Every finding on record at Hospice and Palliative Carecenter

Based on agency policy, clinical record review, and staff interviews, the agency failed to obtain the patients or the patient’s legal representative’s signature confirming receipt of notice of rights and responsibilities for 1 of 3 discharged records [1]. The findings included: --- The policy, Patient Rights and Responsibilities [09/2015], was provided by employee # 4 on 5/1/26 at approximately 11 am. The policy stated, “A copy of the Patient Bill of Rights and Responsibilities will be given to the patient or patient representative ...”The policy, Personal Representatives [05/2019], was provided on 5/1/26 at 11 am by employee # 4. The policy stated, “...Personal representative: a person that is authorized by law to act on behalf of the patient in making health care-related decisions. North Carolina law states the following persons, in the order indicated, are authorized to consent to medical treatment on behalf of a patient...The agency will recognize said person (s) as the patient’s personal representative...The patient’s spouse...”Patient # 1 had a Start of Care date of 1/29/26 with a terminal diagnosis of malignant neoplasm of upper lobe right bronchus or lung [lung cancer]. Review of the clinical record revealed the adult daughter, not the spouse, signed the patient’s election of benefit and consents/patient’s rights on 1/29/26. During an interview with the in-patient administrator on 5/1/26 at approximately 10:30 am, the director stated, “I think the husband was in the room when the papers were signed. I do know he was very hard of hearing and that is probably why the daughter signed.” When asked if the patient or the patient’s husband indicated to the daughter that they wanted her to sign the papers, the in-patient administrator stated, “I don’t think it says that.”Further review of the clinical record revealed the husband was not included on emergency contact paperwork.

Based on clinical record review and staff interviews, the agency failed to respond to the caregivers’ call within a responsible time frame for 1 of 1 patient who required a PRN [as needed visit [#1]. The findings included: --- Patient # 1 had a Start of Care date of 1/29/26 with a terminal diagnosis of malignant neoplasm of upper lobe right bronchus or lung [lung cancer]. The patient was admitted to the in-patient unit for pain management and discharged home on 2/5/26 with home hospice services. Review of the Plan of Care for the certification period 1/29/26-4/23/26 revealed orders for home care hospice of SN [skilled nursing] 3 times a week for 11 weeks; hospice aide 2 times a week for 11 weeks; medical social worker 2 times a week for 11 weeks; chaplain 1 time a week for 11 weeks. Further review of the clinical record revealed LPN # 2 made a PRN [as needed] visit on 2/14/24. LPN # 2 documented the following information, “Reason for PRN visit- oxygen saturation below 80%. Patient appears to be actively dying... Patient noted in hospital bed. Minimally responsive to tactile stimuli. Pulse ox 80% on 4l via nc. Audible secretions noted. Patient is very restless. Repositioned in bed and HOB elevated to facilitate secretions. Caregiver reports lst  [last] doseof morphine and lorazepam at 2100 and have been ineffective. Dr. ______ [name] notified and new orders received to increase routine morphine to q 4 hrs [hours], increase lorazepam to 2 mg every 4 hours and every 2 hours prn anxiety, restlessness,increase prn morphine to 10-15 mg q [every] 2 hrs prn. Teaching done with caregiver on new medication orders. Education provided on s/s [sign and symptoms] of end of life and management of symptoms...Carmen voiced she was not able to reach ______ [agency] for several hours. Triage number provided...”Further review of the clinical record revealed a coordination note dated 2/14/26 at 9:55 pm by RN # 1. The documentation stated, “Call from _____ [agency name with name of nurse] that ________ [daughter] called in regarding patient _______ [patient name] “needing help”-stating they have been calling for 3 hours, left messages, and no one has called back...” The clinical record revealed no follow up or documentation to disprove the caregiver’s report of waiting several hours for a nursing visit. During an interview with employee # 4 on 5/1/26 at approximately 2 pm, employee # 4 confirmed there was no follow-up related to the caregiver’s report.

