Every finding on record at Hendrick Hospice Care Inc

Based on record review and interview, the hospice failed to protect and promote the patients/familys right to be involved in developing the hospice plan of care for 1 of 23 (Patient #15) patients reviewed for development of the Plan of Care. The hospice made changes to the plan of care without notifying the patient/family in advance of implementing the changes to allow the patient/family to have input into developing the plan of care. This failure resulted in Patient #15s Family Member #1 failing to have the opportunity to ask questions and research into whether the changes were beneficial or not prior to the change being initiated and resulted in Family Member #1 feeling that she was excluded by the hospice from participating in developing the patients plan of care. This failure could result in changes to patients care without the approval of the patients and their families. --- The findings included: During an interview conducted on 03/06/23 at 3:10 p.m., Patient #15s Family Member #1 said her biggest concern with the hospice was that she was told at the patients start of care that she would be consulted with changes to the patients plan of care and would be allowed to make decisions as the patient had dementia (a medical condition which affects cognitive function resulting in a loss in judgement and decision-making capability) and was not able to make her own decisions. Patient #15s Family Member #1 said she signed paperwork at the patients admission to hospice regarding this. Patient #15s Family Member #1 said decisions regarding the patients medications were made without her consent or knowledge. Patient #15s Family Member #1 said the patients Lasix (a medication used to reduce the amount of extra fluid in the body) was discontinued and she was not told about this in advance of the change being made. Patient #15s Family Member #1 said she was only told the Lasix had been discontinued after she noted the patient had a cough and asked the nurse at the hospices IPU if the Lasix was still being given. Patient #15s Family Member #1 said the hospice IPU nurse said the Lasix had been stopped but she would have to talk to the hospice physician regarding the reason the medication was stopped. Patient #15s Family Member #1 said later that night she was able to speak with the hospice physician and the physician said the medication was stopped because the patient had a low blood pressure. Patient #15s Family Member #1 said the hospice physician was not a cardiologist (a physician who specializes in the heart) and she had previously been told by the patients cardiologist that the reason the Lasix was not stopped when the patient had a low blood pressure in the past was that the medication was not given only for the blood pressure but also affected heart function in other ways. Patient #15s Family Member #1 said in the past when the patient had a low blood pressure a dose might be held and if the blood pressure increased the next dose would be given. Patient #15s Family Member #1 said the hospice was aware she was upset about the Lasix being discontinued. Patient #15s Family Member #1 said the hospice medical director spoke with her recently and told her the hospice staff advised the medical director to call Patient #15s Family Member #1. Patient #15s Family Member #1 said the hospice medical director said Patient #15s Family Member #1 knew about the medication changes. Patient #15s Family Member #1 said she was told but not until after she asked the hospice staff. Patient #15s Family Member #1 said no one called her before making the changes. Patient #15s Family Member #1 said the hospice medical director told her the Lasix had to be discontinued quickly due to the patients condition without time to notify the family first. Patient #15s Family Member #1 said it was 16 hours between when the Lasix was stopped and when she was first told about the changes. Patient #15s Family Member #1 said the hospice did not tell her anything about the Lasix being discontinued until she specifically asked them. Patient #15s Family Member #1 said because the hospice did not ask her about the medication changes before making them, she did not have the opportunity to ask questions or research into whether it was a good decision or not. Patient #15s Family Member #1 said she was unable to make educated decisions regarding the patients care because the hospice was not keeping her informed regarding what they were doing. Patient #15s Family Member #1 said no medical decisions should have been made for the patient without giving her a chance to consider them and make an informed decision. Patient #15s Family Member #1 said the hospice had documented in the patients clinical record that Family Member #1 was informed and agreed to the patients plan of care and said when she had agreed at times it was to the specific things discussed not to all the changes the hospice had made without notifying her. Patient #15s Family Member #1 said she was not given all the information regarding the hospices full plan of care for the patient. Patient #15s Family Member #1 said she was not informed before the hospice discontinued the Lasix. Patient #15s Family Member #1 said she only learned of the change after the fact and only when she asked the hospice. Patient #15s Family Member #1 said the hospice staff did not initiate the conversation. Patient #15s Family Member #1 said her biggest concern with the hospice was that they made changes to the patients care without keeping her notified and changed the patients plan of care without her permission or consent. Record review of the clinical record for Patient #15 included a plan of care, for the certification period of 10/29/22 - 01/26/23, which indicated the patient had diagnoses of congestive heart failure (a medical condition in which the heart does not pump effectively which can result in the buildup of fluid in the bodys tissues) and end stage heart failure (the most advanced form or heart failure – indicating the heart was no longer able to effectively pump blood to the bodys tissues). The plan of care indicated the patient had orders for Furosemide (a generic medication name for the medication also known as Lasix) 20 mg tablet to be taken twice a day orally for chronic heart failure. The plan of care further indicated the patients mental status was disoriented/confused. Record review of a physicians order, dated 10/30/22 at 10:59 a.m., indicated, ";Medication discontinued 10/30/22 furosemide 20 mg tablet." The order was signed by LVN L. Record review of a hospice form titled, ";Documentation Summary," for the time period of 10/29/22 – 11/04/22, included an entry, dated 10/29/22 at 1:00 a.m., signed by RN V, which indicated, ";SN to perform initial hospice assessment upon admission to Hospice ... Consent for treatment signed by ... --------- [name of Patient #15s Family Member #1] ... Systolic Blood Pressure (the amount of pressure in the blood vessels leading away from the heart when the heart contracts – the top number in the blood pressure reading) ... 141 ... Diastolic Blood Pressure (the amount of pressure in the blood vessels leading away from the heart when the heart is between contractions – the bottom number in the blood pressure reading) 63 ... furosemide Ordered 10/28/2022 .. 20 mg tablet 1 oral 2 times per day ..." Record review of the hospice form titled, ";Documentation Summary," for the time period of 10/29/22 – 11/04/22, included an entry, dated 10/29/22 at 1:00 a.m., signed by RN V, which indicated, ";Intervention: Involve patient/family/caregiver/hospice team and physician in development of and changes to plan of care ... [Family Member #1] present at initial visit and participated in POC. Pt d/t dementia is not decisional." Record review of the hospice form titled, ";Documentation Summary," for the time period of 10/29/22 – 11/04/22, included an entry, dated 10/29/22 at 7:55 a.m., signed by LVN L, which indicated, ";... Systolic Blood Pressure ... 141 ... Diastolic Blood Pressure 63 ..." Record review of the hospice form titled, ";Documentation Summary," for the time period of 10/29/22 – 11/04/22, included an entry, dated 10/29/22 at 8:45 a.m., signed by LVN L, which indicated, ";Med Administration ... furosemide 20 mg tablet take 1 tablet ... by oral route 2 times per day ... Scheduled on: Saturday, Oct 29, 2022 09:00 AM Administered as: Ordered." Record review of the hospice form titled, ";Documentation Summary," for the time period of 10/29/22 – 11/04/22, included an entry, dated 10/29/22 at 7:42 p.m., signed by RN V, which indicated, ";Systolic Blood Pressure ... 67 ... Diastolic Blood Pressure 43." Record review of the hospice form titled, ";Documentation Summary," for the time period of 10/29/22 – 11/04/22, included an entry, dated 10/29/22 at 9:43 p.m., signed by RN V, which indicated, ";Med Administration ... furosemide 20 mg tablet take 1 tablet ... by oral route 2 times per day ... Scheduled on: Saturday, Oct 29, 2022 09:00 PM Administered as: Ordered (This indicated the Furosemide was administered on this date despite the patients blood pressure being 67/43)." Record review of the hospice form titled, ";Documentation Summary," for the time period of 10/29/22 – 11/04/22, included an entry, dated 10/30/22 at 7:59 a.m., signed by LVN L, which indicated, ";Systolic Blood Pressure ... 81 ... Diastolic Blood Pressure 47." Record review of the hospice form titled, ";Documentation Summary," for the time period of 10/29/22 – 11/04/22, included an entry, dated 10/30/22 at 8:41 a.m., signed by LVN L, which indicated, ";Med Administration ... furosemide 20 mg tablet take 1 tablet ... by oral route 2 times per day ... Scheduled on: Sunday, Oct 30, 2022 09:00 AM Administered as: Ordered (This indicated the Furosemide was administered on this date despite the patients blood pressure being 81/47)." Record review of the hospice form titled, ";Documentation Summary," for the time period of 10/29/22 – 11/04/22, included an entry, dated 10/30/22 at 6:12 p.m., signed by LVN L, which indicated, ";Shift Summary ... Lasix ... Dcd, due to low B/P. [Family Member #1] remains very upset about pt being brought over to the inpt unit and is now being told the pt would need to be transitioned (into another care setting - such as an assisted living facility)." There was no documentation to indicate LVN L notified Patient #15s Family Member #1 that the Lasix was discontinued prior to the change being implemented or to indicate LVN L notified Patient #15s Family Member #1 the medication was discontinued on this date. Record review of the hospice form titled, ";Documentation Summary," for the time period of 10/29/22 – 11/04/22, included an entry, dated 10/31/22 at 5:55 a.m., signed by RN V, which indicated, ";Lasix ... Dcd, due to low B/P. [Family Member #1] states her mother needs these medications or she will go into congestive heart failure ..." This was the first documentation which indicated Patient #15s Family Member #1 was notified of the Lasix being discontinued. Record review of the hospice form titled, ";Documentation Summary," for the time period of 10/29/22 – 11/04/22, included an entry, dated 10/31/22 at 11:38 a.m., signed by RN MM, which indicated, ";[Family Member #1] present, update given. She [Family Member #1] has concerns about patients Lasix ... being stopped." Record review of the hospice form titled, ";Documentation Summary," for the time period of 10/29/22 – 11/04/22, included an entry, dated 10/31/22 at 2:28 p.m., which indicated, ";------------ [name of the hospices alternate medical director] round, discussed family concerns ... about medications. Dr. states she will contact [Family Member #1] directly to address the concerns." Record review of the hospice form titled, ";Documentation Summary," for the time period of 10/29/22 – 11/04/22, included an entry, dated 10/31/22 at 3:55 p.m., signed by LMSW DDD, which indicated, ";... SW contacted Pt. [Family Member #1] by phone ... She [Family Member #1] also requested to speak to physician. SW notified physician." Record review of the Medication Administration Record for Patient #15 indicated the hospice skilled nurse administered Furosemide 20 mg 1 tablet on 10/29/22 at 8:45 a.m. and at 9:43 p.m. and on 10/30/22 at 8:41 a.m. There