Every finding on record at Hospice of Darke County, Inc.

Based on record review, and interview, the Registered Nurse (RN) and Licensed Practical Nurse (LPN) failed to consistently document a complete wound assessment of all wounds, including weekly measurements of patients with a/an active wound(s) and failed to notify the patient's physician for a change in condition of a wound of patients with a/an active wound(s) (See L591). Based on the cumulative effect of this systemic problem, EverHeart Hospice was found to be out of compliance with Condition of Participation 418.64 Core Services.

Based on observation, record review, and interview, the Registered Nurse (RN) and Licensed Practical Nurse (LPN) failed to document an assessment for the presence or absence of skin redness or irritation was completed for 2 of 2 active records reviewed of patients with a/an active medication(s) for skin redness or irritation (Patients #2 and #4); failed to complete a complete wound assessment, including weekly measurements, for 2 of 2 active records reviewed of patients with a/an active wound(s) (Patients #16 and 17); failed to notify the patient's physician for a change in condition of a wound for 2 of 2 active records reviewed of patients with a/an active wound(s) (Patients #16 and 17); and failed to conduct a complete lung assessment for 1 of 1 home visit observations of an LPN visit (Patient #3). Findings include: 1. An agency policy titled "Assessments - Comprehensive Assessment of the Patient," revised 01/08/2020 and approved 01/29/2020, indicated but was not limited to "Policy: EverHeart Hospice Interdisciplinary Group (IDG) conducts and documents a patient-specific comprehensive assessment that identifies the patient's needs, including medical, nursing ... care. Procedures: ... 9. The IDG manages symptoms of the patient's disease and/or comorbidity factors based on findings in the comprehensive assessment and reassessments ...." 2. An agency policy titled "Wound Care," last reviewed 01/29/2020, indicated but was not limited to " ... Procedures: Accountability. 1. The Case Managing RN is responsible for oversight of a patient's wound. 2. RN may delegate wound care treatment to an LPN. 3. LPN will collaborate with the RN concerning any wound changes and treatment ... Wound Assessment ... 2. The wound assessment should include: ... Length, width, depth recorded in centimeters ... 3. Wounds should be evaluated and measured by the RN or designee and recorded in the EMR [electronic medical record] ... Wound Care. Wound care includes: ... e. Document wound measurement weekly and record in the EMR ... h. Goals and interventions are part of wound care plan ...." 3. An agency job description for the position of "Licensed Practical Nurse - LPN," dated 04/2021, indicated but was not limited to " ... Responsibilities of Position: 1. Provide competent nursing care to assigned patient ... including ... a. Routine home care visits ... 3. Recognize and report promptly to the registered nurse any changes in the ... physical status of the patient ...." 4. Review of the clinical record of Patient #2 was completed on 08/11/2022 and included a plan of care for the benefit period 08/03/2022 - 10/01/2022, which indicated a benefit election date of 08/03/2022 and terminal diagnosis of Alzheimer's Disease. The plan of care indicated the patient was to receive skilled nursing visits 2 times a week for 8 weeks and 5 as needed visits for "symptom management." The plan of care included a medication list which indicated the patient had an active order for Lotrisone 1%-0.05% topical cream (medication applied to the skin to treat fungal infections) to be applied every 8 hours to "excoriation of ... groin area. Apply until healed." The record included a comprehensive assessment completed on 08/03/2022 by RN #2. The assessment failed to evidence the nurse assessed for the presence or absence of redness to the groin. The record of Patient #2 included skilled nurse visit notes completed on 08/04/2022 and 08/05/2022 by RN #3. The assessment failed to evidence the nurse assessed for the presence or absence of redness to the groin. A home visit observation was conducted on 08/09/2022 at 9:54 AM with Patient #2 and Hospice Aide #1. During the visit, the aide conducted a bed bath on Patient #2 and redness to the patient's groin was observed. 