Every finding on record at Magnolia Hospice, LLC.

Based on policy titled “Symptom Management,” record reviews, and staff interviews, it was determined that the facility failed to implement initial spiritual assessments for the two patients (P) (P#5, P#15) of 15 patients reviewed. --- The findings include: Review of the policy titled “Symptom Management,” revised 3/2025 reveals the following:IV. Policy a)  It is our policy that the care team assesses a patient within five days of admission, develops a written, individualized care plan before services begin, involves the patient and family in planning, specifies the type and frequency of services, and requires regular review and updates to ensure care remains appropriate to the patient’s changing needs. 1. Review of the clinical records for P#5 revealed the start of care was completed by skilled nurse on 1/17/2025.The clinical record failed to reveal an initial spiritual assessment.  2. Review of the clinical records for P#15 revealed that the start of care was completed by skilled nurse on 4/9/2025. The initial spiritual assessment was completed on 4/15/2025, six days after the start of care, and the psychosocial assessment was completed on 4/16/2025, seven days after start of care.  On 9/16/2025 at 1:30 p.m., an interview was conducted with Chaplain (CP), who said he did not know why he skipped P#5, assessment and he had no reason as to why P#15 spiritual assessment was done late. On 9/16/2025 at 1:50 p.m., an interview conducted with the Administrator, who confirmed that the hospice staff failed to implement initial spiritual assessments for P#5 and completed late spiritual and psychosocial assessments for P#15.

Based on review of policy titled “Quality Assessment and Performance Improvement (QAPI) Plan,” Quality Assessment Performance Improvement (QAPI) binder and staff interview, it was determined that the agency failed to develop, implement and evaluate Performance Improvement Projects (PIP) for Quarter four of 2024, Quarter one, Quarter two and Quarter three of 2025. --- Findings include: Review of policy titled “Quality Assessment and Performance Improvement (QAPI) Plan,” revised 5/2023, revealed the following:Performance Expectation1.      For each process identified to be improved, mechanisms to identify levels, patterns or trends in that process that will trigger further evaluation of the process will be identified.Sample size will be determined.2.      For each established process to be improved, the performance expectation will be determined. The frequency of the data collection and analysis will be specified for each process. The QAPI committee, and/or those involved in patient care, will analyze the data collected to pursue opportunities for improvement and identify important problems.3.      A summary of data collection, analysis, recommendations for improvement and report of cumulative findings will be prepared by the QAPI committee. The reports are forwarded to the Governing body. Failure to achieve levels of performance will be documented and an explanation delineated to identify opportunities for improvement. Review of the agency’s Quality Assessment Performance Improvement (QAPI) binder revealed the agency failed to include in the committee meeting minutes, a Performance Improvement Project (PIP) for Quarter four of 2024, Quarter one, Quarter two and Quarter three of 2025. On 9/17/2025 at 9:30 a.m., during an office interview, The Administrator admitted the agency failed to include a PIP in the committee meeting minutes for Quarter four of 2024, Quarter one, Quarter two and Quarter three of 2025.

