Every finding on record at Longleaf Hospice, LLC.

Based on review of clinical records and staff interview, it was determined that the interdisciplinary group failed to ensure the review and update of the plan of care was updated at least every 15 days or as frequently as the patient's condition requires for 1 of 1 patients (P#1). The findings include: Review of the plan of care dated 4/20/22, for P#1 with a diagnosis of Alzheimer's disease revealed the patient was admitted to hospice services on 4/20/22, with co-morbidities of dementia with agitated/aggressive behaviors. According to clinical note documentation on 4/22/22, P#1 became aggressive at home and was unable to be managed by caregivers. P#1 level of care was increase to general inpatient care and the patient was transferred to an inpatient care unit (IPU) for safety and stabilization. The clinical record lacked any documentation to indicate the plan of care was reviewed and updated/modified to include identified new patient behaviors, use of restraints and the less restrictive interventions to manage the agitated and aggressive behaviors. Upon arrival to the IPU on 4/22/22, the patient was medicated and placed in restraints which included a vest restraint, bilateral hand mittens, bilateral bed rails and chemical restraints. P#1 remained in these restraints from 4/22- 5/3/22, at which time the patient was transferred to a hospital setting due to a health decline. During an interview on 5/5/22, at approximately 2:00 p.m., the Director of Clinical Services acknowledged the plan of care had not been updated to address new patient behaviors and the use of restraints.

Based on clinical record review and staff interview, it was determined the hospice agency failed to ensure the clinical records included documentation to reflect patient's medications had been disposed of properly and family education was provided on drug disposal at the time of death for 2 of 5 patients (P) (P#16 and P#18) who expired The findings include : 1. Review of the clinical record for P # 16 who was admitted on 4/5/21, with a diagnosis of multiple myeloma revealed that the patient expired on 5/5/21. The record lacked documentation of proper drug disposal at the time of the patient's death. 2. Review of the clinical record for P #18 who was admitted on 5/21/21, with a diagnosis of pulmonary fibrosis unspecified revealed that the patient expired on 8/13/21. The record lacked documentation of proper drug disposal at the time of the patient's death. During an interview on 5/4/22, at 2:00 p.m., the Administrator confirmed the lack of documentation of drug disposal.

Based on review of clinical records, personnel records, policy review, quality assessment documentation, and staff interview, it was determined Longleaf Hospice failed to ensure that the requirements for the use and monitoring of restraints were met for patient #1, as evidenced by the agency's failure to ensure the restraint order contained the necessary elements to ensure patient safety such as: time limit of restraint, type of restraint and the frequency of monitoring (Refer to L742), failure to ensure a medical and behavior evaluation was conducted to manage violent behaviors (Refer to L752), failed to ensure all staff providing care at the inpatient facility was trained and competent in the application of restraints (Refer to L754), failed to ensure training consisted of techniques to identify patient behaviors, and monitoring of physical and psychological well-being of the patient (Refer to L755), failure to ensure training and alternative techniques was provided prior to the use of restraints (Refer to L756), and failed to ensure staff were provided education and deemed competent prior to the administration of restraint (Refer to L757). The cumulative effects of these systemic problems resulted in the hospice's inability to effectively apply, monitor and evaluate the application and use of restraints which could result in serious patient injury/harm or death.

Based on clinical record review, staff interview and review of the policy titled "" ASSESSMENT AND PLAN OF CARE, RESTRAINTS", it was determined the hospice agency failed to ensure the verbal order for the application of restraints was complete and not used an as needed ( PRN) order for 1 of 1 sampled patients (P) (#1). The findings include: Review of the clinical record for Patient #1 with an admission date of 4/20/22, and diagnosis of Alzheimer's Disease revealed a verbal order dated 4/22/22, for restraints the order does not include necessary elements for the safety of the patient. The order lacks a time limit for restraints, the type of restraint used, frequency of monitoring process as well as a mandatory release at least every 30 minutes per agency policy titled, " ASSESSMENT AND PLAN OF CARE, RESTRAINTS" item B, revised December 2, 2008 page 17. During a telephone interview on 5/3/22, at 11:18 a.m., regarding restraints the Medical Director stated restraints were ordered for P#1 on 4/22/22, if the patient exhibited out of control and combative behavior. According to the Medical Director, P#1 had engaged in combative behaviors at home and needed to be sent to an inpatient unit for stabilization. When asked if he was aware that P#1 had been in restraints from 4/22-5/3/22, the Medical Director states he was not aware the patient had been in restraints and had not been given a report from the staff that P#1 was being restrained. The Medical Director denied giving any orders for the patient to be restrained after 4/22/22, and stated he does not want any of his patients to be restrained however, if the need for restraints is required the expectation is the restraints will be removed immediately when the patient is calm. During an interview on 5/5/22, at 3:00 p.m.,the Director of Clinical Services acknowledged the restraint order was incomplete.

