Every finding on record at Hospice of Montgomery, Inc

Based on observations, review of medical records (MR), agency policy and procedure and interviews with staff, it was determined the hospice staff failed to ensure: 1) all patient medication (med) lists were current and accurate. 2) the presence and/or absence of allergies were assessed and documented in the MR. This affected two of three home visits (HV) conducted including HV # 3, HV # 2, and MR # 2, MR # 1, MR # 7, MR # 6, which was six of of eleven total records reviewed. This deficient practice had the potential to negatively affect all patients served by the agency. Findings include: Agency Policy: Medications - Profile Policy Number: PC.M60 Policy Update: 2020 Policy: A patient- specific medication profile is maintained for each patient... Procedure: 1. When a patient is admitted to hospice, a medication profile is initiated to document all of the patient's prescription and over-the counter drugs...other alternative treatments that could affect drug therapy. 1. HV # 3 was admitted to the agency on 6/24/22 with diagnoses including Chronic Kidney Disease, Stage 5. Review of the Establishment of Plan of Care dated 6/24/22 to 9/21/22 revealed a SN (Skilled Nurse) frequency of 2 (two) x (times) weekly. A HV was conducted on 6/28/22 at 12:55 PM to observe care provided by Employee Identifier (EI) # 4, SW (Social Worker). Prior to the HV, the surveyor was provided a Patient Medication Listing (PML) printed on 6/28/22 at 10:22 AM. The med list was compared to the medications observed in the home, and the following discrepancies were observed: a. Hydralazine 50 mg (milligrams) 1 (one) tab (tablet) po (by mouth) twice a day was listed on the PML, and the prescription (Rx) bottle in the home dated 4/13/22 read Hydralazine 25 mg 1 (one) tab twice a day. The caregiver (cg) stated the patient has been taking the 25mg tab - 1 (one) tab twice a day for several months. b. Magnesium Oxide 400 mg 1 (one) tab po 3 (three) x a day was listed on the PML. The cg stated, "It was discontinued by the nurse when he/she (patient) came out of the hospital on 6/24/22". The cg further stated that he/she and the nurse placed the Magnesium Oxide in the patient's discontinued medications, and he/she (patient) had not been taking the medication. c. Omeprazole delayed release 40 mg 2 tab po once a day was listed on the PML, and the Rx bottle in the home dated 3/28/22 read Omeprazole 1 (one) tab once a day. The cg stated the patient has only been taking 1 (one) tab for several months. d. Potassium Cl (Chloride) ER (Extended Release) 10 (ten) meq (milliequivalents) 1 (one) tab by mouth every day at bedtime Rx dated 6/13/22 was found in the home and not on the PML. The cg stated he/she had been giving her (patient) this medication since 6/13/22. e. Multivitamin 1 (one) tab po daily found in the home and not listed on the PML. The cg stated he/she (patient) has been taking this for years. f. Bumetamide 0.5 mg 1 (one) tab po every morning as directed with Lasix on Monday, Wednesday, and Friday - Rx dated 5/10/22 was found in the home and not listed on the PML. There was no Lasix found in the home. An interview was conducted on 6/30/22 at 8:37 AM with EI # 1, Director of Hospice, who verified the staff failed to ensure HV # 3's medication list was current and accurate. 2. MR # 2 was recertified to the agency from 5/3/22 to 7/31/22 with a primary diagnosis of Cerebral Atherosclerosis. Review of the Plan of Care (POC) dated 5/3/22 to 7/31/22 revealed a SN frequency of twice weekly. Review of the MR revealed allergies were not documented and left blank on the following: a. Routine Nursing Notes dated 5/4/22, 5/11/22, 5/17/22, 5/25/22, 6/1/22, 6/9/22, 6/15/22, and 6/22/22. b. Updated Comprehensive Patient POC's dated 5/12/22, 5/26/22, 6/9/22 and 6/23/22. c. PML printed 6/29/22 at 10:08 AM. In an interview conducted on 6/30/22 at 9:31 AM, EI # 1 confirmed the agency staff failed to assess/document the presence/absence of patient allergies in the MR. 4. MR # 1 was admitted to the agency 4/25/22 with a terminal diagnosis of Chronic Obstructive Pulmonary Disease, Unspecified. MR review revealed allergies were not documented and left blank on the Comprehensive Assessment-Nursing dated 4/25/22, Establishment of the POC dated 4/25/22, Routine Notes-Nursing dated 4/26/22 to 6/27/22, and Updated Comprehensive Patient POC's dated 4/28/22, 5/12/22, 5/26/22, 6/9/22 and 6/23/22. In an interview conducted on 6/30/22 at 8:44 AM, EI # 1 provided the requested the hospice referral documentation dated 4/26/22 which revealed MR # 1 was allergic to Penicillin and tape. EI # 1 confirmed the hospice staff failed to assess and document MR # 1's allergies. 