Every finding on record at Mary Greeley Medical Center

Based on observation and interview, the facility failed to provide emergency illumination that would operate automatically along the paths of egress in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 19.2.9, 7.9.2.3, and 7.9.2.7. The lack of emergency lighting along the path to safety would affect patients in 1 of 2 smoke zones. This facility had a capacity of 0 and a census of 4 residents at the time of the survey. Findings include: Observation and interview on 03/26/24 at 11:01 a.m. revealed the generator supplied emergency lighting within Med Room 125 was provided with a switch that would cut the power to the lighting fixtures. Administrative Staff A observed this finding.

Based on record review and interview, the facility failed to maintain the sprinkler system in accordance with National Fire Protection Association (NFPA) 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 edition. This deficient practice of failing to provide complete, verifiable documentation on the maintenance and repair history did not ensure proper operation and prompt repair of the system. This deficient practice affected 4 patients in 2 of 2 zones. The facility has a capacity of 0 and a census of 4 patients at the time of the survey. Findings include: Record review and interview on 03/26/24 at 12:18 p.m. revealed the facility failed to provide documentation of 5-year maintenance of the sprinkler system. Administrative Staff A acknowledged this finding.

Based on record review and interview, the facility failed to hold fire drills at least quarterly on each shift in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 19.7.1.6. This had the potential of affecting staff preparation and experience in providing for the protection of all residents in the event of a fire. This deficient practice affects 4 patients in 2 of 2 zones. The facility had a capacity of 0 and a census of 4 residents at the time of the survey. Findings include: Record review and interview on 03/26/24 at 12:17 p.m. of the facility fire drill documentation revealed the facility failed to provide documentation of a fire drill for the 3rd shift of the 4th quarter of 2023. Results of the record review were acknowledged by Administrative Staff A.

Based on observation and interview, the facility did not store oxygen tanks in accordance with National Fire Protection Association (NFPA) 99, Health Care Facilities Code, 2012 edition, sections 11.3.1, 11.3.2, 11.3.3, 11.3.4, & 11.6.5, by not separating combustible material from the oxygen cylinders. This deficient practice affected all occupants in 1 of 2 zones. This facility had a capacity of 0 and a census of 4 patients at the time of the survey. Findings include: Observation and interview on 03/26/24 at 11:13 a.m. revealed combustible materials located within 5-feet of the oxygen cylinders in the 146 South Oxygen Room. Administrative Staff A observed this finding.