was no documentation to indicate the hospice skilled nurse administered the Furosemide to Patient #15 following the dose on 10/30/22 at 8:41 a.m. Record review of a clinical note, dated 10/31/22, signed by the hospices alternate medical director, indicated, ";RN told me that pts [Family Member #1] was wondering why Lasix ... stopped ... Pts [Family Member #1] arrived bedside just as I entered room. Long discussion regarding CHF meds ..." Record review of a physician visit note, dated 11/04/22, signed by the hospices alternate medical director indicated, ";------------ [name of Patient #15s Family Member #1] asked whether we will continue to change medications without letting her know. I expressed that from here on out we will discuss all medication changes with her ..." Record review of the clinical record for Patient #15 indicated the Furosemide was last administered by the hospice staff on 10/30/22 at 8:41 a.m. and was discontinued by the hospice on 10/30/22 at 10:59 a.m., after the 9:00 a.m. dose had been administered, which indicated there were 10 hours between when the order was written to discontinue the Lasix and when the next dose of Lasix would have been due to be administered for the hospice to notify Patient #15s Family Member #1 the medication had been discontinued without the patient missing a dose of the medication to allow her to have input into developing the plan of care prior to the change being implemented. There was no documentation to indicate the hospice notified Patient #15s Family Member #1 or attempted to notify Patient #15s Family Member #1 of the discontinuation of the medication during this time period. Record review of the clinical record for Patient #15 included a hospice form titled, ";Consent & Notice of Election to ---------- (name of hospice), signed by Patient #15s Family Member #1, dated 10/28/22, which indicated, ";I request the respect and dignity of maintaining autonomy and being involved in the decision-making process. All hospice treatment and therapy decisions will involve me, my family, my attending physician, and the hospice interdisciplinary team." Record review of the hospices complaint documentation did not include documentation of a complaint regarding Patient #15. During an interview conducted on 02/17/23 at 12:56 p.m., with the administrator and the alternate administrator/supervising nurse, when asked if the hospice had any additional documentation of complaints for the last six months to a year which had not yet been provided to the surveyors, the alternate administrator/supervising nurse said there was one regarding an individual who disagreed with the change in the patients Lasix dosage. The alternate administrator/supervising nurse said the documentation of this complaint was on her desk. The surveyor requested to review this documentation and documentation of any other complaints which had not previously been provided to the surveyors. On 02/17/22 at 2:00 p.m., the alternate administrator/supervising nurse provided a copy of the hospices documentation of the complaint regarding Patient #15 to the surveyors and said this was the complaint she had on her desk. The alternate administrator/supervising nurse said she had not yet put this complaint onto the hospices complaint form and that was why it had not been included in the complaint log. Record review of a written statement, dated 12/06/22 – 12/08/22, signed by the alternate administrator/supervising nurse, provided to the surveyor on 02/17/23 at 2:00 p.m., indicated, ";Patient Name: ------------ [name of Patient #15] ... 12/6/22 Received request from ---------- [name of the bereavement coordinator] to call and speak with ------------ [name of Patient #15s Family Member #1] ... 12/7/22 Called ----------- [name of Patient #15s Family Member #1] ... 12/7/22 Full record review. Documentation shows --------------- [name of Patient #15]s blood pressure went from 141/63 to 67/43 on 10/29/22. Lasix ... discontinued. On 10-31-22 ----------- [name of hospice alternate medical director] documents her conversation and teaching with ------------ [name of Patient #15s Family Member #1] ..." There was no documentation to indicate the hospice notified Patient #15s Family Member #1 of the discontinuation of the Lasix prior to the change being initiated to allow her to be involved in developing the hospice plan of care or to indicate the hospice notified Patient #15s Family Member #1 of the change prior to 10/31/22. Record review of the bereavement record for Patient #15, included a bereavement phone call note, dated 12/01/22, signed by the bereavement coordinator, which indicated, ";I spoke with -------------- [name of Patient #15s Family Member #1] ... She explained that she had a very poor experience with ... --- [initials of hospice] ... I invited her to share a bit more about her concerns; she was reserved but noted that it related to medication changes and nursing care ... I asked if she would be interested in speaking with a nursing supervisor and she said that she would ..." Record review of a hospice clinical note, with a handwritten date of 03/03/22, no signature, indicated, ";---------- [name of Patient #15s Family Member #1] ";I was never told she was not on Lasix" ... When I ask her to review the records that she physically has and point out the multiple conversations with her regarding the contraindications to these medications and that she was not on them ----------- [name of Patient #15s Family Member #1] is able to verbalize ";well yes I was told then but I had to ask questions to get it." She is unable to rationalize that she was informed multiple times regarding changes in the care ... She says I was never spoken to by the hospice team and when I ask her to review the multiple notes where she was spoken to she says ";well then (sic) didnt talk to me, I talked to them." During an interview conducted on 02/17/23 at 2:49 p.m., the alternate administrator/supervising nurse said she first received the complaint regarding Patient #15 on 12/06/22 and said prior to this the complainant had been speaking to the bereavement coordinator. During an interview conducted on 03/14/23 at 11:09 a.m., the hospices bereavement coordinator said she called Patient #15s Family Member #1 and started the conversation with general condolences. The bereavement coordinator said Patient #15s Family Member #1 was reserved but said she was not doing well because of the hospice. The bereavement coordinator said she asked for more information and the most Patient #15s Family Member #1 would tell her was that it was related to the medications and nursing services. The bereavement coordinator said she gave Patient #15s Family Member #1 space to vent. The bereavement coordinator said at first Patient #15s Family Member #1 was pretty hostile but by the end of the conversation was better. The bereavement coordinator said she passed the information onto the alternate administrator/supervising nurse. The bereavement coordinator said at the time Patient #15s Family Member #1 did not say she wanted to file a complaint, just that she had questions. During an interview conducted on 02/22/23 at 11:55 a.m., LVN L said she could not even remember Patient #15. LVN L reviewed the clinical record for Patient #15 and said Patient #15s Lasix was discontinued as of 10/30/22. LVN L said she thought she did education with Patient #15s family member regarding the Lasix and said the family member was not receptive to the teaching. LVN L said the Lasix was stopped due to the patients low blood pressure. During an interview conducted on 03/15/23 at 3:20 p.m., with the administrator, alternate administrator/supervising nurse, and the alternate supervising nurse/IPU nurse manager, when asked if the hospice had notified Patient #15s Family Member #1 of the changes to the patients medications while at the IPU, including the Lasix, before they were made, or at the time they were changed, the alternate supervising nurse/IPU nurse manager said she didnt know if Patient #15s Family Member #1 was notified prior to the change being made or at the time the change was made but she was notified after the change. The alternate supervising nurse/IPU nurse manager said there was no documentation to indicate that Patient #15s Family Member #1 was notified of the changes before they were implemented. The alternate supervising nurse/IPU nurse manager said most of the time the family was in the room with the patient, so it was easy to make the notification before the change was implemented. The alternate supervising nurse/IPU nurse manager said Patient #15s Family Member #1 was not present all the time for this patient. The alternate supervising nurse/IPU nurse manager said she did not have an answer for why Patient #15s Family Member #1 was not notified of the changes prior to them being made or at the time of the change before they were implemented. When asked why the documentation of the complaint regarding Patient #15 was not included in the complaint log which was provided to the surveyor after the entrance conference as it was received in December of 2022 and why the complaint was on notebook paper and not on a hospice complaint form, the alternate administrator/supervising nurse said she didnt have a good excuse. The alternate administrator/supervising nurse said the hospice had seen the complaint through the complaint process. The alternate administrator/supervising nurse said the bereavement coordinator had called Patient #15s Family Member #1 and Patient #15s Family Member #1 said she was unhappy, and the bereavement coordinator asked the alternate administrator/supervising nurse to call Patient #15s Family Member #1 to follow up. The alternate administrator/supervising nurse said she called Patient #15s Family Member #1 and reviewed the patients clinical record and there wasnt an answer she could give Patient #15s Family Member #1 which would make the patient come back. The alternate administrator/supervising nurse said the hospice medical director called Patient #15s Family Member #1 recently and was not able to resolve the issue. The alternate administrator/supervising nurse said they were not working this complaint any longer. During an interview conducted on 03/16/23 at 9:59 a.m., the alternate supervising nurse/IPU nurse manager said LVN L said that she notified Patient #15s Family Member #1 of the medication change on 10/30/22 but nothing was documented to indicate Patient #15s Family Member was notified until 10/31/22. The alternate supervising nurse said Patient #15s Family Member #1 was notified of the change when she came to see the patient that day (10/30/22) according to LVN Ls statement but this notification was not documented. During an interview conducted on 03/17/23 at 1:45 p.m., Patient #15s Family Member #1 said she would not have put Patient #15 on hospice services if she thought she was turning over all control over the patients care to the hospice. Patient #15s Family Member #1 said it was the second or third day after the Lasix had been discontinued when she asked the IPU skilled nurse if the patient was still receiving the Lasix and the hospice IPU skilled nurse told her no. Patient #15s Family Member #1 said she felt like when she elected hospice services, the hospice just took over and didnt let her or the patient have any say into the plan of care. Patient #15s Family Member #1 said Patient #15 was still able to tell the hospice at the time that she was transferred back to the assisted living facility on 11/04/22 that she still wanted to have a say in her care. Patient #15s Family Member #1 said hospice did not have the right to make all the decisions without input from the patient/family. Record review of the hospices policy titled, ";--------- [name of hospice] Patient & Family Rights," not dated, indicated, ";The client has the right to be informed in advance about the care to be furnished, the plan of care, expected outcomes, risks, potential benefits, side effects, barriers to treatment and of any changes in the care to be furnished ... The client has the right to participate in the planning of care or treatment and in planning changes in the care or treatment ... The agency must advise or consult with the client or legal representative in advance of any changes in the plan of care."