Based on clinical record review and staff interviews the skilled nurse failed to notify the physician when a urine culture was not obtained for 1 of 1 patients with an order for a urine culture [#1]. The findings included: --- Patient # 1 had a Start of Care date of 1/29/26 with a terminal diagnosis of malignant neoplasm of upper lobe right bronchus or lung [lung cancer]. The patient was admitted to the in-patient unit for pain management. Review of the clinical record revealed the patient developed a fever of 100 degrees [temporal] with a heart rate of 117. RN # 3 documented the following information, “...2045: Received call from daughter requesting UA [urinalysis] with C [culture] and S [sensitivity] due to fever and confusion...Dr.______ [name] notified and new order received for Augmentin [antibiotic] and order to receive UA C and S...Daughter stated, ‘Just because she has cancer, doesn’t mean I’m going to let her lay here and die...Catheter removed and new...foley catheter placed to obtain clean catch UA with C and S...”  Further review of the clinical record revealed the patient was started on the antibiotic during this shift. The patient was discharged home on 2/5/26. Review of the clinical record revealed a PRN [as needed] visit was made on 2/7/26 by RN # 5. RN # 5 documented the following information, “SN arrived to home to find patient supine in bed...Foley patent draining medium yellow urine. Patient finishes course of Augmentin tomorrow but daughter...asking about results of UA/culture performed at ______ [name of in-patient unit] earlier this week...No results on chart.  SN notified she would check on these and call later today once results available...” Further review of the clinical record revealed no culture results were obtained. Review of the urinalysis indicated the following information, “...Testing of the specimen could not be completed due to a specimen identification problem...No patient identification on container...”  Further review of the urinalysis indicated the urinalysis was abnormal with 2+ WCB [white blood cell] Esterase [enzyme produced by white blood cells, indicating their presence [pyuria] and acting as a key screening marker for urinary tract infections [UTIs] or inflammation; 1+ Protein; 2 + Occult Blood; Greater than 30 WBC; Bacteria-Many.Further review of the clinical record revealed the physician was not notified that the culture results were not obtained.During the onsite survey on 4/30/26-5/1/26 there were still no culture results.During an interview with the employee # 4 on 5/1/26 at approximately 2 pm, it was confirmed the nurse should have notified the physician.

Based on agency policy review, clinical record review, and staff interviews the agency failed to investigate/document an alleged violation involving mistreatment of 1 of 1 patient receiving care at the in-patient hospice house [#1]. The findings included: --- The policy, Patient Rights and Responsibilities [revision date 9/15], was provided by employee # 4 on 1/5/26 at approximately 1 pm. The policy stated, "...The patient has the right to be free of mistreatment, neglect, or verbal, mental sexual and physical abuse..."The policy, Reporting of Suspected Abuse/Neglect of Patients [revision date 1/23], was provided by employee # 4 on 1/5/26 at approximately 12:20 pm. The policy stated, "...__________ [name of agency] will take action to prevent further incidents of abuse/neglect during the investigation of the reported incident..." The policy, Grievances, Complaints, and Concerns [revision date 12/22], was provided by employee # 4 on 1/5/26 at approximately 12:20 pm. The policy stated, "...Resolution of Customer Services complaints will be shared with patients and families once the investigation is completed...Customer Service complaints will be tracked and trended to identify areas of risk and areas for improvement..."Patient # 1 had a Start of Care date of 3/21/25 with a terminal diagnosis of chronic lymphocytic leukemia [cancer of blood]. Review of the clinical record revealed the patient was admitted to the IPU [inpatient unit-hospice home] on 9/17/25. Further review of the clinical record revealed the patient required assistance with activities of daily living which were provided by various staff members while at the IPU. On 11/11/25 the patient received personal care by nursing assistant #1. Review of documentation by RN # 2 dated 11/11/25 revealed the following information, “...Right ear with swelling and drainage after his bath. Brought to my attention by daughters at bedside. ______ and _______ [names of IPU management] notified.  _______ [name of IPU management] met with family...”Review of the verbal warning documented dated 11/18/25 and completed by RN # 3 related to NA # 1 stated, “...It could not be confirmed that ______ [name of NA # 1] caused the injury; however, the family’s perception was that _____ [name of NA # 1] was too rough during care...There have been prior reports of _______ [NA # 1] being too rough with patients..." During an interview with employees # 4 and  # 5 on 1/6/26 at approximately 11:30 am, it was confirmed the agency failed to properly investigate/document alleged mistreatment of patient # 1.Review of the agency complaint tracking documents on 1/6/26 revealed no entry related to the incident involving patient # 1.Review of NA # 1 personnel file conducted on 1/6/26 revealed a disciplinary form dated 11/18/25 completed by RN # 3. The disciplinary form was related to incident reported on 11/11/25 by RN # 2. NA # 1 continued to provide care at the IPU.

