Every finding on record at Hospice of Dayton Inc

Based on observation and staff interview, the hospice center failed to ensure a clear and readily identifiable path of egress was provided for occupants during an emergency in accordance with NFPA 101-2012 Edition, Sections 18.2.1 and 7.10.1.2.1.  This deficiency had the ability to affect all 12 patients in the facility.Findings:Observation on 01/29/26 at 2:12 P.M. during tour of the facility with the Director of Maintenance (DM) revealed the primary evacuation route displayed confusing egress conditions, including an exit sign posted in a manner that did not clearly indicate the direction of travel to exit, resulting in an unclear path the exit during an emergency. Interview with the DM verified the route was intended to serve as the primary means of egress, however they were unable to explain the placement of the exit signage that created confusion in identifying the correct direction of exit travel.

Based on record reviews, observations and staff interviews, the facility failed to maintain the sprinkler system in accordance with NFPA 101-2012 Edition, Sections 18.3.5.1 and 9.7.5; NFPA 25-2011 Edition, Sections 5.3.2, 13.4.4.2 and 13.4.4.2.9.  This could affect 12 patients. --- Findings include:A record review of the life safety documentation containing inspection reports for the wet sprinkler system and the dry sprinkler system in the white binder on 01/29/26 at approximately 12:00 P.M. in the presence of the Facility Coordinator revealed that there was no documentation that the dry sprinkler system had a full trip, and no leak test was completed.Observation on 01/29/26 at 1:48 P.M. during tour of the facility with the Facility Lead revealed the dates on the gauges of the sprinkler system were over five years old.  Five gauges on the Dry sprinkler system were dated 2020.  There were no other calibration dates on these gauges.An interview on 01/29/26 with the Facility Coordinator verified the finding at approximately 12:35 P.M. by calling the sprinkler contractor to get the documentation; however, no documentation was provided by the end of the survey at approximately 3:39 P.M.

Based on observation and staff interview, the facility failed to maintain the integrity of a required fire-rated door assembly in accordance with NFPA 101-2012 Edition, Sections 18.7.6, 4.6.12.1, 8.3.3.1, and 8.3.4.1; NFPA 80-2010 Edition, Section 7.4.3.2. This deficient practice had the potential to affect all 12 patients.Findings include:Observation on 01/29/26 at 11:01 A.M. during tour of the facility with the Director of Maintenance (DM) revealed a 90-minute fire rated cross corridor doors near the chapel, in exit corridor that had vertical top latching rods and missing was the bottom latching rods and floor plates, which resulted in the cross-corridor doors unable to properly latch as required, allowing the passage of smoke and fire.Interview with DM who verified the findings at the time of the observation.

Based on observations and staff interviews, the facility failed to install a generator remote annunciator in accordance with NFPA 99-2012 Edition, Sections 6.4.1.1.17 and 6.4.1.1.17.5.  This could affect all 12 patients. --- Findings include:During a tour of the facility on 01/29/26, with the Senior Director of Facility and Facility Lead at approximately 2:00 P.M., it was observed that the annunciator for the 300-kilowatt diesel generator was in the back dock of the building.  The back dock does not have personnel who could readily observe the annunciator and was not observed as a regular workstation.An interview with the Senior Director of Facilities confirmed the finding, stating that they had moved it at the time of discovery.

Based on record review and staff interview,  the facility failed to ensure the generator was maintained in accordance with NFPA 99 - 2012 Edition, Sections 6.5.4.1.1.2 and 6.4.4.1.1.3 ; NFPA 110 - 2010 Edition, Sections 8.1.1, 8.3.1, 8.3.2, 8.3.3, and 8.3.4. This deficient practice had the potential to affect all 12 patients.Findings include:During record review on 01/29/26  with the Director of Maintenance (DM) upon review of the facility's emergency generator inspection, testing and maintenance record and request of the safety and health consultant, the facility failed to provide a written schedule, based on maintenance procedures and frequencies specified by the manufacturer, to ensure to a reasonable degree that the system is capable of supplying service within the time specified for the type and for the time duration specified for the class. Interview with the Maintenance Director verified the finding at the time of discovery.