Based on interview and record review, the hospice failed to ensure that the comprehensive assessment identified the physical needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process for 1 of 1 (Patient #8) patient reviewed for whom the hospice failed to assess the patients stasis ulcers (wounds caused by decreased blood flow to an area of the body) within the required 5-day window to complete the hospice comprehensive assessment to assess the current condition of the stasis ulcers and ensure the treatment provided to these wounds would meet the patients needs. This failure could have resulted in a decline in the condition of the ulcers and in a decline in the chances of healing the ulcers in the event the treatment provided by the nursing facility where the patient resided was not adequate to address the patients needs. --- The findings included: Record review of the clinical record for Patient #8 included a plan of care, for the certification period of 12/20/22 – 03/19/23, which indicated the patient had a diagnosis of ASHD (a medical condition in which a buildup of substances results in narrowing of the blood vessels which can result in obstruction of blood flow). The plan of care indicated the patient was to receive skilled nurse visits once a week for one week and then twice a week for twelve weeks. The plan of care also indicated, ";SN clean stasis ulcers to legs with NS (a solution of salt and water), pat dry, apply aquacel silver (a type of absorbent wound dressing used to prevent or treat infections) to the wound base and place a cover dressing such as allevyn (a type of absorbent non-adherent wound dressing) MWF and prn until healed." Record review of a hospice form titled, ";SN Hospice Admission Visit," dated 12/20/22, signed by RN KK, indicated, ";Pt has 2 allevyn to his left lower leg ... Ulcer Type ... Stasis ... Collaborated with the wound care nurse (at the nursing facility where the patient resided), she reports the pt has blisters that come up and then rupture to his left lateral (to the side of) leg which are venous (relating to the veins - blood vessels leading toward the heart) stasis ulcers. She reports they are healing, upper one has some bloody drainage. Orders to cleanse, dry, and apply aquacel silver to the site and a cover dressing MWF and prn." There was no documentation to indicate the hospice skilled nurse assessed the patients stasis ulcers during this skilled nurse visit. During an interview conducted on 03/14/23 at 10:05 a.m., RN KK said she did not complete a wound assessment for the patients stasis ulcers during the patients start of care visit on 12/20/22 because the nursing facility had already done the wound care and she did not have the dressings with her. RN KK said sometimes she had to do what she could on the admission visit and then have the case manager follow up. RN KK said that was the standard at their hospice. RN KK said she obtained the information for the documentation regarding the wounds for this visit by reading the notes from the nursing facilitys wound care nurses assessment. RN KK said the hospices policy regarding wound assessment was to try to do the wound assessment on the start of care visit. RN KK said she may have lifted the edge of the dressing to look at the wound, but she could not recall for sure. Record review of hospice forms titled, "SN Regular Visit," dated 12/21/22 and 12/23/22, signed by RN UU, did not include documentation to indicate the hospice skilled nurse assessed the patients stasis ulcers during these visits. During an interview conducted on 02/22/23 at 10:03 a.m., RN UU said on 12/21/22 Patient #8 had no wounds and then said the patient did have an arterial (relating to the arteries - blood vessels leading away from the heart– arterial and venous stasis ulcers are similar in that they are caused by reduced blood flow but are not the same thing) stasis ulcer which was open to air and closing. RN UU said if there was no documentation of a wound assessment on the skilled nurses note the wound was probably not assessed during this visit. RN UU said her responses for the visit on 12/23/22 were the same as for 12/21/22, and if there was no wound assessment documented on the skilled nurses note, the wound was probably not assessed during the visit. Record review of hospice forms titled, "SN PRN Visits," dated 12/24/22 at 4:24 p.m. – 5:00 p.m., 12/24/22 at 5:48 p.m. – 5:58 p.m., 12/25/22 at 1:39 p.m. – 2:14 p.m., and 12/25/22 at 2:40 p.m. – 3:10 p.m., signed by RN EEE, indicated these were PRN visits. There was no documentation to indicate the hospice skilled nurse assessed the patients stasis ulcers during these visits. During an interview conducted on 02/21/23 at 9:32 a.m., RN EEE said when she conducts PRN visits the visit was focused on what she was sent to do. RN EEE said the first PRN visit conducted on 12/24/22 was to assess a complaint of shortness of breath and the second PRN visit on 12/24/22 was to deliver medications. RN EEE said she did not do a wound assessment of the patients stasis ulcers during these visits because this was not the focus of the visit. RN EEE said she did not complete a wound assessment of the patients stasis ulcers on 12/25/22. There was no documentation of any other additional skilled nurse visits conducted during the 5-day window for the comprehensive assessment to be completed for Patient #8. There was no documentation to indicate the hospice skilled nurse completed a comprehensive assessment that identified the physical needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process for Patient #8 which included assessment of his stasis ulcers to assess the current condition of the stasis ulcers and ensure the treatment provided to these wounds would meet the patients needs. During an interview conducted on 03/15/23 at 3:20 p.m., with the administrator, alternate administrator/supervising nurse, and the alternate supervising nurse/IPU nurse manager, when asked regarding the hospices policy and procedure for wound assessment, the alternate administrator/supervising nurse said the wound assessments for home care patients should be done and documented once a week when the comprehensive assessment was completed. Record review of the National Library of Medicines website on 03/19/23 included an article titled, ";Wound Assessment," dated 10/19/22, which indicated, ";Damage or disruption of living tissue's cellular, anatomical, and/or functional continuum defines a wound. Before treatment, the exact cause, location, and type of wound must be assessed to provide appropriate care. Clinicians perform wound assessments to determine the appropriate treatment for extremely diverse disease processes ... The initial assessment is crucial ... without the proper understanding of the nature of the wound, the chances of healing will decline significantly ... Improving patient outcomes requires a proactive method to care that includes accurate and timely assessment and reassessment, treatment of the underlying cause using a multidisciplinary team approach, and implementation of evidence-based practice and clinical judgment to develop an appropriate therapeutic plan." Record review of a Hospice policy titled, ";PE 03: Hospice Assessment, Admission Process, and Reassessment, 4.2673," dated 7/21/2022, indicated, ";To identify patient needs and assess the patients residence as a basis for planning individualized, outcome – oriented care. Assessment/ Admission process : a) a registered nurse will contact the patient or patients representative within 24 hours of receiving the physicians referral for hospice care to schedule an appointment for Skilled Nurse Initial Assessment. b) the registered nurse will complete the Skilled Nurse Initial Assessment identifying immediate needs and support care within 48 hours after the election of hospice care, unless the physician, patient or representative requests otherwise ... the comprehensive health assessment will identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patients well-being, comfort, and dignity throughout the dying process ... The comprehensive assessment will take into consideration information on the following ...physical assessment/review of systems, including functional ability and nutritional status ... immediate needs ... complications and risk factors that affect care planning ... Based on the initial assessment, the registered nurse and the admitting team ... develops goals for care and identifies interventions with patient/family ..."

