Every finding on record at Lakeside Hospice, LLC

Based on record reviews and interviews, the hospice agency failed to ensure the IDG maintained a system of communication, coordination, and integration of services for 2 (#10 and #15) of 14 (#6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, and #19) patients reviewed. --- Patient #10 Review of Patient #10s Clinical Record revealed he was admitted to the hospice agency on 08/01/2023 with diagnoses, which included Alzheimers Disease and History of Falling. Review of Patient #10s Coordination Notes revealed, in part, the following: 03/15/2024 at 1:35 p.m. - Agency office received a call from local assisted living facility reporting Patient #10 fell. Complaining of hip pain. Further review revealed there was no additional documentation regarding Patient #10s fall on 03/15/2024. Review of Patient #10s Calendar and Visit Notes revealed, in part, no visits from agency nursing staff following his fall on 03/15/2024. Review of Patient #10s Physician Orders revealed no new orders following his fall on 03/15/2024. An interview was conducted on 03/19/2024 at 1:10 p.m. with S2RN. She confirmed she provided care for Patient #10. She confirmed she was aware Patient #10 had a fall on 03/15/2024. She stated she was unable to provide documented evidence of her contacting the facility regarding Patient #10s fall. She stated she was unable to provide documented evidence of her notifying the Physician. An interview was conducted on 03/19/2024 at 1:25 p.m. with S1ADM. She reviewed Patient #10s medical record and confirmed she was unable to provide documented evidence to indicate S2RN contacted the facility or notified the physician following Patient #10s fall on 03/15/2024. Patient #15Review of Patient #15s Clinical Record revealed she was admitted to the agency on 03/08/2024 with diagnoses, which included Spinal Stenosis. Review of Patient #15s Social Worker Visit Notes revealed, in part, the following:03/11/2024 - Caregiver and patient noted increased confusion, increased weakness and increased sleeping. Daughter stated patient becoming more and more agitation and experiencing issues with swallowing medications. Review of Patient #15s Coordination Notes revealed no documentation by the Social Worker indicating Patient #15s daughter verbalized the patient had been experiencing issues with swallowing medications. An interview was conducted on 03/19/2024 at 1:00 pm with S1ADM. She reviewed Patient #15s Social Worker assessment documentation completed on 03/11/2024. She confirmed the Social Worker documented he received information from Patient #15s daughter reporting she was experiencing issues with swallowing medications. She confirmed there was no documentation the doctor was made aware and should have been. She said the staff were required to coordinate care to ensure the patients were provided the care they need.

Based on interview and record reviews, the hospice agency failed to ensure nursing services met the needs for 2 (#7 and #8) of 3 (#7, #8 and #11) patients reviewed for pressure wounds. The agency failed to follow acceptable standards of practice for wound care by failing to complete weekly wound measurements for Patients #7 and #8. --- Review of the Louisiana State Board of Nursing Declaratory Statement Scope of Practice for Registered Nurses - Wound Care Management adapted 02/1999 revealed the following in part: Registered nurses 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 conditions involves 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. 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 registered nurse 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 Registered Nurse 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 National Pressure Ulcer Advisory Panel Prevention and Treatment of Pressure Ulcers: Quick Reference Guide revealed, in part, the following: Pressure Ulcer Assessment 1. Assess the Pressure Ulcer initially and re-assess it at least weekly. 