Every finding on record at Harbor Hospice of West Dallas-Fort Worth, LP

Based on record review and interview, the agency failed to take into consideration with its comprehensive assessment, an initial bereavement assessment of the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that could impact their ability to cope with the patients death in that the hospice did not conduct an initial bereavement assessment for 4 (#1, #6, #10, #14) of 14 patient records reviewed.  The failure placed the patients' family or other individuals at risk that appropriate bereavement services would not be provided which could result in complicated grief or inadequate coping. --- Patient #1:Record review of Patient #1's clinical record revealed an Initial Plan of Care dated 2/7/2025 to 5/7/2025. The Plan of Care indicated that Patient #1 started on the agency's services on 2/7/2025. The Plan of Care listed Hypertensive Chronic Kidney Disease with Stage 1-4 Unspecified Chronic Kidney (force of blood pushing against the artery walls consistently too high causing damage to the kidneys) as the terminal diagnosis.  The Supervising Nurse (was not the Supervising Nurse at the time of the visit) performed a start of care comprehensive assessment on 2/7/2025. The Supervising Nurse did not conduct a bereavement risk assessment. The Supervising Nurse documented that the assessment would be completed by the chaplain. Patient #1's record did not contain an initial bereavement assessment.  Patient #6:Record review of Patient #6's clinical record revealed an Initial Plan of Care dated 8/23/2024 to 10/21/2024. The Plan of Care indicated that Patient #6 started on the agency's services on 8/23/2024. The Plan of Care listed Other Speech/Language Deficits following Cerebral Infarction (speech disorder due to weakness or paralysis of the muscles from interrupted or reduced blood flow to the brain) as the terminal diagnosis. Patient #6 died on 9/22/2024. Patient #6 was on services greater than 5 days. Registered Nurse D conducted a start of care comprehensive assessment on 8/23/2024. Registered Nurse D did not conduct a bereavement assessment. Registered Nurse D documented that the bereavement risk assessment was be completed by the Social Worker and Chaplain. Patient #6's record did not contain an initial bereavement assessment. Patient #10:Record review of Patient #10's clinical record revealed an Initial Plan of Care dated 3/1/2025 to 5/29/2025. The Plan of Care indicated that Patient #10 started on the agency's services on 3/1/2025. The Plan of Care listed Heart Failure Unspecified (condition where the heart can't pump enough blood to meet the needs of the body) as the terminal diagnosis. Patient #10 died on 3/7/2025 and was on the agency's services greater than 5 days. Registered Nurse E conducted a start of care comprehensive assessment on 3/1/2025. Registered Nurse D did not conduct an initial bereavement assessment. Registered Nurse E documented that the bereavement assessment was completed by the social worker and chaplain. Patient #10's record did not contain an initial bereavement assessment.  Patient #14:Record review of Patient #14's clinical record revealed a Plan of Care dated 12/16/2024 to 3/15/2025. The Plan of Care indicated that Patient #14 started on the agency's services on 9/17/2024. The Plan of Care listed Hypertensive Heart Disease with Heart Failure (force of blood pushing against the artery walls consistently too high causing damage to the inability of the heart to pump enough blood to meet the body's needs) as the terminal diagnosis. Patient #14 revoked services on 1/15/2025. Patient #14 was on the agency's services greater than 5 days.  The Supervising Nurse (was not the Supervising Nurse at the time) conducted a start of care comprehensive assessment on 9/18/2024. The Supervising Nurse did not conduct a bereavement risk assessment. Patient #14's record did not contain an initial bereavement assessment.  Registered Nurse D and Registered Nurse E were no longer employed at the agency. During an interview on 6/26/2025 at 1:05 p.m. with the Administrator (new Administrator) and Supervising Nurse (new Supervising Nurse), the surveyor discussed that initial bereavement assessments were not completed as part of the comprehensive assessment, no initial bereavement assessments were in the clinical records. The surveyor asked who was responsible to perform the initial bereavement assessments. The Administrator stated, "That would be the Chaplain."  The Administrator and Supervising Nurse did not know why the initial bereavement assessments had not been done. The Administrator informed the surveyor that the social worker would perform the bereavement assessment if chaplain services was declined, and the nurse would perform it if social work services was declined. The surveyor asked why the initial bereavement assessments were not done. The Administrator and Supervising Nurse informed the surveyor that the initial bereavement assessments were to be completed within 5 days of the start of care.  During an interview on 6/27/2025 at 10:04 a.m., with Chaplain F/Bereavement Coordinator, Chaplain F informed the surveyor that the timeframe to complete initial bereavement assessment was 5 days. Chaplain F did not know why the initial bereavement assessments were not done. Chaplain F informed the surveyor that the social workers and nurses could complete the assessments. Review of the agency's policy titled "Initial Assessment", labeled 2-029.1, and dated February 2025 read in part; "Purpose to provide guidelines for the initial assessment to evaluate the patients' physician, psychosocial and emotional needs and determine immediate care and support needs. Policy An initial assessment will be performed by a registered nurse within 48 hours after election of hospice care unless otherwise specified by the physician, patient or representative to be completed in less than 48 hours. Procedure 1. Admitting registered nurse uses an assessment scale/rating tool to assess for problems and to establish a baseline status of each symptom rated. Items assessed may include, but are not limited to, the following...5. Admitting registered nurse will determine the other disciplines to complete the appropriate sections of the comprehensive assessment based on identified problems and needs during this initial assessment. A. Nursing and bereavement sections will always be identified..." Review of the agency's policy titled "Bereavement Services," labeled 2-010.1, and dated February 2025 read in part; "Purpose To ensure that appropriate and coordinated bereavement services are provided to family/caregivers. Policy [Agency] will provide an organized bereavement program supervised by a qualified Bereavement Coordinator for up to one year following the death of the patient...Procedure 1. On admission, the hospice registered nurse will complete a bereavement risk assessment that will be given to the Bereavement Coordinator. If the nurse is unable to complete the bereavement risk assessment on admission the social work and/or spiritual counselor will complete. The information gathered will be incorporated into the plan of care and considered in the bereavement plan of care...7. The bereavement risk assessment will be performed on admission and after death..."

