Every finding on record at Hospice in His Care, LLC

Based on interview and record review, the agency failed to ensure:1. Documentation was present in the record to support the patients need for increased frequency of chaplain service for 1 (#6) of 10 (#5-#14) active patients reviewed in the final sample; and 2. The Plan of Care Orders were updated and individualized following the patients need for increased frequency of chaplain service for 1 (#6) of 10 (#5-#14) active patients reviewed in the final sample. This deficient practice had the potential to affect a current census of 47 patients. --- A review of Patient #6s Clinical Record revealed a Start of Care Date of 08/29/2024 with a current Certification Period of 11/27/2024 through 02/24/2025. A review of Patient #6s Plan of Care for the Certification Period of 08/29/2024 through 11/26/2024 revealed, in part, the following: An order written for Chaplain Visit Frequency: 1 visit per month and as needed (PRN). A review of Patient #6s Chaplain Visit Calendar for the Certification Period of 08/29/2024 through 11/26/2024 revealed, in part, the following: Month of September 2024: 2 visits performed;Month of October 2024: 2 visits performed; and Month of November 2024: 2 visits performed. A review of Patient #6s Plan of Care for the Certification Period of 11/27/2024 through 02/24/2025 revealed, in part, the following: An order for Chaplain Visit Frequency: 1 visit per month and PRN. Further review revealed no documentation indicating the consistent need for PRN visits during September 2024, October 2024 and November 2024 was communicated and discussed with Patient #6s care team. A review of Patient #6s Chaplain Communication and Chaplain Visit Notes, dated 09/01/2024 through 11/30/2024, revealed no documentation indicating the consistent need for PRN visits during September 2024, October 2024 and November 2024 was communicated and discussed with Patient #6s care team. A review of Patient #6s Interdisciplinary Group Notes, dated 09/01/2024 through 11/30/2024, revealed no documentation indicating the consistent need for PRN visits during September 2024, October 2024 and November 2024 was communicated and discussed with Patient #6s care team. An interview was conducted on 12/19/2024 at 9:45 a.m. with S1DON. She confirmed the information from Patient #6s record review. She confirmed Patient #6 was ordered to have a Chaplain visit once monthly and PRN. She confirmed if Patient #6 was consistently requiring PRN visits, the need for the visits should be communicated with his care team and documented in his record and it was not. She confirmed after the need for increased visits was communicated with the care team, the Chaplain visit frequency order should have been updated to reflect the consistent need for 2 visits per month and it was not.

Based on interviews and record reviews, the hospice agency failed to ensure nursing services met the needs of the patients for 1 (#5) of 1 (#5) patient receiving treatment for an active pressure ulcer. The agency failed to follow acceptable standards of practice for pressure ulcer care by failing to document weekly wound measurements for Patient #5. --- A review of the Louisiana State Board of Nursings Declaratory Statement Scope of Practice for Registered Nurses (RN)-Wound Care Management, adapted 02/1999, revealed, in part, the following: RNs render care that is directed towards the prevention and treatment of wounds. Wounds are a common health care challenge that often occur with or result from chronic disorders such as impaired circulation and malnutrition. Nursing care of skin/wound conditions involves the identification, assessment, management, and ongoing evaluation of patients with alterations in skin/tissue integrity that includes but is not limited to draining wounds, pressure ulcers, and vascular