Every finding on record at Kanawha Hospice Care, Inc.

Based on policy review and staff interview, it was determined the agency failed to ensure each patient had an emergency preparedness plan. This failure has the potential to negatively impact all patients receiving care from the agency in the event of an emergency. --- Findings include:A policy was reviewed titled, “EPP01: Disaster Plan & Emergency Preparedness,” dated 11/06/24. The policy states in part, “...Communication Plan for Disaster/Emergency: …4.As permitted under the HIPAA, the agency shall be prepared to disclose the following information regarding patients enrolled, the condition, needs, location, evacuation requirements…8.Field staff will contact all patients currently on their active census to assess patients’ current needs.  Depending on travel restrictions/conditions, visits may be conducted on a limited basis. 9. Staff will report to their Supervisors all patients’ that were un-reachable via phone contact or visit.  Staff should make reasonable attempts to contact all their current patients utilizing all phone numbers currently listed if necessary. 10. Supervisors will notify appropriate agencies responsible of the need to evacuate home patients or of patients that the agency is unable to locate.  Reporting of the patient’s condition and specialized needs will be provided to the Responding Agency while maintaining HIPPA compliance…”An interview was conducted with staff 1 on 12/18/25 at 11:50 a.m. Staff 1 explained there are no patient risk assessments for the emergency plan status due to an Electronic Medical Record (EMR) system error in not making it as a required charting task on admission. The patients do not have individual emergency plans.

Based on record review and staff interview, the facility failed to conduct the required exercises to test the emergency plan at least annually. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 21. --- Findings include:a) The facility had not conducted an exercise for 2025 as required by the emergency preparedness testing requirements.b) Interview on 12/16/25 at the time of discovery with the Maintenance Supervisor verified this finding. The finding was also acknowledged by facility's Maintenance Supervisor during the exit interview on 12/16/25 at approximately 4:30 p.m.

