Every finding on record at Freedom Hospice LLC

Based on record review and interview, the registered nurse failed to prepare written, patient-specific care instructions for the hospice aides in 3 (#1, #2, #3) of 3 patient records reviewed where the patient lived in a skilled nursing facility, had wounds, and received hospice aide services. The failure placed the patients at risk for the omission of care and/or receipt of inappropriate care. --- Patient #1:Record review of Patient #1's clinical record revealed a Plan of Care dated 9/17/2022 to 11/15/2022. The Plan of Care indicated that Patient #1 started on the agency's services on 4/20/2022. The Plan of Care listed Cerebral Infarction (primary diagnosis) and Diabetes Mellitus as diagnoses. The Plan of Care contained an order for skilled nurse visits weekly and aide visits 5 times each week. Registered Nurse C conducted a skilled nurse visit on 10/12/2022 due to a fall. Registered Nurse C documented that wound care was performed to a wound on Patient #1's right 2nd toe. Registered Nurse C documented that the wound was a diabetic ulcer. Registered Nurse C documented that the wound bed was clean, moist, and pink, the wound edges were attached, the peri-wound skin had erythema, had a scant amount of sanguineous/bloody drainage, and did not have an odor. Registered Nurse C documented that the wound measured 1.0 centimeters x 1.5 centimeters. ** Registered Nurse C conducted skilled nurse visits on 10/17/2022, 10/24/2022, and 10/31/2022. Registered Nurse C documented on 10/31/2022 that Patient #1's wound bed to the right 2nd toe was clean, moist and pink, the wound edges were attached, the peri-wound skin had erythema, had a scant amount of serosanguineous drainage, and did not have an odor. Registered Nurse C documented that the wound measured 1.0 centimeters x 1.5 centimeters. Licensed Vocational Nurse D conducted a skilled nurse visit on 11/2/2022 after the agency had received a call from the skilled nursing facility and Patient #1's family requesting a visit to assess Patient #1's toe and complete wound care. Licensed Vocational Nurse D documented that wound care had been done prior to Licensed Vocational Nurse D's arrival to the facility by the skilled nursing facility's ADON (assistant Director of Nursing)/wound nurse. Licensed Vocational Nurse D had documented that Patient #1's family requested an antibiotic due to an odor to the wound and redness to the top of the foot. The family provided Licensed Vocational Nurse D an image of the toe and foot which was forwarded to the physician with the family's permission. The physician ordered an antibiotic for 10 days. Licensed Vocational Nurse D documented that the skilled facility wound nurse had provided a copy of the current wound care orders. Patient #1's clinical record contained physician orders, dated 11/2/2022, from Physician Z. Physician Z ordered Clindamycin Hydrochloride 300 milligrams , three times a day by mouth for 10 days for infection. The updated wound order was to cleanse the right 2nd tow with normal saline, pat dry, apply Dakin's solution 0.125% soaked in gauze and wrap with kerlix, and change every Monday, Wednesday, Friday, and as needed. A review of Patient #1s hospice aide care plan contained instructions that Patient #1 was to receive a bed bath three times a week and a shower two times a week with a start date of 4/21/2022, but no patient-specific instructions for care of the wound during the baths and showers. Hospice Aide E conducted hospice aide visits on 10/14/2022, 10/19/2022, 10/21/2022, 10/25/2022, 10/26/2022, 10/31/2022, 11/2/2022, and 11/4/2022. Hospice Aide E gave Patient #1 a shower during those visits. During an interview on 11/8/2022 at 1:25 p.m. with Registered Nurse C, the surveyor discussed that Patient #1's aide care plan did not contain written, patient-specific care instructions regarding Patient #1's wound for the hospice aide. Registered Nurse C informed the surveyor that the skilled facility wound care nurse would remove the wound dressing, stay in the shower with the aide, and change the dressing. The dressing could get wet. When asked why the procedure was not written as a patient-specific care instruction for the aide, Registered Nurse C stated, "My fault, I didn't put it in the care plan." During an interview on 11/8/2022 at 1:40 p.m. with Hospice Aide E, the surveyor discussed Patient #1's wound and asked what procedures Hospice Aide E performed regarding the wound when Patient #1 was showered. Hospice Aide E informed the surveyor that Hospice Aide E was told by Registered Nurse C not to remove the dressing at all. Hospice Aide E stated, "I cover it with a plastic bag, so water does not go in. I was not told to do this by the nurse." Hospice Aide E informed the surveyor that the skilled facility's wound care nurse would not be present when Patient #1 received a shower. Hospice Aide E informed the surveyor that on 11/2/2022 the wound looked bad. Hospice Aide E had informed the case manager and the skilled facility nurse. Patient #2:Record review of Patient #2's record revealed a Plan of Care dated 10/3/2022 to 12/1/2022. The Plan of Care indicated that Patient #2 started on the agency's services on 4/6/2022. The Plan of Care listed Alzheimer's Disease as the primary diagnosis. The Plan of Care contained an order for skilled nurse visits once a week, and hospice aide visits 5 days a week. Registered Nurse C conducted a skilled nursing visit on 11/2/2022. Registered Nurse C documented that Patient #2 that Patient #2 received a shear tear to the right elbow that measured 2.5 centimeters x 0.5 centimeters x 0.2 centimeters. Registered Nurse C documented that the wound care was that a xeroform dressing was to be