Based on staff interview, observation and review of the agency policy titled, " ASSESSMENT AND PLAN OF CARE, RESTRAINTS" and the lack of evidence provided to the surveyor by Longleaf Hospice it was determined the hospice failed to ensure a medical and behavioral evaluation was conducted to manage the violent behaviors which resulted in the application of restraints for 1of 1 patients (P) #1. During observation on 5/2/22, at approximately 10:30 a.m., with the Registered Nurse (RN) AA from Longleaf Hospice, this surveyor observed an elderly gentleman laying in bed with a vest restraint applied and tied to the bed frame, hand mittens on both hands with full side rails raised on both sides of the bed. Patient #1 was lying still in bed with eyes closed and appeared to be asleep. During the visit P#1 did mumble at times but this surveyor was unable to understand what was said, RN AA assessed P#1 and completed vital signs assessment without difficulty. RN AA prompted P#1 to drink from straw but the patient was unable to follow this command. This surveyor questioned RN AA why patient was restrained and RN AA answered she did not know however, she reported P#1 had been grabbing and squeezing the staff's arms forcefully. No combative or aggressive behavior was exhibited during the visit. The patient required several prompts to awaken and appeared lethargic when awaken with eyes slightly open, mumbling and slow movement. During a telephone interview on 5/3/22, at 11:18 a.m. ,regarding restraints the Medical Director stated restraints were ordered for P#1 on 4/22/22, if the patient exhibited out of control and combative behavior. According to the Medical Director, P#1 had engaged in combative behaviors at home and needed to be sent to an inpatient unit for stabilization. When asked if he was aware the patient had been in restraints from 4/22-5/3/22, the Medical Director states he was not aware the patient had been in restraints and had not been given a report from the staff that the patient was being restrained. The Medical Director denied giving any orders for the patient to be restrained after 4/22/22, and stated he does not want any of his patients to be restrained however, if the need for restraints is required the expectation is the restraints will be removed immediately when the patient is calm. During an interview on 5/5/22, at 3:00 p.m., the Director of Clinical Services acknowledged the lack of a medical and behavioral evaluation conducted to manage the documented behaviors exhibited such as grabbing and squeezing the staff's arms forcefully, combative behavior, agitation, hallucinations and restlessness using alternatives and other less restrictive measures on 4/22, 4/23,4/24, 4/25, 4/26, 4/27, 4/28, 4/29, 4/30, 5/1, and 5/2/22.

Based on clinical record review, agency policy titled "ASSESSMENT AND PLAN OF CARE, RESTRAINTS" revised 12/08, and staff interview, it was determined the hospice failed to ensure all patient care staff working in inpatient hospice had training and able to demonstrate competency in the application of restraints for 7 of 7 personnel files reviewed. The personnel files lacked any evidence of restraint training. The findings include: Review of 7 personnel files for Longleaf hospice did not indicate the staff working for at inpatient hospice was trained and able to demonstrate competency in the application of restraints. The agency policy labeled "Assessment and Plan of Care, Restraint" revised 12/08 states the hospice shall ensure safe and proper application and monitoring of the use of restraints by adequately trained staff with direct observation of competencies. During an interview on 5/5/22, at 3:00 p.m., the Director of Clinical Services acknowledged the Longleaf Hospice staff were not trained and deemed competent in the application of restraints due to not having admitted any patients requiring restraints. Clinical notes dated 4/21, 4/22, 4/23, 4/24, 4/26, 4/29, 5/3, and 5/4/22 indicate Employees Registered Nurse (RN) AA, RN BB, RN CC, RN DD, RN EE, RN FF and RN GG provided homecare/Inpatient Care to P#1 while in restraints however, according to the Director of Clinical Services, none of the staff at Longleaf Hospice who provide care had been trained or deemed competent in restraint training.

Based on personnel file reviews, agency policy titled"" ASSESSMENT AND PLAN OF CARE, RESTRAINTS" revised 12/08 and staff interview, it was determined the hospice failed to ensure evidence of training and demonstration of competency of appropriate staff was successfully completed for restraints for 2 of 7 personnel files reviewed. The findings include: The hospice failed to ensure the staff providing csre for Patient #1 had documented evidence that training and demonstration of competency were successfully completed for restraints. Licensed Practical Nurse (LPN) HH with a hire date of 7/13/20, and Registered Nurse (RN) II with a hire date of 6/28/16, did not have documented evidence of restraint training. The agency policy labeled "Assessment and Plan of Care, Restraint" revised 12/08 states the hospice shall train caregivers in the safe and proper use and monitoring of the restraints and such training shall be documented in the patient's medical record. During an interview on 5/5/22, at 3:00 p.m., the Director of Clinical Services did not provide evidence of a trainer who had education, training and experience in techniques used to address patients' inappropriate behaviors. The Director stated the staff had not been trained in restraints as the agency had not had a patient that required restraints.