1.1. Document the results of all wound assessments. Assess and document physical characteristics including: location, Category/Stage, size, tissue type(s), color, peri-wound condition, wound edges, sinus tracts, undermining, tunneling, exudate, and odor. Patient #7 Review of the Clinical Record for Patient #7 revealed he was admitted to the agency on 02/10/2024. Review of the Plan of Care for certification period 02/10/2024 – 05/09/2024 revealed a diagnosis of Pressure Ulcer of Right Lower Leg, Stage 3. Further review of the Plan of Care revealed orders for the following frequency of Skilled Nurse visits: 1 time a week for 1 week then 2 times a week for 13 weeks. Review of the Physicians Orders for Patient #7, dated February 2024, revealed the following: Cleanse wound with wound cleanser. Apply Medihoney, cover with dressing and change every 2 days and prn. Review of the Skilled Nurse visit wound documentation revealed visits were conducted on the following weeks during the current certification period: Week of 02/12/2024, 02/19/2024, 02/26/2024 and 03/04/2024. Further review revealed there was no documentation of weekly completed wound assessments to include measurements for Patient #7. Patient #8 Review of the Clinical Record for Patient #8 revealed she was admitted to the agency on 12/27/2023. Review of the Plan of Care for certification period 02/25/2024- 04/24/2024 revealed a diagnosis of Sacral Pressure Ulcer, Stage 3. Further review of the Plan of Care revealed orders for the following frequency of Skilled Nurse visits: 3 times a week for 8 weeks then 2 times a week for 1 week. Review of the Physicians Orders for Patient #8, dated February 2024, revealed the following: Cleanse with wound cleaner and pat dry with 4x4. Apply bordered foam dressing every 2 days and as needed for loose or soiled dressing. Review of the Skilled Nurse visit wound documentation revealed visits were conducted on the following weeks during the current certification period: Week of 03/04/2024. Further review revealed there was no documentation of weekly completed wound assessments to include measurements for Patient #8. An interview was conducted on 03/18/2024 at 12:50 p.m. with S1ADM. She verified Patient #7 had a Stage 3 Pressure Ulcer to Right Lower Leg and Patient #8 had a Stage 3 Sacral Pressure Ulcer. She reviewed Patient #7 and #8s Clinical Record and verified on the weeks listed above there was no wound measurements documented. She said measurements of the wound should be documented weekly by the Registered Nurse. She said Patient #7s nurse was a new nurse and was unsure if she was aware wounds needed to be measured weekly and Patient #8s nurse reported she thought wounds were required to be documented monthly. She said measurements and description of the wound should be documented weekly by the Registered Nurse and had not been.

Based on record review, observation, and interview the agency failed to ensure the registered nurse (RN): 1. Placed a barrier on Patient #1s floor while Patient #1 stood on the floor with exposed, open heel wounds; 2. Did not attempt to use a dressing which was contaminated after falling to a surface without a surface barrier; 3. Changed gloves and used appropriate hand hygiene between clean and dirty procedures; and 4. Changes gloves and used appropriate hand hygiene between wounds. This deficient practice was identified for 1 of 1 sampled patients (Patient #1) observed during wound care in a total sample of 5. Findings: --- Review of the CDCs (Center for Disease Control) Clean Hands Count for Healthcare Providers revealed hand hygiene should be used when: Multiple opportunities for hand hygiene may occur during a single care episode. Following are the clinical indications for hand hygiene: immediately before touching a patient; before performing an aseptic task or handling invasive medical devices; before moving from work on a soiled body site to a clean body site on the same patient; after touching a patient or the patients immediate environment; after contact with blood, body fluids or contaminated surfaces; and immediately after glove removal. Further review revealed wear gloves, according to Standard Precautions, when it can be reasonably anticipated that contact with blood or other potentially infectious materials, mucous membranes, non-intact skin, potentially contaminated skin or contaminated equipment could occur. Review revelaed gloves are not a substitute for hand hygiene; if your task requires gloves, perform hand hygiene prior to