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

Based on agency policy, clinical record review, and staff interviews, the agency failed to provide effective symptom control for 2 of 6 discharged patients (#1 and 5).Findings included: --- A policy, Pain/Symptom Management, Assessment and Follow-up (revised 6/1/24), received on 5/12/26 at 10:22 AM from the Director of Quality and Compliance stated, “The patient has the right to receive effective pain and symptom control from the hospice… An action plan is always required when a patient’s pain is not managed to their satisfaction…”1. Patient #1 was admitted on 2/27/25 with a diagnosis of Alzheimer’s disease (impaired mental functioning). Patient #1 was a resident of a skilled nursing facility. The plan of care for 2/27/25-5/27/25 included orders for skilled nursing visits 2 times a week for 1 week with 13 PRN (as needed) and “Oxygen 6-8 LPM [liters per minute] Cont [continuously] NC [nasal cannula].” Review of the clinical record revealed that on 3/3/35 at approximately 2:15 PM registered nurse (RN) #10 documented, “Oxygen: Oxygen – liters/minute 4, nasal cannula…” and on 3/3/25 at approximately 7:33 PM RN #11 documented, “Received pt [patient] very agitated & restless, pulling O2 [oxygen] off… HR [heart rate] 104-RR [respiratory rate] 28 (labored on 4LPM). He has received a PRN dose of morphine & lorazepam at 4:00PM without change in symptoms & a scheduled dose of both meds [medications] at 6:00PM… NP [nurse practitioner name] called & received new orders… Pt passed away prior to adm [administration] of additional meds.”RN #11 was not available for an interview.During an interview on 5/12/26 at 10:25 AM the Director of Quality and Compliance stated, “She’s [nurse] going to do everything that she can to address is comfort and see what orders are available to manage any symptoms of being in distress. She should have confirmed the oxygen order and implemented it to address his needs.”2. Patient #5 was admitted on 2/13/26 with a diagnosis of Cerebral atherosclerosis (buildup of plaque in the arteries of the brain). The patient was a resident of a facility. The plan of care for 2/13/26-3/18/26 included order for skilled nurse (SN) visits 1 time a week for 1 week, 1 time a week for 13 weeks with 3 PRN (as needed) and beginning 3/1/26 SN visits 2 times a week for 11 weeks. Review of the clinical record revealed that on 3/16/26 at 11:48 AM the triage nurse documented, “Message received that [facility staff name] called to report pt [patient] has another wound on bottom and would like a nurse to assess. [facility staff name] reports pt also has pain and they have used all PRNS [as need medications], [indicating the patient was still having pain] Message sent to CM [RN #5, case manager’s name]. Thumbs up received from CM.” Further revealed that there was no documentation of any visit, call, or change to the plan of care to manage pain.During an interview conducted on 5/11/26 at 2:56 PM RN #5 stated, “I may not have documented directly, I am pretty sure I did [call them back], I went the next day.”During an interview conducted on 5/11/26 at 3:15 PM the Vice President of Clinical Services stated, “Every phone call we do to facilities should be documented. Pain should always be addressed immediately.”

Upon patient record review, 3 of 30 (Patient #6,11,12) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #6-1/7/25 Hydrocortisone cream, apply 1 thin layer TID, no evidence of location to apply cream on the medication profile. Corrected on Site. Patient #11-1/2/25 Nystatin powder, apply small amount thin layer BID, no evidence of location to apply powder on the medication profile. Corrected on Site. Patient #12-5/2/25 Fluconazole orders for 5 days PO and Cipro for 3 days PO, no evidence that medication was discontinued on the medication profile. Corrected on Site.

Upon patient record review, 1 of 30 (Patient #5) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient #5-3/3/25, wound care orders for upper left arm in place, SN on 3/17/25 states skin tear is healed and skin in intact, no evidence of updated skin assessment. Corrected on Site.

Upon patient record review, 3 of 30 (Patient #6,11,12) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #6-1/7/25 Hydrocortisone cream, apply 1 thin layer TID, no evidence of location to apply cream on the plan of care. Corrected on Site. Patient #11-1/2/25 Nystatin powder, apply small amount thin layer BID, no evidence of location to apply powder on the plan of care. Corrected on Site. Patient #12-5/2/25 Fluconazole orders for 5 days PO and Cipro for 3 days PO, no evidence that medication was discontinued on the medication profile. Corrected on Site

Upon patient record review, 2 of 15 (Patient #5,12) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient #5-3/3/25 wound care orders for upper left arm in place, SN on 3/17/25 states skin tear is healed and skin in intact, no evidence of revised POC for integumentary. Corrected on Site. Patient #12-5/2/25 Fluconazole orders for 5 days PO and Cipro for 3 days PO, no evidence that medication was discontinued on the medication profile and POC updated. Corrected on Site

Upon client record review, 1 of 30 (Patient #13) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #13-SC POC remains active, however on 5/8/25 SC note states family declined further SC support. Corrected on Site.

Upon patient client record review, 2 of 30 (Patient #3,16) did not have evidence that each patient record contains Advance Directives. Patient #3, #16-No evidence of advance directive on file. Corrected on Site.

