Every finding on record at Hospital Service District No. 1 of Pointe Coupee, La, Inc.

Based on interviews and record reviews, the Hospice agency failed to ensure the care and services provided followed an individualized Plan of Care (POC) established by the Interdisciplinary Group (IDG) in collaboration with the Attending Physician in accordance with the patient’s needs.  The Hospice agency failed to ensure Chaplain Visits were performed as ordered for 1 (#12) of 10 (#5 through #14) live patients reviewed in the sample.  This deficient practice had the potential to affect any of the 8 patients currently ordered to receive Chaplain Services and a current census of 25 patients. --- Review of Patient #12’s Clinical Record revealed he was admitted to the Hospice agency on 04/14/2025 with a terminal diagnosis of Heart Failure.  Further review revealed a current Certification Period of 04/14/2025 through 07/12/2025.     Review of Patient #12’s Plan of Care and Physician Orders for Certification Period of 04/14/2025 through 07/12/2025 revealed, in part, Chaplain Visit Frequency: One Visit Weekly for 12 weeks from 04/20/2025 through 07/12/2025.  Review of Patient #12’s Chaplain Visit Calendar for Certification Period of 04/14/2025 through 07/12/2025, as of 05/12/2025, revealed, in part, no documented evidence of Chaplain Visits conducted from 04/23/2025 through 05/12/2025.Review of Patient #12’s Clinical Record (both EHR and Hard Chart), as of 05/12/2025, revealed no documented evidence of Chaplain Visits conducted or missed from 04/23/2025 through 05/12/2025.Review of Patient #12’s IDG Meeting, dated 05/06/2025, revealed, in part, Chaplain Visit Frequency: One Visit Weekly for 12 weeks from 04/20/2025 through 07/12/2025.  Further review revealed no documented evidence of Missed Chaplain Visits being discussed and/or approved during the IDG Meeting.  An interview was conducted on 05/12/2025 at 12:40 p.m. with S2DON.  S2DON reviewed Patient #12’s Clinical Record and confirmed there was a Physician’s Order for him to receive Chaplain Visits once a week from 04/20/2025 through 07/12/2025.  S2DON confirmed there was no documented evidence of Chaplain Visits conducted or missed from 04/23/2025 through 05/12/2025.  S2DON confirmed she expected visits to be conducted as ordered then documented in a timely manner and it was not for Patient #12.

Based on interviews and record reviews, the Hospice agency failed to ensure physician’s orders met the needs of the patients for 1 (#9) of 3 (#5, #9, and #13) patients reviewed in the sample for wounds.  The Hospice agency failed to follow acceptable standards of practice for wound care by failing to ensure wound care orders included the frequency for which it should be performed.  This deficient practice had the potential to affect any of the 3 patients currently receiving treatment for wounds. --- Review of the Louisiana State Board of Nursing Declaratory Statement Scope of Practice for Registered Nurses (RN) - Wound Care Management adapted 02/1999 revealed, in part, the following: RNs render care that is directed towards the prevention and treatment of wounds. Wounds are a common health care challenge that often occur with or result from chronic disorders such as impaired circulation and malnutrition. Nursing care of skin/wound conditionsinvolves the identification, assessment, management, and ongoing evaluation of patients with alterations in skin/tissue integrity that includes but is not limited to draining wounds, pressure ulcers, and vascular ulcers, and conditions resulting from incontinence, surgical procedures, and/or trauma.Further review revealed, in part, Scope of Practice - The Louisiana State Board of Nursing recognizes that assessment, planning, intervention, teaching, evaluation, and supervision are the major responsibilities of the registered nurse in the practice setting. The RN is responsible for performing a nursing assessment and physical examination for preventative and restorative nursing and for providing patient/family teaching. Recognizing that the physician must always prescribe wound care, the following roles are defined to delineate the scope of practice for each member of the nursing team members. The RN initiates appropriate wound preventative measures, stages wounds and collaborates with the wound care team in the implementation and evaluation of nursing interventions as prescribed by an authorized prescriber.Review of the Medicare Guidelines for Wound and Ulcer Care, effective for services performed on or after 11/28/2021, revealed, in part, when writing an order for wound care the ordering provider must include the frequency of dressing changes.  Review of Wound Care Organization standards revealed, in part, the key elements of a standard wound care order should include the frequency of how often it should be performed.Review of Patient #9’s Clinical Record revealed he was admitted to the Hospice agency on 03/19/2025 for a current Certification Period of 03/19/2025 through 06/16/2025.  Further review revealed he was currently receiving treatment for a wound to his right lateral foot.  Review of Patient #9’s RN Admission Assessment, dated 03/19/2025, revealed, in part, the following: Wound #1: Arterial Ulcer to Right Lateral Foot Narrative: “New wound care orders received to cleanse area with soap and water, apply Betadine to area, and leave open to air per S3MD.”Further review revealed no documented evidence of the ordered frequency for wound care to be performed.   Review of Patient #9’s Plan of Care and Physician’s Orders for the Certification Period of 03/19/2025 through 06/16/2025, as of 05/08/2025, revealed, in part, the following: Wound # 1: Arterial Ulcer to Right Lateral Foot1. Wipe wound area with a povidone iodine solution or skin protectant; 2. Leave open to air or cover with a dry protective dressing such as gauze; 3. Monitor for any change in wound.  Further review revealed no documented evidence of the ordered frequency for wound care to be performed.   An interview was conducted on 05/12/2025 at 1:45 p.m. with S2DON.  S2DON confirmed she expected all wound care orders to include the frequency in which the wound care should be performed.  S2DON reviewed Patient #9’s Clinical Record and confirmed his wound care orders did not include the frequency and should have.   An interview was conducted on 05/12/2025 at 3:45 p.m. with S1ADM.  S1ADM confirmed she would expect staff, including the Medical Director, to follow regulations and accepted standards of practice at all times.

