Every finding on record at Legacy Hospice

Upon patient record review, 7 of 19 (Patient #1,4,5,6,8,9,10) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #1: The record showed the medication profile contained milk of mag and bisacodyl listed for constipation daily prn. No evidence that instructions were given on which medication to give first for constipation. COS Patient #4: The record showed the medication profile contained miralax oral powder with no instructions for a diluent. Medication profile has Senna/Docusate combo, miralax, and saline enema listed for constipation daily PRN. No evidence that instructions were given on which medication to give first for constipation. COS Patient #5: The medication profile contained miralax oral powder with no instructions for a diluent. COS Patient #6: The record showed the medication profile contained miralax oral powder with no instructions for a diluent. Medication profile has Milk of Magnesium, miralax, and bisacodyl listed for constipation daily PRN. No evidence that instructions were given on which medication to give first for constipation. COS. Patient #8: The record showed the medication profile contained miralax oral powder with no instructions for a diluent. COS Patient #9: Medication profile has tylenol, tramadol, and morphine listed for pain PRN q4 hours. No evidence that instructions were given on which medication to give first for pain. COS Patient #10: The record showed the medication profile contained miralax oral powder with no instructions for a diluent. COS

Upon patient record review, 7 of 19(Patient #1,4,5,6,8,9,10) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #1: The record showed the medication profile contained milk of mag and bisacodyl listed for constipation daily prn. No evidence that instructions were given on which medication to give first for constipation. COS Patient #4: The record showed the medication profile contained miralax oral powder with no instructions for a diluent. Medication profile has Senna/Docusate combo, miralax, and saline enema listed for constipation daily PRN. No evidence that instructions were given on which medication to give first for constipation. COS Patient #5: The medication profile contained miralax oral powder with no instructions for a diluent. COS Patient #6: The record showed the medication profile contained miralax oral powder with no instructions for a diluent. Medication profile has Milk of Magnesium, miralax, and bisacodyl listed for constipation daily PRN. No evidence that instructions were given on which medication to give first for constipation. COS. Patient #8: The record showed the medication profile contained miralax oral powder with no instructions for a diluent. COS Patient #9: Medication profile has tylenol, tramadol, and morphine listed for pain PRN q4 hours. No evidence that instructions were given on which medication to give first for pain. COS Patient #10: The record showed the medication profile contained miralax oral powder with no instructions for a diluent. COS

Upon client record review, 4 of 19 (Patient #3,5,7,9) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 3: The record indicates that volunteer services were accepted at the time of admit. The record shoes that a volunteer made a visit on 06/17/2024 and 2 visits for the month of August. No evidence that a frequency was obtained at the start of volunteer services. Patient 5: The record indicates that volunteer services were accepted at the time of admit. The record shoes that a volunteer made a visit on 06/17/2024 and 2 visits for the month of August. No evidence that a frequency was obtained at the start of volunteer services. Patient 7: The record indicates that volunteer services were declined at the time of admit. The record shoes that a chaplain made one month since March 2024. No evidence that an order was received to start chaplain services. Patient 9: The record indicates that the patient received 2 SC visits for the month of June. Plan of care has SC orders for one visit a month. No evidence that an order was received to increase SC visits for that month.

Upon patient record review 1 of 19 (Patient #12) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient 12: Plan of care has orders for the aide to complete 5 visits a week. The record indicates that the patient received 4 visits for the week of 08/25/2024. No evidence that an order was received to decrease visits for that week or that the visit was declined for the day.

Upon observation, there was no evidence that branch (multiple) locations share administration, supervision, and services with the parent hospice location. Upon observation, there was no evidence that the branch has provided services to patients. Reports that the branch is used as an alternate delivery site/drop site and no patients have ever been admitted to the branch.