Based on agency policy review, record review, and staff interviews the registered nurses failed to document effectiveness/specific dosages of PRN [as needed] medications in the clinical record for 1 of 3 discharged patients [#1]. The findings included: --- The policy, Medication Administration and Safety-Hospice Inpatient Units [12/2023], was provided by employee # 3 on 9/3/25 at approximately 10 am. The policy stated, “...Effectiveness of PRN medication administration for a qualifying reason, must be assessed and documented in the medication administration record within 60 minutes of the medication administration unless other parameters ordered...”Patient # 1 was admitted to __________ [name of inpatient hospice agency] on 6/3/25 with a terminal diagnosis of sepsis [infection in the blood stream] due to Streptococcus [type of bacteria]. Review of the clinical record revealed the patient was prescribed the following medications at the time of admission: Lorazepam [anti-anxiety] 2 mg/ml. Administer 1 mg PRN [as needed] every 30 minutes. The order was discontinued on 6/4/25.Haldol [used for agitation] 5 mg/ml. Administer 1 mg PRN every 30 minutes. The order was discontinued on 6/4/25.Morphine [used for pain] 10 mg/ml. Administer 4 mg PRN every 30 minutes.Review of the MAR [medication administration record] revealed the patient received Morphine 4mg IV on 6/3/25 at 3:20 pm. The pain reassessment for effectiveness was not documented until 8:15 pm. The patient received 4 mg of Morphine IV at 7:33 pm, the pain reassessment was not documented until 9:30 pm. Further review of the MAR revealed the patient received Morphine 4 mg IV at 11:27 pm with no effectiveness documented.On 6/4/25 NP [nurse practitioner] 1 prescribed the following medications:Lorazepam 2 mg/ml. Administer 1-2 mg every 30 minutes PRN. The patient received 1 mg of Lorazepam on 6/4/25 at 6:18 am.  No effectiveness of the medication was documented.On 6/5/25 at 1:04 pm, 2:19 pm, 2:55 pm, and 4 pm the patient received PRN Lorazepam. There was no documentation of the specific dose 1 or 2 mg. Further review of the MAR revealed no effectiveness of the PRN Lorazepam was documented for any of the above times.On 6/5/25 at 2:22 pm, 2:55 pm, and 7:04 pm the patient received 4 mg IV of PRN Morphine. No effectiveness was documented for any of the Morphine doses.During an interview with RN # 2 [IPU-inpatient unit] clinical manager on 9/3/25 at approximately 10:15 am, the RN confirmed the nurses failed to document in accordance with agency policy/best practice related to PRN medications.

Based on agency policy, clinical record review, and staff interviews, the plan of care failed to include interventions related to wound care for 1 of 6 patients with a wound [#13]. The findings included: --- The policy, Plan of Care [11/18] was provided by the agencys quality assurance nurse on 12/4/24 at approximately 11:30 am. The policy stated, ";The IDT [interdisciplinary team] will develop an individualized written plan of care for each patient in collaboration with the attending physician [if any], the patient or representative, and the primary caregiver in accordance with the patients needs..." Patient # 13 had a Start of Care date of 11/6/24 with a terminal diagnosis of vascular dementia [general term describing problems with judgement, memory and other thought processes caused by brain damage from impaired blood flow to the brain]. Review of the Plan of Care [POC] for the certification period 11/6/24-2/3/25 included orders for SN [skilled nursing] 1-3 times per week for 13 weeks and 4 PRN [as needed] for palliation of symptoms. RN # 16 conducted a PRN visit on 11/23/24 and documented the following information, ";...Patient has a small sacral [area at the base of the spine] wound to the right side of his buttocks, which is covered with a hydrocolloid dressing. ______ [name of physician] who ________ [name] reports to be the skin/wound doctor has ordered dressings to be changed three times a week..." Further review of the clinical record revealed no wound assessment and the POC did not include interventions related to a sacral wound. During an interview with RN # 8 on 12/4/24 at approximately 11 am, she confirmed the clinical record should have included interventions related to the wound, and a wound assessment.

Based on agency policy, clinical record review, and staff interviews, the agency failed to include treatment and procedures in the plan of care for 1 of 1 patient requiring suctioning. (patient # 20) Findings included: --- A policy, Oral Suction (revised 11/16/2023) received on 12/04/2024 at 12:54 PM from the Director of Nursing stated, ";Obtain/Verify MD/NP [medical doctor/nurse practitioner] physicians order." Patient # 20 was admitted on 06/18/2024 with a diagnosis of Malignant Neoplasm of part of the bronchus (lung cancer). The plan of care for 06/18/2024-09/15/2024 included orders for skilled nurse visits 3-5 times a week. Review of the clinical record revealed that registered nurse (RN) #9 documented a communication note on 07/01/2024 and stated, ";called about suction, verbal explanation how to use." Review of the plan of care revealed no order or interventions related to suctioning. RN #9 was not available for an interview. During an interview on 12/04/2024 at approximately 12:45 PM the director of nursing stated the expectation is ";That we have an order [for suctioning] of who can do it and specifics."