ulcers, and conditions resulting from incontinence, surgical procedures, and/or trauma. Scope of Practice:The Louisiana State Board of Nursing recognizes that assessment, planning, intervention, teaching, evaluation, and supervision are the major responsibilities of the RN in the practice setting. The RN is responsible for performing a nursing assessment and physical examination for preventative and restorative nursing and for providing patient/family teaching. Recognizing that the physician must always prescribe wound care, the following roles are defined to delineate the scope of practice for each member of the nursing team members. The RN initiates appropriate wound preventative measures, stages wounds and collaborates with the wound care team in the implementation and evaluation of nursing interventions as prescribed by an authorized prescriber. A review of the 2019 National Pressure Ulcer Advisory Panel Prevention and Treatment of Pressure Ulcers-Quick Reference Guide revealed, in part, the following: Pressure Ulcer Assessment 1. Assess the pressure ulcer initially and re-assess it at least weekly.1.1. Document the results of all wound assessments. Assess and document physical characteristics including: location, Category/Stage, size, tissue type(s), color, peri-wound condition, wound edges, sinus tracts, undermining, tunneling, exudate, and odor. A review of the agencys Wound Measurement Policy, undated, revealed, in part, the following: Wound size is one of the fundamental parameters used to judge healing and resolution of a wound. Procedure: f. Wound measurements are done with routine wound care procedures. g. Documentation of wound measurements is part of the required documentation for all wound care procedures. A review of Patient #5s Clinical Record revealed a Start of Care Date of 03/29/2023 with a current Certification Period of 11/18/2024 through 01/16/2025. Further review revealed Patient #5 was currently receiving treatment for a Stage 3 Pressure Ulcer to the Coccyx. A review of Patient #5s Plan of Care for the Certification Period of 09/19/2024 through 11/17/2024, revealed in part, the following: Skilled Nurse Visit (SNV) Frequency: once to twice weekly and as needed (PRN); and ";Problem: Altered Skin Integrity". A review of Patient #5s Plan of Care for the Certification Period of 11/18/2024 through 01/16/2024, revealed in part, the following: SNV Frequency: once to twice weekly and PRN; and ";Problem: Altered Skin Integrity". A review of Patient #5s current Wound Care Orders revealed, in part, the following: Change Wound Treatment Order to Coccyx - Clean with wound cleanser, pat dry, apply Lanoseptic every nursing visit and as needed with diaper change. A review of Patient #5s Registered Nurse (RN) Recertification Visit Notes, dated 11/01/2024 through 12/16/2024, revealed, in part, the following: Stage 3 Pressure Ulcer to the Coccyx:11/05/2024 by S2RN – No wound measurements documented. A review of Patient #5s SNV Notes, dated 11/01/2024 through 12/16/2024, revealed, in part, the following: Stage 3 Pressure Ulcer to the Coccyx:11/12/2024 by S2RN – No wound measurements documented; 11/19/2024 by S2RN – No wound measurements documented;11/26/2024 by S3RN – No wound measurements documented;12/03/2024 by S2RN – No wound measurements documented; and12/10/2024 by S2RN – No wound measurements documented. An interview was conducted on 12/19/2024 at 9:40 a.m. with S1DON. S1DON confirmed she would expect the measurements of pressure ulcer wounds to be documented in their chart weekly. S1DON confirmed the only place wound measurements would be documented in the patients chart would be within the RN Recertification Visit Notes and/or the SNV Notes. S1DON reviewed the above documentation for Patient #5 and confirmed measurements were not documented weekly and should have been.

