Every finding on record at Integrity Home Care of Kansas, LLC

Based on document review, policy review and interview the hospice failed to ensure the plan of care was revised to include instructions for skin care and treatments provided by the Hospice Aide for one of eleven active patients reviewed with personal care services provided by the Hospice (Patient 1). The hospice failed to ensure the plan of care was updated to with orders for all medications and treatments for one of seven patients who received wound/skin care treatments (Patient 1). Failure of the hospice to ensure that care and medications for patients changing skin care needs are provided in accordance with the plan of care, has the potential to affect the safe provision of personal care and nursing services to hospice patients. Findings Include: Review of a hospice policy titled, "Hospice Nursing Care," revised 09/21/20 showed Nursing duties will include the responsibility for coordination of care and fostering communication between the patient and the interdisciplinary group. The Case Manager will assure that components of the plan of care are established and implemented by the interdisciplinary group. Review of a hospice policy titled, "Wound Care Policy," dated 05/06/20 showed if wounds were present, the physician would be notified, and orders given for appropriate care and procedure specific to that wound. If a wound developed during the length of stay, an order was entered to update the POC/wound care pathway and if a person other than a nurse was performing wound care, documentation of teaching with response/return demonstration was required in the patient's electronic chart. Written/verbal orders for wound care supplies that are ordered or requisitioned and in the patient's medication profile. Review of a hospice policy titled, "Hospice Aide Services," dated 03/23/18 showed Hospice aide services included personal care services provided by trained hospice aides. These activities in accordance with the plan of care and physician's (or other authorized independent practitioner's) orders will be assigned and supervised by a hospice registered nurse. Patient 1 Review of Patient 1's medical record showed the patient was an 85-year -old admitted for service on 08/27/21 with a primary diagnosis of Senile Degeneration of the Brain. Patient 1 resided in his own home with his son and daughter alternating as caregivers in the home. The hospice Plan of Care showed he received Skilled Nursing services two times a week, chaplain services one time a month and hospice aide services two times a week for personal care. Review of Patient 1's Aide Care Plan Report (Hospice Aide Plan of Care ) dated 08/27/21 by Staff B, Registered Nurse (RN) showed instructions for the hospice aide as follows: stand-by assistance with ambulation every visit, transfer client from chair/bed every visit, bathing (bed bath) every visit, skin care every visit, perineal care every visit, shaving per patient request, nail care per patient request, dressing every visit, file fingernails per patient request. Review of Patient 1's Visit Note Report, completed by Staff B, Registered Nurse (RN), at the start of hospice services on 08/27/21 showed the patient did not have wounds. The report showed Patient 1 had a history of scrotum gaulding (redness and irritation): Onset 08/12/21- Inactivated 08/27/21 with an observation only status. Review of Patient 1's Visit Note Report, completed by Staff C, Chaplain, at the start of hospice services on 08/30/21(2 days later) showed Patient 1 said he was feeling okay and he didn't seem to be experiencing any pain except with his feet, which were all bandaged up. Review of Patient 1's Visit Note Report, completed by Staff D, Hospice Aide on 08/30/21 (2 days later) showed Patient 1 had dressings on both legs and dressing in peri area (perineal area) and patient was red in peri area; the nurse (Staff B) is aware, discussed with the patient daughter the nurse will be getting proper dressings. Review of Patient 1's Visit Note Report, completed by Staff B, RN on 09/01/21 (5 days after admission) showed abnormal integumentary (skin evaluation) assessment findings of pale vesicles (small blisters) on right lower extremity. The report showed supplies delivered: Remedy Antifungal Powder 3 ounce (each)-1. There was no follow-up documented with the physician regarding bandages to the patient's feet as reported by the chaplain and hospice aide, nor the redness in the patient's peri area requiring "proper dressings" as reported by the hospice aide. The Plan of Care was not revised to reflect