Every finding on record at Lhcg Xxix, LLC

Based on medical record (MR) review, agency policy and procedure, and interview, it was determined the hospice failed to ensure the Interdisciplinary Group (IDG) updated the Plan of Care (POC) to reflect changes in the patient's condition. This affected 1 of 8 active records reviewed, including MR # 1, and had the potential to negatively affect all patients served by the agency. Findings include: Agency Policy: IDG Membership and Responsibilities Policy number: 3.002 Date revised: 11/1/21 Purpose: To define roles and responsibilities of the Interdisciplinary Group. Policy: The hospice IDG collaborates with the patient's attending physician to develop and maintain a patient-directed, individualized plan of care... Procedure: ...2. The IDG responsibilities include... b) Reviewing, revising, and documenting the individualized plan of care... A revised plan of care must include information from the patient's updated comprehensive assessment and must note the patient's progress toward outcomes and goals specified in the plan of care. ...e) Ensuring that the care and services provided are based on all assessments of the patient and family needs. f) Providing for and ensuring the ongoing sharing of information between all disciplines providing care... 1. MR # 1 was admitted to the agency on 2/2/22 with diagnoses including Malignant Neoplasm of Rectosigmoid Junction, and Secondary Malignant Neoplasm of Bone. Review of the SN (Skilled Nurse) Visit Note dated 2/11/22 revealed MR # 1's temperature was 100.3 and pulse 103. In the narrative note the SN documented the wound to the coccyx now has a mild odor. There was no documentation the physician was notified. Review of the SN Visit Note dated 2/14/22 revealed the SN documented the following changes in the patient's neurologic status: ...lethargic ...abnormal thought process, abnormal thought content, abnormal insight and judgement... misinterpreting own memories... reporting of certainties not being real... unrealistic judgement. In the narrative note, the SN documented the following, "...When nurse arrived, patient would not answer the door. Nurse called father and he insured that the pt (patient) was at his/her own residence today. Eventually pt answered his/her phone then came to door. Pt was extremely lethargic. His/her ostomy bag had leaked onto his/her abdomen..." There was no documentation the physician was notified of the changes in the patient's neurologic condition. Review of the SN Visit Note dated 2/18/22 revealed the patient's coccyx wound measurement (length x width x depth) in cm (centimeters) was 9 x 7 x 0, an increase from 5 x 5 x 0.5 on 2/11/22. The SN also documented for both lower extremities, " ...4 + (plus) very deep pitting, indentation lasts a long time, extremity is very swollen." There was no documentation the physician was notified of the wound measurement increase or the patient's new 4 + pitting edema. Review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report for meeting date 2/23/22, revealed no documentation of the patient's changes in wound assessment, neurologic changes, or 4 + pitting edema. The agency staff failed to document the IDG was updated about changes in patient's condition. An interview was conducted on 2/24/22 at 10:34 AM with Employee Identifier # 1, Registered Nurse, Executive Director, who confirmed staff failed to report changes in patient condition.

