Every finding on record at Genesis Health System

Based on hospice staff interview, hospice policy review and clinical record review, the hospice failed to ensure the hospice plan of care included all necessary medications and treatments to meet the needs of the patient for 2 of 5 sampled patients (Patients #1 and #5).  Failure to ensure the plan of care included physician orders for all necessary medications, treatments and complete orders for medications placed patients at risk to receive inappropriate treatment of symptoms.  Findings include: --- According to the hospice policy, titled Interdisciplinary Plan of Care, dated 8/2025, identified the plan of care will include drugs and treatment necessary to meet the needs of the patient.  1. Patient #1 had a hospice admission date of 9/30/25 and received services from the hospice while residing in an assisted living facility. Clinical record review revealed:  a. Plan of Care, dated 9/30/25 to 12/28/25, included primary diagnosis of atrial fibrillation and interim physician orders for Eliquis 2.5 mg (milligrams) twice daily, levetiracetam (Keppra) 250 mg twice daily, melatonin and pantoprazole (Protonix).   b. Interim physician order, dated 10/1/25, identified to discontinue melatonin.  c. Interim physician order, dated 10/13/25, identified to discontinue Protonix.   d. IDG (Interdisciplinary Group) update to the plan of care, dated 10/15/25, included physician orders for Melatonin and pantoprazole with start dates of 9/14/25.   e. Interim physician order, dated 10/23/25, identified to discontinue Eliquis 2.5 mg twice a day and start Eliquis 2.5 mg daily, and to discontinue Keppra 250 mg twice a day and to start Keppra ER (extended release) 500 mg daily.  f. IDG updates to the plan of care, dated 10/29/25 and 11/12/25, included physician orders for melatonin, pantoprazole, Eliquis 2.5 mg twice a day with a start date of 9/14/25, Eliquis 2.5 mg daily with a start date of 10/23/25, levetiracetam (Keppra) 250 mg twice a day and Keppra XR (extended release) 500 mg daily.  The hospice RN (registered nurse) failed to identify the incorrect medication orders and duplicate medication orders on the IDG update/s to the plan of care and correct them.  During an interview on 11/25/25 at 1:50 PM, Administrator/Clinical Manager reported the incorrect medication order dates might be related to staff entering the medications into the pharmacy provider site before entering the physician order in the electronic medical record.  2. Patient #5 had a hospice admission date of 8/7/24, a death date of 9/11/25 and received services from the hospice while residing in a long-term care facility. Clinical record review revealed:  a. Interim physician order, dated 8/20/25, identified to discontinue alprazolam 0.25 mg tablet give 1 tablet twice a day every morning and at bedtime, discontinue alprazolam 0.25 mg tablet give 1/2 tablet daily at 1200, and start alprazolam 0.25 mg tablet give 1 tablet three times a day (every morning, 1200 and bedtime).  b. IDG update to the plan of care, dated 9/3/25, included physician orders for alprazolam 0.25 mg tablet give 1 tablet three times a day (every morning, 1200 and bedtime) with a start date of 8/20/25, and alprazolam 0.25 mg  1 tablet three times a day with a start date of 8/30/24.   The hospice RN failed to identify the duplicate medication order on the IDG update to the plan of care and correct the orders.  The above findings were reviewed with the Administrator/Clinical Manager.

Based on hospice staff interview, hospice policy review and clinical record review, the hospice failed to ensure the Interdisciplinary Group maintained a system for communication and integration of patient care and services to ensure hospice staff provided care in accordance with the plan of care for 1 of 5 sampled patients (Patient #5).  Failure of the hospice interdisciplinary group (IDG) members to maintain a system for communication and integration of patient care and services to ensure hospice staff provided care in accordance with the plan of care increased the risk that patients did not receive services to meet assessed needs.  Findings include: --- According to the hospice policy, titled Interdisciplinary Group, dated 8/2024, the IDG is responsible for documenting all care and services provided in a timely manner in accordance with the Hospice’s documentation requirements.  According to the hospice policy, titled Interdisciplinary Plan of Care, dated 8/2025, the Plan of Care will include a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs. Reviews of and changes to the plan of care are documented and communicated to members of the IDG.  Patient #5 had a hospice admission date of 8/7/24, a death date of 9/11/25 and received services from the hospice while residing in a long-term care facility. Clinical record review revealed:  a. IDG update to the Plan of Care, dated 7/16/25, included physician orders to provide volunteer services one time a week.  b.  Volunteer visit notes were completed, dated 7/15/25, 7/29/25 and 8/5/25.   c.  IDG update to the Plan of Care, dated 7/30/25, lacked documentation the IDG was notified of the missed volunteer visit for the week 7/20/25 through 7/26/25.    d.  IDG updates to the Plan of Care, dated 8/13/25, 8/20/25 and 9/3/25, lacked documentation the IDG was notified of missed volunteer visits after 8/5/25.  During an interview on 11/25/25 at 2:15 PM, Administrator/Clinical Manager reported she had contacted the volunteer coordinator and the hospice had no other volunteer visit notes.  The hospice failed to provide volunteer visits as ordered per the IDG updates to the Plan of Care.  The above findings were reviewed with the Administrator/Clinical Manager.

