Every finding on record at Full Life Hospice, LLC

Based on record review and interview, the hospice failed to ensure the plan of care was fully developed to include services provided for the management of wounds for one (Patient #2) of 13 patients reviewed. Findings: Patient #2 A plan of care dated 01/21/22 to 03/21/22 showed a skilled nurse frequency of one visit per week for one week and one visit per week for eight weeks and documented wound care to be provided with no orders for obtaining wound measurements, assessment of wounds or location of wound to be provided wound care. A review of the electronic medical record showed the following: A skilled nurse assessment dated 01/21/22 documented wound care provided with no documented assessment of the wound. A skilled nurse assessment dated 01/27/22 documented wound care provided with no documented assessment of the wound. A skilled nurse assessment dated 02/11/22 documented wound care provided with a documented wound size of 1 centimeter long by 1 centimeter wide and 0.3 centimeters deep. A skilled nurse assessment dated 02/18/22 documented wound care provided with a documented wound size of 1 centimeter long by 1 centimeter wide and 0.3 centimeters deep. A skilled nurse assessment dated 03/04/22 documented wound care provided with a documented wound size of 2.5 centimeter long by 2.5 centimeter wide and 0.3 centimeters deep. A skilled nurse assessment dated 03/18/22 documented wound care provided with no documented assessment of the wound. On 05/18/22 at 1:52 pm, Staff B stated the plan of care for Patient #2 failed to include assessment of documented wounds.

Based on record review and interview, the hospice failed to ensure physician notification of decline in wound status for one (Patient #2) of 13 patients reviewed. Findings: Patient #2 A plan of care dated 01/21/22 to 03/21/22 showed a skilled nurse frequency of one visit per week for one week and one visit per week for eight weeks and documented wound care to be provided with no orders for obtaining wound measurements, assessment of wounds or location of wound to be provided wound care. A review of the electronic medical record showed the following: A skilled nurse assessment dated 01/21/22 documented wound care provided with no documented assessment of the wound. A skilled nurse assessment dated 01/27/22 documented wound care provided with no documented assessment of the wound. A skilled nurse assessment dated 02/11/22 documented wound care provided with a documented wound size of 1 centimeter long by 1 centimeter wide and 0.3 centimeters deep. A skilled nurse assessment dated 02/18/22 documented wound care provided with a documented wound size of 1 centimeter long by 1 centimeter wide and 0.3 centimeters deep. A skilled nurse assessment dated 03/04/22 documented wound care provided with a documented wound size of 2.5 centimeter long by 2.5 centimeter wide and 0.3 centimeters deep with no physician notification of decline in wound status. A skilled nurse assessment dated 03/18/22 documented wound care provided with no documented assessment of the wound with no physician notification of decline in wound status. On 05/18/22 at 1:52 pm, Staff B stated the plan of care for Patient #2 failed to notify physician of the decline in wound status.