Based on agency policy, clinical record review, and staff interviews, the agency failed to assess/measure wounds in accordance with the Plan of Care[POC] for 2 of 6 patients with a wound [ #3 and 7]; and failed to obtain an order to perform abdominal/peritoneal catheter drainage procedure for 1 of 1 patient with an abdominal/peritoneal catheter [#5]; and failed to obtain only 1.5 Liters of fluid from abdominal/peritoneal catheter without notifying the nurse practitioner for 1 of 1 patient with an abdominal/peritoneal catheter [#5]; and failed to obtain INR [international normalized ratio-blood test that measures how long it takes the blood to clot] in accordance with the POC for 1 of 1 patient getting INR testing [#17]. The findings included: --- The policy, Plan of Care [11/18] was provided by the agencys quality assurance nurse on 12/4/24 at approximately 11:30 am. The policy stated, ";The IDT [interdisciplinary team] will develop an individualized written plan of care for each patient in collaboration with the attending physician [if any], the patient or representative, and the primary caregiver in accordance with the patients needs..." The policy, Wound/Pressure Ulcer Management [6/8/15] was provided by the agencys quality assurance nurse on 12/4/24 at approximately 11:30 am. The policy stated, ";...Clinical staff will follow assessment, evaluation, and treatment of wounds as per the plan of care." 1. Patient # 3 had a Start of Care [SOC] date of 11/2/24 and terminal diagnoses of congestive heart failure [heart cant pump enough blood to provide your body with the blood and oxygen it needs] and acute respiratory failure. Review of the Plan of Care [POC] for the certification period 11/2/24-1/30/25 included orders for SN [skilled nursing] 1-3 times per week for 13 weeks and 4 PRN [as needed] palliation of symptoms. Review of the clinical record revealed a supplemental order was written on 11/15/24 to ";SN/facility staff apply duoderm to sacrum [base of the spine] and right ischium [lower/back part of the hip bone] one time a day for skin breakdown". The POC included the following interventions dated 10/20/24 ";Assess wounds weekly; measure wounds for depth, width and length weekly". Review of the clinical record revealed RN # 19 completed the comprehensive assessment at the SOC. The visit note indicates ";skin integrity" was not evaluated. RN # 20 conducted a routine visit on 11/12/24 and documented ";skin integrity ";intact. LPN # 21 conducted a comprehensive visit on 11/20/24 and documented the following information, ";...Pts [sic] does have wounds present to BLE [bilateral extremities] and sacrum that is being cared for by the facility wound care provider/nurse. SN was unable to assess wounds d/t [due to] wound being completed [sic] prior to SN arrival..." On 11/22/24 RN # 20 conducted a routine visit. There was no evidence that the wounds were assessed or measured. On 11/25/24 RN # 20 conducted a comprehensive assessment. The clinical record revealed no wound assessments or measurements. Further review of the clinical record revealed RN # 22 conducted a routine visit on 11/27/24 and no wound assessments/measurements were obtained. RN # 20 conducted a comprehensive assessment on 12/2/24. No wound assessments or measurements were included in the assessment. During an interview with RN # 8 on 12/4/24 at approximately 12:45 pm, she confirmed the wounds should have been measured and assessed in accordance with the POC. 2A. Patient # 5 had a Start of Care date of 10/11/24 with a terminal diagnosis of liver cell carcinoma. Review of the Plan of Care [POC] for the certification period 10/11/24-1/9/25 included orders for SN [skilled nursing] 1-3 times per week for 13 weeks and 4 PRN [as needed] for palliation of symptoms. A supplemental order was written on 10/21/24 for ";SN perform abdominal/peritoneal catheter drainage system [a thin tube or catheter that drains fluid from the abdominal cavity, or peritoneal cavity to relieve symptoms of fluid buildup]. A second supplemental order was written on 10/22/24 for ";SN perform abdominal/peritoneal catheter drainage procedure. Drain patient via pleurX [sic]. Drain M-W-F and prn distension and pain. Do not exceed 1.5 L [liters] at one tim [sic], notify NP [nurse practitioner if 2 L is indicated. Do not drain if SBP [systolic blood pressure – top number is below 100." Review of the clinical record revealed patient # 5 had the abdominal/peritoneal catheter drain placed on 10/19/24. RN # 16 conducted a routine visit on 10/20/24 and documented the following information, ";Call placed to Dr. ______ prior to visit and new order received to perform drain every other day not to exceed 2 L... Drain performed and 2 L of dark amber colored clear [sic] fluid was removed..." Further review of the clinical record revealed no order dated 10/20/24 related to the abdominal/peritoneal drain. During an interview with RN # 8 on 12/4/24 at approximately 12 noon, RN # 8 confirmed there was no order to perform the drain until 10/21/24. 2B. Patient # 5 had a Start of Care date of 10/11/24 with a terminal diagnosis of liver cell carcinoma. Review of the Plan of Care [POC] for the certification period 10/11/24-1/9/25 included orders for SN [skilled nursing] 1-3 times per week for 4 PRN [as needed] for palliation of symptoms. A supplemental order was written on 10/21/24 for ";SN perform abdominal/peritoneal catheter drainage system [a thin tube or catheter that drains fluid from the abdominal cavity, or peritoneal cavity to relieve symptoms of fluid buildup]. A second supplemental order was written on 10/22/24 for ";SN perform abdominal/peritoneal catheter drainage procedure. Drain patient via pleurX [sic]. Drain M-W-F and prn distension and pain. Do not exceed 1.5 L [liters] at one tim [sic], notify NP [nurse practitioner] if 2 L is indicated. Do not drain if SBP [systolic blood pressure – top number is below 100]." Review of the clinical record revealed the patient received abdominal/peritoneal drainage on 10/20/24, 10/23/24, 11/6/24, 11/8/24, 11/13/24, 11/15/24, 11/25/24, 11/27/24, and 11/29/24. With each time the drain was completed the nurse documented 2 Liters of fluid was removed with no notification to the physician. During an interview with RN # 8 on 12/4/24 at 12 pm, she confirmed the order/plan of care was to not remove more than 1.5 liters of fluid without notifying the NP. 3. Patient # 7 had a Start of Care date of 9/18/24 with a terminal diagnosis of malignant neoplasm of larynx [voice box]. Review of the Plan of Care for the certification period 9/18/24-12/16/24 included orders for SN [skilled nursing] 1-3 times a week for 13 weeks and 4 PRN [as needed] palliation of symptoms. Review of the clinical record revealed RN # 15 conducted a visit on 10/28/24 and documented the following information, ";patient has open area on Adams apple. States he awakened this morning to his shirt being wet and when he coughed, he felt the sputum come out of the new opening..." Review of the Plan of Care revealed the following intervention, ";10/28/24-Assess wounds weekly-Adams apple". Review of the clinical record revealed the patient received weekly visits on 11/4/24, 11/12/24, and 11/26/24. During those visits no wound assessment was completed. During an interview with RN # 8 on 12/4/24 at approximately 12:15 pm, she confirmed the wound to the Adams apple was no assessed in accordance with the POC. 4. Patient # 17 had a Start of Care date of 10/26/24 with a terminal diagnosis of malignant neoplasm of overlapping sites of right female breast and secondary malignant neoplasm of liver. Review of the Plan of Care [POC] for the certification period 10/26/24-1/23/25 included orders for SN [skilled nursing] 1-3 times a week for 13 weeks and 4 PRN [as needed] for palliation of symptoms. A supplemental order was written on 11/19/24 to obtain INR [international normalized ratio-blood test that measures how long it takes the blood to clot] on 11/30/24. Review of the clinical record revealed no SN visit on made 11/20/24 and no INR results. Further review of the clinical record revealed RN # 14 conducted a nursing visit on 11/21/24 and obtained an INR. The clinical record contained no order for an INR on 11/21/24. During an interview with RN # 8 on 12/4/24 at approximately 11:30 am, the RN confirmed the INR was not obtained in accordance with the POC.