Based on review of agency policies and procedures, Quality Assessment Performance Improvement (QAPI) binder, review of agency’s emergency preparedness binder, and staff interview, it was determined the agency’s governing body failed to ensure the quality improvement program was maintained and evaluated to include a Performance Improvement Plan (PIP) for Quarter four of 2024 and Quarter one, Quarter two and Quarter three of 2025 and failed to document an annual rehearsed disaster preparedness plan with participants, summary of problems identified, and effectiveness of rehearsal for the years 2024 and 2025. --- Findings include: Review of policy titled “Quality Assessment and Performance Improvement (QAPI) Plan,” revised 5/2023, revealed the following:Achieved and Sustained Improvement1.      The Administrator/Director is responsible for taking appropriate action. Aggregate measures of performance for each process will be compared to pre-establish performance expectations to determine if additional evaluation is required.Performance Expectation7. OpusCare will document what performance improvement projects are being    conducted, the reasons for conducting these projects and the measurable progress achieved on them.8. The QAPI program will be evaluated annually by the Governing Body as a part of the        annual program evaluation. Review of agency policy titled “Emergency Operations Plan,” revised 6/2024, revealed the following:Procedure:1.      OpusCare complies with all applicable federal, state, and local emergency preparedness requirements.Policy2.      OpusCare has established and maintains an emergency preparedness program that meets all requirements. Review of the agency’s Quality Assessment Performance Improvement (QAPI) binder revealed the agency failed to identify and document an ongoing performance improvement project (PIP), with assessment and evaluation, in the committee meeting minutes for Quarter four of 2024 and Quarter one, Quarter two and Quarter three of 2025. Review of agency’s 2024 and 2025 emergency preparedness binder revealed the agency failed to document an annual rehearsed disaster preparedness plan with participants, summary of problems identified, and effectiveness of rehearsal for the years 2024 and 2025. On 9/17/2025 at 9:30 a.m., during an office interview, The Administrator acknowledged that the governing body failed to identify and document an ongoing performance improvement project (PIP), with an assessment and evaluation, in the committee meeting minutes for Quarter four of 2024 and Quarter one, Quarter two and Quarter three of 2025 and additionally acknowledged that the agency failed to document an annual rehearsed disaster preparedness plan with participants, summary of problems identified, and effectiveness of rehearsal for the years 2024 and 2025. The Administrator revealed he was not aware he had to conduct and document an annual rehearsed disaster preparedness plan since the agency no longer had an inpatient unit (IPU).

Based on policy titled “Volunteers Services,” record reviews, and staff interview, it was determined the facility failed to document cost saving achieved through the use of volunteers. --- The findings include: Review of the policy titled “Volunteers Services,” Policy: No.-V001, revised 5/2025 reveals the following:PROCEDURE:1.      OpusCare will document active and ongoing efforts to recruit and retain volunteers.2.      OpusCare will document the cost savings achieved through the use of volunteers and will include:·         Identification of each position occupied by volunteers.·         The work time spent by volunteers occupied by those positions.·         Estimate of the dollar cost that OpusCare would have incurred if paid employees occupied positions identified.·         OpusCare will document and maintain a volunteer staff sufficient to provide administrative and/or direct patient care in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid OpusCare employees and contract staff. OpusCare will document a continuing level of volunteer activity. OpusCare will maintain records on the use of volunteer for patient care and administrative services, including the type of services and time worked. Review of facility documents failed to reveal documentation of cost savings achieved through the use of volunteers. On 9/16/2025 at 1:45 p.m., an interview was conducted with the Administrator who acknowledged that records of cost savings were not documented or computed according to the Volunteer-Services policy.

Based on review of facility documents and staff interview, it was determined the facility failed to provide day to day administrative direct patient care services in an amount minimum equal to five percent of the total patient care hours of all paid hospice employees and contract staff. --- The Findings include: Review of facility document “Cost Saving through Use of Volunteers,” revealed that the document was blank. The agency failed to document from January through September 2025, the Monthly Service percentage that was less than 5%. The hospice agency failed to provide day-to-day administrative direct patient care services in an amount minimum equal to five percent of the total patient care hours of all paid hospice employees and contract staff. On 9/16/2025 at 1:45 p.m. an interview was conducted with the Administrator who acknowledged that the record of day-to-day administrative direct patient care services in an amount minimum equal to five percent of the total care hours of all paid hospice employees and contract staff, were not met, and were not documented. The Administrator also confirmed there was no documentation from January to September 2025 recorded for the volunteer’s services percentage.