Based on interview and record review, the hospice failed to ensure that all hospice care and services furnished to patients and their families followed an individualized written plan of care for 4 of 23 (Patient #5, Patient #9, Patient #14, and Patient #21) patients reviewed. This failure could have resulted in the hospice failing to provide services and care necessary for the palliation and management of the patients terminal illness and related conditions. --- The findings included: Record review of the clinical record for Patient #5 included a plan of care, for the certification period of 02/06/23 – 05/06/23, which indicated the patient had diagnoses of Type 2 Diabetes Mellitus (a medical condition in which the body cannot effectively regulate the amount of glucose or sugar in the blood), ASHD (a medical condition in which a buildup of substances results in narrowing of the blood vessels which can result in obstruction of blood flow), and non-pressure chronic ulcers of left and right lower extremities. The plan of care indicated the patient would be admitted into the hospices IPU for GIP care. The plan of care indicated, ";Reason for Inpatient Admission ... Uncontrolled symptoms ... pt. also has severe lower ext. wounds requiring ongoing nursing interventions." The plan of care further indicated, ";Heparin Lock Flush (a medication used to keep blood flowing smoothly through an IV access) ... 100 unit/ml ... take 3cc (a unit of measurement – 1cc equals 1ml) by intravenous route (injected into the bloodstream via a needle inserted into a vein) 2 times per day Reason maintain patency (openness – freedom from obstruction) of indwelling intravenous catheter (IV access)." The plan of care did not include physicians orders for wound care to the bilateral lower extremity ulcers. Record review of a hospice form titled, ";Medication Administration Record for ---------- (name of Patient #5), indicated, ";Medication Begin Date 02/08/23 ... Heparin Lock Flush ... 100 unit/ml intravenous syringe inject 3cc by intravenous route 2 times per day; Reason: maintain patency of indwelling intravenous catheter ... Sched Time 9:00AM ... 9:00PM ..." The form did not include documentation to indicate the Heparin flush had been administered as ordered in the written plan of care on 02/07/23 at 9:00 a.m. or at 9:00 p.m. or on 02/08/23 at 9:00 a.m. During an interview conducted on 02/16/23 at 9:59 a.m., the alternate supervising nurse/IPU nurse manager said if the dose was given the time would be indicated in the section for the medication and the date on the Medication Administration Record. The alternate supervising nurse/IPU nurse manager said if there was no time entry for a medication on a date that meant the medication was not given. The alternate supervising nurse/IPU nurse manager said the hospices electronic medical record system did have a place where the nurse could document a variance from the orders, but she was not sure if this documentation was provided to the surveyor. The surveyor requested a copy of any variances for Patient #5. During an interview conducted on 02/16/23 at 1:09 p.m., the alternate supervising nurse/IPU nurse manager said the hospice skilled nurse did not administer the heparin flush to Patient #5 on 02/07/23 at all and did not administer the morning dose on 02/08/23. When asked if there was a reason the heparin flush was not administered as ordered in the written plan of care, the alternate supervising nurse/IPU nurse manager said there was no reason. The alternate supervising nurse/IPU nurse manager said a couple of weeks ago they did have a staff meeting and discussed this and other issues that had been identified. When asked if the hospice had completed a QAPI performance improvement plan to address the identified issue with the flushes, the alternate supervising nurse/IPU nurse manager, said, no. The alternate supervising nurse provided a copy of the staff meeting minutes referenced in this interview on 02/16/23 at 1:19 p.m. and said she would start writing a performance improvement plan for the issue with the heparin flush today. Record review of a hospice form titled, ";Activity Attendance Record ... Monthly Staff Meeting," dated January 30, 2023 - February 8, 2023, signed by the alternate supervising nurse/IPU nurse manager, provided on 02/16/23 at 1:19 p.m., by the alternate supervising nurse/IPU nurse manager, indicated flushes were discussed at this meeting but there were no specifics regarding what was discussed. There was no documentation of a performance improvement plan or plan to address and correct the issue provided. Record review of a hospice form titled, ";Performance Improvement Activity Worksheet," dated 2/16/23 (after the survey began), not signed, indicated the problem was ";inconsistent flow of IV Heparin Flush/orders. This problem is more important than others as it affects the patiency (sic) of the patients IV PICC line, and if not addressed could result in loss of that site." The form indicated this problem could affect the majority of the patients of the IPU. The form further indicated an inpatient chart audit indicated the heparin flushes had not been given for several days for several patients. The form indicated the hospices policy would be reviewed and posted for all licensed staff and the hospice would continue to monitor the issue. The form also indicated the hospice had scheduled an in-service for IPU staff, starting 02/21/23, with a goal to reduce the number of errors. Record review of the clinical record for Patient #5 included a hospice form titled, ";Documentation Summary," for the time period of 02/06/23 – 02/14/23, which included an entry, dated 02/06/23, at 5:20 p.m., signed by RN GG, which indicated, ";SN to perform initial hospice assessment upon admission to Hospice ... Primary Diagnosis PVD (a blood circulation disorder which can result in decreased blood flow to the tissues) ... Wound Location bilateral (both sides) lower legs ... dressings intact." Record review of a hospice form titled, ";Documentation Summary," for the time period of 02/06/23 – 02/14/23, included an entry, dated 02/07/23, signed by RN GG, which indicated, ";Dressing changed to both legs xeroform gauze (a type of gauze impregnated with petroleum and xeroform) applied to both legs with 4 by 4s (pieces of gauze measuring 4 inches by 4 inches) covering and curlex (sic) (Kerlix - a type of rolled gauze used to wrap an injury or wound)." Record review of the clinical record for Patient #5 did not include a physicians order for the wound care provided by the hospice skilled nurse on this date. Record review of a hospice form titled, ";Documentation Summary," for the time period of 02/06/23 – 02/14/23, included an entry, dated 02/08/23, at 10:15 p.m., signed by RN V, which indicated, ";Wounds to BLE posterior (back of) calves raw from loss of full thickness tissue loss, areas of eschar (dead tissue) and slough (dead tissue) where skin having serosanguinous (yellowish drainage with a small amount of blood) exudate (drainage) ... all wounds require petroleum dressing to wound bed prior to wrapping w/ kerlix gauze to protect from sticking to wound. Pt moaned a few times while dressing being done ..." Record review of the clinical record for Patient #5 did not include a physicians order for the wound care provided by the hospice skilled nurse on this date. Record review of a hospice form titled, ";Case Conference Summary," dated 02/08/23, indicated, ";— (initial of hospice) IPU IDG Interdisciplinary Note ... Extensive history of wound care for bilateral legs requiring many hospital admissions for wound care and antibiotic therapy ..." There was no documentation of physician orders for wound care to the bilateral lower extremity ulcers. Record review of a hospice form titled, ";Documentation Summary," for the time period of 02/06/23 – 02/14/23, included an entry, dated 02/09/23, at 7:33 p.m., signed by RN V, which indicated, ";Vascular ulcers ... stasis ... Wound Care Provided ... Other ... Other Wound Care Provided ... Vaseline gauze, 4x4, kerlix wrap, tape ..." Record review of a hospice form titled, ";Documentation Summary," for the time period of 02/06/23 – 02/14/23, included an entry, dated 02/10/23, at 6:38 a.m., signed by RN V, which indicated, ";Wound care to BLE stasis ulcers ... daily unless it starts draining more ... pre-medicated prior to bath and drsg chg." Record review of the clinical record for Patient #5 did not include a physicians order for the wound care provided by the hospice skilled nurse on this date. Record review of a physicians order, dated 02/11/23, signed by RN FF, indicated, ";Change dressings to BLE wounds as needed. Cleanse stasis ulcer sites ... with sterile NS, blot dry with sterile gauze. Cover with petroleum gauze to open areas, then pad wound areas with sterile 4x4s, wrap legs with kerlix. Secure with silk tape or medipore tape (a type of medical tape). Then may use stockinette to secure all dressings in place." During an interview conducted on 03/14/23 at 10:44 a.m., with RN GG, when asked regarding the wound care she provided to Patient #5 on 02/07/23, RN GG said the hospice had a verbal physicians order for the wound care provided to the BLE wounds. RN GG said she was not the one who put the order into the hospices clinical record for the patient. RN GG said she did speak with the physician regarding the order, but she did not write it. When asked if she was responsible for creating the plan of care if she admitted the patient to hospice services, RN GG said, yes, and said the wound care orders should have been on the plan of care. During an interview conducted on 02/17/23 at 10:44 a.m., with RN V, when asked regarding Patient #5 and the wound care she provided to the patient on 02/08/23, RN V said she did not receive a physicians order for the wound care she provided to these wounds on 02/08/23 and said she was just following the wound care the patient had been receiving in the hospital. RN V said on 02/08/23 she did not contact the physician or write an order for the wound care provided. When asked regarding the wound care she provided to the patients bilateral lower extremity ulcers on 02/09/23 and 02/10/23, RN V said she provided care to the bilateral lower extremity ulcers per what had been done in the hospital but did not receive or write a physicians order for this wound care on these dates. RN V said it might be helpful to have documentation regarding the type of wound and wound care orders on the patients written plan of care to ensure clarity of the care ordered and to be provided. During an interview conducted on 03/14/23 at 9:08 a.m., RN FF said that she wrote a physicians order on 02/11/23 for wound care for Patient #5. RN FF said she had reviewed the patients clinical record and was not clear on what she was supposed to provide for wound care for these wounds, so she called the physician and got a new order. RN GG said she assumed the wound had been present since the start of care. Record review of the clinical record for Patient #21 included a plan of care, for the certification period of 01/20/23 – 04/19/23, which indicated the patient had diagnoses of acute kidney failure (a sudden development of the kidneys becoming unable to filter wastes from the blood) and rectal fistula (a small tunnel that can form between the anal canal and the skin around the rectum). The plan of care indicated the patient was to receive skilled nursing visits twice a week for twelve weeks. The plan of care did not include orders for wound care to the rectal fistula. Record review of a hospice form titled, ";SN Hospice Admission Visit," dated 01/20/22, signed by RN PP, indicated, ";Peri area (the area