Based on clinical record review and staff interviews, the agency failed to ensure ongoing sharing of information between disciplines for 1 of 1 patient whose family requested grief counseling [#1]; and failed to ensure ongoing sharing of information between disciplines for 1 of 1 patient whom had discussed assisted suicide [#7]. The findings include: --- 1.Patient # 1 had a Start of Care date of 10/18/24 with a terminal diagnosis of Alzheimers Disease. Review of the Plan of Care for the certification period 10/18/24-1/15/25 included orders for SN [skilled nursing] 1-3 times per week for 13 weeks and 4 PRN [as needed] for palliation of symptoms; Chaplain 1-3 times per month; MSW [social worker] 1-3 times per month. Review of the clinical record revealed on 11/14/24, LPN # 18 made a phone call to the patients daughter to update her on the visit conducted on 11/14/24. LPN # 18 documented the daughter ";requested grief support for herself, message sent to SW [social worker]". On 11/25/24 Chaplain # 17 conducted a routine visit and documented the following information, ";...PCG [primary caregiver] is struggling with the situation, and reports she [daughter] asked about a grief counselor a week and a half ago and hasnt heard from anyone...she stated, ";its getting harder..."During an interview with employee #10 on 12/4/24 at approximately 2:15 pm, she reported she was not alerted of the daughters request until 11/27/24. Review of the IDT [interdisciplinary team] minutes dated 11/27/24 revealed the daughters request for grief counseling was not initiated until 11/27/24 by the chaplain. 2. Patient # 7 had a Start of Care date of 9/18/24 with a terminal diagnosis of malignant neoplasm of larynx [voice box]. Review of the Plan of Care for the certification period 9/18/24-12/16/24 included orders for SN [skilled nursing] 1-3 times a week for 13 weeks and 4 PRN [as needed] palliation of symptoms and MSW [social worker] 2 PRN [as needed] emotional support. Review of the clinical record revealed RN # 15 conducted a visit on 10/31/24 and documented the following information, ";...patient is anxious today with the new development of the opening in his throat from his cancer...Patient says his niece is coming to visit tomorrow and patient says niece wants him to think about assisted suicide. Patient said he had no thoughts of doing this...SN to report patients views on assisted suicide with _______ [name]. Task sent to ________ [social worker] requesting to schedule visit with patient..." Further review of the clinical record revealed no social work visit was conducted. During an interview with employee # 12 on 12/4/24 at approximately 1:30 pm, the social worker stated, ";The assisted suicide was something the niece had brought up to the patient. I did get a task related to a visit then I received another task stating everything was ok. I only see the patient as needed." Review of the IDT [interdisciplinary team] minutes dated 10/31/24 and 11/14/24 revealed no evidence that the group was informed of the patients anxiousness and the discussion related to assisted suicide.