Based on record review, staff interviews, and review of agency policy titled ";Wound Documentation" revision date 5/2023, it was determined that the hospice agency failed to ensure the care and services were provided in accordance with the plan of care for one Patient (P) (P#2) out of three sampled patients (P#1, P#2, P#3) who are current hospice beneficiaries. --- The findings include: Review of the policy titled ";Wound Documentation" revision date 5/2023 (IV.,V. B a-j) revealed the following: ";IV. Policy: Wound care treatment will begin upon discovery and follow Dressing Selection and Treatment Guidelines. Pressure ulcers and other wounds will be measured & reassessed by Registered Nurse weekly (every 7 days) to assess for response to treatment interventions. V. Procedure: B. Documentation of wound should include: a) Type of wound b) Location c) Size in centimeters (length...orientation) d) Appearance of wound bed e) Presence/absence of tunneling or undermining using clock face orientation f) Stage or category (as appropriate) g) Color, presence/character of slough and/or eschar h) Presence/character of exudate i) Odor j) condition of surrounding skin" Review of the clinical record for patient P#2 revealed admitted to hospice on 3/8/2023. Review of the plan of care revealed wound care orders dated 3/8/2023 to the right and left lower leg. The plan of care revealed assessment of wounds to include wound size, stage, drainage, wound bed and periwound during wound dressing change. The wound care treatment includes the following: Cleanse wound with wound cleanser/normal saline, pat dry with gauze, apply Triple Antibiotic ointment, cover with gauze and wrap with kerlix. Change every 3 days and as needed. Treatment to wound of the right plantar foot includes the following: clean with wound cleanser, pat dry with gauze, apply Medi honey to slough/eschar in wound bed, cover with optifoam dressing, perform wound care 3 times a week and as needed and perform wound measurement weekly. Review of the clinical record revealed the clinicians visited the patient three times a week from 5/1/23 - 6/2/2023 and the wounds were measured only one time on 5/26/23 for the month of May. Registered Nurse (RN) AA visited the patient on 5/16, 5/17, 5/20, 5/22, 5/29/23 and performed wound care. RN AA failed to document any observations of the wound during each visit. During a telephone interview at the agency office on 6/14/2023 at 11:00 a.m., the Clinical Manager (CM) revealed she only measured wounds at the recertification visit and confirmed that the agency policy required the clinician to measure wounds weekly. The Clinical Manager was only able to provide documentation of wound measurements done on 5/26/2023. During an interview at the agency office with the Administrator on 6/14/23 at 11:00 a.m., the Administrator confirmed that the clinical record contained only one wound measurement for the month of May and that RN AA failed to document complete wound care for the patient.

Based on observation, staff interview, and policy review, the facility failed to follow accepted standards of practice to prevent the transmission of infections and communicable diseases, by staff not wearing hair net to cover their hair while preparing patients food for six Patients (P) of 16 sampled patients. (P#1, P#2, P#4. P#5, P#6, P#7, P#8, P#9, P#10, P#11, P#12, P#13, P#14, P#15, and P#16). --- The Findings include: During kitchen observation of inpatient unit on 2/20/2023 at 11:12 a.m., this surveyor observed Certified Nursing Aide (CNA) AA, enter the kitchen to prepare patients foods, without wearing hair net. The facility failed to follow standard precautions to prevent transmission of infections and communicable diseases while preparing patients meals. On 2/20/2023 at 11:50 a.m., an interview was conducted with (CNA) AA, who confirmed that she did not wear hair net to cover her hair in the kitchen as she prepared patients foods. The facility failed to produce a policy to reference wearing of hair nets during meal preparation.

Based on clinical record review, staff interviews, and review of Hospice Agency policy, it was determined that the agency failed to deliver Patient (P#16), medication (Morphine), within two hours per their policy, drugs must be made routinely available on 24 hours basis for 7 days a week for all patients. The hospice agency failed to comply with the regulation for one (1) of sixteen (16) sampled patients (P#1 P#2, P#3, P#4, P#5, P#6, P#7, P#8, P#9, P#10, P#11, P#12, P#13, P#14, and P#15). --- The Finding include: During the record review conducted on 2/23/2023, at Hospice facility at approximately 12:00 p.m., with Director of Nursing (DON), for (P#16), it was revealed that patient was admitted on 8/19/2022, with a diagnosis of Malignant of neoplasm of bladder, hypertension, and anemia. It was revealed that Registered Nurse (RN) BB, visited P#16's, on 8/31/2022, assessed the patient and reported to the physician that P#16, was unable to swallow tramadol pills and needed morphine liquids. Physicians ordered Morphine Sulfate (Concentrate) 10 milligrams (MG), /0.5milliliters (ML), (20mg/ml) oral solution, give 0.25 every four hours as needed for pain on 8/31/2022. The morphine was delivered by pharmacy on 9/2/2022 (48 hours late). On 2/23/2023 at 1:40 p.m., an interview was conducted with (RN) BB, who stated that she ordered the morphine on 8/31/2022, but did not know why the pharmacy delivered it on 9/2/2022. On 2/23/2023 at 3:40 p.m., an interview was conducted with the Executive Director of Nursing from the head office at Miami Florida, who stated that if patients need morphine, the hospice agency would order it, and the hospice agency pharmacy would deliver it to the patients house within two hours, per hospice policy. In the case of P#16, the hospice failed to follow their policy. On 2/23/2023 at 2:35 p.m., an interview was conducted with DON, stated that she did not know why the pharmacy delivered the morphine 48 hours late. On 2/24/2023 at 12:08 p.m., an interview was conducted with the hospice pharmacist who confirmed that the morphine was delivered on 9/2/2022. He was unable to identify the reason why the medication was delivered late. On 2/24/2023 at 12:20 p.m., an interview was conducted with P#16s son who stated that his mother needed the morphine, but the medication was delivered on 9/2/2022. P#16s son however said his mother died peacefully.