5. Review of Patient #3's clinical record was completed on 08/11/2022 and included a plan of care for the benefit period 07/16/2022 - 10/10/2022. The plan of care indicated the benefit election date was 04/14/2022 and the patient's terminal diagnosis was lung cancer. A home visit observation was conducted on 08/09/2022 at 1:45 PM with Patient #3 and LPN #1. During the visit, the nurse was observed performing an assessment of the patient's lung sounds. The nurse listened to two lower lobes on the right posterior back and one lower lobe on the left posterior back. The nurse failed to assess the patient's upper lobe sounds. An interview was conducted on 08/09/2022 at 3:37 PM with the Administrator, Chief Clinical Officer #1, QAPI Coordinator #1, Team Manager #1, and Chief Quality Officer #1. During the interview, the Administrator reported an assessment of lung sounds should include "all 4 lobes" both anteriorly and posteriorly. 6. Review of Patient #4's clinical record was completed on 08/11/2022 and included a plan of care for the benefit election period 07/11/2022 - 09/08/2022. The plan of care indicated the benefit election date was 05/17/2021 and the patient's terminal diagnosis was congenital (occurred at birth) malformation of the brain. The plan of care indicated the patient was to receive skilled nursing visits 2 times a week for 8 weeks plus 4 as-needed visits for "symptom management." The plan of care included a medication list which indicated the patient's active medications included Nystatin (medication applied to the skin to treat fungal infections) 100,000 units/gram topical powder, apply 3 times a day as needed, "apply powder to reddened areas/folds," and Boudreaux's Butt Paste (medicated ointment used to treat multiple skin conditions) 40% topical ointment, apply 4 times a day as needed, "apply a thin layer to redness/rash on buttocks until healed." The record included skilled nursing visits conducted on 07/12/2022, 07/13/2022, 07/18/2022, 07/20/2022, 07/22/2022, 07/25/2022, 07/25/2022, and 08/05/2022 by LPN #1 which failed to evidence the nurse assessed for the presence or absence of redness or a rash in the patient's skin folds or buttocks. The record included a skilled nursing visit note conducted on 07/15/2022 by LPN #2 which failed to evidence the nurse assessed for the presence or absence of redness or a rash in the patient's skin folds or buttocks. The record included skilled nursing visit notes conducted on 07/16/2022, 07/17/2022, and 07/29/2022 by LPN #3 which failed to evidence the nurse assessed for the presence or absence of redness or a rash in the patient's skin folds or buttocks. The record included skilled nursing visit notes conducted on 07/18/2022 and 07/28/2022 by LPN #4 which failed to evidence the nurse assessed for the presence or absence of redness or a rash in the patient's skin folds or buttocks. The record included skilled nursing visit notes conducted on 07/19/2022 and 08/01/2022 by RN #1 which failed to evidence the nurse assessed for the presence or absence of redness or a rash in the patient's skin folds or buttocks. 7. Review of Patient #16's clinical record was completed on 08/12/2022 and included a plan of care for the benefit period 07/20/2022 - 09/17/2022. The plan of care indicated a benefit election date was 01/21/2022, the patient's terminal diagnosis was heart failure, and secondary diagnoses included but were not limited to unstageable pressure ulcer (type of wound caused by prolonged pressure applied to the body, classified by "stages") of the sacrum (base of the spine connected to the pelvic bone). The plan of care indicated the patient was to receive skilled nursing visits 1 time a week for 1 week, 2 times a week for 8 weeks, and 4 as-needed visits for "symptom management." The plan of care indicated nursing wound care interventions included but were not limited to "cleanse bilateral [both sides of the body] shins with wound cleanser, pat dry, place small square chux pads, change daily and PRN [as needed] if soiled ... Cleanse coccyx wound daily with wound cleanser and apply a contour pad liner and Ultra soft liner inside [the patient's] brief. Change daily and PRN when soiled ... Apply skin prep to red pressure areas on bilateral feet daily and PRN ... Cleanse left lateral ankle with wound cleanser, pat dry, place small square chux pads, change daily and PRN if soiled ... Apply skin prep to red pressure area on left lateral knee daily and PRN ...." The record included a skilled nursing visit conducted