Based on observation and staff interviews, the agency failed to follow accepted standards of practice to prevent the spread of infection for 1 of 2 patients with a medication administration observation. (patient #16) Findings included: --- Patient #16 was admitted to the inpatient unit on 11/12/2024 with a diagnosis of Parkinsons disease. The plan of care for 11/12/2024-02/09/2025 included orders for skilled nurse visits 24 hours a day 7 days a week and carbidopa-levodopa (anti-Parkinsons medication) 25/100mg 2 tablets by mouth 5 times a day. An medication observation was conducted on 12/02/2024 at approximately 2:30 PM with registered nurse (RN) #23. RN #23 removed 2 pills from the packages with bare hands and placed them into a bag to be crushed. An interview conducted on 12/02/2024 at approximately 3:00 PM with RN #23 revealed that it is never acceptable to handle patient pills with bare hands. During an interview on 12/02/2024 at approximately 3:10 PM the clinical manager stated, ";No [pills should not be handled with bare hands.]

Based on observation and staff interviews, the agency failed to remove expired supplies from clean supply storage areas. Findings included: --- During an observation of the clean supply closet on 12/02/2024 at approximately 1:45 PM 4 24-gauge intravenous catheters with an expiration date of 01/31/2022, 5 pairs of sterile gloves with an expiration date of 01/2023, and 1 box of elastic barrier strips with and expiration date of 05/27/2024 were noted. These items were accessible to the staff for use. During an observation of the hospice aide closest on 12/02/2024 at approximately 2:10 PM 1 16-ounce bottle of hand sanitizer with an expiration date of 03/2023 and 13 packets of Thicken Up Clear (a powder used to change the consistency of fluids for patient consumption) with an expiration date of 07/09/2024 were noted. An interview on 12/02/2024 at approximately 2:30 with the clinical manager revealed that the expectation is for all expired supplies be removed from storage.

Corridor doors have positive latching hardware. Reference 2012 NFPA 101 Section 19.3.6.3.5 (1), 18.3.6.3.5 (1) Doors shall be provided with a means for keeping the door closed. The device used shall be capable of keeping the door fully closed if a force of 5lbf (22N) is applied at the latch edge of the door. --- The corridor door to the clean utility across from the charge nurse office did not have positive latching.

Reference 2012 NFPA 101 Sections 18.2.9.1, 19.2.9.1, 7.9.2.4, 2010 NFPA 110: Section 8.3.8 A fuel quality test shall be performed at least annually using test approved by ASTM D975 standards. --- Documentation for the emergency generator annual fuel test was not available.