Based on record review, staff interviews, and policy titled ";Drug Free Workplace", it was determined the agency failed to follow policy and procedure to obtain drug test for all staff at the inpatient unit when morphine liquids 2.5 milliliters (ml) discrepancy was noted for one Patient (P) (P#3) of four sampled patients (P#1, P#2, P#3, and P#4). --- The Findings include: Review of Hospice Agency Policy No.-HR-GA-D005, dated 12/2021, (Page 1-2, POLICY/PROCEDURE TITLE: Drug Free Workplace. Number IV. PROCEDURE: last page ";We may require an employee to be tested at any time. Those who are found to be in violation of our policy, who refuse to be tested, or who adulterate or substitute a sample, will be subjected to disciplinary action up to and including immediate termination. The following will not be tolerated): On 2/21/2023 at 11:35 p.m., a phone interview was conducted with Registered Nurse (RN) CC, who worked 7pm to 7am on inpatient unit on 11/24/2022. RN CC revealed she has been working as a Registered Nurse for fifty years. RN CC revealed that on the night of 11/23/2022, she worked night duty. While she was doing medication administration that night, she mistakenly spilled P#3s morphine liquids 2.5ml. It happened when she was pouring it into the measuring cup; the medication spilled on the bottle label, and she reported it to the day nurse when they were doing the morning count. RN CC also confirmed that the night nurses aide witnessed it when she mistakenly spilled the morphine liquids 2.5ml while pouring it into the measuring cup. RN CC said nobody asked her to do any drug test. RN CC stated that she was the only nurse on 7pm to 7am. On 2/21/2023 at 11:50 p.m., a phone interview was conducted with (CNA) DD said that she worked with RN CC on 11/23/2023 7pm to 7am, and she witnessed RN CC mistakenly spilled P#3s morphine on the medication bottle when she was pouring it. On 2/21/2023 at 11:55 p.m., a phone interview was conducted with the previous DON, who stated that she knew that RN CC had eyes problem and had eye surgery, but she terminated RN CC because she left the facility and refused to do drug test. The previous DON said that she did the narcotic count with another nurse to correct the discrepancy. During an interview on 2/23/2023, at 4:50 p.m., the current DON, confirmed that the previous DON did not follow the Hospice Agency Policy and Procedures to obtain drug test for the night shift staff. The DON called RN BB (who worked 7am to 7pm on 11/24/2022) and left a voice message for her to call the surveyor. But RN BB did not call back. The agency failed to provide a policy and procedure to obtain drug test for all staff when a discrepancy of medication was found.

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Based on staff interview and review of records, it was determined that facility failed to ensure the staff were trained and able to demonstrate competency in the application of restraints. --- The Findings include: A review of 60 active personnel records completed 10/24/22 revealed 15 out of 60 employees were not educated on application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a patient in restraint or seclusion based on specific patient needs.

Based on staff interviews and record reviews it was determined the hospice failed to ensure evidence of training and demonstration of competency of appropriate staff was successfully completed for staff at Inpatient Unit. --- The Findings include: A review of records revealed the facility did not have a completed attendance sheets for initial and periodic training sessions for 100 percent of employees on application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a patient in restraint or seclusion based on specific patient needs.