Based on clinical record review, hospice policy review, and hospice staff interview, the hospice failed to ensure the drug regimen review identified any ineffectiveness of drug therapy, side effects, duplicate drug therapy, actual or potential drug interactions or need for laboratory monitoring associated with all medications taken by the patient for 9 of 23 sampled patients (Patients #5, #7, #11, #12, #14, #18, #20, #22 and #24). Failure to ensure the interdisciplinary group (IDG) members involved in the assessment of patient needs identified actual or potential issues when performing the drug regimen review (DRR) with each update to the comprehensive assessment increased the risk of unidentified side effects and actual interactions of medications. --- 5. Patient #5 had a hospice admission date of 3/16/23, received routine home care hospice services while residing in a private home until 7/5/23 respite and routine home services while residing in the the hospice house, and died on 8/10/23 at the hospice house. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 3/16/23 to 6/13/23, included IDG orders for skilled nursing services and physician orders for duplicate medication therapies to treat constipation (Miralax, Milk of Magnesia and Stool Softener), duplicate medication therapy to treat anxiety (Alprazolam and Lorazepam) and duplicate medication therapy to treat nausea (Prochlorperazine and Ondansetron). The POC included a medication, Levothyroxine, associated with laboratory monitoring related thyroid function. b. The DRR completed by the RN as a part of the comprehensive assessment, dated 3/16/23, and documented in the corresponding coordination note for the comprehensive assessment, identified the patient did not have any duplicative medication therapies and did not take any medications associated with laboratory monitoring. c. The initial IDG meeting, dated 3/22/23, included physician orders for the same medications identified on the POC, dated 3/16/23 to 6/13/23, identified the patient did not have any duplicative medication therapies and did not take any medications associated with laboratory monitoring. The DRRs were inaccurate. 6. Patient #7 had a hospice admission date of 2/25/23, received routine home care hospice services while residing in a private residence and died on 8/9/23. Review of the clinical record revealed the following: a. The POC, dated 2/25/23 to 5/25/23, included IDG orders for skilled nursing services and physician orders for duplicate medication therapies to treat difficulty breathing (Ipratropium-Albuterol Nebulization Solution and Methylprednisolone), to treat urine retention (Doxazosin and Finasteride) and pain (Tramadol and Morphine Concentrate). The POC included a medication, Warfarin, associated with laboratory monitoring related to blood clotting. b. The DRR completed by the RN as a part of the comprehensive assessment, dated 2/25/23, and documented in the corresponding coordination note for the comprehensive assessment, identified the patient did not have any duplicative medication therapies, but did identify the patient's Warfarin was associated with laboratory blood testing monitoring. c. The initial IDG meeting, dated 3/1/23, included physician orders for the same medications identified on the POC, dated 2/25/23 to 5/25/23, identified the patient did not have any duplicative medication therapies and did not take any medications associated with laboratory monitoring. The DRRs were inaccurate. 7. Patient #11 had a hospice admission date of 7/21/23 and received routine home care hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The POC, dated 7/21/23 to 10/18/23, included IDG orders for skilled nursing services and physician orders for duplicate medication therapies to treat constipation (Milk of Magnesia and Docusate Sodium)and duplicate medication therapy to treat pain (Acetaminophen Extra Strength and Morphine Concentrate). The POC included a medication, Levothyroxine, associated with laboratory monitoring related thyroid function. b. The DRR completed by the RN as a part of the comprehensive assessment, dated 7/21/23, and documented in the corresponding coordination note for the comprehensive assessment, identified the patient did not have any duplicative medication therapies, but did identify the patient's Levothyroxine was associated with laboratory blood testing monitoring. c. The initial IDG meeting, dated 7/26/23, included physician orders for the same medications identified on the POC, dated 7/21/23 to 10/18/23, incorrectly identified the patient did not have any duplicative medication therapies and did not take any medications associated with laboratory monitoring. 8. Patient #22 had a hospice admission date of 6/30/23, received routine home care hospice services while residing in the hospice house and died on 7/6/23 at the hospice house. Review of the clinical record revealed the following: a. The POC, dated 6/30/23 to 8/18/23, included IDG orders for skilled nursing services and physician orders for duplicate medication therapies to treat constipation (Bisacodyl, Senna Lax and Miralax), treat pain (Acetaminophen Extra Strength tablets, Acetaminophen suppositories and Morphine Concentrate), treat nausea (ondansetron and prochlorperazine) and to treat anxiety (Restoril and Lorazepam). b. The DRR completed by the RN as a part of the comprehensive assessment, dated 6/30/23, and documented in the corresponding coordination note for the comprehensive assessment, identified the patient took duplicate medication therapies to treat constipation and pain. c. The initial IDG meeting, dated 7/3/23, included physician orders for the same medications identified on the POC, dated 6/30/23 to 8/18/23, incorrectly identified the patient did not have any duplicative medication therapies. 9. Patient #24 had a hospice admission date of 8/8/23 and received routine home care hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The POC, dated 8/8/23 to 10/6/23, included IDG orders for skilled nursing services and physician orders for duplicate medication therapies to treat constipation (Bisacodyl, Miralax and Milk of Magnesia) and treat pain (Acetaminophen and Morphine). The POC included a physician order for Tresiba, a medication associated with laboratory monitoring for blood sugar levels. b. The DRR completed by the RN as a part of the comprehensive assessment, dated 8/8/23, and documented in the corresponding coordination note for the comprehensive assessment, identified the patient did not have any duplicative medication therapies and did not take any medications associated with laboratory monitoring. c. The initial IDG meeting, dated 8/9/23, included physician orders for the same medications identified on the POC, dated 8/8/23 to 10/6/23, inaccurately identified the patient did not have any duplicative medication therapies and did not take any medications associated with laboratory monitoring. d. Review of current physician orders from the patient's nursing home, with a start date of 10/10/22, identified an order for blood sugar testing twice per day as needed and an order for blood sugar testing twice per day every Monday, Wednesday and Friday. The Administrator, Operations Manager, Hospice House and Community Supervisor received the above findings and hospice staff provided no further information prior to the end of the survey. Findings include: According to the hospice policy, titled Comprehensive Assessment, dated 03/2022, the comprehensive assessment of the patient consists of review of all the patients prescription and over-the-counter drugs, herbal remedies and other alternative treatments that could affect drug therapy. This includes, but is not limited to, identification of the following: effectiveness of drug therapy; drug side effects; actual or potential drug interactions; duplicate drug therapy; and drug therapy currently associated with laboratory monitoring. During an interview on 8/10/23 at 11:06 AM, the Operations Manager stated the initial DRR documented by the admit nurse and the case manager on the 24 hour follow up visit note, in the hospice plan of care note, and the IDG notes. 1. Patient #18 had a hospice admission date of 6/9/22, a discharge date of 8/30/22, and received hospice services from the Illinois office while residing in a nursing home. Clinical record review revealed the following: a. The POC, dated 6/9/22 to 9/6/22, included physician orders for magnesium citrate and polyethylene glycol (bowel medications), and levothyroxine (requires laboratory monitoring). b. The initial comprehensive assessment, dated 6/9/22, included documentation a DRR was completed and identified no duplicate medications and no medications that required laboratory monitoring. c. The IDG meeting notes, dated 6/16/22, 6/30/22, 8/11/22 and 8/25/22, included documentation a DRR identified no duplicate medications and no medications that required laboratory monitoring. d. The IDG meeting notes, dated 7/14/22 and 7/28/22, lacked documentation a DRR had been completed. The DRR failed to identify the duplicate bowel medications, medication requiring laboratory monitoring or completed a required DRR. 2. Patient #12 had a hospice admission date of 7/28/23, received hospice services from the Bettendorf parent office while residing in a nursing home. Clinical record review revealed the following: a. The Plan of Care (POC), dated 7/28/23 to 9/25/23, included physician orders for bisacodyl suppository, docusate sodium, enema, milk of magnesia, and polyethylene glycol multiple bowel medications. b. The initial comprehensive assessment, dated 7/28/23, included documentation a DRR was completed and identified duplicate bowel medications. c. The IDG meeting note, dated 8/2/23, included documentation a DRR identified no duplicate drug therapy. The DRR failed to identify the duplicate bowel medications. 3. Patient #14 had a hospice admission date of 7/27/23, received hospice services from the Bettendorf parent office while residing in a nursing home. Clinical record review revealed the following: a. The POC, dated 7/27/23 to 10/24/23, included physician orders for furosemide and spironolactone, both diuretics; ascorbic acid (Vitamin C), cholecalciferol (Vitamin D3), folic acid, and multivitamin, all supplements. b. The initial comprehensive assessment, dated 7/27/23, included documentation a DRR was completed and identified no duplicate medications. c. The IDG meeting note, dated 8/2/23, included documentation a DRR identified no duplicate drug therapy. The DRR failed to identify the duplicate supplements and diuretic medications. 4. Patient #20 had a hospice admission date of 2/21/23, a death date of 2/22/23, and received hospice services from the Illinois office while residing in a private home. Clinical record review revealed the following: a. The POC, dated 2/21/23 to 5/21/23, included physician orders for hydromorphone and morphine sulfate (pain medications) and ondansetron and prochlorperazine (anti-nausea medications). b. The initial comprehensive assessment, dated 2/21/23, included documentation a DRR was completed and identified no duplicate pain or anti-nausea medications. c. The IDG meeting note, dated 2/22/23, included documentation a DRR identified no duplicate drug therapy. The DRR failed to identify the duplicate pain and anti-nausea medications.