Upon patient client record review, 1 of 19 (Patient #5) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient 5: Record shows date on hospice admission agreement listed as 08/01/2020, the record indicates that the patient was admitted on 08/01/2024. COS

Based on record review and interview, the agency nurses failed to update a comprehensive assessment in coordination with the IDG (Interdisciplinary Group) and physician regarding changes in patient condition since the initial assessment in 1 of 10 patients (Patient #1). --- Findings include: Review of agency policy titled ";Hospice Nursing Care" (dated November 2023) revealed in part, ";Procedure: 2. The hospice nurse will participate in developing and implementing the plan of care and will report the condition of the patient and family/caregiver to the attending physician, medical director, and IDG on a regular basis, as well as changes in the plan of care." Review of agency policy titled ";The Plan of Care" (dated November 2023) revealed in part, ";Procedure: 9. The plan of care will be reviewed and revised as frequently as deemed necessary, but not less often than every 15 days, by the IDG, with input from the attending physician, the patient, the family/caregiver, based on ongoing comprehensive assessments of the patient and family/caregiver. 10. Any change in the patient condition must result in a change in the plan of care, prior to implementation of a new service." Record review of Initial Complaint Intake dated 08/08/2024 from Complainant A in part, ";Of note: 7/18 and 7/21, vet (Veteran) called the telephone triage line through the VA (Veterans Administration) and was complaining of full body itching. On 7/22 VA Nurse Practitioner called the hospice RN to report this. Hospice RN saw vet on 7/22 and Patient #1 had no complaints or itching. Another hospice RN was planning to see Patient #1 the next day and was going to specifically ask about the itching. 7/29: Called VA triage line to report lump on left side of face." Review of Patient #1s hospice record revealed Patient #1 was admitted to hospice on 10/06/2023 with primary diagnoses of End Stage Heart Failure. Patient #1 resided in an assisted living facility. Patient #1 had 2 wounds while on hospice service labeled as ";Skin Growth top of head" started 01/15/2024 and ";Left forehead wound" started 04/23/2024. Orders were discontinued on 06/27/2024. On 05/31/2024 to 07/30/2024, Patient #1 had intermittent issues with itching and picking at the wounds and/or arms and scabbing with education and reminders provided by hospice staff. Record review of Patient #1s POC/physician orders revealed: 10/06/2023: ";Skin Breakdown: Fragile skin: Interventions: Hospice SN will notify physician of patients skin condition and any new areas of skin breakdown. Hospice SN will assess for actual and potential skin breakdown during each visit." Record review of Patient #1s ";Nursing Visit Notes" and "IDG (Interdisciplinary Group) Updates" related to skin integrity from 04/15/2024 to 07/31/2024 revealed: Skin Integrity Assessments: 07/02/2024: Skin: ";Redness to buttock area. Barrier cream applied." 07/09/2024 IDG Update: No skin assessment updates documented this IDG." 07/16/2024: Skin: ";Redness to buttock area. Improving. Barrier cream applied." 07/18/2024: Skin assessed, no issues identified. 07/22/2024: No documentation of skin assessment. 07/23/2024 IDG Update: No skin assessment updates documented this IDG. (No SN visit was made on 07/23/2024 to assess skin integrity.) 07/26/2024: Skin: ";Small scabs from scratching skin to lower arms." There was no documentatation that the skin issues for Patient #1 were assessed and discussed with physician and/or IDG. During an interview with RN Director of Clinical Services B on 09/03/2024 at 11:10 AM, when asked for a policy or process regarding this hospice agencys expectations for nurses regarding skin assessments RN Director of Clinical Services B replied, ";There is no specific policy. Would refer to physician orders or plan of care under skin or wound."

Based on record review and interview, the agency nurses failed to provide core nursing services for wound and skin assessment and intervention in 2 of 10 wound patients records reviewed (Patient #1 and Patient#4). --- Findings include: 1.The agency nurses failed to assess the nursing needs of the patients related wound and skin assessments and reporting to physician based on the plan of care orders. See L591: Nursing Services This failure has the potential to have a cumulative effect on all patients that have wounds.