extending from the anus to the scrotum) is excoriated. Nay (sic) have open area to scrotum, perineum (the area extending from the anus to the scrotum). Refused assessment ... Hx of illness ... Patient was brought to ------------- (name of hospital) ... Infection to peri area with purulent (containing pus) drainage was noted to peri area, due to recurrent fourniers gangrene (a type of necrotizing fasciitis or flesh-eating disease that affects the penis, scrotum, and/or perineum) of scrotum ... patient required ... surgery for infected fourniers gangrene of scrotum. Patient declined ... Related Dx ... Rectal fistula ... I found that CT (a diagnostic test in which a computer linked to an x-ray machine creates a detailed picture of structures inside the body) of abdomen and pelvis was performed at emergency room and revealed Cellulits (a common skin infection) to the left of the anus, rectum and gluteal crease in the buttocks. There is a fistula of air between the urinary bladder and the skin surface at the lower midline of the bladder ... Patient declines assessment of peri area, stating that he is fine. However, noted on hospital report that patients peri area is erythematous (reddened), with an open, purulent drainage from the medial (middle or midline) aspect of the left buttock, lateral to the anus. There is also a small open wound to the perineum." Record review of a physicians order, dated 01/22/22, indicated, ";sn prn visit for wound care." There was no documentation of the wound care to be provided or the location and type of wound to which the skilled nurse was to provide wound care. Record review of a hospice form titled, "SN Regular Visit," dated 01/22/22, signed by RN CC, indicated, ";... noted an open wound to the left inner buttock, lateral to anus 2.5x1.0x0.5 with tunneling noted, uneven margins, yellow wound bed, pink periwound (area around the wound), no odor, mod amt of drainage of serosanguinous drainage area cleansed with ns and allevyn dressing cut to fit." Record review of the client record for Client #21 did not include a written physicians order for the wound care provided by the hospice skilled nurse on 01/22/22. During an interview conducted on 02/20/23 at 1:40 p.m., RN BB said Patient #21 had a rectal fistula to the right buttock and had a stage 2 pressure ulcer to the right buttock as well. RN BB said these were not new wounds and said the patient would have had these wounds at the time of his start of care with hospice. RN BB said she could not recall if the hospice had physician orders for wound care to these wounds and said usually the RN who does the initial SN admission assessment would be the one to document the wound care orders. RN BB said the hospice did not have standing orders for wound care to a rectal fistula. Record review of the clinical record for Patient #9 included a plan of care, for the certification period of 12/13/22 – 03/12/23, which indicated the patient had diagnoses of Alzheimers Disease (a medical disorder which results in loss of cognitive function including judgement and ability to make decisions), displaced fracture of left femur (thigh bone), and subsequent encounter for closed fracture with routine healing. The plan of care indicated the patient was to receive skilled nurse visits twice a week for one week and then twice a week for twelve weeks. The plan of care did not include documentation to indicate Patient #9 had an incision with staples to the left hip and upper leg. The plan of care did not include physician orders to remove the staples from Patient #9s left hip and upper leg. Record review of a hospice form titled, ";SN Hospice Admission Visit," dated 12/13/22, signed by RN LL, indicated, ";Wound Location ... surgical wound to left hip healing ..." Record review of a hospice form titled, "SN Regular Visit," dated 12/14/22, signed by RN XX, indicated, ";Pt still has staples in left hip and left upper thigh area ..." Record review of a hospice form titled, ";SN Comprehensive Visit," dated 12/19/22, signed by RN XX, indicated, ";surgical wound to left hip healing ... 11 staples removed ... Left upper leg ... 6 staples removed ... Collaborated with ---------- (name of hospice medical director). Orders received to remove the staples ... staples removed." Record review of the clinical record for Patient #9 did not include a written physicians order for the hospice skilled nurse to remove the staples from the patients hip and upper leg to update the written plan of care. During an interview conducted on 02/22/23 at 2:42 p.m., RN XX said she thought she wrote the physicians order to remove Patient #9s staples on 12/19/22 when she received it. RN XX said she got the order from the hospice medical director. RN XX said she wrote the order at the nursing facility where the patient resided but might not have written one for the patients hospice clinical record. Record review of the clinical record for Patient #14 included a plan of care, for the certification period of 11/01/22 – 01/29/23, which indicated the patient had a diagnosis of Parkinsons Disease (a progressive medical condition of the nervous system causing tremors and muscle rigidity). The plan of care indicated the patient was to receive skilled nurse visits once a week for one week and then twice a week for twelve weeks. Record review of a hospice form titled, "SN PRN Visit," dated 11/05/22, signed by RN EEE, indicated a PRN skilled nurse visit was conducted on this date. The note indicated, ";Consulted ----------- (name of hospice physician) who adjusted Morphine (a type of controlled pain medication) to 20mg q1hr prn sob/pain." Record review of the clinical record for Patient #14 did not include a written physicians order for the patient to receive Morphine 20mg q1hr prn sob/pain to update the written plan of care. During an interview conducted on 02/21/23 at 9:32 a.m., with RN EEE, when asked if she had written the order for the 20mg Morphine every hour PRN documented on her note for the visit she conducted with Patient #14 on 11/05/22, RN EEE that she wrote the order at the assisted living facility where the patient resided but she did not write the order in the patients hospice clinical record. During an interview conducted on 3/15/23 at 3:20 p.m., with the administrator, alternate administrator/supervising nurse, and the alternate supervising nurse/IPU nurse manager, when asked the hospices policy regarding the timeframe for staff to reduce verbal orders to writing, the administrator, the alternate administrator/supervising nurse, and the alternate supervising nurse/IPU nurse manager all said the hospices policy was for staff to reduce verbal orders to writing immediately or as soon as possible after receiving the orders after leaving the bedside. The alternate administrator/supervising nurse said the hospice had made some changes to their processes regarding wounds since the survey began and the surveyors identified the issues. The alternate administrator/supervising nurse said they will be adding specific orders for wound care to the plans of care. Record review of a Hospice policy titled, ";TX 02: Hospice Care Plann ing Process, 4.2687," dated 6/14/2022, indicated, ";To ensure that care provided is appropriately planned in a timely manner to meet the patient/familys specific needs and problems. The Plan of Care will be initiated prior to the start of services. The registered nurse will assess patients needs prior to initiation of plan of care. The registered nurse will collaborate with the other care members (physician, social worker or chaplain) in the development of the Plan of Care. Other Interdisciplinary Group members will perform their initial assessments no later 5 calendar days after the start of hospice care and add frequency orders, goals and interventions. The Plan of Care, based upon the initial/comprehensive health assessment, will be developed within 15 days of the start of care. The Plan of Care will specify the care and services, including the level of care, necessary to meet the patient specific needs, patient care orders, planned interventions for problems identified, and ensure that care and services are appropriate to the severity level of each patient and familys needs. Hospice will utilize data/information gathered during the patient assessments in the care planning process. The patient/caregiver, as well as the patients physician, will be encouraged to participate in the patients care planning process to determine mutually agreed upon goals. Any changes in the plan of care will be discussed with the patient or representative, nursing facility (if applicable) and be approved by the hospice before implementation. Ongoing reviews/updates of the Plan of Care will be documented in the Case Conference Summary. The plan of care for general inpatients shall be reviewed every 7 days. The plan of care for patients in home care shall be reviewed every 15 days and updated as needed based on the changes in the patients/familys needs or environment. The case conference summary includes information from the patients updated comprehensive assessment and notes the patients progress toward outcomes and goals specified in the plan of care. The primary registered nurse will coordinate the plan of care activities in collaboration with other interdisciplinary team members, which at least consists of the physician, registered nurse, social worker, and a pastor or counselor." Record review of a Hospice policy titled, ";TX 14: Hospice Physician Orders for Care, 4.2697," dated 6/14/2022, indicated, ";To ensure patient care is provided in accordance with physicians orders and federal and state laws and regulations. Hendrick Hospice Care will obtain orders and provide care in accordance with physicians orders. The physician responsible for them shall sign all orders. Verbal/telephone orders will be dated, timed and signed by the person receiving the order and/or providing the services. The prescribing practitioner or another practitioner responsible for the care of the patient will authenticate the orders, even if the order did not originate with him or her. The physician will sign Verbal/telephone orders within 30 days. The licensed or professional staff contacts the physician for input and possible orders: a) prior to initial assessment b) a change in patients condition occurs c) the ordered care is ineffective d) there is pertinent patient information to communicate e) and/or desired goals are not being achieved. After creating the order, the person receiving the order will read and mark the read back box on the order to verify it is correct. Symptom management orders shall be accepted upon admission to the inpatient unit and home care by verbal/telephone orders and shall be signed by the physician as outlined above. All orders are communicated to the appropriate staff members as needed." Record review of a Hospice policy titled, ";TX 26: Hospice Central Venous Access Devices, 4.2715," dated 06/14/2022, indicated, ";Hendrick Hospice Care nurses shall comply with the following rules in relation to Hendrick Medical Canters nursing policies and procedures on central venous access devices. The Hendrick Hospice Care inpatient nurses shall comply with Hendrick Medical Centers nursing policies and procedures on central venous access devices as written ... A physicians order is written in maintenance of a central venous access device ... A registered nurse and a licensed vocational nurse certified in intravenous therapy can perform all functions related to the care of the central venous access devices ... Documentation of care related to a central venous access device including teachings will be noted in the hospice nursing clinical notes."