Based on review of medical records (MR), agency policies and procedures, and interview with staff, it was determined the hospice failed to monitor a patient prescribed a high risk medication. This affected HV (Home Visit) # 2, 1 of 2 medical records reviewed with patients diagnosed with Diabetes Mellitus, and had the potential to affect all patients with Diabetes Mellitus admitted to the agency. Findings include: Agency Policy: High Risk Medications Policy number: 12.006 Date revised: 11/01/21 Purpose: To promote and maximize patient health and safety when administering high risk medications. Policy: The agency plans, supports, and coordinates patient and caregiver education designed to promote optimal patient health and safety... ...Procedure: ...2. The agency identifies the following drug categories as high risk. Medications in these categories would be considered high risk medications. ...Insulins Rapid acting... Humalog... ...Long acting... Levemir ...6. The clinician assesses the patient and/or caregiver's level of... compliance and documents such in (the) medical record. Agency Policy: Plan of Care Policy number: 3.003 Date revised: 11/01/21 Purpose: To ensure each patient has an individualized plan of care that includes the specific needs, goals and desires of the patient. ...Procedure: ...2. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including the following: ...d. Drugs, biologicals and treatments necessary to meet the needs of the patient. 1. HV # 2 was admitted to the agency on 1/11/22 with diagnoses including Essential (Primary) Hypertension, and Type 2 Diabetes Mellitus with Hyperglycemia. Review of the Hospice Certification and Plan of Care, dated 1/11/22 to 3/11/22, revealed the following orders: SN (Skilled Nurse) 3WK (Week) 1, 2WK7, 1WK1 HHA (Home Health Aide) 1WK1, 2WK 8 A HV was conducted on 2/22/22 at 2:00 PM to observe care provided by Employee Identifier (EI) # 3, Hospice Aide. Prior to the HV, the surveyor received a current Medicine List, printed on 2/22/22. Review of the current Medicine List, dated 2/22/22, revealed the patient was prescribed the following Insulins: Humalog Kwikpen (U [Units]- 100) Insulin, 100 Unit/Ml (Milliliters), Subcutaneous, as directed per sliding scale... Levemir Flextouch U-100 Insulin, 100 Unit/Ml subcutaneous pen, 35 units, at bedtime. The medications were observed in the home, and doses were confirmed by the patient. Review of the RN (Registered Nurse) Admission Visit Note dated 1/11/22 revealed the nurse documented a fasting blood sugar of 132. Review of 12 RN Visit Notes, dated 1/12/22 to 2/18/22, revealed the SN failed to assess and document the patient's blood sugars. An interview was conducted on 2/24/22 at 10:10 AM with EI # 1, RN, Executive Director, who confirmed staff failed to assess and monitor a patient prescribed a high risk medication, per policy.

Based on observation, review of agency policy and procedure, and staff interviews, it was determined the agency failed to ensure staff followed their policy for hand hygiene. This deficient practice affected 1 of 3 home visits (HV) performed and did affect HV # 1 and had the potential to affect all patients served by the agency. Findings include: Agency Policy: Hand Hygiene Policy Number: 10.002 Revised Date: 3/1/21 Purpose: To help prevent the spread of microorganisms and infection by cross-contamination and to provide practice guidelines. Policy: Staff are required to perform hand hygiene prior to, at specified time points during, and following patient contact... Procedure: 1. Staff performs hand hygiene ... a. before direct contact with patients. ...f. after contact with inanimate objects (including medical equipment...) in the immediate vicinity of the patient, before and after removing personal protective equipment (PPE) such as gloves, ... 1. HV # 1 was admitted to the agency on 7/30/21 and recertified for care 1/26/22 to 3/26/22 with a terminal diagnosis of Alzheimer's Disease Unspecified. A HV was conducted on 2/22/22 at 11:35 AM to observe Employee Identifier (EI) # 2, Registered Nurse (RN), provide wound care and change HV # 1's foley catheter. EI # 2 applied gloves, obtained HV # 1's vital signs then cleaned the vital sign equipment (blood pressure cuff, stethoscope, thermometer) using alcohol wipes. Wearing the same gloves, EI # 2 then proceeded to cleanse the wound to HV # 1's coccyx. EI # 2 failed to change gloves and perform hand hygiene after contact with the medical equipment per the agency policy. Upon completion of the wound care, EI # 2 performed hand hygiene, donned gloves and prepared to change HV # 1's foley catheter. EI # 2, removed his/her gloves and went to his/her car and retrieved a 10 cubic centimeter syringe without performing hand hygiene per the agency policy prior to changing HV # 1's catheter. An interview was conducted on 2/24/22 at 10:23 AM with EI # 1, Registered Nurse Executive Director, who verified the staff failed to follow the agency policy for hand hygiene.