Based on clinical record review, review of employee personnel files and hospice policy review, the hospice failed to ensure 4 of 7 sampled community hospice aides (Staff M, N, O and P) satisfactorily demonstrated competency in the performance of any skills which exceed the level of basic hospice aide skills in the presence of a registered nurse with competency determined at a patient's bedside or using a real person (pseudo-patient) prior to being assigned to perform the task independently for 5 of 9 sampled patients who required an extra skill task to be performed (Patient #1, #3, #10, #17 and #21). The hospice employed a total of 7 community hospice aides at the time of the survey. Failure to ensure hospice aides have a competent ability to perform all skills above and beyond basic hospice aide skills increased the risk that patients received inadequate or inappropriate care. --- Findings include: The Medicare Conditions of Participation direct that the hospice aide may not independently provide any patient cares beyond the basic required skills without successful instruction and demonstration of competency in extra skills assigned on the aide care plan. According to the Policy titled Hospice Aide Orientation, dated 07/22, a Registered Nurse (RN) preceptor works one on one with the hospice aide in personal cares with patient/pseudo patients and determines when the aide is competent to proceed with the competency independently. Each competency sheet is signed and dated by the RN preceptor as it is completed. The aide will have a competency done prior to performing any task independently. A Hospice RN will oversee the competency prior to the aide providing independent care. 1. Patient #1 had a hospice admission date of 2/20/23, and received hospice services while residing in a nursing home. The aide care plan included RN instructions to the aide to assist with feeding the patient. Review of the clinical record showed Staff M, Hospice Aides, provided aide services independently for Patient #1. Staff M, Hospice Aide, had a hire date of 6/25/18. Staff M's personnel file lacked documentation RN had observed Staff M competently perform the task of feeding the patient. 2. Patient #3 had a hospice admission date of 7/26/23, and received hospice services while residing in a private home. The aide care plan included RN instructions to the aide for providing shaving. Review of the clinical record showed Staff M, Hospice Aides, provided aide services independently for Patient #3. Staff M, Hospice Aide, had a hire date of 6/25/18. Staff M's personnel file lacked documentation RN had observed Staff M competently perform the task of shaving. 3. Patient #10 had a hospice admission date of 6/30/23, and received hospice services while residing in an assisted living facility. The aide care plan included RN instructions to the aide to assist with shaving, catheter care and emptying the urinary drainage bag. Review of the clinical record showed Staff P, Hospice Aides, provided aide services independently for Patient #10. Staff P, Hospice Aide, had a hire date of 6/27/22. Staff P's personnel file lacked documentation RN had observed Staff P competently perform the tasks of shaving, catheter care and emptying the urinary drainage bag. 4. Patient #17 had a hospice admission date of 6/2/23, and received hospice services while residing in a nursing home. The aide care plan included RN instructions to the aide to assist with hoyer lift and shaving. Review of the clinical record showed Staff N and Staff O, Hospice Aides, provided aide services independently for Patient #17. a. Staff N, Hospice Aide, had a hire date of 3/12/18. Staff N's personnel file lacked documentation RN had observed Staff N competently perform the task of hoyer lift. b. Staff O, Hospice Aide, had a hire date of 7/24/23. Staff Os personnel file lacked documentation RN had observed Staff O competently perform the task of shaving. 5. Patient #21 had a hospice admission date of 7/13/22, a death date of 8/26/22, and received hospice services while residing in a nursing home. The aide care plan included RN instructions to the aide to assist with shaving and gait belt. Review of the clinical record showed Staff M, Hospice Aides, provided aide services independently for Patient #21. Staff M, Hospice Aide, had a hire date of 6/25/18. Staff M's personnel file lacked documentation RN had observed Staff M competently perform the tasks of shaving and gait belt. The Administrator, Operations Manager, Hospice House and Community Supervisor received the above findings and hospice staff provided no further information prior to the end of the survey.

Based on clinical record review and staff interview, the hospice failed to document all required components of hospice aide supervision including following the patient plan of care, creating successful interpersonal relationships with the patient and family, demonstrating competency of all assigned tasks, complying with infection prevention and control policies, reporting changes in the patient condition every 14 days when the patient receives skilled services in conjunction with the hospice aide services for 5 of 15 sampled patients (Patients #1, #5, #7, #8 and #15) with hospice aide services that required and received hospice aide supervision since the end of the pandemic and resumption of the requirement of hospice aide supervision. The hospice reported 72 patients received hospice aide services at the time of the survey. Failure to ensure the supervision of hospice aide by registered nurses maintained documentation of a review of all required supervisory elements increased the risk of agency staff not meeting the patients' personal care needs. --- 4. Patient #5 had a hospice admission date of 3/16/23, received routine home care hospice services while residing in a private home until 7/5/23 respite and routine home services while residing in the the hospice house, and died on 8/10/23 at the hospice house. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 6/14/23 to 9/11/23, included Interdisciplinary Group (IDG) orders for skilled nursing and hospice aide services twice per week. b. A skilled nursing visit, dated 6/15/23, included documentation of hospice aide supervision by the RN. c. The clinical record lacked documentation of hospice aide supervision after 6/15/23 and prior to the patient entering the hospice house on 7/5/23 (20 days without documentation of hospice aide supervision). 2. Patient #7 had a hospice admission date of 2/25/23, received routine home care hospice services while residing in a private residence and died on 8/9/23. Review of the clinical record revealed the following: a. The POC, dated 5/26/23 to 8/23/23, included IDG orders for skilled nursing services and hospice aide services twice per week. b. A skilled nursing visit, dated 7/6/23, included documentation of hospice aide supervision by the RN. c. The clinical record lacked documentation of hospice aide supervision until a skilled nursing visit, dated 7/24/23 (4 days late). The Administrator, Operations Manager, Hospice House and Community Supervisor received the above findings and hospice staff provided no further information prior to the end of the survey. Findings include: During an interview on 8/10/23 at 11:06 AM the Operation Manager stated the Registered Nurse (RN) supervises the hospice aides and documents the supervision in the RN visit note. 1. Patient #1 had a hospice admission date of 2/20/23 and received hospice services from the Bettendorf parent office while residing in a nursing home. Clinical record review revealed the following: a. The Plan of Care (POC), dated 5/21/23 to 8/18/23, included orders for hospice aide and skilled nursing services. b. The skilled nursing visit notes, dated 6/22/23, included documentation the nurse supervised the hospice aide. c. The skilled nursing visit note, dated 6/25/23, failed to include documentation the nurse supervised the hospice aide. d. The skilled nursing visit note, dated 7/14/23, included documentation the nurse supervised the hospice aide, 22 days after the last aide supervision and 8 days later than required. The hospice failed to document aide supervision every 14 days. 2. Patient #8 had a hospice admission date of 5/30/23 and received hospice services from the Bettendorf parent office while residing in a private home. Clinical record review revealed the following: a. The Interdisciplinary Group (IDG) meeting note, dated 5/31/23, included orders for hospice aide and skilled nursing services. b. The skilled nursing visit notes, dated 6/23/23, 6/27/23, 6/30/23, 7/7/23, 7/18/23 and 7/21/23, failed to include documentation the nurse supervised the hospice aide. c. The skilled nursing visit note, dated 7/28/23, included documentation the nurse supervised the hospice aide, 34 days without documentation of aide supervision. The hospice failed to document aide supervision every 14 days. 3. Patient #15 had a hospice admission date of 6/24/23 and received hospice services from the Illinois office while residing in a nursing home. Clinical record review revealed the following: a. The IDG meeting note, dated 6/28/23, included orders for hospice aide and skilled nursing services. b. The skilled nursing visit note, dated 7/17/23, included documentation the nurse supervised the hospice aide. c. The skilled nursing visit note, dated 7/23/23, failed to include documentation the nurse supervised the hospice aide. d. The skilled nursing visit note, dated 8/1/23, included documentation the nurse supervised the hospice aide, 15 days after the last aide supervision and 1 day later than required. The hospice failed to document aide supervision every 14 days.