5. MR # 7 was admitted to the agency 5/27/22 with a terminal diagnosis of Respiratory Failure, Unspecified. MR # 7 revoked hospice benefits on 6/8/22. MR review revealed allergies were not documented and left blank on the Comprehensive Assessment-Nursing dated 5/27/22, Establishment of the POC dated 5/27/22, Routine Notes-Nursing dated 5/28/22, 5/29/22, 5/30/22, 6/1/22, 6/3/22, 6/6/22, the Updated Comprehensive Patient POC dated 6/9/22, and the PML printed 6/29/22. In an interview conducted on 6/30/22 at 10:08 AM, EI # 1 provided the requested hospice referral documentation dated 5/18/22 which revealed MR # 4 was allergic to "Penicillin's". EI # 1 confirmed the hospice staff failed to assess and document MR # 4s allergies. 6. MR # 6 was admitted to the agency 4/4/22 with a terminal diagnosis of Malignant Neoplasm of the Bronchus/Lung. MR # 6 died on 4/14/22 at a skilled care facility. MR review revealed allergies were not documented and left blank on the Comprehensive Assessment-Nursing dated 4/4/22, Establishment of the Plan of Care dated 4/4/22, Routine Notes-Nursing dated 4/5/22, 4/8/22, 4/11/22, 4/13/22, 4/14/22, and the Updated Comprehensive Patient POC's dated 4/14/22 and 4/28/22. In an interview conducted on 6/30/22 at 9:26 AM, EI # 1 confirmed the hospice staff failed to assess/document the presence/absence of patient allergies in the MR. 3. HV # 2 was admitted to the agency on 6/16/22 with a diagnosis of Acute on Chronic Diastolic (Congestive) Heart Failure. Review of the POC dated 6/16/22 - 9/13/22 revealed documentation of a SN frequency of twice weekly. Review of the agency PML, printed by the agency on 6/28/22 at 10:12 AM, Facesheet, Comprehensive Assessment note dated 6/16/22, Establishment of POC dated 6/16/22 - 9/13/22, and Updated Comprehensive Patient POC dated 6/23/22 revealed no documentation of the patient's allergies. A HV was conducted on 6/29/22 at 9:15 AM with EI # 5, Hospice Aide, to observe care provided. During the HV, the patient, cg and the surveyor compared the home medications with the agency PML, printed by the agency on 6/28/22 at 10:12 AM. The following discrepancies were found: Morphine Sulfate Concentrate 20 mg/ml (milliliter) 0.5 ml - 1 ml every hour as needed for pain, shortness of breath or anxiety was documented on the agency PML. The cg verbalized the agency has never provided the Morphine Sulfate, the nurse spoke about the Morphine Sulfate but was never placed in the home. Aspirin 81 mg 1 (one) tab daily was found in the home with the prescription bottle dated 6/2/22. Review of the agency PML revealed no documentation of the Aspirin. Albuterol 90 mcg (microgram) 2 puffs every 4 hours as needed for shortness of breath was found in the home with the prescription box dated 6/9/23. The patient verbalized he/she had been on Albuterol for "6 months" and last used it "last week." Review of the agency PML revealed no documentation of the Albuterol. Clonazepam 0.5 mg 1 (one) tablet as needed three times daily for anxiety was documented on the agency PML. Review of the SN visit note dated 6/23/22 revealed documentation of "RN (Registered Nurse) to DC (discontinue) Clonazepam d/t (due to) Lorazepam being used in it's place..." The cg verbalized the patient was not taking the Clonazepam and the SN had put a label on the bottle to DC the Clonazepam. An interview was conducted on 6/30/22 at 9:39 AM with EI # 1, who verified the staff failed to document patient allergies and to ensure HV # 2's PML was current and accurate.