Based on review of medical records (MR), policies and procedures, agency job description for Hospice Aide (HA), and interviews with staff, it was determined the agency failed to ensure the HA performed assigned tasks as developed and written by the Registered Nurse (RN) for 3 of 7 active records reviewed with HA services. This affected MR # 2, Home Visit (HV) # 1, HV # 2, and had the potential to negatively affect all patients with HA services. Findings include: Agency Policy: Initial and Comprehensive Admission Assessment and Plan of Care Policy number: 2.002 Date revised: 3/1/21 Purpose: To describe the process of the initial and comprehensive hospice patient assessment. Policy: Within 48 hours of the receipt of a physician's order for hospice care, each patient admitted to the agency will receive an initial assessment performed by a registered nurse... to determine the patient's immediate care and support needs... Procedure: ...2. The initial assessment performed by the RN... will include the assessment of: ...(o) Need for nurse aide services... Agency Policy: Hospice Aide Supervision Policy number: 8.007 Revised date: 11/1/21 ...Policy: The Registered Nurse will supervise the Hospice aides... to ensure quality and appropriateness of the hospice aide service. Procedure: ...3. Aides are assigned to patients based on the assessment made by the staff RN... LHC (Louisiana Health Care) Group Aide Job Description Location: Hospice Job Code: 302 Job Summary: Under the supervision of Hospice nurses, the HA provides direct patient care and services as established in the patient's Plan of Care... Essential Functions: - Under the direction and ongoing supervision of a registered nurse, provides personal direct patient care services as established and delegated in the Plan of Care on a daily basis... 1. MR # 2 was admitted to the hospice agency on 11/4/21, and recertified for care 2/2/22 to 5/2/22 with diagnoses including Chronic Obstructive Pulmonary Disease, Unspecified, and Pressure Ulcer of Sacral Region, Unstageable. Review of the Hospice Recertification Orders dated 1/18/22 revealed a HA visit frequency of 2WK(week)1, 3WK12, 1WK1 effective 2/2/22. Review of the Aide Care Plan Report, effective date 11/5/21, revealed assigned tasks including Shampoo every visit. Review of the Aide Visit Note Reports (VNR) dated 2/2/22, 2/4/22, and 2/11/22 revealed the HA documented shampoo was not completed, "Note, only once a week." In an interview conducted on 2/24/22 at 10:32 AM, Employee Identifier (EI) # 1, RN Executive Director, confirmed Shampoo was assigned for every visit on the Aide Care Plan, and that the HA failed to perform all tasks assigned on the care plan. 2. HV # 1 was admitted to the agency on 7/30/21 and recertified for care 1/26/22 to 3/26/22 with a terminal diagnosis of Alzheimer's Disease Unspecified. Review of the Hospice Recertification Orders dated 1/11/22 revealed a HA visit frequency of 2WK1, 3WK8 effective 1/26/22. Review of the Aide Care Plan Report, effective date 9/23/21, revealed the following ordered tasks: Date of Last BM (Bowel Movement), every visit. Review of the Aide Visit Note Report (VNR) dated 2/11/22 revealed the HA failed to document the date of the last BM. In an interview conducted on 2/24/22 at 10:23AM, EI # 1 confirmed the date of the last BM was assigned for every visit on the Aide Care Plan, and that the HA failed to follow the care plan. 3. HV # 2 was admitted to the agency on 1/11/22 with diagnoses including Essential (Primary) Hypertension, and Type 2 Diabetes Mellitus with Hyperglycemia. Review of the Hospice Certification and Plan of Care, dated 1/11/22 to 3/11/22, revealed orders for HHA (Home Health Aide) 1WK1, 2WK 8. Review of the Aide Care Plan Report effective 1/11/22 revealed the following ordered tasks: Date of Last BM, every visit. Review of the Aide VNR dated 2/3/22 revealed the HA failed to document the date of the last BM. Review of the Aide Care Plan Report effective 2/7/22 revealed the following ordered tasks: Date of Last BM, every visit Review of the Aide VNR dated 2/21/22 revealed the HA failed to document the date of the last BM. Review of the Aide VNR dated 2/22/22 revealed the HA failed to document the date of the last BM. An interview was conducted on 2/24/22 at 10:10 AM with EI # 1, who confirmed the HA failed to complete all tasks listed on the Aide Plan of Care.

