Every finding on record at Guardian Angels Hospice

Based on review of records, home visit observation, and staff interviews, it was determined the hospice failed to ensure the requirements for the interdisciplinary group (IDG), care planning and coordination of services were met for one patient (P) (P#12) of 14 sampled patients. Specifically: · care plan updates were developed for each patient to update the patient's current wound condition and changes in condition; · to communicate the reluctance of caregiver to provide the care necessary for the optimal health of the patient; · to ensure that hospice care and services were furnished to patient by the caregiver followed an individualized written POC established by the IDG; · to ensure that the IDG maintains responsibility for directing, coordinating, and supervising the care and services provided and to ensure the care and services provided are based on all assessments of the patient and family needs; · to ensure the POC reflected all interventions necessary to address the patient's assessed problems and needs --- Findings include: Observation of P#12 at the home of residence with the Licensed Practical Nurse (LPN) AA on 4/16/24 at approximately 10:40 a.m. revealed patient lying in bed with eyes closed. LPN AA proceeded to perform wound care to the left knee. During wound care noted redness around wound, foul odor with heavy serosanguineous (blood tinged) drainage and patient appearing to be in pain during the dressing change as evidenced by patient moaning and shaking during care. P#12 is nonverbal and unable to verbalize wants and needs. LPN AA verbalized during wound care that there had not been any improvement in the wound since admission on 2/11/24. Review of the IDG notes dated from 2/22 through 4/4/24 failed to reveal documentation of wound care assessment findings or updates. Additionally, the IDG notes failed to reveal coordination with the physician of need to reevaluate wound protocol. Review of the undated policy titled; "Wound Care Policy," reveals the following: Procedure 5. All wounds will be reviewed during IDG meetings with the clinical director and/or MD. A plan of care will be established at the time the wound is assessed and updated during IDG meetings. Review of facility undated policy titled; ";Coordination of Patient Care," reveals the following: Procedure 3. Staff provides the physician, Medical Director, and Interdisciplinary Group (IDG) with patient information on an ongoing basis regarding: current condition and changes in condition, outcomes of care and services and changes in the environment and/or caregiver support. The clinical record failed to reveal documentation to indicate that the caregiver is not following the care plan and that the Physician was notified of the caregiver's reluctance to follow the ordered plan of care. During an office interview on 4/17/24 at approximately 11:00 a.m. with the Director of Nursing (DON), it was confirmed that the IDG notes lacked documentation of physician notification of wound care status. The DON revealed the wound has not improved since admission and states the caregiver does not follow the wound care protocol which requires the caregiver to change dressing daily in absence of hospice nurse. On 4/17/24/2024 at 12:00 p.m., an interview with the Administrator confirmed the IDG notes were incomplete in that they did not reflect agency policy to ensure coordination of care regarding the patient's wound care status and caregiver response to the current care plan with the hospice care team.

Based on record reviews, and staff interview, it was determined the hospice agency failed to ensure the Medical Director or physician designee reviewed the clinical information for each hospice patient and provided a written initial physician Certification of Terminal Illness (CTI) and recertification CTI for 10 patients (P) (P#4, P#5, P#6, P#7, P#8, P#9, P#10, P#11, P#13 and P#14) of 14 sampled patients. --- Findings include: 1. Review of clinical records for patient P#4 revealed the patient was admitted to hospice on 12/5/23. The review of the initial physician CTI revealed that the physician's brief narrative statement (review of patient's clinical circumstances and synthesize the medical information to provide the clinical justification or admission to Hospice services) was created, documented, signed, and dated by the Director of Nursing (DON). The clinical record failed to reveal the initial physician CTI was completed by the Medical Director. 2. Review of clinical records for patient P#5 revealed the patient was admitted to hospice on 2/6/2024. The review of the initial physician CTI revealed that the physician's brief narrative statement (review of patient's clinical circumstances and synthesize the medical information to provide the clinical justification or admission to Hospice services) was created, documented, signed, and dated by the DON. The clinical record failed to reveal the initial physician CTI was completed by the Medical Director. 3. Review of clinical records for patient P#6 revealed the patient was admitted to hospice on 3/8/2024. The review of the initial physician CTI revealed that the physician's brief narrative statement (review of patient's clinical circumstances and synthesize the medical information to provide the clinical justification or admission to Hospice services) was created, documented, signed, and dated by the DON. The clinical record failed to reveal the initial physician CTI was completed by the Medical Director. 4. Review of clinical records for patient P#7 revealed the patient was admitted to hospice on 2/28/2024. The review of the initial physician CTI revealed that the physician's brief narrative statement (review of patient's clinical circumstances and synthesize the medical information to provide the clinical justification or admission to Hospice services) was created, documented, signed, and dated by the DON. The clinical record failed to reveal the initial physician CTI was completed by the medical director. 5. Review of clinical records for patient P#8 revealed the patient was admitted to hospice on 12/26/23 and recertified for hospice services on 3/25/2024. The review of physician CTI for the initial benefit period (12/26/2023 to 3/24/2024) and the CTI for recertification benefit period (3/25/2024 to 6/22/2024) revealed that the physician's brief narrative statement (review of patient's clinical circumstances and synthesize the medical information to provide the clinical justification or admission to Hospice services) were created, documented, signed, and dated by the DON. The clinical record failed to reveal the initial and recertification physician CTI was completed by the Medical Director. 6. Review of clinical records for patient P#9 revealed the patient was admitted to hospice on 11/22/2023 and was recertified for hospice services on 2/20/24. The review of physician CTI for the initial benefit period (11/22/2024 to 2/19/2024) and the CTI for recertification benefit period (2/20/2024 to 5/19/2024) revealed that the physician's brief narrative statement (review of patient's clinical circumstances and synthesize the medical information to provide the clinical justification or admission to Hospice services) were created, documented, signed, and dated by the DON. The clinical record failed to reveal the initial and recertification CTI was completed by the Medical Director. 7. Review of clinical records for patient P#10 revealed the patient was admitted to hospice on 7/28/23. The review of the initial physician CTI revealed that the physician's brief narrative statement (review of patient's clinical circumstances and synthesize the medical information to provide the clinical justification or admission to Hospice services) was created, documented, signed, and dated by the DON. The clinical record failed to reveal the initial physician CTI was completed by the Medical Director. 8. Review of clinical records for patient P#11 revealed the patient was admitted to hospice on 8/8/23. The review of the initial physician CTI revealed that the physician's brief narrative statement (review of patient's clinical circumstances and synthesize the medical information to provide the clinical justification or admission to Hospice services) was created, documented, signed, and dated by the DON. The clinical record failed to reveal the initial physician CTI was completed by the medical director. 9. Review of clinical records for patient P#13 revealed the patient was admitted to hospice on 3/20/23. The review of the initial physician CTI revealed that the physician's brief narrative statement (review of patient's clinical circumstances and synthesize the medical information to provide the clinical justification or admission to Hospice services) was created, documented, signed, and dated by the DON. The clinical record failed to reveal the initial physician CTI was completed by the Medical Director. 10. Review of clinical records for patient P#14 revealed the patient was admitted to hospice on 3/8/2024. The review of the initial physician CTI revealed that the physician's brief narrative statement (review of patient's clinical circumstances and synthesize the medical information to provide the clinical justification or admission to Hospice services) was created, documented, signed, and dated by the DON. The clinical record failed to reveal the initial physician CTI was completed by the Medical Director. An interview was conducted on 4/17/2024 at 12:00 p.m. with the DON at the office. The DON verbalized that the initial and the recertification CTI was completed by the DON.