Based on clinical record review and staff interview, the hospice failed to ensure the hospice staff sent a copy of a discharge summary to the attending physician for 2 of 2 sampled (live) discharged patients (Patients #18 and #19). Failure to ensure the hospice staff included the attending physician in the process for imminent discharge placed the patient at risk for not receiving ongoing medical care and services to meet the needs of the patients. --- Findings include: During an interview on 8/22/22 at 4:27 PM, the Operation Manager reported the IDG summary note and physician order for discharge are faxed to the physician to notify of patient discharge. The discharge summary is not sent to the physician. 1.Patient #18 had a hospice admit date of 6/9/22, a discharge date of 8/30/22, and received services while residing in a nursing home. Clinical record review revealed a completed discharge summary, dated 8/30/22. The clinical record lacked documentation the discharge summary was forwarded to the patient's attending physician. 2. Patient #19 had a hospice admit date of 3/16/23, a discharge date of 4/9/23, and received services while residing in a private home. Review of the clinical record lacked documentation the discharge summary was completed or forwarded to the patient's attending physician. The Administrator, Operations Manager, Hospice House and Community Supervisor received the above findings and hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, hospice policy review, hospice house security video review, family and staff interview, the hospice failed to ensure the following: 1) hospice pharmacy services identified adverse drug interactions when setting up a hospice house Medication Administration Record for patients (see L688); and, 2) hospice house nursing staff included the reason on the patient's Medication Administration Record for as needed medications and assessed the patient's condition prior to giving as needed medications in order to ensure the accurate dispensing/administration of medications (see L691). --- The cumulative effect of these practices resulted in the failure of the hospice to ensure patient's receiving hospice services from the hospice's own hospice house received safe and effective medication administration.

Based on clinical record review, hospice policy review, medication administration observation and staff interview, the hospice failed to ensure hospice pharmacy services identified adverse drug interactions when setting up a hospice house Medication Administration Record for patients based on the physician's orders for 1 of 3 sampled patients (Patient #23). Failure to ensure hospice pharmacy services identified adverse drug interactions when setting up hospice house Medication Administration Record for patients placed patient's at risk to experience adverse or ineffective drug treatment. --- aaa Review of the hospices policy, titled Medication Management Administration and Medication Review, dated 5/2023, revealed the hospice uses a collaborative medication management and monitoring approach between the hospice staff, pharmacist, physician, patient and caregivers. A contracted pharmacist creates the Medication Administration Record (MAR). The pharmacy delivers a paper MAR with all new admissions, and a nurse is responsible to check directly against the physician orders for accuracy. Patient #23 had a hospice admission date of 7/11/23 and received routine home care services while residing at the hospice's own hospice house. Review of the clinical record revealed the following: The Plan of Care (POC), dated 7/11/23 to 10/8/23, included Interdisciplinary Group (IDG) orders for skilled nursing 24 hours a day, 7 days a week and for the nurse to administer the patient's medications. The POC included physician orders for Levothyroxine 100 micrograms (mcg) every day by mouth (to treat underactive thyroid functioning) and Omeprazole 20 mg daily by mouth (to treat gastric reflux). On 8/10/23 at 8:36 AM, during an observation, Staff E, Hospice House Registered Nurse (RN), reviewed the Medication Administration Record (MAR) for Patient #23 scheduled medications to be administered at 8:00 AM. The MAR had both the Levothyroxine and Omeprazole scheduled for 8:00 AM. Staff E, Hospice House RN, removed the 8:00 AM medications from the medication cart, put the medications in medication cups and took the medications to the patient. Staff E, Hospice House RN, handed the medications to the the patient and observed the patient take the medications. Review of the Federal Drug Administration Administration Prescribing Information identified Levothyroxine should not be given with Proton Pump Inhibitors (Omeprazole) due to the Proton Pump Inhibitor may cause a decrease in the body's absorption of the Levothyroxine. On 8/10/23 at 10:29 AM, during an interview, the Hospice House Supervisor explained the pharmacy creates the MAR and sets up the medication administration times on the MAR. The MARs for the patients come pre-printed from the pharmacy. The Hospice House Supervisor reported that they talked with the pharmacy and they did not know why they set up the Levothyroxine and Omeprazole to be administered at the same time for Patient #23, but they planned to fix this. Review of the patient's MAR for July 2023 and August 2023 revealed the hospice had been administering Omeprazole with Levothyroxine to the patient at 8:00 AM daily from 7/11/23 to 8/10/23. The pharmacy and hospice nurses failed to identify the potential adverse reaction with administering Omeprazole and Levothyroxine at the same time. The Administrator, Operations Manager, Hospice House and Community Supervisor received the above findings and hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, hospice policy review, hospice house security video review, family and staff interview, the hospice failed to ensure hospice house nursing staff included the reason on the patient's Medication Administration Record for as needed medications and assessed the patient's condition prior giving as needed medications in order to ensure the accurate dispensing/administration of medications for 1 of 4 sampled patients (Patient #22) who received hospice house services. Failure to ensure hospice house nursing staff included the reason on the patient's Medication Administration Record for as needed medications and assessed the patient's condition prior giving as needed medications in order to ensure the accurate dispensing/administration of medications resulted in a patient receiving unnecessary medications. --- aa Review of the hospices policy, titled Medication Management Administration and Medication Review, dated 5/2023, revealed the hospice uses a collaborative medication management and monitoring approach between the hospice staff, pharmacist, physician, patient and caregivers. As needed (PRN) Medication orders must identify the purpose for use. Nurses will administer medications per physician orders and the nurse is directly responsible for knowledge on any medication they administer. When administering an as needed medication, nurses will document the indicated use in the patient's electronic medical record. Patient #22 had a hospice admission date of 6/30/23, received services at the hospice house and died on 7/6/23. The Plan of Care, dated 6/30/23 to 8/18/23, identified a diagnosis of lung cancer, included interdisciplinary group orders for skilled nursing services 24 hours a day, 7 days a week while the patient received routine home care services at the hospice house and physician orders for Morphine Concentrate 100 milligrams (mg)/5 milliliters (ml) (20 mg/ml) oral solution, 5-10 mg oral hourly for pain or dyspnea (difficulty breathing) as needed and Lorazepam 0.5 mg 1 to 2 tabs every 2 hours for anxiety/restlessness as needed by mouth or sublingual (under the tongue, liquid form). The Plan of Care did not include any direction to hospice nursing staff to pre-medicate the patient prior to repositioning the patient or providing any cares. The Interdisciplinary Group meeting note, dated 7/3/23, included physician orders for the same medications as the Plan of Care, dated 6/30/23 to 8/18/23, and did not include any direction to hospice nursing staff to pre-medicate the patient prior to repositioning the patient or providing any cares. The hospice houses Medication Administration Record (MAR) for Patient #22 identified the following: 1. On 7/3/23, the patient received Lorazepam 1 mg by mouth two times during a 24 hour period. The daily encounter visit notes completed by the nurse, dated 7/3/23, included documentation of symptoms to support the administration of the as needed medication. 