Every finding on record at Heart of Hospice, LLC

Based on interview and record reviews, the hospice agency failed to ensure nursing services met the needs of the patients for 2(#6 and #10) of 3(#5, #6 and #10) patients reviewed for pressure wounds. The agency failed to follow acceptable standards of practice for wound care specifically for complete wound assessments and weekly wound measurements, including the size and stage of the wounds for Patients #6 and #10. --- Review of the agencys policy titled ";Wound Assessment, Documentation and Photography revealed the following: Purpose: To ensure the accurate and consistent assessment and documentation of wounds. Policy: Upon initial visit and subsequently as applicable, all wounds will be assessed with appropriate documentation within the medical record. Procedure: 3. Document the following in the medical record: c. wound measurements (weekly) including the length, depth, and width of the wound in centimeters. g. Stage the wound weekly. Review of the Louisiana State Board of Nursing Declaratory Statement Scope of Practice for Registered Nurses - Wound Care Management adapted 02/1999 revealed the following in part: Registered nurses render care that is directed towards the prevention and treatment of wounds. Wounds are a common health care challenge that often occur with or result from Chronic disorders such as impaired circulation and malnutrition. Nursing care of skin/wound conditions involves the identification, assessment, management, and ongoing evaluation of patients with alterations in skin/tissue integrity that includes but is not limited to draining wounds, pressure ulcers, and vascular ulcers, and conditions resulting from incontinence, surgical procedures, and/or trauma. Scope of Practice - The Louisiana State Board of Nursing recognizes that assessment, planning, intervention, teaching, evaluation, and supervision are the major responsibilities of the registered nurse in the practice setting. The registered nurse is responsible for performing a nursing assessment and physical examination for preventative and restorative nursing and for providing patient/family teaching. Recognizing that the physician must always prescribe wound care, the following roles are defined to delineate the scope of practice for each member of the nursing team members. The registered nurse initiates appropriate wound preventative measures, stages wounds and collaborates with the wound care team in the implementation and evaluation of nursing interventions as prescribed by an authorized prescriber. Review of the National Pressure Ulcer Advisory Panel Prevention and Treatment of Pressure Ulcers: Quick Reference Guide revealed, in part, the following: Pressure Ulcer Assessment 1. Assess the pressure ulcer initially and re-assess it at least weekly. 1.1. Document the results of all wound assessments. Assess and document physical characteristics including: location, Category/Stage, size, tissue type(s), color, peri-wound condition, wound edges, sinus tracts, undermining, tunneling, exudate, and odor. Patient #6 Review of the clinical record for Patient #6 revealed a start of care date of 01/24/2023. Review of the plan of care for the current certification period 01/24/2023 – 04/23/2023 revealed diagnoses which included Coccyx wound. Further review of the plan of care revealed orders for the following Frequency/Duration of Skilled Nurse visits; 1 time a week for 1 week, 2 times a week for 12 weeks and 2 as needed visits for urgent symptom management needs/change in condition. Orders of Discipline and Treatment included the following: Irrigate wound with sterile water, cleanse with wound spray and cover with foam dressing twice a week as needed. Review of the Skilled Nurse visit wound documentation revealed visits were conducted on the following weeks during this current certification period: Week of 01/23/2023, 01/30/2023, 02/06/2023 and 02/13/2023 revealed there was no documentation of weekly completed wound assessments to include measurements of Patient #6's wounds. Further review revealed a Registered Nurse did not assess the wound at least once a week. Patient #10 Review of the clinical record for Patient #10 revealed a start of care date of 01/13/2023. Review of the plan of care for the current certification period 01/13/2023 – 03/13/2023 revealed diagnoses which included Left Sacral Pressure Ulcer Stage III, Medial Sacral Pressure Ulcer Stage II, and Left Greater Trochanter Pressure Ulcer Stage II. Further review of the plan of care revealed orders for the following Frequency/Duration of Skilled Nurse visits; 1 time a week for 1 week, 2 times a week for 6 weeks, 3 times a week for 1 week, 2 times a week for 1week, 1 time a week for 1 week and 9 as needed visits for urgent symptom management needs/change in condition. Orders of Discipline and Treatment included the following: Cleanse wound to Left Hip, Right Hip and Sacrum with wound cleaner, Apply Zinc Oxide to area and cover with dressing. Review of the Skilled Nurse visits wound documentation revealed visits were conducted on the following weeks during this current certification period: Week of 01/16/2023, 01/23/2023, 01/30/2023, 02/06/2023 and 02/13/2023 revealed there was no documentation of weekly completed wound assessments to include measurements of Patient #10's wounds. Further review revealed a Registered Nurse did not assess the wound at least once a week. An interview was conducted on 02/20/2023 at 9:00 a.m. with S1DON. She reviewed Patient #6 and #10s clinical record and verified on the weeks listed above there was no wound measurements documented. S1DON confirmed there was no documentation to indicate a complete weekly assessment of the wounds were obtained by the Registered Nurse. She confirmed there was no documentation indicating if Patient #6 and #10s wounds had improved or deteriorated. She said measurements and description of the wound should be documented weekly by the Registered nurse.

