Every finding on record at Hospice of Carteret County

Based on agency policy, observation, and staff interviews, the agency failed to perform hand hygiene after coming in contact with a contaminated surface for 1 of 1 patient who received a registered nurse home visit. (patient #3) Findings included: --- A policy, HOME HEALTH & HOSPICE: Infection Prevention and Control (signed 09/13/2024) received on 03/03/2025 at approximately 1:00 PM from the agency director stated, ";Frequent hand hygiene will be performed by Home Care staff (at a minimum): ... After handling soiled or contaminated materials" Patient #3 was admitted on 12/03/2024 with diagnoses of Parkinsons dis w/o dyskinesia (disorder of the central nervous system without involuntary movements) and pressure ulcer of left buttock unstageable (wound where the depth cannot be determined). The plan of care for 12/03/2024-03/02/2025 included orders for skilled nurse (SN) visits 1 time a week for 13 weeks with 6 PRN (as needed) and ";Wound care to the coccyx [tailbone] decubitus unstageable- 2xw [2 times a week] and prn by sn or trained cg [caregiver] using aseptic technique [a procedure used to prevent the spread of germs], cleanse with wound cleanser and Vashe [solution to cleanse and debride], pack tunnel with Aquacel ag rope [antimicrobial dressing] then cover with Polyman max [wound dressing] and top with adhesive foam dressing." During a home visit conducted on 03/04/2025 at approximately 9:00 AM registered nurse (RN) #6 performed wound care as ordered. While wearing clean gloves RN #6 inserted a cotton tipped swab into an area of tunneling (an area that extends from the surface to deeper layers), removed the swab, and placed it into a trash bag. The gloved hand came in contact with the inside of the trash bag. RN #6 failed to remove the contaminated glove and perform hand hygiene prior to continuing wound care. During an interview conducted on 03/04/2025 at approximately 10:30 AM RN #6 stated, normally ";After throwing away anything, I would remove my gloves and perform hand hygiene."

Based on agency policy, clinical record review, and staff interviews, the agency failed to document a discharge summary for 1 of 2 patients that revoked hospice services. (patient #1) Findings included: --- A policy, HOME CARE Discharge-Hospice (reviewed 04/2023) received on 03/04/2025 at approximately 2:00 PM from the Clinical Operations Manager stated, ";A discharge summary will be completed by the primary nurse, when the patient no longer receives services for any reason." Patient #1 was admitted on 02/26/2024 with a diagnosis of acute myeloblastic leukemia (blood cancer). The plan of care for 02/26/2024-05/25/2024 included orders for skilled nurse visits 1 time a week for 1 week, 2 times a week for 6 weeks, 1 time a week for 1 week, and 8 PRN (as needed). A review of the clinical record revealed that patient #1 revoked (self-discharged) hospice care on 05/21/2024. Further review revealed that no discharge summary was documented. During an interview on 02/04/2025 at 10:23 AM the agency director stated, ";Discharge summaries are part of our process. Apparently, this one was missed."

Based on agency policy review, clinical record review, staff interviews, the agency failed to include all medications on the Plan of Care [POC] for 1 of 3 patients that received a home visit [Patient #8]. The findings include: Patient #8 had a Start of Care [SOC] date of 12/02/2021. The POC for 03/02/2022 through 05/30/2022 included Skilled nursing 1 time per week for 13 weeks with 10 PRN [as needed] visits. The Agency policy, Patient Care Services Policy Manual on Medication Administration (revised 12/2020), given by Agency Director [AD] on 05/04/2022 at 5:10 p.m., stated, "The admitting nurse is responsible for documenting all medications on the Plan of Care and on the medication profile. The medication profile is kept current throughout the patient's admission to home health services. The list of medication is updated at least every 60 days. Each patient's Medication Profile will be reconciled with their attending physician upon admission, transfer and with any medication change. At each nursing and therapy visit the staff member will review the medication profile and will assess the patient for any medication changes and will reconcile discrepancies with the attending physician." A clinical record review of the Skilled nursing initial assessment from 12/02/2021 stated, "Patient currently using O2 {oxygen} at 4 Liters continuously." The record review confirmed the patient had used oxygen through 05/01/2022. A staff interview with Clinical operations manager on 05/04/2022 at 4:00 p.m., stated oxygen was not on the initial POC and subsequent POC's.