2. On 7/4/23, the patient received Lorazepam 1 mg by mouth three times during a 24 hour period. The daily encounter visit notes completed by the nurse, dated 7/4/23, included documentation of symptoms to support the administration of the as needed medication. The nurse administered the patients first dose of Morphine 10 mg at 4:05 PM for pain along with the third dose of Lorazepam for restlessness. 3. On 7/5/23, the nurse administered Lorazepam 1 mg at 10:47 AM, Lorazepam 1 mg 1:00 PM and Morphine 10 mg at 1:01 PM, and Morphine 10 mg and Lorazepam 1 mg at 5:05 PM. The daily encounter visit notes completed by the nurse, dated 7/5/23, included documentation of symptoms, including pain and restlessness, to support the administration of the as needed medications. A daily encounter visit note, dated 7/5/23 at 5:45 PM, included documentation that Staff H, Hospice House RN, contacted the Medical Director due to the patient pulling the oxygen tubing off and not letting staff put the oxygen back on the patient. Staff H, Hospice House Registered Nurse (RN), documented the patient had increased respirations after removing the oxygen. Staff H, Hospice House RN, documented that the Medical Director directed them to give the patient Morphine 20 mg for a respiration rate of 24 breaths per minute. 4. On 7/5/23, the MAR included a discontinued order for Morphine 5 to 10 mg as needed every hour for pain and shortness of breath and a new hand-written order for Morphine 10 mg to 20 mg every hour as needed by mouth or sublingual. The MAR lacked documentation of a reason to administer the as needed medication. On 8/22/23 at 7:47 AM, during an interview, with Nancy Calmer, Staff J, Hospice House RN, and Staff G, Hospice House RN, Staff J reported working 3rd shift at the hospice house since the end of June 2023. Both Staff G, Hospice House RN, and Staff J, Hospice House RN, reported that when giving an as needed medication, they look at the patients MAR to know what and why they are giving the medications. Both Staff G, Hospice House RN, and Staff J, Hospice House RN, reported that when they receive a verbal physician order, they hand-write the order on the MAR and include the reason for giving the medication if the medication is an as needed (prn) medication. Both Staff G, Hospice House RN, and Staff J, Hospice House RN, reported that they are required to assess the patient prior to giving a prn medication and document this in the daily encounter note. On 8/22/23 at 7:54 AM, during an interview, Staff K, Hospice House RN, a day shift hospice house nurse reported that when giving an as needed medication, they look at the patients MAR to know what and why they are giving the medications. Staff K, Hospice House RN, reported when they receive a verbal physician order, they hand-write the order on the MAR and include the reason for giving the medication if the medication is a prn medication. Staff K, Hospice House RN, reported that they are required to assess the patient prior to giving a prn medication and document this in the daily encounter note. On 8/22/23 at 10:32 AM, during an interview, Staff L, Admissions RN for both the Hospice House and the Community, reported when they receive a verbal physician order, they hand-write the order on the MAR and include the reason for giving the medication if the medication is a prn medication. Staff L, RN, reported that they are required to assess the patient prior to giving a prn medication. On 8/22/23 at 2:56 PM, during an interview, Staff H, Hospice House RN, reported working at the hospice house for 7 years, and works second shift. Staff H, Hospice House RN, reported that when giving a prn medication, they look at the patients MAR to know what and why they are giving the medications. Staff H, RN, reported when they receive a verbal physician order, they hand-write the order on the MAR and include the reason for giving the medication if the medication is a prn medication. Staff H, Hospice House RN, reported that they are required to assess the patient prior to giving a prn medication and document this in the daily encounter note. Staff H, Hospice House RN, confirmed they should have included the reason in the order they wrote for Morphine 10 to 20 mg on 7/5/23 for Patient #22. 5. On 7/5/23 at 5:45 PM, the MAR included documentation Staff H, Hospice House RN, administered Morphine Concentrate 20 mg orally. Review of the clinical record for Patient #22 revealed a verbal physician order, dated 7/5/23, for Morphine Concentrate 100 mg/5 ml (20 mg/ml) oral solution 10-20 mg hourly as needed oral for tachypnea (rapid breathing). 5. On 7/5/23 at 7:25 PM, the MAR included documentation Staff H, Hospice House RN, administered Morphine concentrate 20 mg and Lorazepam 1 mg orally. The daily encounter visit note completed by Staff H, Hospice House RN, revealed they administered the medications related to symptoms of rapid breathing and restlessness. The daily encounter notes, dated 7/5/23 at 10:12 PM, 10:41 PM and 11:50 PM, identify the patient was resting in bed. On 7/6/23 at 2:13 AM, Staff F, Hospice House Aide documented that they repositioned the patient and completed oral cares. On 7/6/23 at 2:20 AM, Staff G, Hospice House RN, documented that they "pre-medicated (the patient) with Roxanol (Morphine) and Ativan (Lorazepam) before repositioning". The nurse documented the patients feet were mottled and cool. A daily encounter note, dated 7/6/23 at 2:31 AM, Staff G, Hospice House RN, included documentation that the patient's family member/Durable Power of Attorney (DPOA) entered the hallway and reported the patient was no longer breathing. Staff G, Hospice House RN, pronounced the patient's death at 2:36 AM. On 8/15/23 at 10:05 AM, during an interview, the Medical Director reported that if a hospice nurse was planning on pre-medicating a patient with Morphine Concentrate prior to the hospice staff repositioning the patient to lessen pain or difficulty breathing, the nurse would need to administer the medication and allow at least 15 minutes for the medication to take effect before repositioning the patient. On 8/16/23 at 8:00 AM, during an interview, Staff F, Hospice House Aide, reported the nurse typically pre-medicates patients 45 minutes to 1 hour prior to going into the room to provide cares or reposition patients. The hospice aide and nurse usually give cares to the patients together. Staff F, Hospice House Aide, recognized the patient name and the patients family member/DPOA, but could not remember the specifics