Based on clinical record review, hospice policy review and staff interview, the hospice failed to ensure hospice nurse members of the Interdisciplinary Group failed to update the comprehensive assessment with changes to the patient condition regarding wound measurements for 1 of 3 sampled community patients with an open wound (Patient #5). Failure by the hospice Interdisciplinary Group (IDG) registered nurses to update the comprehensive assessment with complete wound descriptions and measurements placed the patient at risk for ineffective staff collaboration and communication regarding patient's wound status and effectiveness of treatments and interventions. --- Findings include: According to hospice policy, titled Hospice Wounds, dated 11/2022, nurse performs wound assessment with each comprehensive assessment, if unable to assess the wound, the reason needs to be documented; wound documentation may include but is not limited to location, wound type, wound measurement in centimeters. During an interview on 3/12/24 at 4:00 PM, the Clinical Manager revealed wound measurements should include length, width and depth. During an interview o 3/19/24 at 3:30 PM, the Clinical Manager reported wound measurements are completed with comprehensive assessments weekly. Patient #5 had a hospice admission date of 3/24/23 and received hospice services while residing in a private home from 3/24/23 to 12/28/23, in the Hospice House from 12/29/23 to 1/1/24, and in nursing home from 1/2/24 to current date. Clinical record review revealed the following: a. Skilled nurse visit note, dated 1/17/24, included documentation of stoma wound and to see the LDA (line, drain, airway) and wound assessment section in the note. The LDA and wound assessment section lacked documentation of stoma wound. b. Skilled nurse visit notes, dated 1/23/24, 1/30/24, 2/6/24, 2/13/24 and 2/19/24, included documentation of stoma wound 1/17/24 and to see the LDA and wound assessment section in the note. The LDA and wound assessment section lacked documentation of stoma wound. c. Wound photo, dated 2/16/24, identified reddened area around stoma. During an interview on 3/13/24 at 10:05 AM, Staff I, Home Health Clinical Manager, reviewed Patient #5 clinical record and reported no wound measurements documented in clinical record. The Administrator and Clinical Manager received the above findings. Hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, review of employee personnel files and staff interview, the hospice failed to ensure 7 of 12 sampled hospice aides (Staff D, E, G, H, J, K, L) satisfactorily demonstrated competency in the performance of any skills which exceed the level of basic hospice aide skills in the presence of a registered nurse with competency determined at a patient's bedside or using a real person (pseudo-patient) prior to being assigned to perform the task independently for 2 of 12 sampled patients who required an extra skill task to be performed (Patient #1, Patient #17). Failure to ensure hospice aides have a competent ability to perform all skills above and beyond basic hospice aide skills increased the risk that patients received inadequate or inappropriate care. --- The Medicare Conditions of Participation direct that the hospice aide may not independently provide any patient cares beyond the basic required skills without successful instruction and demonstration of competency in extra skills assigned on the aide care plan. The policy entitled Orientation/Competence Assessment, dated 2/2020, did not address requirements specific to hospice aide training. 1. Patient #1 had a hospice admission date of 2/26/24, and received hospice services while residing in their home. The hospice aide care plan included RN instructions for the hospice aide to complete the following tasks: feeding the patient and using a gait belt. The clinical record showed Staff E,G,H,J and L, hospice aides, provided hospice aide series independently for patient #1. Staff E, hospice aide, had a hire date of 8/28/23. Staff E's personnel file lacked documentation a RN had observed Staff E competently perform the tasks of feeding the patient and using the gait belt. Staff G, hospice aide, had a hire date of 3/27/23. Staff G's personnel file lacked documentation a RN had observed Staff G competently perform the tasks of feeding the patient and using the gait belt. Staff H, hospice aide, had a hire date of 2/12/24. Staff H's personnel file lacked documentation a RN had observed Staff H competently perform the tasks of feeding the patient and using the gait belt. Staff J, hospice aide, had a hire date of 7/14/08. Staff J's personnel file lacked documentation a RN had observed Staff J competently perform the tasks of feeding the patient and using the gait belt. Staff L, hospice aide, had a hire date of 6/24/19. Staff L's personnel file lacked documentation a RN had observed Staff L competently perform the tasks of feeding the patient and using a gait belt. 2. Patient # 17 had a hospice admission date of 12/15/23 and received hospice services in the home. The hospice aide care plan included RN Instructions for the hospice aide to complete the following task: obtain a weight. The clinical record showed Staff D, K, Hospice Aides, provided services independently for patient #17. Staff D, hospice aide, had a hire date of 2/14/22 . Staff D's personnel file lacked documentation a RN had observed Staff D competently perform the task of obtaining a weight. Staff K, hospice aide, had a hire date of 2/19//18. Staff K's personnel file lacked documentation a RN had observed Staff K competently perform the task of obtaining a weight. The above findings were reviewed with the Hospice Administrator, and Clinical Manager. Hospice staff provided no further information prior to the end of the survey.

Based on review of written contractual agreements and hospice staff interview, the hospice failed to ensure the written agreement between the hospice and 1 of 1 sampled services underarrangement included all of the required contract components. The hospice reported a total of 1 written agreements for services under arrangement with companies and individuals at the time of the survey. Failure to include the required contract components within the contractual agreement increased the potential that hospice management and oversight failed to occur and the patient would not receive services as specified on the plan of care. --- A hospice Durable medical equipment contract, dated 11/1/2013, failed to include the following contractual language: the hospice retains administrative management, financial management, oversight of staff and services; all services are authorized by the hospice, and delivered in accordance with the patient's plan of care.The above findings were reviewed with the Administrator and Clinical Manager no further evidence was provided prior to the end of the survey.

Based on clinical record review, hospice policy review and staff interview, the hospice failed to ensure patient clinical records included a physician order for all treatments for 1 of 11 sampled patients with documentation of heat therapy (Patient #9). Failure to have physician order for all treatments created the potential for patients to receive incorrect or ineffective treatment to meet assessed needs. --- Findings include: Review of the hospice policy, titled Ongoing Assessments, dated 3/23/21, during each home visit, the Case Manager or other discipline will re-evaluate the patient according to the problems identified during the initial visit and subsequent visits. The nurse will ass the patient on each visit for current treatment related to the identified symptoms and the patients response. Based upon the findings of the reassessment, additional orders will be generated and forwarded to the physician for signature. The physician will be notified to verify any changes in medications and treatment or interventions that require physician approval. Review of the hospice policy, titled Interdisciplinary Team Plan of Care, dated 3/23/21, the comprehensive plan of care contains, but will not be limited to pain and symptom management, medications and treatments, and physician orders. Patient #9 had a hospice admission date of 1/10/24 and received hospice services while residing in an assisted living facility. Skilled nursing visit note, dated 2/9/24, included documentation the Registered Nurse (RN) instructed the patient to utilize heat on the left shoulder for complaints of pain. The clinical record lacked documentation the RN contacted the physician for an order for heat therapy for pain management. During an interview on 3/19/24 at 2:13 PM, the Clinical Manager reported hospice expectation was for staff to obtain physician orders for heat and or ice therapy for patients. The Administrator and Clinical Manager received the above findings. Hospice staff provided no further information prior to the end of the survey.