Based on interview and record review, the hospice failed to ensure the plan of care included all services necessary for the palliation and management of the terminal illness and related conditions, including drugs and treatments necessary to meet the needs of the patient, for 2 of 23 (Patient #16 and Patient #20) patients reviewed. This failure could have resulted in harm to patients due to a failure of all hospice staff members to have access to and knowledge of the patients current physician orders for treatments, including wound care, to ensure the appropriate treatment was provided. --- The findings included: Record review of the clinical record for Patient #16 included a plan of care, for the certification period of 01/12/22 – 04/11/22, which indicated the patient had diagnoses of Alzheimers Disease (a medical disorder which results in loss of cognitive function including judgement and ability to make decisions) and pressure ulcer of the right buttock, stage 3 (a pressure ulcer which presents with a full thickness loss of tissue and in which subcutaneous fat may be visible but bone, tendon, and muscle are not visible). The plan of care indicated the patient was to receive skilled nurse visits once a week for one week, twice a week for twelve weeks, and then once a week for one week. The plan of care indicated, ";Pressure Injury Stage 3 ... (Requires a separate order to be entered)." The plan of care did not include physician orders for wound care to the stage 3 pressure ulcer to the right buttock. Record review of a hospice form titled, ";SN Hospice Admission Visit," dated 01/12/22, signed by RN LL, indicated, ";Wound Location pressure ulcer to rt buttock ... Pressure ulcer ... Stage 3 ... wound 4cm x 2cm ..." During an interview conducted on 03/13/23 at 3:31 p.m., RN said she thought writing the wound care orders was missed for Patient #16. RN LL said they were not on the initial plan of care at the patients admission to hospice. RN LL said she looked at the orders in the hospices electronic clinical record for Patient #16 and did not see an order for wound care on 01/12/22. When asked who was responsible for putting the wound care orders into the clinical record from the start of care/admission SN visit, to go on the initial plan of care, at the start of care with hospice, RN LL said usually it would be the admitting nurse. Record review of the clinical record for Patient #20 included a plan of care, for the certification period of 03/21/22 – 06/18/22, which indicated the patient had diagnoses of ischemic cardiomyopathy (a medical condition in which the heart has a decreased ability to pump blood), type 2 diabetes mellitus (a medical condition in which the body cannot effectively regulate the amount of glucose or sugar in the blood), peripheral vascular disease (a blood circulation disorder which can result in decreased blood flow to the tissues), and non-pressure chronic ulcer of other part of right foot. The plan of care indicated the patient was to receive skilled nurse visits twice a week for thirteen weeks. The plan of care indicated, ";silver sulfadiazine (a topical medication used to treat or prevent infections) ... topical cream ... 2 x per week ... apply topically to foot wounds." The plan of care did not include physician orders for wound care to the patients feet and legs to indicate the wounds were to be covered with telfa (a type of absorbent wound care dressing) and wrapped twice a week and PRN. Record review of a hospice form titled, ";SN Hospice Admission Visit, dated 03/21/22, signed by RN KK, indicated, ";Skin Integumentary ... multiple blisters ... bil feet deep red with multiple blisters on the right foot ... ulcer ... Stasis ... Pt has had ongoing fluid filled blisters to bilateral feet with bright red feet. Left foot is nearly healed, but the right foot has blisters along with 2 black eschar (dead tissue) areas to toe 3 and 4. Family are cleansing her feet, applying Silvadene (a brand name for the medication also known as silver sulfadiazine), and covering with telfa and wrapping 2 x a week and prn." During an interview conducted on 03/14/23 at 10:05 a.m., RN KK said she bet she didnt write an order for the wound care for Patient #20. RN KK said she is getting better about getting the wound care orders on the plan of care. RN KK said the patients family had been applying dressings and the hospice medical director said it was ok to continue the wound care being done by the family. RN KK said at that time the hospices standard was if there were no open areas on the wound then you didnt have to write an order for the wound care being provided. RN KK said for this reason she didnt write an order for this wound care and just documented it on her skilled nurses note. During an interview conducted on 3/15/23 at 3:20 p.m., with the administrator, alternate administrator/supervising nurse, and the alternate supervising nurse/IPU nurse manager, the alternate administrator/supervising nurse said the hospice had made some changes to their processes regarding wounds since the survey began and the surveyors identified the issues. The alternate administrator/supervising nurse said the hospice would be adding specific orders for wound care to the plans of care. Record review of a Hospice policy titled, ";TX 14: Hospice Physician Orders for Care, 4.2697," dated 6/14/2022, indicated, ";To ensure patient care is provided in accordance with physicians orders and federal and state laws and regulations. ------------ (name of hospice) will obtain orders and provide care in accordance with physicians orders. The physician responsible for them shall sign all orders. Verbal/telephone orders will be dated, timed and signed by the person receiving the order and/or providing the services. The prescribing practitioner or another practitioner responsible for the care of the patient will authenticate the orders, even if the order did not originate with him or her. The physician will sign Verbal/telephone orders within 30 days. The licensed or professional staff contacts the physician for input and possible orders: a) prior to initial assessment b) a change in patients condition occurs c) the ordered care is ineffective d) there is pertinent patient information to communicate e) and/or desired goals are not being achieved. After creating the order, the person receiving the order will read and mark the read back box on the order to verify it is correct. Symptom management orders shall be accepted upon admission to the inpatient unit and home care by verbal/telephone orders and shall be signed by the physician as outlined above. All orders are communicated to the appropriate staff members as needed." Record review of a Hospice policy titled, ";TX 02: Hospice Care Planning Process, 4.2687," dated 6/14/2022, indicated, ";To ensure that care provided is appropriately planned in a timely manner to meet the patient/familys specific needs and problems. The Plan of Care will be initiated prior to the start of services. The registered nurse will assess patients needs prior to initiation of plan of care. The registered nurse will collaborate with the other care members (physician, social worker or chaplain) in the development of the Plan of Care ... The Plan of Care will specify the care and services, including the level of care, necessary to meet the patient specific needs, patient care orders, planned interventions for problems identified, and ensure that care and services are appropriate to the severity level of each patient and familys needs. Hospice will utilize data/information gathered during the patient assessments in the care planning process. The patient/caregiver, as well as the patients physician, will be encouraged to participate in the patients care planning process to determine mutually agreed upon goals. Any changes in the plan of care will be discussed with the patient or representative, nursing facility (if applicable) and be approved by the hospice before implementation."