Based on interviews and record review, the hospice agency failed to ensure the patient's right to voice complaints/grievances regarding patient care by failing to identify, investigate and resolve a complaint/grievance received from a patient's representative for 1 (#1) of 3 (#1, #2 and #3) sampled patients. --- Review of the agencys policy titled ";Complaint Resolution" revealed the following, in part:Policy Statement: Hospice agency has a complaint resolution process that is implemented whenever a complaint is received. Procedures:4. All complaints are documented in a complaint log by the QAPI no more than five business days from the date the complaint was first received. 5. A documented investigation is conducted by appropriate personnel of all written or verbal complaints received by the hospice. 8. Corrective action is implemented in response to substantiated complaints.9. Complaints are tracked and regularly reviewed to identify patterns or trends and performance improvement opportunities. Review of Patient #1s Clinical Record revealed she was admitted to the Hospice agency on 06/28/2022 with a terminal diagnoses of Alzheimers Disease. Further review revealed Patient #1 expired on 11/26/2023. Review of the Grievance log dated November 2023 - February 2024 revealed no entries for Patient #1. Review of the Complaint log dated November 2023 - February 2024 revealed no entries for Patient #1. Review of the Social Workers Progress Note dated 11/28/2023 revealed the following, in part: A phone call was made to Patient #1s Daughter-in-law for bereavement support. She was angry and grieving. She said she was upset the hospice nurse was not there prior Patient #1s passing away. Notified S1DON of the issue. An interview was conducted on 02/19/2024 at 9:00 a.m. with S3SW. She said on 11/28/2023 she called Patient #1s family member to offer bereavement support from the Hospice agency staff. She said Patient #1s Daughter in law verbalized she was very upset with the Hospice Agency because she felt the nurse should have been at Patient #1s home when she died. She said she informed S1DON about Patient #1s Daughter in laws complaint. An interview was conducted on 02/19/2024 at 10:20 a.m. with S2LPN. She said she was the Quality Assurance Performance Improvement Nurse for the Hospice agency. She said when a complaint/grievance is filed, she is responsible for recording the complaint/grievance and conducting an investigation. She said she had not received a complaint/grievance regarding Patient #1s from a family member, S1DON or S3SW. An interview was conducted on 02/19/2024 at 11:15 a.m. with S1DON. She said on 11/28/2023, S3SW informed her Patient #1s Daughter in law verbalized she was very upset the Hospice nurse was not in the home when Patient #1 passed away. She verified Patient #1s Daughter in laws concern should have documented as a complaint/grievance. She said S2LPN should have been informed and a formal complaint/grievance investigation should have been documented and investigated and had not been. She said she did not contact the family after receiving the complaint/grievance. She confirmed it was her responsibility to follow the Hospice Agencys complaint resolution process and had not. .

Based on interview and record review, the hospice agency failed to ensure nursing needs of the patient were met as identified in the updated assessment for 1 (#6) of 3 (#3, #6, #9) patients reviewed for wounds. The hospice agency failed to ensure nursing staff documented a complete assessment of a stageable pressure wound identified on 01/05/2022 for Patient #6. Findings: Review of the clinical record revealed Patient #6 began receiving services with the agency on 12/04/2021 and had an admitting terminal diagnosis of Senile Degeneration of the Brain. The patient was to receive 1-2 SN (Skilled Nursing) visits a week. The patient resided in a skilled nursing facility. Review of the Hospice SN visit notes for the patient revealed the following: 12/22/2021- Shearing noted to sacral area 12/27/2021- Skin Section: Wound Care completed per facility nurse 01/03/2022- Skin Section: Wound Care completed by facility nurse 01/05/2022- Stage 2 to sacrum 01/10/2022- No documentation of assessment of wound 01/12/2022- Skin Section: Wound Care completed by facility nurse for Stage 3 sacral wound. Dressing intact. 01/19/2022- Skin Section: Wound care completed by facility nurse for Stage 3 sacral wound. Dressing intact. 01/21/2022- Skin Section: Wound care completed by facility nurse for Stage 3 sacral wound. Further review of the nursing notes revealed no documentation the hospice nurses were assessing the patient's pressure ulcer to determine the size and status of the wound. An interview was held with S3RN on 01/27/2022 at 9:00 a.m. She stated when a hospice patient had a wound, they were still required to assess the wound, treat according to physician orders, and document findings in their notes. She confirmed the nurse was to assess and monitor the patient's wounds to ensure there was no decline. She verified if the patient resided in a skilled nursing facility, the nurse was expected to monitor the pressure wound and document the status of the wound in the hospice notes. An interview was held with S2RN on 01/27/2022 at 11:30 a.m. She verified there was no documentation of wound measurements or treatments in the records for Patient #6 because the facility was the entity providing the wound care. She verified she did not document her measurements because there would be inconsistencies on her assessments and the facility wound nurse assessments. She stated she did not notify the wound care nurse when she conducted her assessments. An interview was held with S1QAPI on 01/27/2022 at 2:20 p.m. She confirmed there was no documentation of the status of the pressure ulcer for Patient #6 in the record but there should have been.