surrounding the care and medication administration to the patient the night the patient died. On 8/17/23 at 7:37 AM, during an interview, Staff G, Hospice House RN, reported they work night shift at the hospice house. Staff G, Hospice House RN, reported the hospice house aides check on patients every hour, while the nurses check on the patient's every 2 hours, unless they need something. Staff G, Hospice House RN, reported they remembered the patient, but not the administration of the medication. Staff G, Hospice House RN, reported if they documented on the MAR that they gave the medications at 2:20 AM, then that is when Staff G gave the medications. Staff G, Hospice House RN, thought the patient might have been one of those patients that needed to be pre-medicated before repositioning. On 8/17/23 at 11:20 AM, review of security video feed of Patient #22s room at the hospice house, dated 7/6/23 at 1:00 AM to 2:23 AM, with the Operations Manager revealed the following: At 1:00 AM to 1:11 AM, video observation revealed the patient to be resting in bed on the patients back with eyes closed and no movement. The patient had a person laying in the bed next to the patient and another person laying on the sofa in the patients room. At 1:11 AM, Staff F, Hospice House Aide (identified by the Operations Manager), entered the patients room and went into the patients bathroom. Staff F exited the room and returned at 1:12 AM with supplies. Staff F, Hospice House Aide, exited the room and shut the door at 1:13 AM. The patient did not move in response to the staff person being in the room. The patient continued to lay in bed in the same position with eyes closed and no signs of distress from 1:13 AM to 2:13 AM. At 2:13 AM, the person on the sofa sat up and laid back down. The patient continued to lay in bed in the same position with eyes closed and no signs of distress or movement. At 2:14 AM, Staff F, Hospice House Aide, entered the patients room and woke up the person in bed next to the patient. The person that was in bed next to the patient moved to the sofa. Staff F, Hospice House Aide, raised the patients hospital bed up from low position and started to uncover the patient. At 2:17 AM, a second staff person entered the room, identified by the Operations Manager as Staff I, Hospice House Aide, and began to assist Staff F, Hospice House Aide, in repositioning the patient in bed. At 2:18 AM, a third staff person entered the room, identified by the Operations Manager as Staff G, Hospice House RN. The Operations Manager agreed that the patient had no response or voluntary movement while Staff F and Staff I, Hospice House Aides, repositioned the patient. At 2:19 AM, Staff I, Hospice House Aide, provided oral care per the Operations Manager. At 2:20 AM, Staff G, Hospice House RN, used a syringe to deliver a liquid substance into the patients mouth. All staff had exited the room by 2:23 AM. The Operations Manager agreed the patient did not move throughout the time staff provided care to the patient. The Operations Manager agreed Staff G, Hospice House RN, had entered the patient's room with the syringe already filled with a liquid substance. The Operations Manager agreed the timing of the administration of the liquid in the syringe on the video corresponded with the timing of the documentation of the administration of the Morphine and Lorazepam by Staff G, Hospice House RN. The Operations Manager also agreed the medication had not been administered prior to the hospice aides repositioning the patient, as previously documented by Staff G, Hospice House RN. The Operations Manager pointed out that the video did not have sound, so the observers could not ascertain if the patient was groaning in pain. On 8/17/23 at 1:19 PM, during an interview with a family member of Patient #22, the family member confirmed that they were present and awake during the time staff had repositioned the patient for the last time. The family member reported the patient had no voluntary movement or response of any kind while staff repositioned the patient. The family member reported being unaware the hospice RN had administered any medications to the patient. On 8/22/23 at 8:25 AM, during an interview, the Medical Director reported the expectation for nursing staff to assess the patient for signs and symptoms related to the reason for giving an as needed medication prior to giving that medication. Staff may pre-medicate the patient prior to moving the patient if a patient has a history of being uncomfortable in the past when staff are providing cares and moving the patient. Staff would even possibly pre-medicate the patient even if the patient is not displaying any signs of discomfort. If a patient is to be pre-medicated by nursing staff, the hospice team (interdisciplinary group) care plans the premedication. If a patient is not responsive and not displaying any signs of discomfort or restlessness, then the patient would not need to be medicated. In the case of Patient #22, the Medical Director reported the nurse should not have administered the Morphine 20 mg and Lorazepam 1 mg to the patient if the patient did not have any signs or symptoms of dyspnea (difficulty breathing), restlessness or signs of discomfort. The Medical Director reported it was possible the Morphine and Lorazepam administered by the hospice house nurse at 2:20 AM on 7/6/23 hastened the death of the patient at 2:36 AM. The Medical Director reported the earlier doses of Morphine would have been out of the patients system unless the patient was in liver failure. The Medical Director discussed the possibility that the patient was displaying signs of terminal restlessness (a symptom of a patient near the final stages of death) on 7/5/23 by pulling out the oxygen. On 8/22/23 at 9:07 AM, during an interview, the Operations Manager and Hospice House Supervisor both reported the hospice nurses should be assessing the patients prior to administering prn medications in relation to the reason for giving the medication. The Hospice House Supervisor reported that the nurses should document their assessment of the of the symptoms in the daily encounter notes. The Operations Manager and Hospice House Supervisor both reported that they would be reviewing the MARs and current orders for patients to ensure accuracy and provide education to staff. Hospice staff failed to assess the patients condition in order to ensure they dispensed medications accurately as prescribed by the physician for the reason the physician ordered the medications. Hospice staff administered unnecessary medications to the patient. The Administrator, Operations Manager, Hospice House and Community Supervisor received the above findings and hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, hospice policy review and staff interview, the hospice failed to ensure hospice nurse members of the Interdisciplinary Group updated the comprehensive assessment with changes to the patient condition regarding wound measurements for 1 of 3 sampled patients with an open wound (Patient #3). Failure by the hospice Interdisciplinary Group (IDG) registered nurses to update the comprehensive assessment with complete wound measurements placed the patient at risk for ineffective staff collaboration and communication regarding patient's wound status and effectiveness of treatments and interventions. --- Findings include: According to the hospice policy, titled Hospice Wound Care Documentation, dated 03/2023, whether wounds are present on admission or discovered during subsequent nursing visits, documentation will include measurements of