Based on clinical record review and staff interview, it was determined the Magnolia Hospice Inpatient Unit in Conyers failed to ensure a qualified trainer provided staff training on restraints as evidence by lack of education, training and experience in techniques used to address patients' behaviors. --- The Findings include: During an interview with DON, on 10/25/22 at 12:58 p.m., the DON acknowledged the facility lacked evidence of a qualified trainer to provide staff training on application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a patient in restraint or seclusion based on specific patient needs. A review of the training curriculum for the use of restraints or seclusion, provided by DON on 10/24/22 revealed the curriculum did contain required content for application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a patient in restraint or seclusion based on specific patient needs. The hospice failed to ensure a qualified trainer was available to provide staff training as evidenced by lack of documentation, training and experience in techniques used to address patient's behavior.

Based on record review and staff interview, it was determined the hospice failed to ensure evidence of training and demonstration of competency was successfully completed for staff working in the IPU units. --- The Findings include: During an interview with the DON on 10/25/22 at 12:50 pm, DON stated Magnolia Hospice could not produce a copy of new employee orientation content assuring that information on use of restraints or seclusion was included for all new employees. During an interview on 10/25/22 at 12:58 p.m., the Director of Nursing (DON) and the Administrator did not provide evidence of a qualified trainer who had education, training and experience in techniques used to address patients' behaviors.

Based on review of clinical records, personnel records, quality assessment documentation, and staff interviews, it was determined Magnolia Hospice in Macon, GA failed to ensure that the requirements for the use and monitoring of restraints were met for three patients (P#1, P#2, P#3). The agency' failed to ensure that training and restraint techniques were provided prior to the use of side rails and restraints, failed to document the use of any attempts to use less restricted or alternative methods for behavior modification, failed to ensure a medical and behavior evaluation was conducted to manage violent behaviors, failed 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, and failed to ensure staff were provided education and deemed competent prior to the administration of restraint, (Refer to L755, L756, L757, L754, L742, and L752). The cumulative effects of these systemic problems resulted in the hospice's inability to effectively monitor and evaluate the application and use of restraints which could result in serious patient injury and harm or death. Based on review of clinical records, personnel records, quality assessment documentation, and staff interview, it was determined Magnolia Hospice, Conyers, Georgia, failed to ensure that the requirements for the use and monitoring of restraints were met for patient (P#1). The agency's failure to ensure training and restraint techniques was provided prior to the use of restraint, failure to document the use of any attempts to use less restricted or alternative methods for behavior modification, failure to ensure a medical and behavior evaluation was conducted to manage violent behaviors, and 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, and failure to ensure staff were provided education and deemed competent prior to the administration of restraint (Refer to L755, L756, L757, L754, L742, and L752). The cumulative effects of these systemic problems resulted in the hospice's inability to effectively monitor and evaluate the application and use of restraints which could result in serious patient injury/harm or death.