applied daily by the wound care nurse at the skilled facility. Patient #2's record contained a physician order dated 11/2/2022 that indicated that the wound was to be cleaned with normal saline, apply Xeroform, cover with a dry dressing and change daily until healed. Review of Patient #2's hospice aide care plan contained instructions that Patient #2 was to receive a shower on Mondays, Wednesdays, and Fridays with a start date of 5/18/2022, but no patient-specific instructions for care of the wound during the baths and showers. Hospice Aide F conducted a visit on 11/4/2022. Hospice Aide F documented that Patient #2 received a shower. During an interview on 11/8/2022 at approximately 1:25 p.m. with Registered Nurse C, the surveyor discussed Patient #2's hospice aide care plan, that there were no written patient-specific instructions regarding Patient #2s wound. Registered Nurse C informed the surveyor that Patient #2 would receive showers three times a week. The wound care nurse at the skilled nursing facility would remove the dressing, Patient #2 would get a shower, then the wound care nurse would apply the dressing. When asked why the procedure was not included as a written patient-specific instruction for the aide in the aide care plan, Registered Nurse C stated, "We are not being specific enough" on the aide care plans. Patient #3:Record review of Patient #3's record revealed a Plan of Care dated 10/1/2022 to 11/29/2022. The Plan of Care indicated that Patient #3 started on the agency's services on 10/1/2022. The Plan of Care listed Senile Degeneration of Brain as the primary diagnosis. The Plan of Care contained an order for wound care to a Stage III Pressure Ulcer on the posterior buttocks/coccyx. The wound care order was to cleanse the wound with normal saline, pat dry, apply collagen, and cover with a dry dressing daily. The Plan of Care contained an order for a skilled nurse visit once a week and hospice aide visits 5 times a week. The clinical record contained documentation of an interdisciplinary group meeting conducted on 10/6/2022. The document titled "Interdisciplinary Group Meeting" contained documentation of the initial skilled nurse visit that was conducted on 10/1/2022 by Registered Nurse G. Registered Nurse G documented that Patient #3 had a new Stage III Pressure Ulcer to the coccyx area that measured 1.0 centimeters x 0.5 centimeters x 0.2 centimeters. Review of Patient #3's hospice aide care plan contained instructions that Patient #3 was to receive a bed bath three times a week and a partial bed bath two times a week with a start date 10/1/2022, but no patient-specific instructions for care of the wound during the baths. During an interview on 11/8/2022 at approximately 1:25 p.m. with Registered Nurse C, the surveyor discussed Patient #3's hospice aide care plan, that there was written patient-specific instruction for the hospice aide in the hospice aide care plan regarding Patient #3s wound. Registered Nurse C informed the surveyor that Patient #3 had a wound to the sacrum, was getting showered, but then was getting a bed bath. Registered Nurse C informed the surveyor that the wound care nurse would remove the dressing so the aide could clean as close as possible to the wound and then wound care nurse would apply the dressing. When asked why the procedure was not written as a patient-specific care instruction for the aide, Registered Nurse C stated, "My fault, I didn't put it in the care plan."." During an interview on 11/8/2022 at 2:03 p.m. with the Administrator/Director of Nursing and the Alternate Administrator/Alternate Director of Nursing, the surveyor discussed Patient #1, #2, and #3's hospice aide care plans, that there were no written patient-specific instructions for the hospice aide in the hospice aide care plans regarding the patients wounds. The surveyor asked what the aides would do when patients had wounds. The Administrator/Director of Nursing informed the surveyor that, "depending on the wound, directions should be on the aide care plans and be patient specific." The Administrator/Director of Nursing did not dispute that written patient-specific instructions for the hospice aides were not included in the hospice aide care plans regarding the wounds. The Administrator/Director of Nursing stated, ";Ideally you want to see it on the care plan." The registered nurse failed to prepare written patient-specific instructions regarding Patient #1, #2, and #3s wound for the hospice aide in the hospice aide care plan. The agency had a policy titled "Hospice Care for Nursing facility Residents - Coordination of Services" that was labeled Policy Number : PC.H40. The policy read in part; "...Policy: Freedom Palliative and Hospice Care ensures that mechanisms are in place to provide for the coordination of all hospice services provided to patients residing in facilities. 1. The hospice designates a member of each interdisciplinary group that is responsible for a patient who is a resident of a facility. The designated interdisciplinary group member is responsible for:...b. communicating with facility representatives and other health care providers participating in the provision of care for the terminal illness and related conditions and other conditions to ensure quality of care for the patient and family..." The agency had a policy titled "Hospice Aide Assignments and Duties" that was labeled PC.H20. The policy read in part: "Hospice aides are assigned specific patients by a hospice RN (registered nurse) and follow written patient care instructions in providing care to assigned patients. 1. Hospice RN responsible for supervising the hospice aide prepares written patient care instructions that are patient-specific and not generic..."