Based on medical record (MR) review, agency policies and procedures and interview it was determined the agency failed to ensure wound care was provided as ordered in the Plan of Care (POC). This affected one of three home visits (HV) including HV # 1 and had the potential to affect all patients served by the agency. Findings include: Agency Policy: Plan of care Policy Number: PC.P40 No date: Policy: The care and services provided to patients and their families are in accordance with an individualized, written POC established by the hospice Interdisciplinary Group (IDG) in collaboration with the patient's attending physician (if any) and if appropriate, the patient and/or his/her representative. Procedures: 1. The patient's POC specifies the care and services necessary to meet the needs of the patient family as identified in the initial, comprehensive and updated assessments of the patient... Agency Policy: Plan of Care- Content Policy Number: PC.P45 No date: Policy: The POC reflects the patient and family goals and interventions that are based on the problems identified in the initial, comprehensive and updated assessments. Procedure: 1. The patient's POC includes all services necessary for the palliation and management of the terminal illness and its related conditions. 2. The POC includes, but is not limited to: ...d. drugs and treatments necessary to meet the needs of the patient... 1. HV #1 was admitted to the agency 2/8/22 and recertified for care 5/9/22 to 8/6/22 with diagnoses Unspecified Dementia with Behavioral Disturbance and Body Mass Index 19 or less, Adult. Review of the Updated Comprehensive POC dated 4/28/22 revealed skilled nurse (SN) visits five times weekly and included a Physician Order dated 4/13/22 for wound care to the stage III coccyx/sacral wound: Clean wound with spray wound cleanser, pat dry with 4 inch by 4 inch (4x4) gauze, apply hydrogel, cover with 4x4's and foam dressing. RN every SN visit and as needed (PRN). Caregiver (CG) on other days PRN. MR review revealed Routine Notes-Nursing dated 5/10/22 to 6/28/22 with documentation the stage III sacral wound was cleansed with wound spray cleanser, wound patted dry with 4x4 gauze, applied hydrogel then foam dressing applied. There was no documentation the wound was covered with 4x4 gauze prior to the foam dressing applied to the wound per the 4/13/22 wound care order. An interview conducted on 6/30/22 at 9:08 AM with Employee Identifier # 2 Executive Director confirmed there was no documentation the wound was covered with 4x4 gauze prior to the foam dressing being applied to the wound as ordered from 5/10/22 to 6/28/22.