Based on interviews and record review, the hospice failed communicate with skilled nursing facility staff that were participating in the provision of care for 1 (#6) of 3 (#3, #5, #6) patients reviewed that resided in a skilled nursing facility. The hospice agency failed to ensure hospice nursing staff communicated with facility staff when a sacral pressure ulcer was discovered to ensure coordination of care. Findings: Review of the Policy provided by the agency regarding Hospice Nursing Care: Purpose: To specify the role of Hospice Nursing Care Policy: The Hospice nurse (RN/LPN) is a member of the interdisciplinary team. The RN is the central person in coordinating care of patient with the family or caregiver and interdisciplinary team ... Procedure: The Hospice nurse performs the initial and ongoing assessments of the patient, family and the caregiver ... Review of the clinical record for Patient #6 revealed the patient began receiving services with the agency on 12/04/2021 and had an admitting terminal diagnosis of Senile Degeneration of the Brain. The patient was to receive 1-2 SN (Skilled Nursing) visits a week. The patient resided in a skilled nursing facility. Review of the Hospice SN visit notes for the patient revealed the following: 12/22/2021- Shearing noted to sacral area 12/27/2021- Skin Section: Wound Care completed per facility nurse 01/03/2022- Skin Section: Wound Care completed by facility nurse 01/05/2022- Stage 2 to sacrum 01/10/2022- No documentation of assessment of wound 01/12/2022- Skin Section: Wound Care completed by facility nurse for Stage 3 sacral wound. Dressing intact. 01/19/2022- Skin Section: Wound care completed by facility nurse for Stage 3 sacral wound. Dressing intact. 01/21/2022- Skin Section: Wound care completed by facility nurse for Stage 3 sacral wound. 01/26/2022- Skin Section- Stage 3 healed Review of the Skilled Nursing Facility Departmental Notes revealed the following: 01/01/2022- Body Audit Completed- Skin intact- No New Skin Issues Noted 01/05/2022- No Skin Impairments noted 01/08/2022- Body Audit Complete- No New Skin issues noted 01/11/2022- No skin impairments noted 01/12/2022- No skin impairments noted 01/14/2022- No skin impairments noted 01/17/2022- No skin impairments noted 01/21/2022- No skin impairments noted 01/24/2022- No skin impairments noted 01/26/2022- No skin impairments noted An interview was held with S2RN on 01/27/2022 at 11:30 a.m. She stated she would get her information regarding the resident's skin from what she "saw." She reviewed her notes and verified Patient #6's skin initially presented as shearing. She stated then there was an increase in COVID-19 cases and she was only allowed to conduct telehealth visits. She said she assessed the patient as having a Stage 2 pressure wound at that time. She stated when she was finally able to get back into the facility, she assessed Patient #6 as having a Stage 3 pressure wound. She stated she would not get the wound care nurse to come with her to the bedside to assess the wound. She verified there were inconsistencies with her notes and the nursing home notes. She verified if she documented there was a Stage 3 wound present, the skilled nursing facility notes should also reflect the same. An interview was held with S4LPN on 01/27/2022 at 11:45 a.m. She verified the patient had a Stage 3 sacral wound to his sacral area. She confirmed the last time she saw it, it was healing and it was getting better. She stated there was some yellowing in the middle of the wound and the facility was putting a dressing on it. She stated the skilled nursing facility was treating the wound. She verified S5SNF was the treatment nurse for the facility. An interview was held with S5SNF on 01/27/2022 at 12:35 p.m. She verified she was the wound care nurse for the skilled nursing facility. She stated she never assessed the patient to have a stageable pressure ulcer to his sacral area. She stated if the hospice nurse assessed a Stage 3 wound, she should have been notified and they should have assessed the patient together. She stated the hospice nurses never notified her of a pressure wound. She verified the nursing home was the entity primarily responsible for providing the wound care. An interview was held with S1QAPI on 01/27/2022 at 10:00 a.m. She reviewed the skilled nursing facility documentation and verified their documentation did not match what the hospice nurses documentation. She verified the hospice staff should coordinate with the facility staff when they conducted their assessments of the patients in the facility.