length, width and depth, and any ordered wound care treatments. Hospice nurses will document any and all wounds. Community based hospice nurses will document wound care in the ICC (Integumentary Command Center) once weekly and Hospice House nursing staff will document in the hospice shift summary narrative note with the weekly shift visit. Hospice nursing personnel will collaborate with residential facility to ensure Plan of Care for wound management are consistent. Upon request, Hospice nursing personnel will provide this policy to residential facility and provide documented education to facility staff that pain control, drainage/odor management and infection prevention, rather than healing is primary goal. When wound care is responsibility of a facility, nursing will indicate this by documenting so as well as obtaining all wound criteria from facility nurse and documenting this in hospice record weekly. During an interview on 6/27/23 at 11:06 AM, the Clinical Manager reported the agency expectation is for wounds to be measured weekly, including length, width and depth, description of wound and cares provided. Patient #3 had a hospice admission date of 5/10/23, a death date of 6/18/23 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The skilled nurse visit notes, dated 5/11/23, 5/25/23, 6/2/23 and 6/15/23, included wound measurements. b. The skilled nurse visit note, dated 5/14/23, included documentation the nurse called and spoke with the facility nurse, who reported the patient is calmer after starting Haldol, no pain reported, patient will be seen for comfort check on Sunday. The visit note lacked documentation of wound measurements. c. The skilled nurse visit note, dated 5/15/23, included documentation of a wound on right 2nd toe and right distal dorsum (top of foot), wound not assessed, wound care not provided, caregiver completed care. d. The skilled nurse visit note, dated 5/16/23, included documentation the patient reported pain at a 9 on a scale 0 to 10, patient did not show any nonverbal signs/symptoms of pain, patient appeared relaxed and calm during visit, wounds: yes, wound changes noted: no. The visit note lacked documentation of wound measurements or wound care provided. e. The skilled nurse visit note, dated 5/17/23, included documentation the patient reported pain at a 10 on a scale 0 to 10, patient did not show any nonverbal signs/symptoms of pain, patient appeared relaxed and calm, did receive a dose of morphine sulfate immediate release medication, wounds: yes, wound changes noted: no. The visit note lacked documentation of wound measurements or wound care provided. f. The skilled nurse visit note, dated 5/18/23, included documentation pain well controlled, facility staff changed dressings to bilateral lower extremities prior to the skilled nursing visit, bandages were clean, dry and intact, wounds: yes, wound changes noted: no. Wound care not provided, caregiver completed care, new wound on left mid dorsum (top of foot) identified but lacked wound measurements. The visit note lacked documentation of wound measurements for any wound. g. The skilled nurse visit note, dated 5/20/23, included documentation a call received from facility nurse reporting a new wound to left leg, facility utilizing same treatment as wound to right leg. The visit note lacked documentation of wound measurements. h. The skilled nurse visit note, dated 6/5/23, included documentation of right 2nd toe wound, right distal dorsum wound, left mid dorsum wound, right great toe wound, right 3rd toe wound, and documentation wound measurements not due; bilateral lower extremity wounds wrapped in gauze, facility nurse performed wound care, patient tolerated well, denies pain at this time, wounds: yes, wound changes noted: no. The visit note lacked documentation of wound measurements. i. The skilled nurse visit note, dated 6/6/23, included documentation of as needed (PRN) visit for report of maggots noted to right foot during morning dressing change. Skilled nurse and Director of Nursing at the facility undress right foot wound dressing, no maggots noted until submerged into water which is done per medical director direction. Approximately 5 maggots emerged from in between 4th and 5th toes tunneling area, all 5 toes to right foot are black in color. Area dressed per facility wound care orders, left foot wound care also completed, and wound care to bilateral upper forearms completed. Patient tolerated extremely well, did not grimace or complain of discomfort. The visit note lacked documentation of wound measurements. j. The skilled nurse visit note, dated 6/7/23, included documentation of right 2nd toe wound, right distal dorsum wound, left mid dorsum wound, right great toe wound, right 3rd toe wound, and documentation wound measurements not due; facility nurse had changed patient dressing this morning and provided wound care, maggots still present in wound, wounds: yes, wound changes noted: no. The visit note lacked documentation of wound measurements. k. The skilled nurse visit note, dated 6/8/23, included documentation patient sleeping in hospital bed, coordinated with facility nurse, bilateral lower extremity wounds wrapped, wounds: yes, wound changes noted: no. The visit note lacked documentation of wound measurements. l. The skilled nurse visit note, dated 6/9/23, included documentation of right 2nd toe wound, right distal dorsum wound, left mid dorsum wound, right great toe wound, right 3rd toe wound, and documentation wound measurements not due; maggots in bilateral lower extremity feet wounds, patient sleeping in bed, did not want to be bothered, bilateral lower extremity wounds wrapped, wounds: yes, wound changes noted: no. The visit note lacked documentation of wound measurements. During an interview on 6/27/23 at 10:28 AM, Staff F, Registered Nurse (RN), reported wounds should be measured weekly and would include length, width and depth. Staff F would try and obtain wound measurements herself for patients that resided in nursing homes. Staff F reported Patient #3 would usually have his wound dressings changed by facility staff between 6:30 AM and 7:00 AM and Staff F made skilled nursing visits in the afternoon at the facility. There were a few times she coordinated visits with the facility to obtain wound measurements but other times it did not work to coordinate. Staff F was able to visualize Patient #3s wounds approximately 3 times during the episode of care. Staff F reported the patient was noncompliant, patient would remove the dressings to the lower extremities at times when outside the facility. Staff F had seen flies land on the patients dressings when outside the facility. The clinical record lacked wound measurements for the weeks of 5/14/23 through 5/20/23 and 6/4/23 through 6/10/23. The clinical manager received the above findings and hospice provided no further information prior to the end of the survey.

Based on clinical record review, hospice policy review and hospice staff interview, the hospice failed to: 1) ensure the provision of care in accordance with the patient's plan of care (L0543); 2) ensure the plan of care included all medical equipment and supplies necessary to meet identified patient needs (L0550) and 3) ensure the Interdisciplinary Group maintained a system for communication and integration of patient care and services to ensure hospice staff provided care in accordance with the plan of care (L0555). --- This systemic practice resulted in the failure of the hospice to ensure the Interdisciplinary Group of personnel provided care in accordance with the plan of care.