2. HV # 2 was admitted to the agency on 6/16/22 with a diagnosis of Acute on Chronic Diastolic (Congestive) Heart Failure. A HV was conducted on 6/29/22 at 9:15 AM with EI # 5, Hospice Aide, to observe care provided. During the HV, EI # 5 placed clean folded paper towel on a barrier along with other clean supplies, including gloves. EI # 5 removed used gloves, performed hand hygiene and reached onto barrier to obtain clean gloves. When EI # 5 obtained the clean gloves two of the folded paper towels fell to the floor. EI # 5 unsuccessfully attempted to don gloves. EI # 5 placed gloves in the trash then reached down and picked up the paper towels from the floor and placed the paper towels back on the clean barrier. EI # 5 obtained clean gloves from agency bag without first performing hand hygiene, placed the clean gloves on top of the paper towel retrieved from the floor, which contaminated the clean gloves. EI # 5 donned the contaminated gloves, filled two basins with water, obtained clean bed supplies, socks and pants. EI # 5 then washed the patient's groin, buttock and applied clean diaper, bed pad, socks and pants with the contaminated gloves. An interview was conducted on 6/30/22 at 9:39 AM with EI # 1, who verified the staff failed to follow the agency policy for hand hygiene, bag technique and contamination of clean supplies. Based on observations, agency policies and procedures, Lysol Disinfecting Wipes Manufacturer's Guideline for Use, and staff interviews, it was determined the agency failed to ensure the staff followed the agency policy for Hand Hygiene and Infection Control. This deficient practice affected two of three home visits (HV) including HV #1, HV # 2 and had the potential to negatively affect all patients admitted to this agency Findings include: Agency Policy: Infection Control-Hand Hygiene Policy Number: PC 125 Updated: 2018 Policy: Hospice of Montgomery follows hand hygiene guideline recommended by the Centers for Disease Control (CDC) and The World Health Organization (WHO). Procedures: 1. Hospice staff must wash hands: a. before touching a patient b. before performing clean/aseptic procedures... c. after touching a patient... ...e. before and after wearing gloves... f. after any activity involving physical contact with a patient's immediate environment. ...3. Alcohol based hand cleanser provided as part of their routine supply inventory. Agency Policy: Regarding Infection Control of Equipment Used in Home Care Policy Number: Not documented Revised: 3/1/2004 Policy: Hospice of Montgomery direct patient care staff will follow clinical practice guidelines to prevent the spread of infection via equipment and supplies which are used for patient care. Procedure: ...i.Wipes are to be commercially prepared and pre-moistened with a germicidal/alcohol solution... ...iii. Staff shall wear gloves for cleaning equipment... Agency Policy: Regarding Bag Technique Policy Number: Not documented Revised: 7/27/2021 Purpose: To reduce the risk of cross contamination between patients via the visit bag and the supplies it contains. To establish guidelines for the handling of patient care bags and multiple-use-equipment in order to minimize the risk of transmission of micro-organisms... Procedure: ...Clean & (and) Dirty areas of the bag ...11... The inside of the bag is regarded and maintained as a clean area... ...b. Clean area includes an inside closeable area to keep patient care items. ...ii. Single use items and personal protective equipment... 12. Bag technique requires keeping the inside of the bag and all its contents 'clean': a. Only enter clean part of the bag with clean hands (perform hand hygiene immediately prior to entering/re-entering bag). ...Equipment Cleaning (items transported in the bag) Noncritical item ...The most commonly used noncritical items in patient care in the home include stethoscopes, blood pressure cuffs...and pulse oximeters. Methods of disinfection Such noncritical items (as above stated as 'noncritical items') should be cleaned between patient use and may undergo low-level disinfection. Low-level disinfection for noncritical items that will come in contact with intact skin may be disinfected using ...germicidal solutions such as antibacterial wet wipes. Manufacturer's Guideline: Lysol Disinfecting Wipes Date: 2018 ...To disinfect: Allow surface to remain wet for 4 (four) minutes. Allow surface to air dry. 1. HV # 1 was admitted to the agency 2/8/2022 and recertified for care 5/9/2022 to 8/6/2022 with diagnoses Unspecified Dementia with Behavioral Disturbance and Body Mass Index 19 or less, Adult. Review of the Updated Comprehensive Patient Plan of Care (POC) dated 5/12/22 revealed Skilled Nurse (SN) visits 5 (five) times weekly and Hospice Aide (HA) visits 3 (three) times weekly and included the following wound care orders: Clean wound with spray wound cleanser, pat dry with 4 inch by 4 inch (4x4) gauze, apply hydrogel, cover with 4x4's and foam dressing every SN visit and as needed (PRN). Caregiver (CG) on other days prn. A HV was conducted on 6/28/2022 to observe Employee Identifier (EI) # 3 Registered Nurse perform wound care. HV # 1 had a total of two wounds including a stage 3 sacral wound and a stage 2 left heel wound. EI # 3 completed wound care to the sacral wound then completed wound care to the left heel. EI # 3 was observed removing gloves 8 (eight) times and 5 (five) of the times EI # 3 failed to perform hand hygiene after glove removal. EI # 3 cleaned the blood pressure cuff, stethoscope, pulse oximeter and thermometer with a Lysol wet wipe and immediately wrapped, folded blood pressure cuff, stethoscope, pulse oximeter, and thermometer and placed them in equipment bag without allowing the equipment to dry. In an interview conducted on 6/30/2022 at 9:08 AM, EI # 1, Director of Hospice, confirmed hand hygiene should be performed after glove removal per agency policy and the equipment should have been allowed to dry for 4 (four) minutes per manufacturer's instructions before placing the equipment in the equipment bag.