Based on clinical record review, and staff interview it was determined the Inpatient Unit Magnolia Hospice in Macon, the agency failed to ensure that a physician order was obtained for the application of restraint for 3 of 3 sampled patient (P#1, P#2, P#3). The findings include: During an observation of the inpatient hospice unit, on 8/9/22 at 11:30 a.m., it was revealed that the agency had three patients (P#1, P#2, and P#3) confined to bed with two full side rails up and in locked position. Clinical record review of all three patients, lacked evidence of physician orders for the usage of side rails (restraint) to confine the patients in bed. The patients were alert and confused. The review of the care plan also lacked evidence of safety usage, and management and complications of locked side rails to prevent harm to the confused patients. During an interview on 8/9/22 at 1:20 p.m., certified nurse assistant (CNA)AA reported the night shift staff gives verbal and written reports on each patient every morning, however (CNA)AA is unable to locate paper report for night shift from last night. (CNA)AA reports she didn't know the agency needed physician orders for full side rails on patients' bed and orders to turn and reposition patients every two hours. During an interview on 8/9/22 at 12:10 p.m., the Licensed Practical Nurse (LPN)BB reported that she didn't know agency needed physician orders for full side rails on patients' bed. During an interview on 8/9/22 at 11:00 a.m., the Director of Nursing (DON) verbalized that she didn't know the agency needed physician orders for full side rails on patients' beds. Based on clinical record review and staff interview, it was determined the Inpatient Unit at Magnolia Hospice in Conyers, the agency failed to ensure that a physician order was obtained for the application of restraint for 1 of 1 sampled patient (P) (#1). The findings include: During an interview with the Administrator and the Director of Nursing (DON) on 8/8/22, at 12:58 p.m., the DON explained there was an incident where Registered Nurse (RN) AA and Certified Nursing Assistant (CNA) BB used restraints on (P#1) without an order. The DON verbalized that (CNA) CC sent a photograph of (P#1) via text message to a family member. The family member called the facility and reported that (P#1) was being "tied to a chair and was sure this was illegal." The DON stated that an investigation by DON revealed the (RN) AA tied the patient to a chair with a blanket around the waist and a knot at the back of the patient, and a robe around the shoulders to "prevent the patient from falling". During a phone interview with (RN) AA on 8/8/22, at 1:12 p.m., (RN) AA admitted that she restrained (P#1) without an order. (RN) AA stated she had tied a blanket around the (P#1)'s waist and a robe around the patient's shoulders to prevent the patient from falling on the floor. During an interview on 5/5 /22, at 3:00 p.m., the DON acknowledged the restraint order was not obtained before applying restraint on (P#1).

Based on observation, staff interview, clinical record review the Magnolia Hospice Inpatient Unit in Conyers, Georgia, failed to ensure a medical and behavioral evaluation was conducted to manage the behaviors which resulted in the application of restraints for 1of 1 patients (P #1). The Findings include: During an interview with the Administrator, and Director of Nursing (DON), on 8/8/22 at 12:58 p.m., the DON explained there was an incident where (RN) AA and (CNA) BB used restraints on (P#1) without an order. The DON verbalized that (CNA) CC sent photograph of (P#1) via text message to a family member. The family member, called the facility and reported that (P#1) was being "tied to a chair and was sure this was illegal." The DON stated that during an investigation by the DON, it was revealed the Registered Nurse (RN) AA tied (P#1) to a chair with a blanket around the waist and a knot at the back of the patient and a robe around the shoulders to "prevent patient from falling". During an interview on 8/8/22 at 12:06 p.m., with Certified Nursing Assistant (CNA) BB stated she had not received education or in-service on restraints. During an interview on 8/8/22 at 12:58 p.m., the DON and the Administrator acknowledged that medical and behavioral evaluation was conducted and documented prior to using restraint on (P#1). During an interview on 8/8/22 at 1:12 p.m., the (RN) AA, reported that she had not received education or an in-service on restraints since she was employed at the facility. Based on staff interview, observation and clinical record review the Inpatient Unit of Magnolia Hospice in Macon failed to ensure a medical and behavioral evaluation was conducted to manage the behaviors which resulted in the application of restraints for 3 of 3 patients (P#1, P#2, and P#3). The Findings include: During an observation of the inpatient hospice unit at Macon, on 8/9/22 at 11:30 a.m., it was revealed that the agency had three patients (P#1, P#2, and P#3) confined to bed with two full side rails up and in locked position. Clinical record review of all three patients, lacked evidence of physician orders for the usage of side rails (restraint) to confine the patients in bed. Clinical record also lacked evidence of documentation of medical and behavioral evaluations prior to using restraint on (P#1, P #2 and P#3). The patients were alert but confused. The review of the care plan also lacked evidence of safety usage, and management and complications of locked side rails to prevent harm to the confused patients. During an interview on 8/9/22 at 11:00 a.m., the Director of Nursing (DON) and the Administrator acknowledged that medical and behavioral evaluation was not conducted and documented prior to using restraint on (P#1, P #2 and P#3). During an interview on 8/9/22 at 1:20 p.m., Certified Nursing Assistant (CNA) AA reported the night shift staff gives verbal and written reports on each patient every morning, however, (CNA) AA was unable to locate paper report for night shift from the night before. (CNA) AA reports she didn't know the agency needed physician orders for full side rails on patients' bed and orders to turn and reposition patients every two hours.