on 0710/2022 by LPN #1 which indicated the nurse assessed 4 wounds - one Stage 2 pressure ulcer to the coccyx which measured 5.4 centimeters (cm) in length by 4.9 cm in width by 0.6 cm in depth, one Stage 2 pressure ulcer to the left lower leg measuring 22 cm in length by 4.4 cm in width by 0.1 cm in depth, one Stage 2 pressure ulcer to the left heel measuring 1.2 cm in length by 0.7 cm in width by 0 cm in depth, and one Stage 2 pressure ulcer to the right lower leg measuring 25 cm in length by 3 cm in width by 0.3 cm in depth. The record included a comprehensive recertification assessment completed on 07/18/2022 by RN #1. The visit note indicated the nurse assessed 2 wounds - one Stage 2 pressure ulcer to the left lower leg measuring 24.8 cm in length by 3.2 cm in width by 0.5 cm in depth, and one Stage 2 pressure ulcer to right shin measuring 22.1 cm in length by 4.4 cm in width by 0.1 cm in depth. The visit note failed to evidence the nurse assessed the patient's coccyx wound. The record included skilled nursing visits conducted on 07/22/2022 and 07/25/2022 by LPN #1. The visit notes indicated the presence of Stage 2 pressure ulcers to the patient's coccyx and bilateral shins, however the nurse indicated they did not assess the wounds as the patient's wound care had already been completed by their caregiver. The record included a skilled nursing visit conducted on 07/28/2022 by LPN #1. The visit note indicated the Stage 2 pressure ulcer to the left shin was measured at 23 cm in length by 4.6 cm in width (no depth indicated), the Stage 2 pressure ulcer to the right shin was measured at 24.6 cm in length by 2.7 cm in width by 0.2 cm in depth, and the Stage 2 pressure ulcer to the coccyx was noted but not measured. The record included a skilled nursing visit conducted on 07/31/2022 by RN #1. The visit note indicated the Stage 2 pressure ulcer to the coccyx was measured at 7.0 cm in length by 5.0 cm in width by 1.5 cm in depth (an increase of 1.6 cm in length and 1.1 cm in depth since the last measurement on 07/10/2022), the Stage 2 pressure ulcer to the left shin was measured at 23.1 cm in length by 4.5 cm in width by 0.1 cm in depth and the Stage 2 pressure ulcer to the right shin was measured at 25.0 cm in length by 4.0 cm in width by 0.1 cm in depth. The visit note indicated the nurse applied Vaseline gauze to the wounds and obtained an order from the patient's primary physician for the change in dressing orders. The record included a skilled nursing visit conducted on 08/02/2022 by LPN #1. The visit note indicated the Stage 2 pressure ulcer to the coccyx was measured at 7.2 cm in length by 5.4 cm in width by 1.4 cm in depth, the Stage 2 pressure ulcer to the left shin was measured at 21.7 cm in length by 4.3 cm in width by 0.1 cm in depth, and the Stage 2 pressure ulcer to the right shin was measured at 23.9 cm in length by 4.1 cm in width by 0.1 cm in depth. The note also indicated purulent green drainage was noted coming from the coccyx wound, however the record failed to evidence the patient's physician was notified of the change in drainage. 8. Review of Patient #17's clinical record was completed on 08/12/2022. The record included a plan of care for the benefit period 06/22/2022 - 09/19/2022, which indicated a benefit election period of 03/24/2022 and terminal diagnosis of heart disease. The plan of care indicated the patient was to receive skilled nursing visits for 1 time per week for 1 week then 2 visits per week for 4 weeks. The record included a skilled nursing visit note completed on 06/23/2022 by LPN #6 which indicated the patient had a new pressure ulcer to the "right side of butt cheek" measuring 15 cm in length by 15 cm in width (no depth noted). The record failed to evidence the patient's physician was notified of the new wound. The record included a skilled nursing visit note completed on 06/28/2022 by RN #1. The note indicated the presence of two Stage 2 pressure ulcers to the right buttocks, the first measuring 3.4 cm in length by 1.0 cm in width with no depth noted and the second measuring 1.0 cm in length by 0.3 cm in width and no depth noted. The record indicated orders were obtained to "assess and monitor progress of wound healing to right buttocks every visit" and "cleanse pressure areas to right buttock with soap and water. Pat dry. Apply a thin layer of Calazime [medicated cream used to treat a variety of skin conditions] BID [twice a day] and PRN