Based on observation and staff interview, the hospice failed to ensure staff stored, prepared and served meal under sanitary conditions in the hospice house. The hospice reported providing services to 4 patients at the Hospice House at the time of the survey.Failure to ensure sanitary conditions maintained during meal preparation and storage of food under sanitary conditions put the patients at risk for food borne illness. --- During an interview on 3/0/24 at 4:10 PM the Administrator stated the hospice did not have a policy for food storage or preparation. Observation on 3/19/24 beginning at 7:43 AM revealed Staff C Hospice Aide prepared the morning meal. She washed her hands, put on hair net and donned gloves. Took tray out of cabinet and placed an empty plate, bowl and a 4 oz glass that she had removed from different cabinet onto the tray. Took egg container with 6 eggs out of the refrigerator and placed the egg container on the counter beside the tray. At 7:47 AM, Staff C, removed from the refrigerator, an 8 oz carton of milk out and poured milk into a 4 oz glass. Staff C removed from the freezer, 3 strips of bacon, from a multipack of bacon, from the freezer and opened the lid to George Foreman Grill. Staff C placed the bacon on the grill and closed the lid. Staff C removed from the freezer, 2 Waffles, from a multipack of frozen waffles, and placed the waffles in a toaster to heat. Staff C opened a package of oatmeal and put the oatmeal into the bowl on the tray and covered with a lid. Staff C removed a fork, knife, spoon from a silverware drawer and placed the silverware on a tray on a napkin that was removed from a drawer. Staff C removed a glass bowl from a cabinet and cracked 2 eggs into the bowl. Staff C removed her gloves and donned new gloves on. Staff C removed a pen from the counter and dated milk carton and placed the milk carton back into the refrigerator. Staff C added milk/salt/pepper to eggs and fluffed eggs with a fork that Staff C had removed from a drawer. Staff C placed the egg mixture into the microwave and turned on the microwave for 2 minutes. After 1 minute, Staff C removed the egg mixture bowl from the microwave and used the fork to mix eggs. Staff C turned the toaster on and started the Waffles. Staff C opened the George Foreman Grill lid and removed the bacon strips with a fork and placed on the plate on the tray. Staff C removed the waffles from toaster with a fork and placed on the plate. Staff C removed knife from drawer and buttered waffles with 2 containers of butter and poured 2 prepackaged containers of syrup over waffles. Staff C removed egg mixture from microwave and placed on plate and put cover over plate with egg, bacon and waffles. Staff C removed her gloves and washed her hands. Staff C wrote Month on empty dairy temperature log on day of observation (3/19/24). Staff C reported, she had never filled out the dairy temperature log before. At 8:03 AM, Staff C brought prepared breakfast meal into Patient #1 room. Milk temperature of 4 oz glass of milk was 45.7 degrees Farenheit. The above findings shared with the Administrator and Clinical Manager. No further information provided prior to the end of the survey.