Based on document reviews, and staff interviews, it was determined the agency failed to ensure hospice aides were competent to perform their assigned duties, by not delineating the care of bed, tub, and shower bath, and bed, tub and shower shampoo, in eighteen (18) out of twenty-one (21) staff reviewed, staff # 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, and 21. This failure had the potential to negatively impact all patients receiving hospice aide care at the agency. --- Findings include:A review of the initial competency evaluation of staff 4 dated 11/21/24 lists the staff was observed by a Registered Nurse (RN) performing a “bath/shower,” and  “shampoo with bath/shower” with no delineation of which was performed, and no competency for sponge bath, sink shampoo, and bed shampoo. A review of the initial competency evaluation of staff 5 dated 11/21/24 lists the staff was observed by a Registered Nurse (RN) performing a “bath/shower,” and  “shampoo with bath/shower” with no delineation of which was performed, and no competency for sponge bath, sink shampoo, and bed shampoo. A review of the initial competency evaluation of staff 6 dated 11/21/24 lists the staff was observed by a Registered Nurse (RN) performing a “bath/shower,” and  “shampoo with bath/shower” with no delineation of which was performed, and no competency for sponge bath, sink shampoo, and bed shampoo. A review of the initial competency evaluation of staff 7 dated 11/21/24 lists the staff was observed by a Registered Nurse (RN) performing a “bath/shower,” and  “shampoo with bath/shower” with no delineation of which was performed, and no competency for sponge bath, sink shampoo, and bed shampoo. A review of the initial competency evaluation of staff 8 dated 09/06/24 lists the staff was observed by a Registered Nurse (RN) performing a “bath/shower,” and  “shampoo with bath/shower” with no delineation of which was performed, and no competency for sponge bath, sink shampoo, and bed shampoo. A review of the initial competency evaluation of staff 9 dated 08/08/24 lists the patient was observed by a Registered Nurse (RN) performing a “Tub or Shower Bath” and a “Shampoo-sink, tub, or bed” with no delineation of which was performed, and no competency for sponge bath.A review of the initial competency evaluation of staff 10 dated 06/11/24 lists the staff was observed by a Registered Nurse (RN) performing a “bath/shower,” and  “shampoo with bath/shower” with no delineation of which was performed, and no competency for sponge bath, sink shampoo, and bed shampoo. A review of the initial competency evaluation of staff 11 dated 01/10/24 lists the patient was observed by a Registered Nurse (RN) performing a “Tub or Shower Bath” and a “Shampoo-sink, tub, or bed” with no delineation of which was performed, and no competency for sponge bath.A review of the initial competency evaluation of staff 12 dated 11/30/23 lists the patient was observed by a Registered Nurse (RN) performing a “Tub or Shower Bath” and a “Shampoo-sink, tub, or bed” with no delineation of which was performed, and no competency for sponge bath.A review of the initial competency evaluation of staff 13 dated 11/28/23 lists the patient was observed by a Registered Nurse (RN) performing a “Tub or Shower Bath” and a “Shampoo-sink, tub, or bed” with no delineation of which was performed, and no competency for sponge bath.A review of the initial competency evaluation of staff 14 dated 11/27/23 lists the patient was observed by a Registered Nurse (RN) performing a “Tub or Shower Bath” and a “Shampoo-sink, tub, or bed” with no delineation of which was performed, and no competency for sponge bath.A review of the initial competency evaluation of staff 15 dated 08/25/23 lists the patient was observed by a Registered Nurse (RN) performing a “Tub or Shower Bath” and a “Shampoo-sink, tub, or bed” with no delineation of which was performed, and no competency for sponge bath.A review of the initial competency evaluation of staff 16 dated 07/10/23 lists the patient was observed by a Registered Nurse (RN) performing a “Tub or Shower Bath” and a “Shampoo-sink, tub, or bed” with no delineation of which was performed, and no competency for sponge bath.A review of the initial competency evaluation of staff 17 dated 04/21/23 lists the patient was observed by a Registered Nurse (RN) performing a “Tub or Shower Bath” and a “Shampoo-sink, tub, or bed” with no delineation of which was performed, and no competency for sponge bath.A review of the initial competency evaluation of staff 18 dated 04/17/23 lists the patient was observed by a Registered Nurse (RN) performing a “Tub or Shower Bath” and a “Shampoo-sink, tub, or bed” with no delineation of which was performed, and no competency for sponge bath.A review of the initial competency evaluation of staff 19 dated 03/20/23 lists the patient was observed by a Registered Nurse (RN) performing a “Tub or Shower Bath” and a “Shampoo-sink, tub, or bed” with no delineation of which was performed, and no competency for sponge bath.A review of the initial competency evaluation of staff 20 dated 02/27/23 lists the patient was observed by a Registered Nurse (RN) performing a “Tub or Shower Bath” and a “Shampoo-sink, tub, or bed” with no delineation of which was performed, and no competency for sponge bath.A review of the initial competency evaluation of staff 21 dated 02/06/23 lists the patient was observed by a Registered Nurse (RN) performing a “Tub or Shower Bath” and a “Shampoo-sink, tub, or bed” with no delineation of which was performed, and no competency for sponge bath.An interview was conducted with staff 3 on 12/18/25 at 9:15 a.m. Staff 3 explained the initial competency sheets have bath-shower, bed, or tub and shampoo- bed, shower or tub, and staff 3 did not know they had to be individually listed. The competencies are done in person, and whichever task is performed of each of the three is observed, and the aides describe the process for the other tasks prior to being allowed to work independently.

Based on document review and staff interview, it was determined the facility failed to ensure that required emergency lighting systems were tested in accordance with NFPA (National Fire Protection Association) 101. This deficient practice could affect all patients, staff, and visitors in the areas referenced. --- Findings include: Document review on 6/07/23 at approximately 2:00 p.m. revealed no documentation of battery powered emergency lights receiving annual functional testing for a minimum of one and a half (1.5) hours or a monthly sixty (60) second functional test at Peyton Hospice House. These findings were verified with Administrator, Life Safety Officer, and Maintenance Supervisor, at the time of discovery and again at the time of exit on 6/07/23 at 3:30 p.m. Document review on 6/08/23 at approximately 10:00 a.m. revealed no documentation of battery powered emergency lights receiving annual functional testing for a minimum of one and a half (1.5) hours or a monthly sixty (60) second functional test at Hubbard Hospice House. These findings were verified with Administrator, Life Safety Officer, and Maintenance Supervisor, at the time of discovery and again at the time of exit on 6/08/23 at 11:30 a.m.