Based on record review and interview, the agency nurses failed to provide nursing services per physician POC (Plan of Care) orders related to wound and skin assessment and reporting changes in condition in 2 of 10 wound patient records reviewed (Patient #1 and Patient #4). --- Findings include: Record review of Initial Complaint Intake dated 08/08/2024 from Complainant A in part, ";Of note: 7/28 and 7/21, vet (Veteran) called the telephone triage line through the VA (Veterans Administration) and was complaining of full body itching. On 7/22, VA Nurse Practitioner called the hospice RN to report this. Hospice RN saw vet on 7/22 and Patient #1 had no complaints or itching. Another hospice RN was planning to see Patient #1 the next day (07/23/24) and was going to specifically ask about the itching. 7/29: Called VA triage line to report lump on left side of face." Review of Patient #1s hospice record revealed Patient #1 was admitted to hospice on 10/06/2023 with primary diagnoses of End Stage Heart Failure. Patient #1 resided in an assisted living facility. Patient #1 had 2 wounds while on hospice service labeled as ";Skin Growth top of head" started 01/15/2024 and ";Left forehead wound" started 04/23/2024. Orders were discontinued on 06/27/2024. On 05/31/2024 to 07/30/2024, Patient #1 had intermittent issues with itching and picking at the wounds and/or arms and scabbing with education and reminders provided by hospice staff. Review of agency policy titled ";Hospice Nursing Care" (dated November 2023) revealed in part, ";Procedure: 2. The hospice nurse will participate in developing and implementing the plan of care and will report the condition of the patient and family/caregiver to the attending physician, medical director, and IDG. 3. The hospice nurse will: G. Prepare clinical and progress notes that demonstrate progress toward established goals" Review of agency policy titled ";The Plan of Care" (dated November 2023) revealed in part, ";Procedure: 10. Any change in the patient condition must result in a change in the plan of care, prior to implementation of a new service. 14. Care provided to the patient will be in accordance with the plan of care." During an interview with RN Director of Clinical Services B on 09/03/2024 at 11:10 AM, when asked for a policy or process regarding expectations for skin assessments, wound assessments and wound care, RN Director of Clinical Services B replied, ";There is no specific policy. Would refer to physician orders or plan of care under skin or wound." Record review of Patient #1s POC/physician orders revealed: 10/06/2023: ";Skin Breakdown: Fragile skin: Interventions: Hospice SN will notify physician of patients skin condition and any new areas of skin breakdown. Hospice SN will assess for actual and potential skin breakdown during each visit." 01/15/2024: ";Wound Care for skin growth on top of head: Hospice RN to assess for further wound care needs. Hospice RN to assess for signs of infection. Notify physician of patients skin condition and any new areas of skin breakdown. Document appearance, measurements (length, wide, depth), drainage, and stage of skin at least weekly. Wound care as follows: Remove old dressing, cleanse, pat dry, xeroform and covered with bordered foam dressing. Complete weekly and as needed. Orders discontinued 06/27/2024." 04/23/2024: ";Wound Care for mass on left forehead: Hospice RN assess for signs of infection. Notify physician of patients skin condition and any new areas of skin breakdown. Document appearance, measurements (length, wide, depth), drainage, and stage of skin at least weekly. Wound care as follows: Remove old dressing, cleanse, pat dry, xeroform and covered with bordered foam dressing. Complete weekly and as needed. Orders discontinued 06/27/2024." Record review of Patient #1s ";Nursing Visit Notes" for assessment of "skin growth on top of head" and "mass on left forehead" from time period 04/14/2024 to 07/31/2024 revealed no documented wound assessments that included appearance and measurements per POC/Physician orders the week of 04/14/2024, 04/21/2024, 04/28/2024, 05/05/2024, 05/12/2024, 05/19/2024, 05/26/2024, 06/02/2024, 06/09/2024, 06/16/2024, and 06/23/2024. Record review of Patient #1s ";Nursing Visit Notes" for assessment of skin from time period 04/14/2024 to 07/31/2024 revealed an SN visit was made on 07/18/2024 and no issues identified. There was no additional documentation regarding concerns from 7/21/2024. A SN visit was made on 07/22/2024 with no evidence of a skin assessment documented. No follow up skin assessment for 07/23/2024 or documented evidence of skin assessment related to the skin issues of full body itching . 