Based on hospice clinical record review, hospice policy review and hospice staff interview, the hospice failed to ensure the provision of care in accordance with the patient's plan of care for 1 of 3 sampled patients (Patient #3) with wounds. Failure to follow the patient's Plan of Care (POC) as directed by the Interdisciplinary Group (IDG) puts the patient at risk of inconsistent care that may not meet the needs of the patient. --- Findings include: Review of the hospice's policy, titled Interdisciplinary Group, dated 10/2022, identified the Interdisciplinary Group (IDG) is responsible for establishing, implementing, reviewing and revising the patients plan of care as frequently as the patients condition requires, but no less frequently than every 15 calendar days. During an interview on 6/27/23 at 11:06 AM, Clinical Manager reported hospice charts had been audited and it had been identified hospice staff needed education on wound care and documentation of wounds. The hospice is currently in the process of educating staff. Patient #3 had a hospice admission date of 5/10/23, a death date of 6/18/23 and received hospice services while residing in a nursing home. Clinical record review revealed: a. Interim physician order, dated 5/11/23, included orders to cleanse wound with normal saline, pat dry, apply ABD pad, wrap with kerlix, hold in place with tape twice a day and as needed if dressing becomes dislodged or soiled. Cleanse wound with each dressing change. If staging changes, discontinue stage 2 orders and order new wound care protocol based on staging of wound. The order failed to identify the location of the wound. b. Interim physician order, dated 5/18/23, included orders to clean area with normal saline, pat dry, apply ABD pad, wrap with kerlix, hold in place with tape twice a day and as needed if bandage becomes soiled or dislodged. The order failed to identify the location of the wound. c. Interim physician order, dated 5/22/23, included orders to cleanse wound with wound cleanser or soap and water, pat dry. Apply foam dressing to affected area, change foam dressing every 3-7 days and as needed if becomes dislodged or soiled. Cleanse wound with each dressing change. If staging changes, discontinue stage 2 orders and order new wound care protocol based on staging of wound. If patient has fragile skin, a gauze bandage roll may be used to secure dressing and tape applied to bandage. The order failed to identify the location of the wound. d. The skilled nurse visit note, dated 6/6/23, included documentation of as needed (PRN) visit for report of maggots noted to right foot during morning dressing change. Skilled nurse and Director of Nursing at the facility undress right foot wound dressing, no maggots noted until submerged into water which is done per medical director direction. Approximately 5 maggots emerged from in between 4th and 5th toes tunneling area, all 5 toes to right foot are black in color. Area dressed per facility wound care orders, left foot wound care also completed, and wound care to bilateral upper forearms completed. Patient tolerated extremely well, did not grimace or complain of discomfort. e. The skilled nurse visit notes, dated 6/5/23, 6/7/23, 6/8/23, 6/9/23, 6/12/23, 6/14/23, 6/15/23, 6/16/23 and 6/17/23, lacked documentation of a tunneling wound between the 4th and 5th toes on the right foot and wounds on the bilateral upper forearms. f. The IDG meeting notes, dated 5/17/23, 5/31/23 and 6/14/23, lacked documentation and wound care orders for a tunneling wound between the 4th and 5th toes on the right foot and wounds on the bilateral upper forearms. g. The IDG meeting note, dated 6/14/23, included documentation of interim physician order, dated 6/6/23, to submerge right foot in water prior to wound care to attempt to drown any remaining maggots for 2 days. h. The skilled nurse visit note, dated 6/7/23, included documentation maggots still present in wound, wounds: yes, wound changes noted: no, but lacked documentation of the wound care provided including the new order to submerge the right foot in water prior to wound care. i. The skilled nurse visit note, dated 6/9/23, included documentation of right 2nd toe wound, right distal dorsum wound, left mid dorsum wound, right great toe wound, right 3rd toe wound, maggots in bilateral lower extremity feet wounds, wound care not provided, caregiver provided care, patient sleeping in bed, did not want to be bothered, bilateral lower extremity wounds wrapped, wounds: yes, wound changes noted: no. The visit note lacked documentation of what wound care was provided and if the physician had been notified maggots remained in the wound. During an interview on 6/27/23 at 10:28 AM, Staff F, Registered Nurse (RN), reported patient had maggots in wound for 3 days (6/6/23, 6/7/23 and 6/8/23) and physician was not contacted regarding orders to continue to submerge right foot prior to wound care due to maggots no longer present. The skilled nurse failed to document all wounds and wound care orders for all wounds. The hospice provided no further information prior to the end of the survey.

Based on clinical record review, hospice policy review and hospice staff interview, the hospice failed to ensure the Plan of Care (POC) for 1 of 4 sampled patients (Patients #3) included all medical equipment and supplies necessary to meet identified patient needs. Failure to include all needed items of medical equipment and supplies the patient used on the Plans of Care placed the patients at risk of unanticipated decline or injury and of needs not met. --- Findings include: Review of the hospice's policy, titled Interdisciplinary Group, dated 10/2022, identified the Interdisciplinary Group is responsible for establishing, implementing, reviewing and revising the patients plan of care as frequently as the patients condition requires, but no less frequently than every 15 calendar days and documenting all care and providing or coordinating care and services in accordance with the patients plan of care. Patient #3 had a hospice admission date of 5/10/23, a death date of 6/18/23 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 5/10/23 to 8/7/23, identified the patient used the following medical equipment and supplies: wound spray cleaner, foam dressing, wheelchair and alternating pressure pump mattress. b. The interdisciplinary group (IDG) meeting note, dated 5/17/23, identified the patient used the following medical equipment and supplies: wound spray cleaner, foam dressing, gait belt, walker, wheelchair and alternating pressure pump mattress. c. The IDG meeting notes, dated 5/31/23, identified the patient used the following medical equipment and supplies: chux, ABD pads, kerlix, tape, normal saline solution, gait belt, walker, wheelchair, over the bed table, hospital bed. During an interview on 6/27/23 at 10:28 AM, Staff F, Registered Nurse, reported the patient had an alternating pressure pump mattress provided by the hospice and a ROHO (pressure relieving) cushion provided by the nursing home. Staff F was not able to assess the ROHO cushion due to the patient sitting in the wheelchair during skilled nursing visits. The mattress on the bed was pumped up and functioning when Staff F was in the facility. The POC and IDG meeting notes failed to identify all necessary medical equipment and supplies used by the patient, including the ROHO cushion. The hospice provided no further information prior to the end of the survey.

Based on clinical record review, hospice policy review and hospice staff interview, the hospice failed to ensure the Interdisciplinary Group maintained a system for communication and integration of patient care and services to ensure hospice staff provided care in accordance with the plan of care for 1 of 4 sampled patients (Patient #3). Failure of the hospice interdisciplinary group (IDG) members to maintain a system for communication and integration of patient care and services to ensure hospice staff provided care in accordance with the plan of care increased the risk that patients did not receive services to meet assessed needs. --- Findings include: Review of the hospice's policy, titled Interdisciplinary Group, dated 10/2022, identified the Interdisciplinary Group is responsible for establishing, implementing, reviewing and revising the patients plan of care as frequently as the patients condition requires, but no less frequently than every 15 calendar days and documenting all care and services provided in a timely manner in accordance with the Hospices documentation requirements. Patient #3 had a hospice admission date of 5/10/23, a death date of 6/18/23 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The Plan of Care, dated 5/10/23 to 8/7/23, included physician orders for skilled nursing 2 times a week but lacked documentation for as needed (PRN) visits. b. Skilled nursing visits were completed on 5/10/23, 5/11/23, 5/12/23, 5/13/23, 5/14/23, 5/15/23, 5/16/23 and 5/17/23. c. PRN (As needed) skilled nursing visits were completed on 5/11/23, 5/12/23 and 5/13/23. d. The IDG meeting note, dated 5/17/23, included documentation the patient was receiving skilled nursing visits daily but lacked documentation of physician orders for PRN visits. e. Skilled nursing visits were completed on 5/18/23, 5/20/23, 5/22/23, 5/25/23, 5/26/23, 5/27/23, 5/28/23, 5/28/23, 5/30/23 and 5/31/23. f. PRN skilled nursing visits were completed on 5/23/23 and 5/24/23. g. No skilled nursing visits were completed on 5/19/23 and 5/21/23. h. The IDG meeting note, dated 5/31/23, included documentation the patient was receiving skilled nursing visits daily but lacked documentation of physician orders for PRN visits or notification of missed visits on 5/19/23 and 5/21/23. i. Skilled nursing visits were completed on 6/2/23, 6/3/23, 6/5/23, 6/7/23, 6/8/23, 6/9/23, 6/10/23, 6/11/23, 6/12/23, 6/13/23, 6/14/23. j. PRN skilled nursing visits were completed on 6/6/23 and 6/14/23. k. The IDG meeting note, dated 6/14/23, included documentation the patient was receiving skilled nursing visits 3 times a week but lacked documentation of physician orders for PRN visits. The hospice failed to provide skilled nursing visits as ordered per the IDG meeting notes. The hospice provided no further information prior to the end of the survey.