new skin care treatments or services. Review of Patient 1's Visit Note Report, completed by Staff D, Hospice Aide on 09/02/21 showed Patient 1 had dried areas in his peri area. Daughter reported they at times bleed they were not today, placed ABD (abdominal) pads per patient request after bath. The Hospice Aide Care Plan Report (Hospice Aide Plan of Care) did not list instructions for caring for dried, bleeding areas nor instructions for proper placement of the pads. Review of Patient 1's Visit Note Report, completed by Staff B, RN on 09/03/21 showed identification and treatment of a new lower left leg venous stasis ulcer. The was no documented follow up to Staff D's report from the previous day, of the patient having dried areas, that at times bled in the peri area, for which the hospice aide placed ABD Pads. There was no documented revision to the plan of care nor the revision of the Hospice Aide plan of care to regarding instructions for care to the area that included placement of ABD pad. Review of Patient 1's Visit Note Report, completed by Staff D, Hospice Aide on 09/07/21 showed Patient 1 had red fungal area under the left side of his belly, he reported was sore, applied barrier cream and pad; will report to care manager. The hospice aide plan of care did not include instructions for the hospice aide to apply barrier cream nor the ABD pad. Review of Patient 1's Visit Note Report, completed by Staff B, RN on 09/08/21 showed Patient 1's Integumentary system (skin assessment) and lower leg wound were assessed. There was no documentation to support the skilled nurse updated the plan of care, nor the hospice aide plan of care to address the previous day's hospice aide report of a red, sore fungal area to the left side of the patient's belly for which Staff D, Hospice Aide, applied barrier cream and ABD pad. The skilled nurse failed to ensure the care and services were provided in accordance with an updated plan of care. Review of Patient 1's Visit Note Report, completed by Staff D, Hospice Aide on 09/09/21 showed Patient had a severe yeast rash on the right side of his groin, areas under his belly and on his "balls" applied barrier cream and powder and educated on changing out the ABD pads; will report to Staff B, RN and have her look. Review of Patient 1's Visit Note Report, completed by Staff B, RN on 09/10/21 showed Patient 1's Integumentary system and lower leg wound were assessed. There was no documentation to support the skilled nurse updated the plan of care, nor the hospice aide plan of care instructions to address the previous day's hospice aide report of a severe yeast rash on the right side of his groin, areas under his belly and on his "balls" for which Staff D, Hospice Aide applied barrier cream and powder and educated on family on changing out the ABD pads. The skilled nurse failed to ensure the care and services were provided in accordance with an updated plan of care. Review of Patient 1's Visit Note Report, completed by Staff D, Hospice Aide on 09/13/21 showed Patient had a red rash in the groin area and under right side of belly has a small area left. Applied barrier cream and powder. Applied ABD pads. Review of Patient 1's Visit Note Report, completed by Staff B, RN on 09/14/21 showed Patient 1's Integumentary system and lower leg wound were assessed; There was no documentation to support the skilled nurse updated the plan of care, nor the hospice aide plan of care with instructions to address the previous day's hospice aide report of the red rash continuing in the groin area and under the right side of Patient 1's belly for which Staff D, Hospice Aide applied barrier cream, powder and ABS pads. Review of Patient 1's Visit Note Report, completed by Staff D, Hospice Aide on 09/16/21 showed Applied barrier cream and ABD pads to the peri area. Patient has areas on his upper thighs under his bottom that are rough with shedding skin. When this aide cleaned the area, it removed some of the flaky skin and cause the left side to bleed. This aide reported to the daughter and will report to RN Case Manager (Staff B) Patient is having pain today. Review of Patient 1's Visit Note Report, completed by Staff B, RN on 09/17/21 showed Patient 1's Integumentary system and lower leg wound were assessed; there was no documentation to support the skilled nurse assessed for and updated the plan of care, nor the hospice aide plan of care instructions to address the previous days hospice aide report of the new finding of rough, shedding skin that bled when the area was cleansed during the provision of personal care by Staff D, Hospice