Every finding on record at Guardian Hospice of Nashville, LLC

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as: hand hygiene. This standard was not met as evidenced by document review and observation. Agency protocol #4003 "Hand Hygiene" (effective 06/19/2008) (revised 06/09/2021) stated in part, "The following steps will be performed when washing hands with soap and water... Rinse the hands well under running water to remove residual soap... dry hands with a clean paper towel... use the paper towel to turn off the faucet." In 1 of 4 (25%) home visit observations, the agency did not ensure hand hygiene was performed correctly when indicated per the agency's protocol. HOME VISIT 2: The patient elected hospice care on 06/17/2025 with diagnoses of cerebrovascular disease, Alzheimer's disease, hypertensive heart disease, and heart failure. The patient resided in an assisted living facility (ALF). During the home visit with the Hospice Aide (HA) [Personnel Record 4] on 07/30/2025, the HA washed their hands with the liquid soap in the patient's bathroom, however, the HA did not have a paper towel, so the HA left the bathroom, dripping water onto the floor, walked out of the bathroom to their bag and removed two barrier pads. The HA dried their hands with one of the barrier pads, walked back to the bathroom, and turned the faucet off with the second barrier pad.

It is required that nursing care and services are provided by or under the supervision of a registered nurse and per the patient plan of care. Nursing services ensure that the nursing needs of the patient are met as identified in the patient’s initial assessment, comprehensive assessment, and any updated assessments. This standard was not met as evidenced by clinical record review and interview. In 2 of 19 (11%) clinical records reviewed, the agency did not ensure the nursing needs of the patient were met as identified in the patient’s initial assessment, comprehensive assessment, and any updated assessments. CLINICAL RECORD 6: The patient elected hospice care on 10/19/2024 with diagnoses of hepatic failure, unspecified without coma, unspecified viral hepatitis B without hepatic coma, and other ascites. The plan of care for the certification periods dated 04/17/2025 through 06/15/2025 and 06/16/2025 through 08/14/2025, ordered, "Insert/maintain Foley catheter; Size 16F Balloon size 10cc. Change every 30 days and prn for blockage or dislodgement." The SN visit note dated 05/15/2025 documented that the Foley catheter was changed due to blockage. There was no documented evidence that the Foley catheter was changed in June or July. CLINICAL RECORD 10: The patient elected hospice care on 02/23/2025 with diagnoses of osteomyelitis, unspecified, unspecified asthma, and depression, unspecified. The patient's hospital history and physical dated 02/21/2025 documented in part, "This is a 43-year-old male currently on hospice care with past medical history notable for paraplegia secondary to T8 spinal cord injury. Wheelchair/bedbound, traumatic brain injury, large sacral decubitus ulcer, sacral osteomyelitis." The patient was admitted to hospice services on the day of discharge from the hospital. The hospital provided the patient's sacral wound care before discharge. The plans of care for the certification period dated 02/23/2025 through 05/23/2025 ordered skilled nursing (SN) "4wk1 and 2wk12." The IDG dated 02/26/2025 documented an update to the plan of care wound care orders: "cleanse the sacral wound with wound cleanser spray, Dakin solution-soaked packing, and cover with foam dressing. Change every 3rd day." The SN visit note dated 02/27/2025 documented that the wound was assessed and measured 1.5 cm x 0.5 cm x 2cm and that the patient tolerated the dressing change well. The SN visit note dated 03/06/2025 documented, "cleansed sacral wound with wound cleanser spray, Dakin solution-soaked packing, covered with foam dressing. Change every 3rd day." The SN visit notes documented sacral wound provided on 03/03/2025, 03/06/2025, 03/10/2024 (4 days), 03/13/2025, 03/17/2025 (4 days), 03/20/2025, 03/25/2025 (5 days), 03/27/2025, 03/31/2025 (4 days), 04/04/2025 (4days), 04/08/2025, (4 days), 04/11/2025, 04/15/2025 (4 days), 04/18/2025,04/22/2025 (4 days), 04/25/2025,04/29/2025 (4 days) 05/02/2025, 05/08/2025 (6 days), 05/12/2025 (4 days), 5/15/2025, 05/20/2025 (5 days),05/22/2025. There was no documented evidence that the SN provided wound care every "3rd day" as ordered. During the joint record review on 08/01/2025, the Director of Clinical Services (DCS) agreed that the skilled nurse visits were not every three days as ordered. I do know that the caregiver (the patient's father) is changing the dressings also." During a joint clinical record review and interviews on 07/31/2025, the Director of Clinical Services (DCS) (Personnel Record 1) stated, "I spoke with the physician, and he stated that he did not want the Foley changed every 30 days; they should only be changed if blockage, dislodgement, or leaking. During the interview on 08/01/2025, the DCS stated that the Plan of care was updated by the physician to only change the Foley catheter for the reasons stated, "dislodgment, blockage, or leaking, and the change every 30 days was incorrect."