Based on agency policy, clinical record review, and staff interviews the agency failed to report an allegation of abuse to the health care personnel registry within 24 hours after learning of the allegation and failed to submit a finding of the investigation within 5 days for 1 of 1 patient who alleged he had been kissed by the nursing assistant [#1]. The findings included: A policy, Reporting Violations Involving Mistreatment, Neglect or Abuse [12/3/24], was provided by the RN # 2 on 4/28/25 at 1:41 pm. The policy stated, “_____ [agency name] ensures that verified violations are reported to ________ [deeming body] and DHSR [Division of Health Service Regulation within 5 business days...” --- Patient # 1 had a Start of Care date of 3/6/25 with terminal diagnoses of other malignant neuroendocrine tumors [a cancerous growth that originates from neuroendocrine cells], secondary carcinoid of liver, and secondary carcinoid tumors of the bone. The patient was admitted to _______ [inpatient hospice unit]. Review of the agency’s incident log on 4/28/25 revealed an incident report [no date]. Review of the incident report revealed the patient had reported to the RN [on 4/3/25]  who was administering his medications that nursing assistant # 1 had kissed him that morning. The patient reported the nursing assistant kissed him on his lips and indicated the aide had come into his room that morning to give him a hug and “swooped in and kissed him on the lips.” The patient went on to state this action “made him very uncomfortable”. Further review of the incident report revealed the agency failed to notify the health care personnel registry of the alleged incident. The agency also failed to report the alleged incident within 24 hours of the patient reporting the incident. The agency also failed to submit their findings after the investigation within 5 days.  During a phone interview with the agency’s chief compliance officer on 4/28/25 at approximately 12:15 pm, the compliance officer stated, “Yes, I knew we had to do that. I just failed to take care of it.”

Upon patient record review, 2 of 20 (Patient #7, #18) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient #7-The patient was admitted 05/04/21 and refused Social Worker at the start of care. A psychosocial assessment was not performed by the nurse or Chaplain. The Social Worker was later accepted and psychosocial assessment performed 06/24/21 past 5 days. Patient #18-The patient was admitted 02/27/22 and a psychosocial assessment was not performed until 03/09/22.

Upon patient record review, 1 of 20 (Patient #16) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient #16-The patient was admitted 03/22/22 and a psychosocial assessment is not on record. The patient is only receiving nursing services and a psychosocial assessment was not performed by the nurse.

Upon patient record review, 3 of 20 (Patient #1, #3, #7) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. Patient #1-The 02/18/22 plan of care has orders for the nurse to flush the port a cath monthly. The medication profile does not include the medications to be utilized and amount for flushes. (corrected on site) Patient #3- The medication profile includes Miralax 17 gm scoop daily po. A diluent is not included. (corrected on site) Patient #7-The medication profile includes Polyethylene Glycol 17 gm scoop daily po. A diluent is not included. (corrected on site)

Upon patient record review, 3 of 20 (Patient #7, #16, #18) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient #7-The patient was admitted 05/04/21 and a bereavement assessment was not performed until 06/24/21. Patient #16-The patient was admitted 03/22/22 and a bereavement assessment is not on record. Patient #18-The patient was admitted on 02/27/22 and a bereavement assessment was not performed until 03/09/22.

Upon patient record review, 6 of 20 (Patient #1, #2, #3, #7, #8, #17) did not have evidence the plan of care included all services necessary for the palliation and management of the terminal illness and related conditions, including specific orders for all medications and treatments. Patient #1-The 02/18/22 plan of care includes orders for the nurse to flush the patients port a cath monthly and every three months. The orders are not specific for the cleansing of site, needle type and medications for flushes are not listed on the plan of care. The frequency for flushes is also unclear. (corrected on site) Patient #2 - The 03/07/22 orders to update the plan of care are to flush the patients port a cath monthly with 0.9% NS 10ml and follow with Heparin 100u/ml 5 ml q56 days. The orders do not include cleansing the site and type of needle to be used for access. (corrected on site) Patient #3- The 3/02/22 plan of care includes Miralax 17 gm scoop daily po. A diluent is not included. (corrected on site) Patient #7- The 02/28/22 plan of care includes Polyethylene Glycol 17 gm scoop daily po. A diluent is not included. (corrected on site) Patient #8-The 05/06/21 plan of care includes orders for the nurse to flush the patients port a cath monthly with 10 ml of 0.9 % NS followed by Heparin 100u/ml 5 ml. The orders do not address cleansing of the port site and type of needle to be utilized for accessing the site. (corrected on site) Patient #17- On 04/05/22 orders were received to update the plan of care for Aspira Dressing to be changed every 5 days or as needed after Pleurx drainage. The orders are not specific for the cleansing agent and/or actual dressing change to be performed.

Upon patient record review, 1 of 20 (Patient #3) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient #3- The 03/02/22 plan of care documents the patient does not have medical equipment. The nursing admission note on 03/02/22 indicates the patient was admitted with a walker, lift chair, wheelchair and shower chair.

Upon personnel record review, 1 of 1 applicable (Personnel # 7) did not have evidence in the personnel file of a complete competency assessment performed by the aide with a patient or pseudo patient which included all of the following: ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Reading and recording temperature, pulse, and respiration ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(A) Bed bath ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed ·(D) Nail and skin care ·(E) Oral hygiene ·(F) Toileting and elimination Personnel #7-The competency assessment on record was performed 2 weeks post hire and was incomplete. The competency assessment did not evidence the following were observed with a patient or pseudo patient prior to providing care independently: Reading and recording temperature, pulse, and respiration Safe transfer techniques and ambulation. Sponge, tub, and shower bath Nail care Oral hygiene Toileting and elimination

Upon patient record review, 1 of 8 applicable (Patient #18) did not evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group and Included in the plan of care. Patient #18- The Aide is assigned to perform catheter care each visit. On 03/02/22, 03/23/22, 03/30/22, and 04/06/22 the task is documented as information only. Empty drainage bag was assigned each visit and the task was documented as information only on 03/02/22, 03/23/22, 03/30/22, ad 04/06/22. A shave was assigned each visit and the task was documented as information only on 03/09/22, 03/16/22, 03/30/22 and 04/06/22.