Based on review of medical records (MR), agency policies and procedures, and interview with agency staff, it was determined the agency failed to ensure the staff: 1. Accurately documented the size of foley catheter's. 2. Documented accurate assessments of wounds. This affected 2 of 8 active records reviewed, including Home Visit (HV) # 1, MR # 1, and had the potential to negatively affect all patients admitted to the hospice. Findings include: Agency Policy: Hospice Medical Record Policy Number: 9.001 Revision Date: 11/1/21 Purpose: To define the contents and requirements of the hospice medical record. Procedure: ...2. The hospice medical record shall contain the following clinical information: ...m. Any assessment relevant to care, treatment or services. ...7. Changes in entries in the Hospice record must be according to aceptable standards of practie. a. All entries recorded in the hospice record must be legible and accurate... Agency Policy: Wound Assessment, Documentation and Photography Policy Number: 3.029 Revision Date: 3/1/21 Purpose: To ensure the accurate and consistent assessment and documentation of wounds. Policy: Upon initial visit and subsequently as applicable, all wounds will be assessed with appropriate documentation within the medical record... Procedure: ...3. Document the following in the medical record: ...g. Stage the wound weekly ...i. Other pertinent findings: i. Wound ulcer classification 1. HV # 1 was admitted to the agency on 7/30/21 and recertified for care 1/26/22 to 3/26/22 with a terminal diagnosis of Alzheimer's Disease Unspecified. Review of a physician's order dated 9/23/21 revealed, "Skilled Nurse (SN) to insert 18 French Foley Catheter ... and change foley every month..." Review of the SN Visit Note Report (VNR) dated 1/24/22 revealed, "18 French Catheter inserted..." Review of the SN VNR's dated 2/2/22, 2/9/22 and 2/16/22 revealed indwelling catheter, "size 16". The SN failed to accurately document the size of the foley catheter. An interview was conducted on 2/24/22 at 10:23 AM with Employee Identifier (EI) # 1, Registered Nurse Executive Director, who verified HV # 1 had a size 18 foley catheter and that the staff failed to accurately document the size of the foley catheter. 2. MR # 1 was admitted to the agency on 2/2/22 with diagnoses including Malignant Neoplasm of Rectosigmoid Junction, and Secondary Malignant Neoplasm of Bone. Review of the Hospice RN (Registered Nurse) Start of Care Note dated 2/2/22 revealed the nurse documented the following in the Wound Assessment: "# 1- Mid Post (middle posterior) Coccyx, Art (arterial) Ulcer w/o (without) Bone Necros (Necrosis)... Wound Assessed- No, covered by non-removable dressing or device... Wound care provided- wound care not provided: covered by non-removable dressing or device." In the Narrative note, the RN documented, "... stage 4 pressure ulcer to coccyx..." Review of the RN Subsequent Visit Note dated 2/3/22 revealed the nurse documented the wound as a "...susp (suspected) DTI (Deep Tissue Injury)," in the wound assessment, and in the Narrative note documented, "...patient has a (an) unstageable pressure ulcer that was documented as a stage 4 in the hospital." Review of the physician's order dated 2/3/22 revealed the following wound care orders, "SN (Skilled Nurse) or caregiver to clean coccyx pressure ulcer with soap and water, pat dry, apply 1/4 inch of collagen pellets, cover with border dressing 3 times a week or as needed if soiled. Review of 4 SN Visit Notes, dated 2/11/22, 2/15/22. 2/18/22, and 2/21/22, revealed the SN continued to document the wound was both a suspected DTI and pressure ulcer. An interview was conducted on 2/24/22 at 10:34 AM with EI # 1, who confirmed the patient had no "non-removable dressing or device" covering the wound. EI # 1 further confirmed the wound was a pressure ulcer, incorrectly staged by the RN as a suspected DTI.