Based on staff interview and lack of evidence, it was determined that Magnolia Hospice Inpatient Unit of Macon failed to ensure the staff were trained and able to demonstrate competency in the application of restraints. The Findings include: During an observation of the inpatient hospice unit, on 8/9/22 at 11:30 a.m., it was revealed that the agency had three patients (P#1, P#2, and P#3) confined to bed with two full side rails up and in locked position. Clinical record review of all three patients, lacked evidence of physician orders for the usage of side rails (restraint) to confine the patients in bed. The patients were alert but confused. The review of the care plan also lacked evidence of safety usage, and management and complications of locked side rails to prevent harm to the confused patients. During an interview on 8/9/22 at 11:00 a.m., the Director of Nursing (DON) and Administrator both reported that there had not been any education, competency checklist, or in-service for the staff about use of restraints. During an interview on 8/9/22 at 12:10 p.m., the Licensed Practical Nurse (LPN)BB reported that she didn't know agency needed physician orders for full side rails on patients' bed. During an interview on 8/9/22 at 1:20 p.m., Certified Nursing Assistant (CNA)AA reported the night shift staff gives verbal and written reports on each patient every morning, however, (CNA)AA is unable to locate paper report for night shift from the night before. (CNA)AA reports she didn't know the agency needed physician orders for full side rails on patients' bed and orders to turn and reposition patients every two hours. Based on staff interview and lack of evidence, it was determined that Magnolia Hospice Inpatient Unit of Conyers failed to ensure the staff were trained and able to demonstrate competency in the application of restraints. The Findings include: During an interview with the Administrator, and the Director of Nursing (DON), on 8/8/22 at 12:58 p.m., the DON explained there was an incident where (RN)AA and (CNA)BB used restraints on (P#1) without an order. The DON verbalized that (CNA) CC sent photograph of (P#1) via text message to a family member. The DON furhter stated the family member, called the facility and reported that (P#1) was being "tied to a chair and was sure this was illegal." The DON stated that during an investigation by DON, revealed the Registered Nurse (RN) AA tied (P#1) to a chair with a blanket around the waist and a knot at the back of the patient , and a robe around the shoulders to "prevent patient from falling". During an interview on 8/8/22 at 12:06 p.m., with Certified Nursing Assistant (CNA) BB stated she had not received education or in-service on restraints. During an interview on 8/8/22 at 12:58 p.m., the DON and Administrator both reported that there had not been any education or in-service for the staff about use of restraints. During an interview on 8/8/22 at 1:12 p.m., the (RN) AA, reported that she had not received education or in-service on restraints since she was employed at the facility.

Based on staff interviews it was determined the hospice failed to ensure evidence of training and demonstration of competency was successfully completed for staff at Inpatient Unit Hospice in Macon GA. The findings include: The hospice failed to ensure the staff who provided restraint for (P#1, P#2 and P#3) had documented evidence that training and demonstration of competency were successfully completed for restraints. Licensed practical nurse (LPN)BB and Certified Nursing Assistant (CNA)AA did not have documented evidence of restraint training. During an interview on 8/9/22 at 11:00 a.m., the Director of Nursing (DON) and Administrator both reported that there had not been any education or in-service for the staff about use of restraints. Based on staff interviews it was determined the hospice failed to ensure evidence of training and demonstration of competency of appropriate staff was successfully completed for staff at Inpatient Unit Hospice in Conyers, GA. The findings include: The hospice failed to ensure the staff who provided restraint for patient (P#1) had documented evidence that training and demonstration of competency were successfully completed. Registered Nurse (RN) AA and Certified Nursing Assistant (CNA) BB did not have documented evidence of restraint training. During an interview on 8/8/22 at 12:06 p.m., with (CNA) BB stated she had not received education or in-service on restraints. During an interview on 8/8/22 at 12:58 p.m., the DON and Administrator both reported that there had not been any education or in-service for the staff about use of restraints. During an interview on 8/8/22 at 1:12 p.m., the (RN) AA, reported that she had not received education or in-service on restraints since she was employed at the facility.