Based on observation, hospice medical record review, review of police reports, review of emergency medical services (EMS) reports, review of hospital documentation, review of local forecast information, review of the facility investigation, and staff interview, the facility failed to ensure all real or potential threats to the safety of the patients were addressed to prevent patient elopement. (L0825)

Based on observation, hospice medical record review, review of police reports, review of emergency medical services (EMS) reports, review of hospital documentation, review of local forecast information, review of the facility investigation, and staff interview, the facility failed to ensure all real or potential threats to the safety of the patients were addressed to prevent patient elopement.  This affected one (Patient #1) of nine medical records reviewed and had the potential to affect all patients in the facility.  The facility's census was 1106. Findings include: --- Review of the medical record for Patient #1 revealed an admission to the Troy inpatient unit (IPU) and hospice on 11/22/25 at 12:50 PM.  The pre-admission note completed by hospice staff dated 11/20/25 documented Patient #1 was 72 years old and unable to sign his own consents due to sundowning at this time.  Patient #1's diagnoses included chronic systolic congestive heart disease, non-ST elevation myocardial infarction (NSTEMI), coronary artery disease multiple vessels with severe left anterior descending artery, Lewy body dementia, chronic obstructive pulmonary disease, and diabetes. The pre-admission note stated Patient #1 was admitted to the hospital on 11/15/25 (prior to the hospice admission) for a mental status change and dizziness.  Patient #1 required a sitter and medication management for increased confusion.  Patient #1 was able to ambulate with one person assistance to the nurse's station from his room with frequent breaks.  Per the physical and occupation therapy notes, Patient #1's standing tolerance was six minutes.  Patient #1 had been having a fall average of once a week and that Patient #1 would get combative with sundowning at night. The note requested that the inpatient unit manage the patient for pain and agitation and that the patient would need family assistance with placement. Review of the IPU hand off report dated 11/22/25 revealed the day shift nurse noted that the patient wandered and no sitter was arranged.  It stated Patient #1 was on fall precautions and Patient #1's door was to be open for observation of him. Review of the nurses note dated 11/22/25 at 7:20 P.M. revealed due to a report received about the potential for Patient #1 to wander, the fire doors in the hallway were closed and the back entryway doors that lead to the outside were manually locked. Frequent rounding was to be completed by this nurse as well as Patient Care Services/Aides (PCS). Review of the nurses note dated 11/22/25 at 9:50 P.M. revealed the nurse documented that they did not disturb Patient #1 at this time for an accucheck (a device used to measure blood sugar readings) and assessment. Patient #1 continued to rest in bed with eyes closed and they would attempt at a later time. Review of the nurses note dated 11/22/25 revealed staff noticed Patient #1 was not in his room on 11/22/25 at 9:59 P.M. and began to search for him. The Information Technology (IT) department (located off-site) checked the security cameras and observed Patient #1 walking out the front automatic doors on 11/22/25 at 9:46 P.M.  The hospital security team for the neighboring hospital was notified at 10:09 P.M. and 911 was called at 10:23 P.M.  An attempt was made to reach the patients daughter at 10:28 P.M., no answer was received, and staff were unable to leave a message, so the resident's son was called at 11:31 P.M. and notified of the elopement.Review of the website titled Accuweather.com revealed the weather in Troy on 11/22/25 was a high of 50 degrees F and a low of 36 degrees F. Review of the Miami County Sheriff's Office report dated 11/22/25 noted they responded to the hospice facility.  Staff stated they immediately began searching the facility for the patient and notified campus security.  The Sheriff's department requested a last known clothing description and was advised they did not believe Patient #1 was wearing any clothing due to the clothing he had arrived in, was on the floor of his room and his shoes were also in his room.  Due to this information, the officer requested EMS response due to the temperatures in the 30's.  The Officer went to one of the ponds and began searching on foot.  Another deputy began searching the second pond on the property.  A drone was requested to assist with the search and a BOLO (be on the lookout for) was sent out.  Several units began searching the property.  Campus security was able to pull up surveillance footage from another facility that showed a male walking towards the interstate.  Patient #1 was then located in a cornfield just north of the hospital.  Officer went to that location and observed the patient in a pair of boxers with no shoes.  