Based on record review and interviews, the Hospice agency failed to ensure drugs and biologicals were disposed of properly, in accordance with all applicable laws and regulations, after a patient’s death. This deficient practice was evidenced by failure to ensure the Registered Nurse (RN) documented the name of the witness present for the final count and destruction of Patient #3’s controlled substances following his death.This deficient practice had the potential to affect any of the 106 patients who expired over the past 12 months and a current census of 25 patients. --- Review of the memo issued by the Louisiana Department of Health (LDH) - Health Standards Section, dated 06/25/2018, revealed the following, in part: In accordance with Act 23 of the 2018 Regular Legislative Session, regarding the 2018 Regular Legislative Session, the LDH Health Standards Section is issuing this notice to all licensed hospice providers. Effective 08/01/2018, Act 23 amends and reenacts Louisiana (LA) Revised Statute (RS) 40:2191 relative to disposal of controlled substances by hospice providers; to provide for ownership; to provide for written procedures; to provide for patient records; to provide for disposal; to provide for patient notification; and to provide for related matters. Review of LA RS 40:2191 revealed the following, in part: Disposal of deceased patient's unused controlled substances:A. Upon death of a patient receiving hospice services, ownership of the patient's unused Schedule II, III, IV, or V controlled substances under 21 CFR 1308 may transfer to the hospice for immediate disposal pursuant to the following provisions:(1) Each hospice shall establish a written procedure to ensure safe disposal of unused controlled substances by a hospice nurse at the time of a patient's death.(2) Upon the death of a patient receiving hospice services, in the presence of a witness, the hospice nurse shall record in the medical record the name and quantity of each unused controlled substance.(3)(a) The hospice nurse shall conduct immediate disposal of the controlled substance at the site of care … (b) … the hospice nurse shall perform the disposal in the presence of a witness, who shall sign a document indicating their witnessing the disposal. (5) The hospice nurse shall record the method of disposal in the medical record.Review of Patient #3’s Clinical Record revealed he was admitted to the Hospice agency on 02/08/2025.  Further review revealed he expired at a local assisted living facility on 05/08/2025.  Review of Patient #3’s Plan of Care and Physician’s Orders for the Certification Period of 02/08/2024 through 05/07/2024 revealed, in part, the following:Lorazepam 0.5 milligram by mouth every 4 hours as needed for anxiety; and Morphine Sulfate 15 milligram by mouth every hour as needed for air hunger or pain (20mg/ml suspension. Take 0.75ml to equal 15mg by mouth every hour as needed).Review of Patient #3’s Death Visit Note, dated 05/08/2024, revealed, in part, the following: Medication Disposal Method: Per the local assisted living facility’s policy.  Medications disposed of with amount: Lorazepam - 3 Tabs. Morphine Sulfate - 21 mL.Further review revealed no documented evidence of the witness for the final count or destruction of either of the controlled substances.  Review of Patient #3’s Report of Death Form, dated 05/08/2024, revealed, in part, no documented evidence of the witness for the final count or destruction of either of the controlled substances.  Review of Patient #3’s Clinical Record, in the EHR and Hard Chart, revealed, in part, no documented evidence of the witness for the final count or destruction of either of the controlled substances.  An interview was conducted on 05/12/2025 at 1:45 p.m. with S2DON.  S2DON confirmed she expected the RN to document the name of the witness present when narcotics were counted and destroyed following a patient’s death.  S2DON reviewed Patient #3’s Clinical Record in the EHR and Hard Chart and confirmed there was no documented evidence of the witness present and should have been. An interview was conducted on 05/12/2025 at 3:45 p.m. with S1ADM.  S1ADM confirmed she would expect staff to follow regulations and state laws at all times.