Based on medical record (MR), and review of the National Association of Social Worker (NASW) Standards, and interview, it was determined the hospice failed to ensure the Social Worker (SW) met the patient's/caregiver's needs. This affected MR # 6, and MR # 1 in two of eleven records reviewed and had the potential to negatively affect all patients and families served by the hospice. Findings include: National Association of Social Worker (NASW) From the web site http://www.naswdc.org NASW Standards for Social Work Practice in Palliative and End of Life Care, page 9. Introduction: All social workers, regardless of practice settings, will inevitably work with clients facing acute or long-term situations involving life-limiting illness, dying, death, grief, and bereavement. Using their expertise in working with populations from varying cultures, ages, socioeconomic status, and nontraditional families, social workers help families across the life span in coping with trauma, suicide, and death, and must be prepared to assess such needs and intervene appropriately. 1. MR # 6 was admitted to the hospice 4/4/22 with a terminal diagnosis of Malignant Neoplasm of the Bronchus/Lung. MR # 6 died on 4/14/22 at a skill nurse facility. Review of the Initial SW Assessment Note documentation dated 4/6/22 revealed the facility nurse administered pain medication upon the SW arrival, and the visit concluded before the SW was able to obtain information regarding the psychosocial history, spirituality, and coping/behavior. Further review of the 4/6/22 SW Note documentation revealed the SW will follow up (FU) with the patient's POA (Power of Attorney) to obtain additional information. MR review failed to reveal documentation the SW performed FU and completed the psychosocial assessment to identify needs of the patient/family/POA. In an interview conducted on 6/30/22 at 9:26 AM, Employee Identifier (EI) # 1, Director of Hospice, confirmed the SW failed to complete the psychosocial assessment, conduct FU with the POA and identify psychosocial needs of the patient/family/POA. 2. MR # 1 was admitted to the hospice 4/25/22 with a terminal diagnosis of Chronic Obstructive Pulmonary Disease, Unspecified. Review of the Initial SW Assessment Note dated 4/29/22 revealed documentation MR # 1 was a Korean War Veteran, currently not receiving VA (Veteran's Administration) benefits, the SW will FU to determine if the family is interested in applying for benefits and agreed for a FU visit in 1 (one) month. Review of the SW Note dated 5/27/22 revealed no documentation of a FU regarding interest in application of VA benefits. MR review revealed Focused Note documentation dated 6/21/22 completed by the SW that SW visits were discontinued at this time. In an interview conducted on 6/30/22 at 8:44 AM, EI # 1 confirmed the SW failed to conduct and document FU of patient/family interest in VA benefit application.

