05/24 revealed orders for wound care. 2. The Center for Disease Control publication Morbidity and Mortality Weekly Report dated October 25, 2002 Vol. 51/N. RR-16 ";Guide for Hand Hygiene in Health-Care Settings" viewed at: https://www.cdc.gov/mmwr/PDF/rr/rr5116 defined the indications for hand washing and hand antisepsis including after removing gloves and prior to donning another pair of gloves. 3. On a home visit conducted on 04/04/24 observed SN provide wound care. Soiled dressing removed, wound cleansed, and clean dressing applied. SN failed to change gloves and complete hand hygiene during wound care after soiled dressing removed and prior to clean supplies handled and new dressing applied. 4. An interview on 04/04/24 at 4:50 Pm with Agency Personnel #3 confirmed failure to follow standard or contact precautions.