07/30/2024 SN Visit: ";Left forehead growth now appears larger and has small amount of blood coming from area. Some very light pink surrounding skin. Not warm to touch. Writer cleansed area with wound cleanser and applied xeroform followed by bordered foam dressing. Patient tolerated well, with some grimacing when touching area. Patient has blood under nails, appears he was picking at area. Patient does have small scabs on arms from scratching. Patient then starting touching bandage saying oh honey I dont know why this is hurting me." There was no documentation that the physican was notified of the assessed wound changes in condition on 07/30/2024. During an interview with RN Director of Clinical Services B on 09/03/2024 at 1:25 PM, the above findings regarding missing wound assessments and measurements for Patient #1 were discussed. When asked if documentation for wounds would be found anywhere else in the record, RN Director of Clinical Services B replied, ";No, you would not." When asked if it would be agreed that the wounds were not assessed or measured, RN Director of Clinical Services B replied, ";That is correct. They were not. I had specific conversations with nurses about the need for weekly assessments and measurement." During an interview with Nurse D (Hospice nurse involved in Patient #1s care) on 09/03/2024 at 1:40 PM, when asked the agency protocol for wound patients in terms of assessment, Nurse D replied, ";We should assess weekly and include measurements and appearance." When asked if there is a significant change in the wound status and what the protocol would be, Nurse D replied, ";I would call our wound nurse to get a plan in place. Do a wound assessment and let the facility and family know about the new area and what the treatment would be." Regarding care of Patient #1 specifically, when asked if made aware of Patient #1 and any new skin issues or concerns, Nurse D replied, ";There were no skin issues. I often toileted him and I did not see anything." When asked if there was any significant change in condition related to the skin or scalp wound that warranted notification to a physician, Nurse D replied, ";There was no drainage, just a scab near the end, and was healing nicely. The last 2 weeks on service was the first sign of new bleeding or drainage. I did continued education on not picking, as he liked to pick at scabs...I noticed redness on day when he was sent in. I did not see any other signs and symptoms of infection prior to." Review of Patient #4s hospice record revealed Patient #4 was admitted to hospice on 07/30/2024 with primary diagnoses of Malignant Neoplasm of female breast. Patient #4 resided in an assisted living facility and had 1 right breast wound while on hospice service. Record review of Patient #4s POC/physician orders revealed, "07/30/2024: Skilled Nursing: 2 times per week and as needed. 07/30/2024: For right breast wound: Hospice Skilled Nurse to Document appearance, measurements (length, wide, depth), drainage, and stage of skin at least weekly. Wound Care: Skilled nurse facility to complete wound care." Record review of Patient #4s ";Nursing Visit Notes" for assessment of "right breast wound" from time period 07/30/2024 to 08/29/2024 revealed no documented wound assessments that included appearance and measurements per POC/Physician orders the week of 08/04/2024, 08/11/2024, 08/18/2024, and 08/25/2024. During an interview with RN Director of Clinical Services B on 09/03/2024 at 1:25 PM, the findings regarding missing wound assessments for Patient #1 were discussed. When asked if it would be agreed that the wounds were not assessed or measured, RN Director of Clinical Services B replied, ";That is correct. They were not. I had specific conversations with nurses about the need for weekly assessments and measurement." During an interview with RN Director of Clinical Services B and Executive Director C on 09/03/2024 at 4:10 PM, findings for Patient #4 were reviewed and confirmed regarding missing wound assessments and measurements. RN Director of Clinical Services B stated, ";There were no assessments. Care was done by the facility." When asked for hospice patients that reside in a facility that do wound care, would the expectations be that hospice nurses still assess and measure wounds weekly based on the plan of care, Executive Director C and RN Director of Clinical Services B replied, ";Yes."