Based on observation, review of medical records (MR) agency policy and procedure and staff interviews, it was determined the agency failed to ensure the Hospice Aide (HA) followed the written HA Plan of Care (POC) prepared by the Registered Nurse (RN) and documented only tasks performed during a Home Visit (HV). This affected four of nine records reviewed receiving HA services, including MR # 1, MR # 7, HV # 2, HV # 1, and had the potential to negatively affect all patients served by the agency. Findings include: Agency Policy: HA Assignments and Duties Policy Number: PC. H20 Date: Not documented Policy: HA's are assigned...by a hospice RN... Procedures: ...2. A HA provides services that are: ...b. included in the plan of care (POC). 4. HA must report changes...to a RN, as the changes relate to the POC... ...5. HA must complete accurate and legible documentation of services provided to the patient. 1. MR # 1 was admitted to the agency 4/25/22 with a terminal diagnosis of Chronic Obstructive Pulmonary Disease, Unspecified. MR review revealed the POC dated 4/25/22 to 7/23/22 which included orders for HA visits 2 (two) x (times) weekly and 2 (two) x weekly vital signs (VS) for b/p (blood pressure), pulse, respiration, and temperature. MR review revealed the Aide Note visits dated 4/26/22 and 5/3/22 failed to include VS documentation. In an interview conducted on 6/30/22 at 8:44 AM, EI (Employee Identifier) # 1, Director of Hospice confirmed the HA failed to document VS per the HA POC. 2. MR # 7 was admitted to the agency 5/27/22 with a terminal diagnosis of Respiratory Failure, Unspecified. MR # 7 revoked hospice care on 6/8/22. MR review revealed the POC dated 5/27/22 to 8/24/22 included the Aide POC dated (activated) 5/31/22 with orders to measure cath (catheter-urinary) output 3 (three) x weekly, and monitor VS-b/p, pulse, respiration, and temperature 3 (three) x weekly. Review of the Aide Note visit dated 5/31/22 revealed VS were documented, however no care was provided which included services ordered 3 (three) x weekly for range of motion, bedbath, hair care, shampoo, oral care, change linens, and measure cath output. There was no documentation the HA reported to the RN services were not provided as ordered. Review of the Aide Note visits dated 6/1/22, and 6/7/22 revealed the HA "complete"(d) measure cath output, however there was no documentation of the amount or measurement of the catheter output. During an interview conducted 6/30/22 at 10:08 AM, EI # 1 confirmed the HA failed to document VS, catheter output measurement, and notify the RN when services were not provided. 3. HV # 2 was admitted to the agency on 6/16/22 with a diagnosis of Acute on Chronic Diastolic (Congestive) Heart Failure. Review of the Hospice POC dated 6/16/22 to 9/13/22 revealed a HA frequency of twice weekly. Review of the Aide POC activated 6/20/22 revealed the HA was assigned the following tasks: a. Activity of wheelchair twice weekly. b. Measure the catheter output twice weekly. c. Change bed linens twice weekly. d. Make bed twice weekly. e. Apply lotion twice weekly. f. Shampoo Hair twice weekly. Review of the Aide Notes dated 6/20/22, 6/23/22 and 6/27/22 revealed no documentation the HA measured the catheter output amount. A HV was conducted on 6/29/22 at 9:15 AM with EI # 5, HA, to observe care provided. During the HV, the patient declined sitting up in the wheelchair, bed linen change, bed being made and lotion application. EI # 5 failed to offer hair shampoo during the visit. Review of the HA note dated 6/29/22 revealed EI # 5 completed the activity of wheelchair, bed linen change, bed being made, lotion application and hair shampoo as completed. There was no documentation the patient had not been provided the activity of wheelchair, bed linen change, bed being made, lotion application and shampoo services. An interview was conducted on 6/30/22 at 9:39 AM with EI # 1, who confirmed there was no documentation the HA measured the catheter output amount on 6/20/22, 6/23/22 and 6/27/22 accordance with the RN instructions and EI # 5 failed to document only tasks performed on 6/29/22. 4. HV # 1 was admitted to the agency 2/8/22 and recertified for care 5/9/22 to 8/6/22 with diagnoses Unspecified Dementia with Behavioral Disturbance and Body Index 19 or less, Adult. Review of the Hospice POC dated 5/9/22 to 8/6/22 revealed a HA frequency of three times weekly. Review of the Aide POC activated 4/1/22 revealed the HA was assigned to measure catheter output three times weekly. Review of the Aide Notes dated 5/11/22, 5/13/22, 5/20/22, 5/23/22 revealed no documentation the HA measured the amount of catheter output. An interview was conducted on 6/30/22 at 9:08 AM with EI # 1, who confirmed there was no documentation the HA measured the amount of catheter output on 5/11/22, 5/13/22, 5/20/22, 5/23/22 in accordance with the Aide POC.