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by clinical record review, document review, and interview. Agency protocol #2112 Hospice Aide Plan of Care" (revised 06/10/2024)" stated in part, "If the aide care plan cannot be completed as ordered, or there is a concern regarding the patient's condition, the hospice aide will: Contact RN Case Manager, or TD during the visit to report concern via phone. Document interventions not performed as "not complete" and indicate the reason. Notify the RNCM/TD and include who was notified." In 2 of 11 (18%) clinical records reviewed of patients who received Hospice Aide (HA) services, the agency did not ensure that the Hospice Aide reported changes in the needs of the patient to the Registered Nurse (RN) as per agency policy. CLINICAL RECORD 5: The patient elected hospice care on 06/25/2025 with diagnoses of malignant neoplasm of the duodenum, secondary malignant neoplasm of the liver, and intrahepatic bile duct. The patient resided in a non-skilled long-term care facility (LTC). For the certification period dated 06/25/2025 through 09/22/2025, the plan of care ordered HA services effective 06/29/2025, one (1) time a week for 12 weeks. The HA care plan dated 06/26/2025 assigned the HA the relevant tasks every visit: bathing- shower seated, shampoo, hair care, skin care, and assist to the toilet. The HA visit note dated 07/24/2025 documented, " Bathing...shower seated, Completed N... patient refused...hair care, refused." A clinical record review revealed no documented evidence that the HA reported the tasks not performed to the RN per the agency policy. CLINICAL RECORD 17: The patient elected hospice care on 12/17/2024 with diagnoses of unspecified protein-calorie malnutrition, pulmonary fibrosis, and essential (primary) hypertension. The patient resided in an assisted living facility (ALF). For the certification period dated 12/17/2024 through 03/14/2025, the plan of care ordered HA services one (1) time a week for 13 weeks. The HA care plan dated 12/17/2024 assigned the HA the relevant tasks every visit: bathing- shower seated, and skin care. The HA visit notes dated 12/19/2024 and 12/27/2024 documented, "Shower seated...Completed: N... Patient refused. " A clinical record review revealed no documented evidence that the HA reported the tasks not performed to the RN per the agency policy. During the joint record review on 07/31/2025, the Director of Clinical Services (Personnel Record 1) stated that the HA "didn't report to the Registered Nurse."

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current: prescription and over-the-counter (OTC) drugs. The medication review process includes the identification of the following: the effectiveness of drug therapy, drug side effects, actual or potential drug interactions and duplicate drug therapy. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and, as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by a review of clinical records and interviews. In 3 of 13 (24%) clinical records reviewed revealed that the drug profile did not include all current prescription and OTC drugs. Clinical Record 23 was reviewed and revealed that the patient elected the hospice benefit on 2/26/2022. During a home visit, the facility medication record did not include a medication present on the agency drug profile. Amlodipine 2.5mg tablet, one tablet daily, was written on 2/26/2022. The Director of Clinical Operations was interviewed on 8/17/2022 and agreed that the identified medication was not on the facility's drug profile. She had no additional information to provide. Clinical Record 12 was reviewed and revealed that the patient elected the hospice benefit on 2/4/2021. During a home visit, it was identified that the facility medication record included a Morphine Sulfate (concentrate) Solution of 20 mg/ml. Give 0.25 ml by mouth every 1 hour as needed for mild pain or mile dyspnea AND Give 0.5 ml by mouth every 1 hour as needed for moderate pain or dyspnea AND Give 1 ml by mouth every 1 hour as needed for severe pain and dyspnea written on 10/13/2021 and Ativan 0.5mg Give one tablet by mouth every 4 hours as needed for moderate to severe agitation or anxiety written on 10/5/2021. Neither of these medications appeared on the agency drug profile. The Director of Clinical Operations was interviewed on 8/17/2022 and agreed that the identified medications were not on the agency drug profile. Clinical Record 7 was reviewed and revealed that the patient elected the hospice benefit on 7/7/2022. In the initial assessment completed on 7/7/2022 and the CTI written on 7/13/2022, it was identified that the patient required oxygen at three lpm continuously. Oxygen was not present on the drug profile. The Director of Clinical Operations was interviewed on 8/17/2022 and agreed that oxygen was not present on the drug profile. She had no additional information to provide.