The Officer advised personnel to have the patient wait and have the squad respond to this location as the patient was bleeding from hands and feet.  Patient #1 was visibly cold from being out in the elements.  A Troy Fireman advised they would carry the patient out to the deputy's truck due to the terrain.  Patient #1 was loaded into the back of the deputy's truck without incident and then transported by squad.  Review of the EMS note dated 11/22/25 noted they received call at 11:11 P.M. and arrived on scene at 11:20 P.M.  They were notified of a missing person, possibly found in the tree line near the hospice. The medic crew arrived and found Patient #1 sitting in the back of a Miami County Sheriff pickup truck.  Patient #1 was covered with blankets.  Patient #1 had been located in the field after getting out of the facility.  The Sheriff did not think Patient #1 was injured, but needed to be taken in for evaluation.  Per the family, he was missing for an hour.  Patient #1 was wearing a white t-shirt and underwear when he was found outside.  Patient #1 reported he was cold and his feet hurt.  Patient #1 had walked through a corn field and had multiple small scrapes to his feet and left hand and his feet were noted to be muddy.  All bleeding was controlled.  Patient #1 was able to get out of the cruiser, was walked to the cot, secured to the cot, and secured in the ambulance.  Box heat was turned up.  Per the patient he was very cold.  Patient #1's temperature was 96.4 degrees Fahrenheit (F) (normal ranging from 97 degrees F to 99 degrees F), blood pressure 125/57 millimeters of mercury (mmHg) (normal range being around 120/80 mmHg), pulse 115 beats per minute (BPM) (normal rages from around 60 to 100 BPM), respirations 20 breaths per minute (normal ranges from around 12 to 20 breaths per minute), and oxygen saturation of 96 percent (%) (normal ranges from around 92% to 100%).  Patient #1 was confused as to where he was but recalled being in a field.  Patient #1 appeared to have the mental capacity of a dementia diagnosed patient.  Transport to the emergency department (ED) began and report was called to the ED.  Patient #1 remained alert and talking throughout transport.  Patient #1 arrived in the ED at 11:35 P.M.  Hypothermia from cold exposure and dementia were listed as complaints.  Review of the hospice nurses note dated 11/22/25 at 11:25 P.M., the facility was notified that Patient #1 was in the ED of the neighboring hospital and was being treated for hypothermia.   Review of the hospital ED notes dated 11/22/25 at 11:34 P.M. revealed the physician's note stated Patient #1 had been wearing only a t-shirt and underwear and had a temperature of 95.5 degrees F rectally on arrival.  Patient #1 had various scrapes and abrasions to his lower legs and feet and ear.  The patient was found in a corn field and was outside for approximately one hour by report from the police officer on the scene.  Patient #1 denied complaints other than feeling cold.  The patient was placed on a Bair hugger system (forced air-warming system).    Review of the hospice nurses note dated 11/23/25 at 2:32 A.M. revealed the patient was discharged back to the inpatient unit with a family member one on one with Patient #1 at bedside until transfer could be arranged to the Dayton inpatient unit.Review of the facility investigation revealed a root cause analysis meeting was held on 12/03/25.  The root cause identified the exit doors did not alarm and were not locked, there were only three staff for two nursing units, and the IPU did not have access to camera footage.  Staff also did not contact the Team Leader when they realized Patient #1 was exit seeking and he did not have a bed alarm.  The analysis noted there was no security staff at the Troy IPU and the hospital security was out of the hospice's control.  The analysis stated Emergency Services could have been contacted sooner to expand the search for Patient #1.  They identified a need for education, access to facility cameras, motion sensor alarms, and flashlights. The investigation revealed no documentation of implementation dates or a goal date of completion, no staff educations and no documented staff witness statements.Observation on 12/04/25 at 11:18 A.M. revealed the inpatient unit was observed as a stand-alone building located on a hospital campus. Additionally, the inpatient unit and hospital campus was surrounded by fields, wooded areas, two ponds, and was just off of a four-lane highway that was heavily traveled with a speed limit of 70 miles per hour.Interview on 12/04/25 at 12:47 P.M. with the Team Leader for the Inpatient Unit, the Director of Care for the Inpatient Units, and the Director of Accreditation Readiness stated on 11/22/25 a patient eloped and a root cause investigation was completed.  They stated Patient #1 had no harm, was evaluated at the hospital, transferred back to this inpatient unit in Troy, and was later transferred to the inpatient unit in Dayton since they had security on-site and a WanderGuard system.  The Team Leader stated that the referral from the hospital initially stated that Patient #1 was unsteady on his feet, used a walker, and was not very mobile per the occupational therapy notes.  