donning gloves, before touching the patient or the patient environment; perform hand hygiene immediately after removing gloves; change gloves and perform hand hygiene during patient care, if gloves become damaged, gloves become visibly soiled with blood or body fluids following a task, moving from work on a soiled body site to a clean body site on the same patient or if another clinical indication for hand hygiene occurs. Review of Patient #1s Wound record Report revealed the following active wounds: Mid-coccyx pressure ulcer stage IV; Left Mid-calf stage II; Left mid-heel unstageable wound; Right mid heel unstageable wound; Right medial proximal upper leg stag II; Left lateral proximal thigh proximal stage III; Left lateral mid-lower leg stage II; and right medical malleolus stage II pressure ulcer. Observation on 10/17/2022 at 8:33am, revealed Patient #1 was brought into his room for wound care with open wounds present, without any dressings present. S4HA (Hospice Aide) stood Patient #1 up on the floor with maximum assistance for wound care to be provided to his sacrum. Observation revealed no barrier was placed on the floor for Patient #1 to stand on during wound care while Patient #1s bilateral (both left and right) heel wounds were touching the floor uncovered. Further observation revealed S3RN had applied 3 pairs of gloves to her hands prior to providing wound care. S3RN proceeded to clean Patient #1s sacral wound, without changing gloves, S3RN proceeded to obtain the dressing she had previously setup on a bedside table when the dressing fell to the unprotected floor with the exterior of the dressing facing the floor. S3RN then stated to herself in a low tone ";it landed face up" and then proceeded to place back on her barrier and remove her outer layer of gloves and proceeded with wound care. S3RN then looked at surveyor and then decided to replace the dressing. S3RN then proceeded to measure, clean, and dress wounds to Patient #1s left ischium (lower part of the buttock on pelvic bone), left lower buttock, and right lower buttock without removing gloves and performing hand hygiene (either use of handwashing or hand sanitizer to cleanse the hands) between the clean and dirty procedures of wound care, and between wounds. Patient #1 was then placed in bed for wound care to bilateral lower extremities (both legs and feet), at which time S3RN removed one of the outer sets of gloves and did not perform hand hygiene. S3RN then set up her remaining dressings, measured the wounds to the right lower extremity, and photographed the wounds. S3RN then removed gloves, used hand sanitizer and applied 3 sets of gloves. S3RN proceeded to clean the multiple wounds to the right lateral lower extremity with the same gauze and without changing gloves between wounds. S3RN proceeded to use the same sterile cotton tipped applicator to apply all ointments to the multiple wounds, and then dressed the wounds. S3RN then removed an outer layer of gloves, however did not perform hand hygiene, prior to starting wound care to the left lower extremity. S3RN provided wound care to left heel and left lateral leg without changing gloves or using hand hygiene between wounds. S3RN then removed a set of gloves with one remaining set on and without using hand hygiene and placed an additional set of gloves on. S3RN then applied a cream to the scabs on the left foot toes, removed her gloves and applied a bandage to the left foot toes. In an interview on 10/17/2022 at 2:50pm, surveyor reviewed the above observation with S3RN. S3RN stated she should have placed a barrier between Patient #1s open heel wounds and the floor. S3RN further stated she did not realize she could not apply multiple gloves in the place of changing gloves and use of hand hygiene. S3RN stated she should have ensured she had clean gloves on between each wound, and clean and dirty procedures. S3RN further stated she should not have placed the dressing which fell to the floor back on her barrier for use. In an interview on 10/17/2022 at 3:36pm, S1Administrator and S2Branch Director were informed of the above mentioned observation. S1Administrator and S2Branch Director stated based on the observations discussed the nurse had several breaks in infection control.