Based on document review and staff interview, it was determined the facility failed to ensure that required emergency lighting systems were tested in accordance with NFPA (National Fire Protection Association) 101. This deficient practice could affect all patients, staff, and visitors in the areas referenced. --- Findings include: Document review on 6/07/23 at approximately 2:00 p.m. revealed no documentation of battery powered emergency lights receiving annual functional testing for a minimum of one and a half (1.5) hours or a monthly sixty (60) second functional test at Peyton Hospice House. These findings were verified with the House Supervisor at the time of discovery and again with Administration at the time of exit on 6/07/23 at 3:30 p.m. Document review on 6/08/23 at approximately 10:00 a.m. revealed no documentation of battery powered emergency lights receiving annual functional testing for a minimum of one and a half (1.5) hours or a monthly sixty (60) second functional test at Hubbard Hospice House. These findings were verified with Administrator, Life Safety Officer, and Maintenance Supervisor at the time of discovery and again at the time of exit on 6/08/23 at 11:30 a.m.

Based on record review, observation, document review, and staff interview it was determined the facility failed to ensure patient bed alarms could be heard through a closed door in one (1) out of ten (10) records reviewed (patient #1) (See Tag L 517).

Based on record review, observation, document review, and staff interview it was determined the agency failed to ensure care was provided in a safe setting, by ensuring bed alarms could be heard behind a closed door in one (1) out of ten (10) medical records reviewed (patient #1). This failure could have potentially led to the patient receiving a subdural hematoma that ultimately contributed to his death. Findings include: 1. A review of the medical record of patient #1 revealed the patient was admitted to the inpatient unit on 10/4/21 with a diagnosis of Covid-19 positive and End Stage Heart Disease. The patient was a fall risk with a bed alarm attached to the bed. The door had to remain closed due to the patient being Covid-19 positive. The patient was in Room 4, located at the end of the hall from the nursing desk, when the patient had the fall. The record indicates on 10/10/21 at 3:30 p.m., the patient was found lying in the floor with blood on his head and on the floor around him. The patient was able to talk and denied pain. The family was notified and requested the patient be transferred to a local Emergency Department (ED) for evaluation. The physician was notified, and the patient was transferred to the hospital. The patient was diagnosed with a subdural hematoma and returned to the inpatient hospice unit on the evening of 10/10/21. The patient began to deteriorate and ultimately passed away on 10/13/21. 2. An interview was conducted with Licensed Practical Nurse (LPN) #1 on 10/27/21 at 11:00 a.m. During the interview the LPN stated, "All our patients are a fall risk. They automatically get bed alarms put on the bed for safety reasons." 3. On 10/27/21 at 11:20 a.m., this surveyor, the Administrator of Clinical Services and the Compliance Officer witnessed Certified Nursing Assistant (CNA) #1 go into Room 5 (which was directly across the hall from Room 4 that patient #1 had been in) and close the door to test the loudness of the bed alarm. The CNA set off the bed alarm. The hallway was quiet, and the sound of the bed alarm was very faintly heard at the nursing station. 4. An interview was conducted with the Administer of Clinical Services and the Compliance Officer on 10/27/21 at 11:25 a.m. They concurred that it would be difficult for nursing staff to hear the bed alarm with the door closed. 5. An interview was conducted with Registered Nurse (RN) #1 on 10/28/21. The RN stated, "I was sitting at the nurse's desk doing some charting and I heard a loud noise. I jumped up and ran down the hall and when I got closer to patient #1's room I could hear the bed alarm. I opened the door and didn't see the patient in the bed, so I stepped in the room and found him laying in the floor with blood on his head and in the floor. I immediately called for other staff to help assist me with the patient. While I was taking care of the patient the other nurse was calling the family and notifying the physician and Administrator on call. The patient's son wanted the patient to be sent out to a local emergency department to be checked and possibly have a CT (Computed Tomography) scan." The RN further stated the bed alarms could not be heard when the doors were closed. When questioned if administration had been made aware of the issue, RN #1 stated, "Not that I am aware of." 6. A review of the agency document entitled "Fall Prevention Protocol" states: "Scheduled safety checks at least q (every) 30 (thirty) mins (minutes) when patient is alone." 7. A review of the medical record of patient #1 revealed thirty (30) minute safety checks were not documented. 8. A review of the agency document entitled "Consolo Patient Fall Tracking," dated 10/27/21, revealed that on 8/5/21 patient #11 had a fall in Room 4. Under the section labeled 'comments', the document states: "Pts. (patient's) bed alarm sounding, unable to hear with the door closed at the end of the hallway." 9. An interview was conducted with the Administrator of Clinical Services on 10/27/21 at approximately 2:30 p.m. The Administrator concurred that nothing had been changed after the fall of patient #11 in August 2021, to increase the volume of the bed alarms.