Based on record review and interview, the agency failed to include all services necessary for the palliation and management of the terminal illness and related conditions that included drugs and treatment necessary to meet the needs of the patient in that the plans of care did not include the wound care treatment to be performed, the frequency that would care treatments were to be performed, or changes made in the wound care to be provided for 3 (#4, #6, #7) of 3 patient records reviewed where the patients were receiving wound care.  The failure placed the patients at risk that wound would worsen or become infected. --- Patient #4:Record review of Patient #4's clinical record revealed a Plan of Care dated 9/25/2024 to 12/23/2024. The Plan of Care indicated that Patient #4 started on the agency's services on 9/25/2024. The Plan of Care listed Alzheimer's Disease (brain disorder that destroys memory and thinking skills over time eventually losing the ability to carry out simple tasks) as the terminal diagnosis.  The Supervising Nurse conducted a skilled nurse visit on 10/11/2024. The Supervising Nurse documented that Patient #4 had a fall and received a skin tears to the right forearm, right elbow, and left forearm. The Supervising Nurse documented that Patient #4 experienced soreness when the Supervising Nurse provided wound care.  Patient #4's record did not contain a physician's order for wound care to be provided to Patient #4's skin tears. The agency did not include in the Plan of Care the wound care treatment that was provided to Patient #4's skin tears.  Patient #6:Record review of Patient #6's clinical record revealed an Initial Plan of Care dated 8/23/2024 to 10/21/2024. The Plan of Care indicated that Patient #6 started on the agency's services on 8/23/2024. The Plan of Care listed Other Speech/Language Deficits following Cerebral Infarction (speech disorder due to weakness or paralysis of the muscles from interrupted or reduced blood flow to the brain) as the terminal diagnosis.  The Supervising Nurse conducted a skilled nurse visit on 9/21/2024. The Supervising Nurse documented that Patient #6's right toe was bruised, swollen, and wound care was provided. The Supervising Nurse documented that Patient #6's right toe was cleaned, antibiotic ointment was applied, and covered with a bandage.  Patient #6's record did not contain a physician's order for the wound care that was provided to Patient #6's right toe. The agency did not include in the Plan of Care the wound care treatment to be provided to Patient #6's right toe.  Patient #7:Record review of Patient #7 clinical record revealed a Plan of Care dated 4/2/2025 (sic) to 5/31/2025. The Plan of Care indicated that Patient #7 started on the agency's services on 4/7/2024 (sic). The Plan of Care listed Type 2 Diabetes Mellitus with Diabetic Polyneuropathy (group of metabolic -chemical reactions in the body's cells that change food into energy, diseases that cause nerve damage affecting the extremities, hands, and feet due to high blood sugar levels) as the terminal diagnosis.  Patient #7's clinical record contained documentation of an Interdisciplinary Group Meeting dated 4/24/2025. The Interdisciplinary Group Meeting contained wound care orders to clean the wounds to Patient #7's left lower leg and left heel. The wound care per the Interdisciplinary Group meeting:  Left lower leg -clean with normal saline or wound cleaner, apply collagen (used as a dressing to promote healing by stimulating new tissue growth) powder, and Xeroform (a fine-mesh gauze wound dressing, designed to not stick to a wound and to maintain a moist wound environment to promote healing). Cover with an abdominal pad (large, highly absorbent dressing used to absorb moderate to heavy draining wounds) and wrap with gauze.  Left heel -clean with normal saline or wound cleaner, apply Xeroform to open area. Cover with abdominal pad and wrap with gauze.  The Plan of Care did not include the frequency that the wound care was to be provided. The Supervising Nurse performed skilled nurse visits on 5/5/2025 and 5/7/2025. The Supervising Nurse documented providing wound care to Patient #7's left heel. The Supervising Nurse documented applying Therahoney (medical-grade honey dressing used to treat burns, cuts, and chronic wounds) to the wound.  Patient #7's clinical record did not contain a physician order to apply Therahoney to Patient #7's left heel wound.  The agency did not include in the Plan of Care the frequency that the wound care was to be performed to Patient #7's wounds and did not include the use of Therahoney.  During an interview on 6/26/2025 at 1:05 p.m. with the Administrator and Supervising Nurse, the surveyor discussed that the Plans of Care did not include wound care treatments, the frequency that the wound care was to be performed, or when the wound care treatment changes. The surveyor asked who would be responsible for including wound care treatments in the Plans of Care. The Administrator informed the surveyor that the nurse wound put in the orders. The Administrator informed the surveyor that the nurse would have talked with the physician and would then put in the order. The surveyor asked if the nurses received orders for wound care from the physicians. The Administrator informed the surveyor that the Administrator felt sure they did. The Supervising Nurse stated, "Yes." The surveyor asked the reason why the wound care treatments were not included in the Plans of Care. The Administrator and Supervising Nurse did not know why the orders were not included in the Plans of Care. The surveyor asked what the frequency for wound care was for Patient #7. The Supervising Nurse stated, "Twice a week."  Review of the agency's policy titled "The Plan of Care," labeled 2-044.1, and dated February 2025 read in part; "Purpose To ensure that an individualized plan of care is completed that complies with accepted standards of care and regulatory issues. Policy A written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care...Procedure...The plan of care will identify the patient's needs and services to meet those needs...12. The written plan of care will contain, but will not be limited to, the following...Q. Drugs and treatments..."