until healed." The record included a skilled nursing visit note completed on 06/30/2022 by LPN #1. The note indicated the nurse applied Calazime to the patient's wounds but failed to evidence an assessment of the wounds. The record included a skilled nursing visit note completed on 07/06/2022 by LPN #5. The note indicated the nurse applied Calazime to the patient's wounds but failed to evidence an assessment of the wounds. The record included a skilled nursing visit note completed on 07/08/2022 by LPN #1. The note indicated the presence of one Stage 1 pressure ulcer to the "buttocks" that was "open." The nurse noted the wound "appears to be healing." The record included a skilled nursing visit note completed on 07/12/2022 by RN #3. The note indicated the presence of two Stage 2 pressure ulcers to the right buttock, the first measuring 3 cm in length by 4 cm in width by 0.1 cm in depth (an increase in 3 cm in width since last measured 06/28/2022), and the second measuring 4 cm in length by 0.75 in width and 0.1 com in depth (an increase in 3 cm in length since last measured 06/28/2022). The record failed to evidence the patient's physician was notified of the increase in size of the wounds. The record included a skilled nursing visit note completed on 07/18/2022 by LPN #1. The note indicated the presence of only one Stage 2 pressure ulcer to the right buttock measuring 2 cm in length by 0.6 cm in width and no depth noted. The record included a skilled nursing visit note completed on 07/22/2022 by LPN #1. The note indicated the presence of one Stage 1 pressure ulcer to the "buttocks" which was "closed." The note also indicated the "area improving." The record included a skilled nursing visit note completed on 07/26/2022 by RN #3. The note indicated the presence of one Stage 2 pressure ulcer to the right buttock which was "open" and measured 1.5 cm in length by 0.25 cm in width by 0.1 cm in depth. The visit note stated the wound was "somewhat smaller." The record included a skilled nursing visit note completed on 07/28/2022 by LPN #1. The note indicated the presence of one Stage 2 pressure ulcer to the "coccyx" which was noted to be "improving." The record included a skilled nursing visit note completed on 08/02/2022 by RN #1. The note indicated the presence of one Stage 2 pressure ulcer to the "inner buttock" measuring 1.5 cm in length by 0.4 cm in width and no depth noted. The record included a skilled nursing visit note completed on 08/05/2022 by LPN #1. The note indicated the presence of one Stage 1 pressure ulcer to the right buttock which was "closed." The record included a skilled nursing visit note completed on 08/09/2022 by LPN #7. The note indicated the presence of one Stage 1 pressure ulcer to the right buttock which was "closed." The record included a skilled nursing visit completed on 08/11/2022 by RN #3. The note indicated the presence of one Stage 2 pressure ulcer to the right buttock which was "open" and measured 3.75 cm in length by 2.5 cm in width by 0.1 cm in depth. 9. An interview was conducted on 08/11/2022 with the Administrator, Chief Clinical Officer #1, QAPI Coordinator #1, Team Manager #1, and Chief Quality Officer #1. During the interview, the Chief Clinical Office confirmed if a patient had an active medication order for skin redness or irritation the nurse should document the presence or absence of redness at each assessment. A follow up interview was conducted on 08/12/2022 at 9:30 AM with the Administrator, Chief Clinical Officer #1, QAPI Coordinator #1, Team Manager #1, and Chief Quality Officer #1. During the interview, the Chief Clinical Officer #1 indicated the nurse visit notes reviewed for Patients #2 and #4 had skin assessments documented, and because skin redness or irritation was not documented, it was assumed the redness or irritation was not present. A second follow-up interview was conducted on 08/12/2022 at 11:21 AM the Administrator, Chief Clinical Officer #1, QAPI Coordinator #1, Team Manager #1, and Chief Quality Officer #1. During the interview, the Team Manager #1 confirmed wounds should be measured "once a week." The agency staff was queried on what increase in wound size would require notification of the provider but were unable to provide a response. The Chief Clinical Officer #1 indicated this would fall to the agency policy, however the agency policy did not reference notification of the physician for a change in wound size.