Based on clinical record review and staff interview, it was determined the hospice failed to ensure the trainer providing staff training was qualified as evidenced by education, training and experience in techniques used to address patients' behaviors. The findings include: The hospice failed to ensure a trainer was available to provide staff training as evidenced by documentation, training and experience in techniques used to address patient's behavior. During an interview on 5/5/22, at 3:00 p.m., the Director of Clinical Services did not provide evidence of a trainer who had education, training and experience in techniques used to address patients' behaviors.

Based on personnel file reviews, review of agency policy titled " ASSESSMENT AND PLAN OF CARE RESTRAINTS" revised 12/08, and staff interview, it was determined the hospice failed to ensure evidence of training and demonstration of competency was successfully completed for 7 of 7 personnel files reviewed. The findings include: The hospice failed to ensure the personnel files had documented evidence that training and demonstration of competency were successfully completed for restraint training. The agency policy labeled "Assessment and Plan of Care, Restraint" revised 12/08 states the hospice shall ensure safe and proper application and monitoring of the use of restraints by adequately trained staff with direct observation of competencies. During an interview on 5/5/22, at 3:00 p.m., the Director of Clinical Services acknowledged the Longleaf Hospice staff were not trained and deemed competent in the application of restraints due to not having admitted any patients requiring restraints. Clinical notes dated 4/21, 4/22, 4/23, 4/24, 4/26, 4/29, 5/3, and 5/4/22 indicate Employees Registered Nurse (RN) AA, RN BB, RN CC, RN DD, RN EE, RN FF and RN GG provided homecare/Inpatient Care to P#1 while in restraints however, according to the Director of Clinical Services, none of the staff at Longleaf Hospice who provide care had been trained or deemed competent in restraint training. The Director of Clinical Services did not provide evidence of a trainer who had education, training and experience in techniques used to address patients' behaviors.

Based on clinical record reviews, and staff interviews, it was determined that the interdisciplinary group (IDG) failed to ensure comprehensive assessments were updated and included evaluation and documentation of the patient's response to wound care treatment and progress toward desired outcomes. The agency also failed to ensure assessment updates and changes were documented in the clinical record for two of three patients P# (P#4, and P#5) reviewed for altered skin conditions. The findings include: 1. Review of the plan of care for Patient #5 revealed that patient was admitted to hospice on 7/3/21, with the diagnosis of frontal temporal dementia and stage III sacral wound. The wound care as follows: cleanse wound with wound cleanser, pat dry with gauze, apply Flagyl powder to wound bed then pack with calcium alginate and cover with bordered gauze. Change wound dressing every other day and as needed for soilage/dislodged. Review of the IDT meeting dated 3/9 and 3/23/22 and skilled nurse (SN) visit notes dated 3/2, 3 /4, 3/10, 3/12, 3/14, 3/16, 3/28 and 3/30/22 lacks wound measurements and progress or lack of progress toward the desired outcomes/goals. The IDT meeting notes and SN visit notes for each of the above dates lacked documentation of the size, and progress or lack of progress toward the desired outcomes/goals of the sacral wound and P#5's response to the treatment. 2. Review of the plan of care for Patient #4 revealed an admission date of 9/4/18 with the diagnosis of Alzheimer's disease and non-healing surgical wound to the left hip. The wound care as follows: cleanse wound with wound cleanser, gently pat dry with clean gauze, may apply skin prep to peri wound apply silver sulfadiazide 1 % ointment to wound bed. Cover with calcium alginate dressing, secure with gauze and pad and tape. Change wound dressing every other day and as needed for soilage/dislodged. Review of the IDT meeting dated 3/9 and 3/23/22 and skilled nurse (SN) visit notes dated 3/10, 3/12, 3/14, 3/16, 3/18, 3/24,3/26 and 3/30/22 lacks wound measurements and progress or lack of progress toward the desired outcomes/goals. The IDT meeting notes and SN visit notes for each of the above dates lacked documentation of the size, and progress or lack of progress toward the desired outcomes/goals of the sacral wound and P#4's response to the treatment. During an office interview on 4/21/22, at 12:30 p.m., the Director of Nursing stated the SN visit notes and IDG notes lacked the measurement and progress or lack of progress toward the desired outcomes/goals of the sacral wound and the patient's response to the treatment.