Because of this, they did not think Patient #1 was capable of wandering.  They had reviewed his hospital record and the family was insistent that he went to the Troy IPU.  They stated normally any potential wander risk patients would go to the Dayton IPU and they had informed the family, prior to his admission, that if he started to wander, he would have to be sent to the Dayton IPU.  The Team Leader stated that it was her understanding that the family wanted Patient #1 at the Troy IPU and that was a risk they were willing to take. Interview on 12/04/25 at 1:40 P.M. with the Team Leader for the Inpatient Unit, the Director of Care for the Inpatient Units, and the Director of Accreditation Readiness revealed a review of the facility investigation and root cause analysis.  The Team Leader stated they had internal discussions prior to the meeting on 12/03/25, but had assembled the entire group on 12/03/25 for the root cause meeting.  They stated when Patient #1 had returned to the Troy IPU, the staff were instructed that someone had to be with him at all times until he was transferred to the IPU in Dayton.  The family came with Patient #1 from the hospital and stayed at his bedside until he was transferred to the Dayton IPU and placed on the WanderGuard hallway, as the Troy IPU did not have a sitter available.  The Director of Care stated that they had not done any formal education yet, but did tell the staff that they could make the decision to transfer patients to the Dayton IPU due to behaviors observed.  The Team Leader stated she was planning to email the education out on this day [12/04/25] to staff and there were scheduled staff meetings next week where this education was to be discussed.  The Team Leader stated they normally did not accept patients with a history of wandering at the Troy IPU.  If a patient had a history of wandering that they learned about after admission, they transferred the patient to Dayton IPU if they were mobile.   Interview on 12/04/25 at 3:55 P.M. with Night Shift Registered Nurse (RN) (Staff F) revealed that she received report from Day Shift RN (Staff G) that Patient #1 was pretty active and walking around the unit and had noted Patient #1 could wander.  Patient #1 did laps of the nursing station during the day shift and then put himself to bed.  Staff F stated when she arrived [indicating on 11/22/25], Patient #1 was in bed asleep.  They manually locked the ambulance doors and closed the fire doors between the two units.  They had considered manually locking the front doors, but then they would have had to unlock and re-lock them for any staff or visitors to come and go, and it would have also been a fire hazard.  She stated Patient #1 was sleeping the entire shift until they found his bed empty.  They were letting him rest as long as possible since he did not have any medications due and she had not completed her assessment of him at this point.  Staff F stated she thought she was in the medication room when he eloped.  The aide was keeping an eye on him from the nurses station until she did her 9:00 P.M. rounds and Staff F was also keeping an eye on his room too.  She stated the aide answered the call light in the room next door to Patient #1's, where they had an actively dying patient.  Staff F went to see why the call light was on and looked into Patient #1's room on her way to the actively dying patient's room and did not see Patient #1.  Staff F stated she went into Patient #1's room and checked the room and the bathroom.  They immediately began searching for Patient #1 inside and outside and making calls.  The aide walked over to the hospital searching for Patient #1 and notified the hospital campus police as Staff F was calling them.  Staff F stated it was cold outside, maybe in the 30's [degrees F] with no precipitation.   Interview on 12/08/25 at 11:15 A.M. with Staff G revealed that she admitted Patient #1 and he was alert and oriented at that time.  She reviewed his medical records and noticed he had sundowners and kept an eye on him.  She stated Patient #1 just wanted to walk around, stating he could walk out of his room, around the building and to the bathroom unassisted, he had intact skin and was answering questions appropriately.  She stated Patient #1 walked out of his room several times and as the day ended he started to get confused.  She stated they rounded on him every hour and sat closer to his room to keep an eye on him.  They did not think he needed a sitter so no arrangements were made.  She stated she told the night shift nurse to keep an eye on him as he liked to walk and wander.  She stated Patient #1 did not try to leave the building on day shift.  Staff G stated they did not receive any paperwork from the hospital that said he wandered, but in the hand off report from the hospital and in his hospice record it mentioned sundowning.  Interview on 12/09/25 at 1:20 P.M. with the Director of Care Inpatient Units (Staff B) stated that they did not have an elopement precautions policy.  They had portable bed alarms, but no bed alarm was used for Patient #1 before he eloped.