Based on review of the hospice complaint logs and investigations, review of the hospice policies, and hospice staff and patient caregiver interviews, the agency failed to ensure that all alleged violations involving mistreatment, neglect, mental, sexual, and physical abuse, including injuries of unknown source and misappropriation of patient property by anyone furnish services on behalf of the hospice, are reported immediately by hospice employees and contactracted staff to the hospice administrator for 1 of 3 sampled patients (Patient #3) with hospice complaints. Failure for all staff to report immediately all alleged violations involving mistreatment, neglect, mental, sexual, and physical abuse, including injuries of unknown source and misappropriation of patient property by anyone furnish services on behalf of the hospice to the hospice administrator increases the risk of continued violations to occur putting current and future hospice patients at risk of substandard care. Findings include: --- Interview with the patient's caregiver on 10/24/22 at 1:00 PM reported the caregiver's last contact with the agency was on the patient's 8 week death anniversary and the caregiver did not want any further contact from the agency. The caregiver spoke with a volunteer and informed the volunteer about the caregiver's dissatisfaction with the hospice house and the hospice nurse in the home lied to the caregiver and raised his/her voice and the volunteer told the caregiver the concerns would be passed along. Interview on 10/25/22 at 3:48 PM with Hospice Administrator reported the hospice goal is to get ahead of complaints by speaking with hospice house patients and home patients in advance to identify any concerns regarding timing and equipment concerns. The hospice follows up and investigates the complaints by going to the source and will visit with the complainant after the investigation is completed in person. According to hospice policy, titled Patient Concerns and Grievance, dated 9/2021, ...patients and families have the right to communicate any concerns or grievances that arise in the provision of their care, without threat of discrimination or reprisal. They have the right to have their concern/grievance reviewed in person, by phone, or in writing by a staff member, manager, Administration, or Quality Management. The appropriate persons will respond to the patient in a timely manner....Response procedures include when an expression of dissatisfaction or concern is addressed to a representative of the organization, the staff should take ownership of the issue and take the appropriate action to remedy the situation as soon as possible. Staff present includes any hospital staff/medical staff, or volunteer present at the time the concern is expressed or who can quickly me at the patient's location (i.e. Administration, Managers, Quality Management, etc.) to resolve the patient's concern. If the verbal concern cannot be resolved by staff present, is postponed for later resolution, is referred to other staff for later resolution, requires investigation, and/or requires further action for resolution, then the concern becomes a grievance. Investigation of all grievances will be addressed as quickly as possible and should be resolved within 7 calendar days. If the medical center is unable to resolve the grievance within 7 calendar days from receipt, a written notice of acknowledgement, including estimated time for the final response, will be sent to the patient or his/her representative. A phone call may be added per patient/family request. All grievances wil be thoroughly investigated by a review of the patient's perceptions (and/or family members, friends) of the incident, a review of all related records (medical records, billing, etc.) and interviews with the staff and caregives involved in the incident or as described in the patient's concern. Once the investigation is complete the investigator will provide the patient or his/her representative with a written notice of findings, steps that were taken during the investigation, date of completion, and the name of the contact person for any follow up..... Review of the hospice's complaint log on 10/25/22 at 7:33 AM, revealed the hospice had received a total of 6 complaints from 3/1/22 through 10/24/22. Patient #3 was admitted to hospice on 3/31/22 with a diagnosis of terminal metastatic cancer of the the prostate and passed away at the hospice house on 6/23/22. Clinical record review revealed: a. The patient's bereavement record, dated 6/7/22 completed by Staff J, Bereavement Volunteer, documented the patient's spouse was very frustrated and upset with the hospice house. The spouse stated hospice staff did not follow the patient's wishes of dying at home and a nurse yelled at the spouse. The spouse requested no contact from the Bereavement Coordinator due the spouse upset with the coordinator as well. The volunteer listened and provided reassurance that the spouse's frustration would be passed on to staff. The volunteer talked to the hospice social worker who advised the volunteer to call the spouse back and assess if eating, resting, going outside, and taking walks. The volunteer left a message encouraged the patient to practice self care. b. Review of the hospice's complaint log lacked documentation of the complaint reported to Staff J, Bereavement Volunteer. Interview on 10/26/22 at 1:58 PM with Staff J, Bereavement Volunteer reported the volunteer notified Staff H, Social Worker of the patient's spouse not being happy with the services received at the hospice house. The social worker told the volunteer to call the patient back and assess how the spouse was doing. The volunteer also notified the Bereavement Coordinator of the concerns the spouse had. The volunteer did not notify any other staff members of the complaint. Interview on 10/26/22 at 2:37 PM with Staff I, Bereavement Coordinator reported the coordinator did not notify the Administrator or Clinical Manager about the concern reported by the volunteer as the volunteer reported it to the social worker, Staff H. The Bereavement Coordinator did remember having a conversation with the Clinical Manager, about the the patient's wishes and the spouse's wishes were not in alignment. Interview on 10/26/22 at 3:19 PM with Staff H, Social Worker (SW) reported the volunteer notified the social worker of the concern of not being happy with the hospice house. The social worker did not remember telling any leadership about the complaint. The spouse was receptive to the volunteer so the social worker did have the volunteer call the spouse to ask how the spouse was eating, sleeping, drinking and functioning and instructed the volunteer if so to have the spouse seek medical help. The spouse did not want any more contact with the Bereavement Coordinator. The surveyor provided the above findings to the Administrator and Clinical Manager. Both the Administrator and Clinical Manager denied notification of the concerns the spouse reported to the volunteer.