Aide. The Hospice Aide plan of care was not updated to include instructions for the application of barrier cream and ABD pads. Review of Patient 1's Visit Note Report, completed by Staff D, Hospice Aide on 09/20/21 showed Patient's daughter reports the patient had not been changing out his ABD pads in his peri area. The ABD pads that were removed were soiled. Patient was red in his peri area both left and right side and states it is sore. Applied Barrier cream and powder. Patient bottom is red on the right side. Review of Patient 1's Visit Note Report, completed by Staff B, RN on 09/21/21 showed Patient 1's Integumentary system and lower leg wound were assessed; There was no documentation to support the skilled nurse assessed for and updated the plan of care, nor the hospice aide plan of care instructions to address the previous days hospice aide report of redness in the patient's peri area from soiled pads left in place by the patient and right side bottom by Staff D, Hospice Aide. The Hospice Aide plan of care was not updated to include instructions for the application of barrier cream and ABD pads. Review of Patient 1's Visit Note Report, completed by Staff D, Hospice Aide on 09/23/21 showed the patient had minimal redness in his peri area. Cream and powder applied and ABD pads. Review of Patient 1's Visit Note Report, completed by Staff B, RN on 09/24/21 showed Patient 1's Integumentary system and lower leg wound were assessed; The assessment showed new heel Stage 1: 1.7 x 1.7 x 0. There was no documentation to support the skilled nurse updated the Plan of care, nor the hospice aide plan of care instructions to address the new finding of a stage 1 Pressure Ulcer on the patient's heel. The Hospice Aide plan of care was not updated to include instructions for the application of barrier cream and ABD pads by the hospice aide. Review of Patient 1's Visit Note Report, completed by Staff D, Hospice Aide on 09/27/21 showed the patients bottom right side had several areas that could break down, patient reports it is sore, applied barrier cream. Will report to RN care Manager (Staff B). Patient reports being sore in the peri area left side, this aide did not observe sores and is not red. Barrier cream, powder and ABD pads applied to peri area. Review of Patient 1's Visit Note Report, completed by Staff B, RN on 09/28/21 showed Patient 1's Integumentary system was assessed and presence of one Stage One pressure ulcer noted. There was no documentation to support the skilled nurse updated the plan of care related to the pressure ulcer nor updated the hospice aide plan of care related to the findings reported by Staff D, Hospice aide that included the patient's bottom having several areas that could breakdown with soreness and soreness to the peri area. The Hospice Aide plan of care was not updated to include instructions for the application of barrier cream, powder and ABD pads by the hospice aide. Review of Patient 1's Visit Note Report, completed by Staff D, Hospice Aide on 09/30/21 showed the patient was a little red in the peri area and barrier cream was applied. The Hospice Aide plan of care was not updated to include instructions for the application of barrier cream by the hospice aide. There was no documentation to support the hospice ensured the skilled nurse reviewed and updated the plan of care, including the hospice aide plan of care, to include new wound and skin findings reported by the hospice aide between the dates of 08/27/21 through the date of survey (10/07/21). Review of medications on the hospice Plan of care showed the hospice did not include orders for barrier cream and topical powder, that were documented as applied by the hospice aide between the dates of 09/03/21 and 10/05/21(32 days). Review of Hospice Physician Order dated 10/05/21 showed: Calazime Protect Paste (barrier cream) 0.2%-20% topical per instructions as needed and Phytoplex Antifungal 2% topical powder (skin protectant) per instructions as needed, were added to the Medications on the Plan of Care effective 10/05/21. The hospice failed to ensure the plan of care was updated with orders for treatments and medications to that reflected the patient's changing needs for skin care and services. During an interview on 10/06/21 at 8:03 AM, Staff A, Administrator confirmed the plan of care did not contain all medications for the patient and that a physician's order for topical yeast powder and barrier cream was obtained by the nurse on 10/05/21. Staff A confirmed the Hospice Aide plan of care did not include instructions for use of ABD dressings, powders or creams.