Based on review of agency personnel files which included the hospice Position Description for Registered Nurse (RN), agency policy and procedure, and staff interview, it was determined the agency failed to ensure nursing staff demonstrated clinical competency for annual wound assessment and wound care. This deficient practice affected three of three RN personnel files reviewed including Employee Identifier (EI) # 3, date of hire 2/5/10, EI # 6, date of hire 3/12/18, EI # 7, date of hire 6/21/11. Findings include: Agency Position Description Registered Nurse Revised: 12/2008 Competencies: ...2. Assessment skills- Physical/Psycho-social. Possesses basic physical and psychosocial assessment skills, including the following systems:...skin... ...19. Standards of Practice. Demonstrates working knowledge of nursing standards of practice... Essential Job Functions. ...2...Participates in ongoing interdisciplinary comprehensive assessment... II. Participates in personal and professional growth and development ...2. Maintains professional competence through participation in continuing education or other appropriate learning activities... ...8. Seeks additional training/education as determined by self-assessment and Clinical Director. General Work Requirements ...2. Policies and procedures- Follows agency policies and procedures. Agency Policy: Competency Assessment Policy Number: REG.C30 No Date Policy: The hospice implements a systematic competency assessment program to assure that all staff and volunteers are competent to perform their jobs effectively. Procedures:...4. Competency evaluations are specific to the skills needed for each job category and specific competencies are delineated in job descriptions and performance evaluations. ...6. Competency assessment occurs during the orientation period, annually as a component of performance evaluations, and as needed...related to an individual's performanc 1. Review of personnel files on 6/29/22 at 10:09 AM for three RN's, EI # 3, EI # 6, EI # 7 on 6/29/22 revealed no documentation of annual wound assessment/wound care competencies. An interview was conducted on 6/29/22 at 3:40 PM with EI # 2 Executive Director, who confirmed there was no documentation wound assessment/wound care competencies for EI # 3, EI # 6, EI # 7 were completed annually.

Based on observation during a Home Visit (HV), medical record (MR) review, agency policy and procedure, and interview, it was determined the agency failed to ensure staff documented accurate assessments of wounds. This deficient practice affected one of three HV's and included HV # 1 and had the potential to negatively affect all patients serviced by the agency. Findings include: Agency Policy: Clinical Records Policy Number: REG C20 No Date Policy: A clinical record is established and maintained for every patient receiving care and services at Hospice of Montgomery. The record is complete, promptly, and accurately documented... Procedures: 1. Entries are made in the clinical record for all services provided... are legible, clear, and complete... ...3. Each patient's clinical record includes, at a minimum, the following: ... c...updated comprehensive assessments, clinical notes... 1. HV # 1 was admitted to the agency 2/8/22 and recertified for care 5/9/22 to 8/6/22 with diagnoses Unspecified Dementia with Behavioral disturbance and Body Mass Index 19 or less, Adult. Review of the Updated Comprehensive Patient Plan of Care dated 4/28/22 revealed orders for skilled nurse (SN) visits 5 (five) times weekly with orders for wound care to coccyx/sacrum: Clean wound with spray wound cleanser, pat dry with 4 inch by 4 inch (4x4) gauze, apply hydrogel, cover with gauze 4x4's and apply foam dressing. Registered Nurse (RN) every skilled nurse (SN) visit and as needed (PRN). Caregiver on other days PRN. During the HV conducted on 6/28/22 at 10:55 AM, EI # 3 RN was observed providing wound care to the two wounds. EI # 3 did not measure the wounds during the HV. Review of the Routine Note-Nursing dated 6/28/22 revealed wound measurements were documented. EI # 3 failed to document the visit accurately and only document assessments and care provided on 6/28/22. An interview was conducted on 6/30/22 at 9:08 AM with EI # 1, Director of Hospice, who stated she believed the computer program was pulling previous wound measurements over onto the next visits. EI # 1 confirmed the 6/28/22 nurse documentation was not accurate.