Observed in Record Review. A review of 3 of 20 medical records revealed that the organization did not ensure that the comprehensive assessment update included all required information. For example, during a review of the medical record for HV#1, RR#6, RR#7, it was noted that the comprehensive assessment update did not include information about the patient’s progress toward desired outcomes and goals of care, treatment. This observation was reviewed with the Director of Admissions Team, and the VP of Clinical Care. Observed in Record Review. In 2 of 20 patient records reviewed, it was noted that the organization did not ensure that the comprehensive assessment was updated at least every 15 days. For example, during a review of the medical record for RR#4, it was noted that the first update to the comprehensive assessment was completed 41 days after the start of care date. Example #2: During a review of the medical record for RR#10, it was noted that the first update to the comprehensive assessment was completed 20 days after the start of care date.

Observed in Record Review. In 5 of 20 patient records reviewed, it was noted that the organization did not ensure that the plan of care goals included outcome measures for specific care activities. For example, during a review of the medical record for HosInpt#1, the following goal statement was noted, “Prevent aspiration r/t Dysphagia”. The goal statement did not include a method to measure the effectiveness of problem interventions. Example #2: During a review of the medical record for HV#5, the comprehensive assessment included the description of a stage 2 pressure ulcer at the right hip. The plan of care did not include interventions related to wound care and a goal statement to evaluate the response to care, treatment, and services related to wound care interventions. Example #3: During a review of the medical record for RR#4, the following goal statement was noted, “Patient will achieve/maintain optimal pain control”. The goal statement did not include a method to measure the effectiveness of problem interventions. In addition, the comprehensive assessment included the description of a stage 2 pressure ulcer at the right buttocks. The plan of care did not include interventions related to wound care and a goal statement to evaluate the response to care, treatment, and services related to wound care interventions. Example #4: During a review of the medical record for RR#9, the following goal statement was noted, “Patient will achieve/maintain optimal pain control”. The goal statement did not include a method to measure the effectiveness of problem interventions. Example #5: During a review of the medical record for RR#13, it was noted that the comprehensive assessment identified the patient as high risk for falls, the plan of care did not include a goal statement to evaluate response to care, treatment and services related to fall prevention interventions. This observation was reviewed with the Director of Admissions Team, and the VP of Clinical Care.

Observed in Record Review. In 2 of 20 patient records reviewed, it was noted that the organization did not ensure the plan of care was revised when the patient’s condition changed. For example, during a review of the medical record for HV#2, it was noted that the patient experienced a fall during week 8 of services. The plan of care was not updated with interventions to maintain patient safety, strategies to prevent injury, and a goal statement to evaluate response to care, treatment and services related to fall prevention interventions. Example #2: During a review of the medical record for RR#2, it was noted that during the 3rd benefit period the patient experienced a fall. The plan of care was not updated with interventions to maintain patient safety, strategies to prevent injury, and a goal statement to evaluate response to care, treatment and services related to fall prevention interventions. In addition, during the 4th benefit period the patient had changes with the pain management plan. The plan of care was not updated with interventions to maintain patient comfort, and a goal statement to evaluate response to care, treatment and services related to pain management. This observation was reviewed with the Director of Admissions Team, and the VP of Clinical Care.

Observed in Individual Tracer. In 1 of 5 Individual Tracers, it was noted that the organization did not ensure its infection prevention and control activities were implemented. For example, the policy titled Home Care Staff Bag Technique includes the following information: 2) The bag may be placed anywhere that is clean enough for the staff member to sit. The bag is never placed on the floor, unless it is the roller bag which holds the computer and printer. The Hospice surveyor noted that the clinician placed her nursing bag on the floor. The nursing bag was placed on a barrier, however the clinician stepped on the barrier 3 times during the course of patient care activities. This observation was reviewed with the VP of Clinical Care.

Observed in Building Tour. During the review of the above ceiling area in Corridor #1, and Corridor #2, of the Hospice Inpatient Building, it was noted that the piping for the automatic sprinkler system was supporting other items – gray cords, yellow cords, and blue cords were resting on this piping. This observation was reviewed with the Director of Facilities. This finding was observed during survey activity, but corrected onsite prior to the surveyor's departure. The corrective action taken needs to be included in the organization's Evidence of Standards Compliance submission. Observed in Building Tour. During the review of the above ceiling area in Corridor #1, and Corridor #2, of the Hospice Inpatient Building-Franklin, it was noted that the piping for the automatic sprinkler system was supporting other items – gray cords, and a condensation pipe were resting on this piping. This observation was reviewed with the Director of Facilities. This finding was observed during survey activity, but corrected onsite prior to the surveyor's departure. The corrective action taken needs to be included in the organization's Evidence of Standards Compliance submission. Observed in Building Tour. The organization did not ensure that fire protection features were designed and maintained to minimize the effects of fire, smoke, and heat. For example, during the building tour it was noted that the smoke barrier door in Corridor #1 had a gap between the bottom of the door and the floor that was larger than 3/4 of an inch. This observation was reviewed with the Director of Facilities. This finding was observed during survey activity, but corrected onsite prior to the surveyor's departure. The corrective action taken needs to be included in the organization's Evidence of Standards Compliance submission.