Based on record review and interview the agency failed to ensure a hospice aide did not perform complex wound care for 1 of 4 sampled patients (Patient #1) who had wound care and hospice aide services in a total sample of 5. Findings: --- Review of Patient #1s Wound record Report revealed the following active wounds: Mid-coccyx pressure ulcer stage IV; Left Mid-calf stage II; Left mid-heel unstageable wound; Right mid heel unstageable wound; Right medial proximal upper leg stag II; Left lateral proximal thigh proximal stage III; Left lateral mid-lower leg stage II; and right medical malleolus stage II pressure ulcer. Review of Patient #1s Wound Care Orders dated 10/10/2022 revealed wound care orders for Coccyx, left mid-calf, left mid-heel, right mid-heel, right proximal upper leg, right malleolus, left lateral thigh, left lateral mid-lower leg, right lateral malleolus, right lateral edge of foot, left anterior mid dorsal foot, left lateral ankle. Further review revealed to clean wounds with soap and water or wound cleanser, pat dry, crush Flagyl (medication used to treat infections) to wound bed apply Dakins solution or medi-honey apply calcium alginate with silver dressing. Cover with foam dressing or ABD (thick absorbent dressing) pad and secure with mepilex dressing. Change dressing 2-3xwk and prn (as needed). In an interview on 10/17/2022 at 8:33am, Patient #1s spouse stated S4HA (hospice aide) would place the medications and pads on Patient #1s wounds. Patient #1s spouse stated whenever the nurse was not scheduled for wound care S4HA would perform the dressing changes. In an interview on 10/17/2022 at 10:09am, S4HA stated he had asked for a nurse to assess Patient #1s wounds. S4HA stated when the agency sent someone out he thinks it was maybe to assess the sacrum, both heels, and the lower extremity wounds. S4HA stated the nurse would drop off the supplies for wound care when Patient #1 would become combative during wound care, and Patient #1s spouse would tell me the nurse told her to inform me the dressing supplies were delivered. S4HA stated the nurses did not attempt to train me for wound care. S4HA stated after Patient #1s showers, he would clean the wound with either wound cleanser or betadine and apply the cream which was left there and apply a gauze pad. S4HA stated S3RN never spoke to me about the dressing changes, and I never dated the dressings because I knew I would be back the next day. In an interview on 10/17/2022 at 2:50pm, S3RN stated Patient #1 was often refusing wound care and was even combative with the familys attempts to provide wound care. S3RN stated there had been times when she provided wound care and the dressing to his buttock/sacrum was different than the dressing she had applied at the previous visit. S3RN stated when she had questioned the family about the dressing changes, the family had told her S4HA had changed the dressing because S4HA was the only person Patient #1 would allow to do the dressing changes. S3RN stated she had notified S2Branch Director of the issue because this was not within his scope of practice. In an interview on 10/17/2022 at 3:22pm, S2Branch Director stated when started with the agency in May 2022 the agency had a meeting with the hospice aides and discussed them only providing care within their scope of practice. S2Branch Director stated the hospice aides have been taught if a dressing comes off, they can cover the wound with a plain dressing and notify the nurse to make a visit to provide wound care. S2Branch Director further stated she was not aware of any issues of S4HA or any other hospice aides providing wound care.

Based on record review and interview the agency failed to ensure the registered nurse documented wound care assessment or refusal of wound care in the patients clinical record for 1 of 4 sampled patients (Patient #1) reviewed for wound care assessments in a total sample of 5. Findings: --- Review of Patient #1s IDG (Interdisciplinary Group) Notes dated 07/15/2022 revealed Patient #1 was assessed as having a deep tissue injury to the left heel. Review of Patient #1s IDG Notes dated 07/29/2022 revealed Patient #1 was assessed as having a left heel pressure injury, and coccyx pressure injury. Review of Patient #1s IDG Notes dated 08/12/2022 revealed Patient #1 was assessed as having pressure injuries with some mild improvement to the right heel and buttock. Review of Patient #1s IDG Notes dated 08/25/2022 revealed Patient #1 was assessed as having new skin shearing to the buttock, a chronic pressure injury to coccyx, unstageable pressure injury to the right heel. Review of Patient #1s Nurses Notes and Wound Assessment revealed no documented evidence of skin assessments or refusals of care having been documented on 07/19/2022, 07/27/2022, 08/19/2022, and 08/26/2022. In an interview on 10/17/2022 at 2:50pm, S3RN stated she had been taking measurements since the beginning and would document any assessment in her notebook and later transfer into the computer charting. Review of S3RNs Personal Notebook with multiple dates and multiple patients recorded per date revealed wound measurements were obtained on 07/19/2022, 07/27/2022, refusal of wound care on 08/19/2022, and 08/26/2022. In an interview on 10/18/2022 at 1:49pm, S3RN stated all wound assessments and patient refusals of care should have been documented in the clients medical record and was not.