Based on policy and procedure, record review and staff interview the agency failed to conduct initial bereavement assessments on 9 of 20 clients (3,4, 9,10,12,19, 1, 5 and 14). Findings included: Review of a policy "Bereavement Services", revised 11/21 was received from vice president of compliance on 01/26/22 at 9:26 a.m. The policy stated," ....assessment of the bereavement needs of caregivers/family members begins upon admission to hospice services as part of the comprehensive psychosocial assessment' ... 1.Client #3 was admitted on 12/21/21 with diagnoses of alzheimer's disease, adult failure to thrive, anxiety disorder, history of pulmonary embolism, and history of falling . The social worker completed an assessment on 12/22/21, no initial bereavement assessment was conducted. 2.Client #4 was admitted on 11/16/21 with diagnoses of cva (cerebral vascular accident) , vascular dementia, dysphagia, moderate protein calorie malnutrition, chronic atrial fibrillation, and repeated falls. The social worker completed an assessment on 11/17/21, no initial bereavement assessment was conducted. 3. Client #9 was admitted on 12/24/21 with diagnoses of malignant neoplasm to bronchus or lung, acute respiratory failure with hypoxia, pneumonia, emphysema, acute kidney failure, and abnormal weight loss. The social worker completed an assessment on 12/28/21, no initial bereavement assessment was conducted. 4. Client #10 was admitted on 11/29/21 with diagnoses of CVA, vascular dementia, ataxia, and mixed hyperlipidemia. The social worker completed an assessment on 12/01/21, no initial bereavement assessment was conducted. 5. Client #12 was admitted on 12/08/21 with diagnoses of other nonspecific abnormal finding of lung field, localized swelling, copd (chronic obstructive pulmonary disease), disorder of bone, and anorexia. The social worker completed an assessment on 12/10/21, no initial bereavement assessment was conducted. 6. Client #19 was admitted on 12/02/21 with diagnoses of acute respiratory failure with hypoxia, chronic kidney disease, unspecified protein calorie malnutrition, pneumonia, atrial fibrillation, and acute kidney disease. The social worker completed an assessment on 12/06/21, no initial bereavement assessment was conducted. An interview with the director of regulatory was conducted on 01/26/22 at 1:04 p.m., revealed, "they are conducting assessments just not clicking the caregiver box on each of the assessments". 7. Patient # 1 had a Start of Care [SOC] date of 4/14/21 and a terminal diagnosis of Acute respiratory failure with hypoxia, Acute respiratory failure with hypercapnia, Anoxic brain damage. A review of the clinical record revealed the social worker completed the psychosocial assessment on 4/15/21 but no initial bereavement assessment was completed by the social worker. 8. Patient # 5 had a Start of Care [SOC] date of 12/4/21 and a terminal diagnosis of Chronic obstructive pulmonary disease [COPD]. A review of the clinical record revealed the social worker completed the psychosocial assessment on 12/8/21 but did not complete an initial bereavement assessment. 9. Patient # 14 had a Start of Care [SOC] date of 12/29/21 to _______ [name of the hospice home] and a terminal diagnosis of Pneumonia. A review of the clinical record revealed the social worker completed the psychosocial assessment on 1/3/22 but did not complete an initial bereavement assessment. An interview with the director of regulatory was conducted on 01/26/22 at 1:04 p.m., revealed, "they are conducting assessments just not clicking the caregiver box on each of the assessments".