Based on interview and record review, the hospice failed to develop and maintain a system of communication and integration, in accordance with the hospice's own policies and procedures, to provide for and ensure the ongoing sharing of information between all disciplines providing care and services in all settings for 2 of 23 (Patient #5 and Patient #20) patients reviewed. This failure could have resulted in a failure of all hospice staff, including the hospice physician, to be aware of the patients current condition and needs to ensure appropriate treatment was provided. --- The findings included: Record review of the clinical record for Patient #5 included a plan of care, for the certification period of 02/06/23 – 05/06/23, which indicated the patient had diagnoses of Type 2 Diabetes Mellitus (a medical condition in which the body cannot effectively regulate the amount of glucose or sugar in the blood), ASHD (a medical condition in which a buildup of substances results in narrowing of the blood vessels which can result in obstruction of blood flow), and non-pressure chronic ulcers of left and right lower extremities. The plan of care indicated the patient would be admitted into the hospices IPU for GIP care. The plan of care indicated, ";Reason for Inpatient Admission ... Uncontrolled symptoms ... pt. also has severe lower ext. wounds requiring ongoing nursing interventions." The plan of care did not include physicians orders for wound care to the bilateral lower extremity ulcers. Record review of the clinical record for Patient #5 included a hospice form titled, ";Documentation Summary," for the time period of 02/06/23 – 02/14/23, which included an entry, dated 02/06/23, at 5:20 p.m., signed by RN GG, which indicated, ";SN to perform initial hospice assessment upon admission to Hospice ... Primary Diagnosis PVD (a blood circulation disorder which can result in decreased blood flow to the tissues) ... Wound Location bilateral (both sides) lower legs ... dressings intact." Record review of a hospice form titled, ";Documentation Summary," for the time period of 02/06/23 – 02/14/23, included an entry, dated 02/08/23, at 10:15 p.m., signed by RN V, which indicated, ";Wounds to BLE posterior (back of) calves raw from loss of full thickness tissue loss, areas of eschar (dead tissue) and slough (dead tissue) where skin having serosanguinous (yellowish drainage with a small amount of blood) exudate (drainage) ... all wounds require petroleum dressing to wound bed prior to wrapping w/ kerlix gauze to protect from sticking to wound. Pt moaned a few times while dressing being done ..." Record review of the clinical record for Patient #5 did not include a physicians order for the wound care provided by the hospice skilled nurse on this date. There was no documentation to indicate the hospice skilled nurse provided for and ensured the ongoing sharing of information between all disciplines providing care and services in that there was no documentation the physician was notified of the need for wound care orders for the patients bilateral lower extremity ulcers on this date. Record review of a hospice form titled, ";Case Conference Summary," dated 02/08/23, indicated, ";— (initial of hospice) IPU IDG Interdisciplinary Note ... Extensive history of wound care for bilateral legs requiring many hospital admissions for wound care and antibiotic therapy ..." There was no documentation of physician orders for wound care to the bilateral lower extremity ulcers. There was no documentation to indicate the hospice skilled nurse provided for and ensured the ongoing sharing of information between all disciplines providing care and services in that there was no documentation the physician was notified of the need for wound care orders for the patients bilateral lower extremity ulcers on this date. Record review of a hospice form titled, ";Documentation Summary," for the time period of 02/06/23 – 02/14/23, included an entry, dated 02/09/23, at 7:33 p.m., signed by RN V, which indicated, ";Vascular ulcers ... stasis ... Wound Care Provided ... Other ... Other Wound Care Provided ... Vaseline gauze, 4x4, kerlix wrap, tape ..." Record review of a hospice form titled, ";Documentation Summary," for the time period of 02/06/23 – 02/14/23, included an entry, dated 02/10/23, at 6:38 a.m., signed by RN V, which indicated, ";Wound care to BLE stasis ulcers ... daily unless it starts draining more ... pre-medicated prior to bath and drsg chg." Record review of the clinical record for Patient #5 did not include a physicians order for the wound care provided by the hospice skilled nurse on this date. There was no documentation to indicate the hospice skilled nurse provided for and ensured the ongoing sharing of information between all disciplines providing care and services in that there was no documentation the physician was notified of the need for wound care orders for the patients bilateral lower extremity ulcers on this date. Record review of a physicians order, dated 02/11/23, signed by RN FF, indicated, ";Change dressings to BLE wounds as needed. Cleanse stasis ulcer sites ... with sterile NS, blot dry with sterile gauze. Cover with petroleum gauze to open areas, then pad wound areas with sterile 4x4s, wrap legs with kerlix. Secure with silk tape or medipore tape (a type of medical tape). Then may use stockinette to secure all dressings in place." During an interview conducted on 02/17/23 at 10:44 a.m., with RN V, when asked regarding Patient #5 and the wound care she provided to the patient on 02/08/23, RN V said she did not receive a physicians order for the wound care she provided to these wounds on 02/08/23 and said she was just following the wound care the patient had been receiving in the hospital. RN V said on 02/08/23 she did not contact the physician or write an order for the wound care provided. When asked regarding the wound care she provided to the patients bilateral lower extremity ulcers on 02/09/23 and 02/10/23, RN V said she provided care to the bilateral lower extremity ulcers per what had been done in the hospital but did not receive or write a physicians order for this wound care on these dates. During an interview conducted on 03/14/23 at 9:08 a.m., RN FF said that she wrote a physicians order on 02/11/23 for wound care for Patient #5. RN FF said she had reviewed the patients clinical record and was not clear on what she was supposed to provide for wound care for these wounds, so she called the physician and got a new order. RN GG said she assumed the wound had been present since the start of care. Record review of the clinical record for Patient #20 included a plan of care, for the certification period of 03/21/22 – 06/18/22, which indicated the patient had diagnoses of ischemic cardiomyopathy (a medical condition in which the heart has a decreased ability to pump blood), type 2 diabetes mellitus, peripheral vascular disease, and non-pressure chronic ulcer of other part of right foot. The plan of care indicated the patient was to receive skilled nurse visits twice a week for thirteen weeks. The plan of care included standing orders for wound care to specific types of wounds but did not include a standing order for wound care to a non-pressure chronic ulcer. Record review of a hospice form titled, ";SN Hospice Admission Visit, dated 03/21/22, signed by RN KK, indicated, ";Skin Integumentary ... multiple blisters ... bil feet deep red with multiple blisters on the right foot ... ulcer ... Stasis ... Pt has had ongoing fluid filled blisters to bilateral feet with bright red feet. Left foot is nearly healed, but the right foot has blisters along with 2 black eschar areas to toe 3 and 4 ..." Record review of a hospice form titled, ";SN Regular Visit," dated 04/07/22, signed by RN EE, indicated, ";Dressings are in place. ----------- (name of Patient #20s Family Member #1) reports the blisters are healing. 1 silver dollar size blister on the left foot has broken, weeping clear fluid in small amts." This was the first documentation of an open blister to the left foot. There was no documentation to indicate the hospice skilled nurse provided for and ensured the ongoing sharing of information between all disciplines providing care and services in that there was no documentation the physician was notified of the new blister to the left foot on this date. Record review of a hospice form titled, ";Case Conference Summary," dated 04/20/22, indicated, ";IDG Nursing Note ..." The form did not include documentation regarding the new wound to the left foot reported during the visit conducted by the hospice skilled nurse on 04/07/22. There was no documentation to indicate the hospice skilled nurse provided for and ensured the ongoing sharing of information between all disciplines providing care and services in that there was no documentation the physician was notified of the new blister to the left foot. During an interview conducted on 02/20/23 at 3:58 p.m., with RN EE, when asked regarding the visit on 04/07/23 and the documentation of the new left foot blister, RN EE said that there was a new wound to the left foot on this date. When asked what the hospices policy and procedure was when a new wound was observed, RN EE said the hospice had standing orders and they could put the orders in for treatment. RN EE said they would present the information in IDG every other week and would report any new wounds then. RN EE said they fill out the skilled nurse note section of the Case Conference Summary form at the IDG meeting. When asked if it was something was not documented on the Case Conference Summary form if that would mean it was not discussed at that meeting, RN EE said this was correct. When asked if the hospice nurses were allowed to deviate from the standing orders without obtaining specific wound care orders, such as using the standing orders designated for one type of wound for a different type of wound, RN EE said she used the type of dressing she thought was appropriate for the type of wound. RN EE said she would not necessarily call and get a physicians order. RN EE said she probably did not call the physician on 04/07/23 because the patients Family Member #1 was adamant on the type of dressings she wanted to use. During an interview conducted on 3/15/23 at 3:20 p.m., with the administrator, alternate administrator/supervising nurse, and the alternate supervising nurse/IPU nurse manager, when asked regarding the hospice's policy regarding notifying the physician of new wounds, changes in the wounds, or deterioration of the wounds, the alternate supervising nurse/IPU nurse manager said the nurse should notify the physician during rounds for IPU patients. The alternate administrator/supervising nurse said for homecare patients for a complex wound the physician should be called for orders and if the wound was not a complex wound it should be discussed in IDG. Record review of a Hospice policy titled, ";TX 02: Hospice Care Planning Process, 4.2687," dated 6/14/2022, indicated, ";To ensure that care provided is appropriately planned in a timely manner to meet the patient/familys specific needs and problems. The Plan of Care will be initiated prior to the start of services. The registered nurse will assess patients needs prior to initiation of plan of care. The registered nurse will collaborate with the other care members (physician, social worker or chaplain) in the development of the Plan of Care ... Hospice will utilize data/information gathered during the patient assessments in the care planning process. The patient/caregiver, as well as the patients physician, will be encouraged to participate in the patients care planning process to determine mutually agreed upon goals. Any changes in the plan of care will be discussed with the patient or representative, nursing facility (if applicable) and be approved by the hospice before implementation. Ongoing reviews/updates of the Plan of Care will be documented in the Case Conference Summary. The plan of care for general inpatients shall be reviewed every 7 days. The plan of care for patients in home care shall be reviewed every 15 days and updated as needed based on the changes in the patients/familys needs or environment. The case conference summary includes information from the patients updated comprehensive assessment and notes the patients progress toward outcomes and goals specified in the plan of care. The primary registered nurse will coordinate the plan of care activities in collaboration with other interdisciplinary team members, which at least consists of the physician, registered nurse, social worker, and a pastor or counselor."

