Every finding on record at Inspiration Hospice, LLC

Based on interview and record review, it was determined the hospice agency did not develop an individualized written plan of care (POC) for each patient. Specifically, the hospice agency did not develop a POC that included all services necessary for the palliation and management of the terminal illnesses and related conditions for 1 of 6 sample patients. (Patient identifier: 6) Findings include: Patient 6 was admitted to the hospice agency on 1/4/2022 with a terminal diagnosis of Lewy Body Dementia. Patient 6's medical record was reviewed on 9/13/2022. 1. On 7/20/2022, a physician's order was received to administer Diflucan 150 mg 1 tablet by mouth for three days related to an infection under the left armpit. There was no documentation in the nursing notes that reflected patient 6 had a infection under her left arm or that the rash was resolved after taking the Diflucan for 3 days. The agency social worker, documented on 7/20/2022 that patient 6 had a "yeast infection and fungus on her toes that needs attention." 2. On 7/22/2022, patient 6 was seen by a podiatrist. A new order was received. The podiatrist documented, "Ulcer B/L (bilateral) Hallux. Clean with alcohol, apply prisma (small amount), cover with Band-Aid QOD (every other day)". There was no documentation in the nurse's notes from 7/22/2022 until she was discharged on 8/25/2022, that patient 6 had an ulcer to the bilateral toes or that the treatment was performed. Furthermore, there was no description of the wound or the size of the wound. The care plan developed for patient 6 was not updated to include the treatments above,. An interview was conducted with registered nurse (RN) 1 on 9/13/2022 at 9:00 AM. RN 1 stated that wounds, rashes and treatments were to be documented in the nurse's notes. RN 1 stated the care plan should have been updated to reflect the wound care, treatment and the rash. An interview was conducted with licensed practical nurse (LPN) 1 on 9/13/2022 at 9:20 AM. LPN 1 stated that she should have documented the rash, ulcer and wound care in the nurse's notes. LPN 1 was unable to giver an explanation as to why she did not. LPN 1 stated that the care plan had not been developed or updated. An interview was conducted with the director of nursing (DON) on 9/13/2022 at 11:45 AM. The DON stated the nurses should have been documenting a description of the wound, size of the wound, and wound treatments.

Based on interview and record review, it was determined the hospice agency did not ensure the patients revised plan of care (POC) included information from their updated comprehensive assessments for 1 of 6 sampled patients who had a full medical record review completed by the survey team. (Patient identifier: 6.) Findings include: Patient 6 was admitted to the hospice agency on 1/4/2022 with a terminal diagnosis of Lewy Body Dementia. A review of patient 6's medical record was completed on 9/13/2022 1. On 7/20/2022, an order was received to administer Diflucan 150 mg by mouth for three days related to a rash under the left armpit. On 7/21/22 there was an interdisciplinary group (IDG) meeting held. There was no documented evidence that patient 6 had a rash and was being treated with Diflucan. 2. On 7/22/2022, an order was written by the podiatrist. The Podiatrist documented, "Ulcer B/L (bilateral) hallux. Clean with alcohol, apply prisma (small amount), cover with Band-Aid QOD (every other day)." On 8/4/2022, there was an IDG meeting held. There was no documented evidence that patient 6 had an ulcer to the bilateral toes or that a treatment had been ordered. An interview was conducted with the director of nursing (DON) on 9/13/2022 at 11:45 AM. The DON was asked if the above should have been documented in the IDG meeting notes. The DON stated, "Yes".