Based on record review and interview, the hospice agency failed to ensure drugs and biologicals were disposed of properly, in accordance with all applicable laws and regulations, after patient death. This deficient practice was evidenced by failure to ensure the remaining counts of controlled drugs were documented in the patients' death notes for 2 (#3, #5) of 3 (#2, #3, #5) sampled patient death records reviewed from a total patient sample of 5 (#1- #5). Findings: Review of a memo issued by LDH-Health Standards Section, dated 06/25/2018, revealed the following: In accordance with Act 23 of the 2018 Regular Legislative Session, the LDH- Health Standards Section is issuing this notice to all licensed hospice providers. Effective 08/01/2018, Act 23 amends and reenacts LA RS 40:2191 relative to disposal of controlled substances by hospice providers; to provide for ownership; to provide for written procedures; to provide for patient records; to provide for disposal; to provide for patient notification; and to provide for related matters. Review of LA RS 40:2191 revealed the following: Disposal of deceased patient's unused controlled substances: A. Upon death of a patient receiving hospice services, ownership of the patient's unused Schedule II, III, IV, or V controlled substances under 21 CFR 1308 may transfer to the hospice for immediate disposal pursuant to the following provisions: 1. Each hospice shall establish a written procedure to ensure safe disposal of unused controlled substances by a hospice nurse at the time of death. 2. Upon death of a patient receiving hospice services, in the presence of a witness, the hospice nurse shall record in the medical record, the name and quantity of each unused controlled substance. Review of the hospice policy titled," Disposal of Medications in the Home", revealed the following, in part: Policy: The hospice nurse advises the destruction of all prescription medications when a medication is no longer needed by the patient or in the event of the patient's death at home. Disposal of controlled substances must be conducted in accordance with all applicable laws and regulations. Home hospice personnel may not dispose of controlled substances unless authorized by state law. Procedure: 1. When a patient no longer needs prescription medications or upon the death of the patient in the home, the nurse instructs the family/caregiver in the disposal of the medications. 2. The nurse obtains the consent to dispose of prescription medications from the patient or caregiver: a. medications are destroyed by the family with the nurse providing witness. b. the nurse documents the disposal of the medication in the clinical record. Patient #3 Review of Patient #3's medical record revealed a start of care date of 09/23/2021. Further review revealed the patient expired on 10/01/2021. Patient #3 was receiving routine hospice care in a SNF. Review of Patient #3's plan of care revealed the patient had current orders (prior to death) for the following medications: Morphine concentrate ( Schedule II Drug) 100 mg/5ml (20 mg/ml) oral solution: Dose: 0.5 ml; Route: Oral; Frequency: q 2 hours as needed for pain or SOB; Lorazepam ( Schedule IV Substance) 2 mg/ml oral concentrate: Dose: 0.5 ml q 4 hours as needed for restlessness. Review of Patient #3's death note documentation, dated 10/01/2021 10:05 a.m. revealed the following, in part: Medications: Agency staff did not dispose of medications; Reason: per facility protocol. Further review revealed there were no final counts documented in the death note, for the above referenced controlled medications, that had been destroyed by the SNF after the patient's death, Patient #5 Review of Patient #5's medical record revealed a start of care date of 09/20/2021. Further review revealed the patient expired at home on 09/29/2021. Review of Patient #5's plan of care revealed the patient had current orders (prior to death) for the following medications: Morphine concentrate 100 mg/5ml (20 mg/ml) oral solution: Dose: 0.5 ml; Route: Oral; Frequency: hourly as needed for pain or SOB. Lorazepam 0.5 mg tablet: Dose: 1 tablet by mouth every 4 hours as needed for anxiety. Review of Patient #5's death note documentation, dated 09/30/2021, revealed the following: 09/29/2021 - 11:55 p.m. Death note: patient expired at home. Summary of visit: Hospice nurse confirmed time of death at 11:55 p.m. Controlled medications counted and destroyed in deactivation kit with caregiver witnessing waste. Further review revealed there were no final counts, documented in the death note, for the above referenced controlled medications destroyed after the patient's death. In an interview on 12/01/2021 at 3:00 p.m. with S1PCM, she confirmed the hospice provided medications for patients who received hospice services in SNF's as well as for patients receiving in -home hospice services. S1PCM confirmed the death note documentaiton for Patients #3 and #5 failed to contain final counts of the patients' remaining controlled narcotics that were destroyed following the patients' deaths.