Based on interview and record review, the hospice failed to ensure each patients records included physicians orders for 4 of 23 (Patient #9, Patient #14, Patient #16, and Patient #20) patients reviewed. This failure could have resulted in harm to patients due to a failure of all hospice staff members to have access to and knowledge of the patients current physician orders for care and treatment. --- The findings included: Record review of the clinical record for Patient #14 included a plan of care, for the certification period of 11/01/22 – 01/29/23, which indicated the patient had a diagnosis of Parkinsons Disease (a progressive medical condition of the nervous system causing tremors and muscle rigidity). The plan of care indicated the patient was to receive skilled nurse visits once a week for one week and then twice a week for twelve weeks. Record review of a hospice form titled, "SN PRN Visit," dated 11/05/22, signed by RN EEE, indicated a PRN skilled nurse visit was conducted on this date. The note indicated, ";Consulted ----------- (name of hospice physician) who adjusted Morphine (a controlled pain medication) to 20mg q1hr prn sob/pain." Record review of the clinical record for Patient #14 did not include a written physicians order for the patient to receive Morphine 20mg q1hr prn sob/pain. During an interview conducted on 02/21/23 at 9:32 a.m., with RN EEE, when asked if she had written the order for the 20mg Morphine every hour PRN documented on her note for the visit she conducted with Patient #14 on 11/05/22, RN EEE said that she wrote the order at the assisted living facility where the patient resided but she did not write the order in the patients hospice clinical record. Record review of the clinical record for Patient #16 included a plan of care, for the certification period of 01/12/22 – 04/11/22, which indicated the patient had diagnoses of Alzheimers Disease (a medical disorder which results in loss of cognitive function including judgement and ability to make decisions) and pressure ulcer of the right buttock, stage 3 (a pressure ulcer which presents with a full thickness loss of tissue and in which subcutaneous fat may be visible but bone, tendon, and muscle are not visible). The plan of care indicated the patient was to receive skilled nurse visits once a week for one week, twice a week for twelve weeks, and then once a week for one week. The plan of care indicated, ";Pressure Injury Stage 3 ... (Requires a separate order to be entered)." The plan of care did not include physician orders for wound care to the stage 3 pressure ulcer to the right buttock. Record review of a hospice form titled, ";SN Hospice Admission Visit," dated 01/12/22, signed by RN LL, indicated, ";Wound Location pressure ulcer to rt buttock ... Pressure ulcer ... Stage 3 ... wound 4cm x 2cm ..." During an interview conducted on 03/13/23 at 3:31 p.m., RN said she thought writing the wound care orders was missed for Patient #16. RN LL said they were not on the initial plan of care at the patients admission to hospice. RN LL said she looked at the orders in the hospices electronic clinical record for Patient #16 and did not see an order for wound care on 01/12/22. When asked who was responsible for putting the wound care orders into the clinical record from the start of care/admission SN visit, to go on the initial plan of care, at the start of care with hospice, RN LL said usually it would be the admitting nurse. Record review of the clinical record for Patient #20 included a plan of care, for the certification period of 03/21/22 – 06/18/22, which indicated the patient had diagnoses of ischemic cardiomyopathy (a medical condition in which the heart has a decreased ability to pump blood), type 2 diabetes mellitus (a medical condition in which the body cannot effectively regulate the amount of glucose or sugar in the blood), peripheral vascular disease (a blood circulation disorder which can result in decreased blood flow to the tissues), and non-pressure chronic ulcer of other part of right foot. The plan of care indicated the patient was to receive skilled nurse visits twice a week for thirteen weeks. The plan of care indicated, ";silver sulfadiazine (a topical medication used to treat or prevent infections) ... topical cream ... 2 x per week ... apply topically to foot wounds." The plan of care did not include physician orders for wound care to the patients feet and legs to indicate the wounds were to be covered with telfa (a type of absorbent wound care dressing) and wrapped twice a week and PRN. Record review of a hospice form titled, ";SN Hospice Admission Visit, dated 03/21/22, signed by RN KK, indicated, ";Skin Integumentary ... multiple blisters ... bil feet deep red with multiple blisters on the right foot ... ulcer ... Stasis ... Pt has had ongoing fluid filled blisters to bilateral feet with bright red feet. Left foot is nearly healed, but the right foot has blisters along with 2 black eschar (dead tissue) areas to toe 3 and 4. Family are cleansing her feet, applying Silvadene (a brand name for the medication also known as silver sulfadiazine), and covering with telfa and wrapping 2 x a week and prn." During an interview conducted on 03/14/23 at 10:05 a.m., RN KK said she bet she didnt write an order for the wound care for Patient #20. RN KK said she is getting better about getting the wound care orders on the plan of care. RN KK said the patients family had been applying dressings and the hospice medical director said it was ok to continue the wound care being done by the family. RN KK said at that time the hospices standard was if there were no open areas on the wound then you didnt have to write an order for the wound care being provided. RN KK said for this reason she didnt write an order for this wound care and just documented it on her skilled nurses note. Record review of the clinical record for Patient #9 included a plan of care, for the certification period of 12/13/22 – 03/12/23, which indicated the patient had diagnoses of Alzheimers Disease, displaced fracture of left femur (thigh bone), and subsequent encounter for closed fracture with routine healing. The plan of care indicated the patient was to receive skilled nurse visits twice a week for one week and then twice a week for twelve weeks. The plan of care did not include physician orders to remove the staples from Patient #9s left hip and upper leg. Record review of a hospice form titled, ";SN Hospice Admission Visit," dated 12/13/22, signed by RN LL, indicated, ";Wound Location ... surgical wound to left hip healing ..." Record review of a skilled nurses note, dated 12/14/22, signed by RN XX, indicated, ";Pt still has staples in left hip and left upper thigh area ..." Record review of a hospice form titled, ";SN Comprehensive Visit," dated 12/19/22, signed by RN XX, indicated, ";surgical wound to left hip healing ... 11 staples removed ... Left upper leg ... 6 staples removed ... Collaborated with ---------- (name of hospice medical director). Orders received to remove the staples ... staples removed." Record review of the clinical record for Patient #9 did not include a written physicians order for the hospice skilled nurse to remove the staples from the patients left hip and upper leg. During an interview conducted on 02/22/23 at 2:42 p.m., RN XX said she thought she wrote the physicians order to remove Patient #9s staples on 12/19/22 when she received it. RN XX said she got the order from the hospice medical director. RN XX said she wrote the order at the nursing facility where the patient resided but might not have written one for the patients hospice clinical record. During an interview conducted on 3/15/23 at 3:20 p.m., with the administrator, alternate administrator/supervising nurse, and the alternate supervising nurse/IPU nurse manager, when asked the hospices policy regarding the timeframe for staff to reduce verbal orders to writing, the administrator, the alternate administrator/supervising nurse, and the alternate supervising nurse/IPU nurse manager all said the hospices policy was for staff to reduce verbal orders to writing immediately or as soon as possible after receiving the orders after leaving the bedside. The alternate administrator/supervising nurse said the hospice had made some changes to their processes regarding wounds since the survey began and the surveyors identified the issues. The alternate administrator/supervising nurse said the hospice would be adding specific orders for wound care to the plans of care. Record review of a Hospice policy titled, ";TX 14: Hospice Physician Orders for Care, 4.2697," dated 6/14/2022, indicated, ";To ensure patient care is provided in accordance with physicians orders and federal and state laws and regulations. ------------ (name of hospice) will obtain orders and provide care in accordance with physicians orders. The physician responsible for them shall sign all orders. Verbal/telephone orders will be dated, timed and signed by the person receiving the order and/or providing the services. The prescribing practitioner or another practitioner responsible for the care of the patient will authenticate the orders, even if the order did not originate with him or her. The physician will sign Verbal/telephone orders within 30 days. The licensed or professional staff contacts the physician for input and possible orders: a) prior to initial assessment b) a change in patients condition occurs c) the ordered care is ineffective d) there is pertinent patient information to communicate e) and/or desired goals are not being achieved. After creating the order, the person receiving the order will read and mark the read back box on the order to verify it is correct. Symptom management orders shall be accepted upon admission to the inpatient unit and home care by verbal/telephone orders and shall be signed by the physician as outlined above. All orders are communicated to the appropriate staff members as needed." Record review of a Hospice policy titled, ";TX 02: Hospice Care Planning Process, 4.2687," dated 6/14/2022, indicated, ";To ensure that care provided is appropriately planned in a timely manner to meet the patient/familys specific needs and problems. The Plan of Care will be initiated prior to the start of services. The registered nurse will assess patients needs prior to initiation of plan of care. The registered nurse will collaborate with the other care members (physician, social worker or chaplain) in the development of the Plan of Care ... The Plan of Care will specify the care and services, including the level of care, necessary to meet the patient specific needs, patient care orders, planned interventions for problems identified, and ensure that care and services are appropriate to the severity level of each patient and familys needs. Hospice will utilize data/information gathered during the patient assessments in the care planning process. The patient/caregiver, as well as the patients physician, will be encouraged to participate in the patients care planning process to determine mutually agreed upon goals. Any changes in the plan of care will be discussed with the patient or representative, nursing facility (if applicable) and be approved by the hospice before implementation."