Based on clinical record review and staff interview, it was determined the Magnolia Hospice Inpatient Unit in Macon failed to ensure a qualified trainer provided staff training on restraints as evidence by lack of education, training and experience in techniques used to address patients' behaviors. The findings include: The hospice failed to ensure a qualified trainer was available to provide staff training as evidenced by lack of documentation, training and experience in techniques used to address patient's behavior. During an interview on 8/9/22 at 11:00 a.m. the Director of Nursing (DON) and the Administrator did not provide evidence of a qualified trainer who had education, training and experience in techniques used to address patients' behaviors, and the DON and Administrator both reported that there had not been any education or in-service for the staff about use of restraints. Based on clinical record review and staff interview, it was determined the Magnolia Hospice Inpatient Unit in Conyers failed to ensure a qualified trainer provided staff training on restraints as evidence by lack of education, training and experience in techniques used to address patients' behaviors. The findings include: The hospice failed to ensure a qualified trainer was available to provide staff training as evidenced by lack of documentation, training and experience in techniques used to address patient's behavior. During an interview on 88/22 at 12:58 p.m., the Director of Nursing (DON) and the Administrator did not provide evidence of a qualified trainer who had education, training and experience in techniques used to address patients' behaviors, and the DON and Administrator both reported that there had not been any education or in-service for the staff about use of restraints.

Based on record review and staff interview, it was determined the Magnolia Hospice Inpatient Unit in Macon failed to ensure evidence of training and demonstration of competency was successfully completed for staff providing care in the IPU units. The findings include: During an observation of the inpatient hospice unit, on 8/9/22 at 11:30 a.m., it was revealed that the agency had three patients (P#1, P#2, and P#3) confined to bed with two full side rails up and in locked position. Clinical record review of all three patients, lacked evidence of physician orders for the usage of side rails (restraint) to confine the patients in bed. The patients were alert but confused. The review of the care plan also lacked evidence of safety usage, and management and complications of locked side rails to prevent harm to the confused patients. During an interview on 8/9/22 at 11:00 a.m., the Director of Nursing (DON) and the Administrator verbalized none of the staff at Magnolia Hospice in Macon who provide care had been trained or deemed competent in restraint training. The DON did not provide evidence of a qualified trainer who had education, training and experience in techniques used to address patients' behaviors. During an interview on 8/9/22 at 12:10 p.m., the Licensed Practical Nurse (LPN) BB reported that she didn't know agency needed physician orders for full side rails on patients' bed. During an interview on 8/9/22 at 1:20 p.m., Certified Nursing Assistant (CNA) AA reported the night shift staff gives verbal and written reports on each patient every morning, however, (CNA) AA is unable to locate paper report for night shift the night before. (CNA) AA reports she didn't know the agency needed physician orders for full side rails on patients' bed and orders to turn and reposition patients every two hours. Based on record review and, and staff interview, it was determined the hospice failed to ensure evidence of training and demonstration of competency was successfully completed for staff working in the IPU units. The findings include: During an interview with the Administrator, and Director of Nursing (DON), on 8/8/22 at 12:58, the DON explained there was an incident where (RN) AA and (CNA) BB used restraints on (P#1) without an order. The DON verbalized that Certified Nursing Assistant (CNA) CC sent photograph of (P#1) via text message to a family member. The DON furhter stated the family member called the facility and reported that (P#1) was being "tied to a chair and was sure this was illegal". The DON stated that during an investigation by DON, revealed that the Registered Nurse (RN) AA tied the patient to a chair with a blanket around the waist and a knot at the back of the patient and a robe around the shoulders to "prevent patient from falling". During an interview on 8/8/22 at 12:06 p.m., with Certified Nursing Assistant (CNA) BB stated she had not received education or in-service on restraints. The hospice failed to ensure the personnel files had documented evidence that training and demonstration of competency were successfully completed for restraint training. During an interview on 8/8/22 at 12:58 p.m., the DON and the Administrator verbalized none of the staff at Magnolia Hospice who provide care had been trained or deemed competent in restraint training. The DON did not provide evidence of a trainer who had education, training and experience in techniques used to address patients' behaviors. During an interview on 8/8/22 at 1:12 p.m., the (RN) AA, reported that she had never received education or in-service on restraints since she was employed at the facility.