Based on agency policy, clinical record review and staff interviews the agency failed to POC [plan of care] failed to include wound care orders for 2 of 4 patients with a wound [#11 and 14]; Failed to include orders to hold a tube feeding for 1 of 1 patient receiving tube feeding [#1]; failed to include all mediations on the POC for 1 of 1 patient with a tube feeding [#1]. The findings included: The policy, Plan of Care [11/18], was provided by the VP of Compliance on 1/26/22. The policy stated, " ...Content of the Plan of Care ...Medications and allergies ...Treatments and procedures ..." 1. Patient # 11 had a Start of Care [SOC] date of 11/29/21 and a terminal diagnosis of Alzheimer's disease. A review of the Plan of Care [POC] for the certification period 11/29/21 to 2/28/22 revealed orders for SN [skilled nursing] 1-3 times per week for 13 weeks and 4 PRN [as needed] for palliation of symptoms. A review of the clinical record revealed a SN visit was made on 1/13/22 by LPN # 1. During the visit LPN documented the following information, " ...No falls reported, however patient does have 2 steristrips [sic] noted to right lateral forearm with dried blood ...SN covered with small primapore dressing ..." Further review of the clinical record revealed no order for the dressing. An interview was conducted with RN # 2 on 1/26/22. During the interview the RN confirmed there was no order for the dressing. 2. Patient # 14 had a Start of Care [SOC] date of 12/29/21 to _______ [name of the hospice home] and a terminal diagnosis of Pneumonia. A review of clinical record revealed the following documentation: 12/30/21- " ...Skin Integrity: Protective dressing to sacrum is intact ..." 1/8/22- " ...Sacrum dressing soiled and changed at this time. Sacrum red with scattered small open areas ..." 1/10/22- "Wounds: scattered small st [stage] 2 to sacral areas, dressing CDI [clean dry and intact] ..." A review of the clinical record revealed no order for a dressing to the sacrum area. An interview was conducted with RN # 2 on 1/26/22. During the interview RN # 2 confirmed there was no order on the POC. 3 A. Patient # 1 had a Start of Care [SOC] date of 4/14/21 and a terminal diagnosis of Cute respiratory failure with hypoxia, Acute respiratory failure with hypercapnia, Anoxic brain damage. A review of the Plan of Care for the certification period 10/11/21 to 1/8/22 revealed orders for SN [skilled nursing] 1-3 times per week for 13 weeks; 4 PRN [as needed] for palliation of symptoms. A review of the IDT [interdisciplinary team] minutes dated 11/22/21 revealed the following documentation, " ...Patient with tube feeding coming out a trach [sic] last week. Feedings were held ..." Further review of the clinical record revealed no order to hold the tube feedings. An interview was conducted with RN # 2 on 1/26/22. During the interview RN # 2 confirmed there was no order to hold the tube feedings. 3 B. Patient # 1 had a Start of Care [SOC] date of 4/14/21 and a terminal diagnosis of Cute respiratory failure with hypoxia, Acute respiratory failure with hypercapnia, Anoxic brain damage. A review of the Plan of Care for the certification period 10/11/21 to 1/8/22 revealed orders for SN [skilled nursing] 1-3 times per week for 13 weeks; 4 PRN [as needed] for palliation of symptoms. A review of the clinical record dated 12/13/21 by RN # 4 revealed the following documentation, " ...PCG [patient caregiver] ________ [name] has requested that tube feedings be increased as tolerated stating pt is almost at ' starving point ' . SN met with registered dietician ______ [name] recommends that pts Prostat AWC [protein supplement] be increased to 60ml TID [three times per day] ..." A review of the medication profile/Plan of Care [POC] revealed this medication was not listed on the current med list. An interview was conducted with RN # 3 on 1/26/22. During the interview the RN confirmed the POC did not include the medication.

Based on agency policy, direct observation and staff interviews the hospice aide failed to follow proper hand hygiene for 1 of 2 visits. The findings included: The policy, Handwashing/Hand Hygiene [3/2016], was provided by the VP of Compliance on 1/26/22. The policy stated, " ...Hand hygiene is to be performed: ...at onset of patient care and between procedures on the same patient ..." Patient # 18 was admitted to hospice on 1/1/22 with a terminal diagnosis of Acute and chronic respiratory failure with hypoxia and Pulmonary fibrosis. The patient was transferred to ______ [name of hospice home] on 1/22/22 for respite care. A joint visit was made on 1/24/22 at approximately 2 pm with hospice aide # 5 and # 6. During the visit the hospice aides were noted to be doing perineal care on the patient. The hospice aides applied gloves and proceeded to check the patient ' s adult diaper. The patient was noted to have had a small bowel movement. Hospice aide # 5 obtained wipes from the bathroom and cleaned the patient ' s perineal area. The adult brief was changed. At that point Hospice aide # 5 obtained swabs from the bathroom and attempted to swab the patient ' s mouth, then applied a moisturizer to the lips of Patient # 18. The hospice aide did not perform any type of hand hygiene after performing perineal care on the patient.

Based on observations, staff interview, and/or documentation on Janusry 25, 2022, the following deficiencies were noted: The standard is non-compliant, specific findings include: 1. The exit path from the exit discharge Williams Wing to the public way from the back of the building and from the kitchen corridor were not cleared of snow and ice from the last winter event. This was evident from the ice remaing in the path of egress and staff interview. Reference 2012 NFPA 101 Section 18.2.2, 19.2.2 General; Every Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7 unless modified by 18.2.2, 19.2.2 through 18.2.11, 19.2.11. Reference 2012 NFPA 101 Section 7.1.10.1 Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency.