Every finding on record at Hospice of the Valley

Based on interview and record review, the Interdisciplinary group (IDG) failed to revise the Plan of Care based on the patient's updated comprehensive assessments and failed to note the patient's progress towards outcomes and goals specified in the Plan of Care for 1 of 7 patients whose records were reviewed (Patient #2). Findings include: --- 1. The clinical record for Patient #2 was reviewed on 9/12/23. The patient was admitted for hospice care and services on 11/1/21, with a terminal diagnosis of Alzheimer's disease. The Plan of Care orders for the certification period dated 8/23/23 to 10/21/23 included orders for skilled nurse (SN) services one to two times a week for four months for assessment and pain management; medical social worker (MSW) and Spiritual services once in four months for psychosocial and bereavement support; home health aide/certified nurse aide (CNA) services three to five times a week for four months; and homemaker services once a week for five to seven times per week for four months. a) The IDG failed to ensure the Plans of Care were updated according to the updated comprehensive assessment. Review of the clinical record revealed the nurse documented the left big toe was red and inflamed, applied iodine and a bandage on 7/13/23 and continued until brought to the agency's attention by surveyor on 9/13/23 that there was no physician order and no documentation of the discussion in IDG. Review of the initial plan of care, dated 8/23/23-10/21/23 and verbal authorization by the physician on 8/14/23, failed to reveal an order for wound care treatment for the iodine and bandage to the left big toe. Review of the IDG Notes dated 11/4/20 through 1/27/21 revealed the IDG documented Patient #2 had monitoring of the integumentary system, however, there was no documentation of how many or what each wound's status was, and further review of the IDG Notes revealed no IDG discussion of wound goals or outcomes, including whether the wounds were healing or deteriorating at each IDG meeting. During an interview on 9/13/23 at 3:40 p.m., registered nurse (RN) #12 stated she worked for the agency for over three years and had prior experience with complicated wound care and treatments. RN #12 said she thought she wrote an order for the iodine wound treatment. She said since the order was not found she thought she must have forgotten to write it. She said usually the order was written on the day of finding the left great toe being red. She said then the information would be documented on the plan of care and communicated verbally with the interdisciplinary group (IDG) every 15 days. RN #12 stated she discussed the wound treatment at IDG on 7/20/23 but agreed no order was written for all 15 times she used it. She said it was a common treatment used for this client with treating the redness in the left great toe. She said it had healed before and then got red again so the same treatment was used. This was the reason she thought the order was written. RN #12 said the treatment stopped on 9/11/23 since the toe healed. During an interview on 9/13/23 at 3:40 p.m., the alternate administrator and director of nursing (DON) acknowledged there was no iodine and bandage wound treatment ordered by the physician. They stated the agency started doing check-in meetings with the nurses at the end of certification periods to try and catch issues like not having physician orders for a wound treatment and documenting changes of condition to the plan of care. They said care plans were reviewed in IDG at least every 15 days, however, if more frequent changes occurred then they communicated to the IDG via TigerText, email, and phone calls. They recognized TigerText information deletes after five days and hindered their ability to ensure communication was documented in the clinical record. They recognized the care plans did not indicate a review of the interventions and goals established in the plan every 15 days. However, concerns that needed to be addressed with the IDG members were documented in the IDG notes. They recognized the minutes did not reflect the discussion regarding the change in condition for Patient #2's left great toe redness and wound treatment of iodine and bandage.

Based on interview and record review the hospice failed to ensure the patients clinical record contained all appropriate physician orders for treatment/interventions and discipline frequencies, for 1 of 7 patients receiving wound care services (Patient #2). Findings include: --- 1. The clinical record for Patient #2 was reviewed on 9/12/23. The patient was admitted for hospice care and services on 11/1/21, with a terminal diagnosis of Alzheimer's disease. The Plan of Care orders for the certification period dated 8/23/23 to 10/21/23 included orders for skilled nurse (SN) services one to two times a week for four months for assessment and pain management; medical social worker (MSW) and Spiritual services once in four months for psychosocial and bereavement support; home health aide/certified nurse aide (CNA) services three to five times a week for four months; and homemaker services once a week for five to seven times per week for four months. a) The hospice failed to ensure physician orders were obtained for wound care treatment. Review of the clinical record revealed the nurse documented the left big toe was red and inflamed, applied iodine and a bandage on 7/13/23 and continued until brought to the agency's attention by surveyor on 9/13/23. Review of the initial plan of care, dated 8/23/23-10/21/23 and verbal authorization by the physician on 8/14/23, failed to reveal an order for wound care treatment for the iodine and bandage to the left big toe. During an interview on 9/13/23 at 3:40 p.m., registered nurse (RN) #12 stated she worked for the agency for over three years and had prior experience with complicated wound care and treatments. RN #12 said she worked with Patient #2 since admission and did monitoring of the skin as part of the care and services provided to the patient. RN #12 said she thought she wrote a physician order for the iodine and bandage wound treatment. She said since the order was not found she must have forgotten to write it. She said usually the order was written on the day of finding any changes in condition that require treatment. She said then the information would be documented on the plan of care and communicated verbally with the interdisciplinary group (IDG). RN #12 stated she discussed the wound treatment at IDG on 7/20/23 but agreed no order was written for all 15 times she used it. She said it was a common treatment used for this client with treating the redness in the left great toe. She said it had healed before and then got red again, so the same treatment was used. RN #12 said the treatment stopped on 9/11/23 since the toe healed. During an interview on 9/13/23 at 3:48 p.m., the alternate administrator and director of nursing (DON) acknowledged there was no iodine and bandage wound treatment ordered by the physician. They stated the agency started doing check-in meetings with the nurses at the end of certification periods to try and catch issues like not having physician orders for a wound treatment.