Every finding on record at Maylath Valley Health Systems Inc.

Based on review of hospice policies/procedures and clinical records, pressure injury (bedsore) guidance from the Cleveland Clinic and based on interview with the administrator and the hospice director, the hospice failed to ensure a wound assessment was completed as per hospice policy/procedure for two (2) of two (2) active patients for whom skilled nursing (SN) provided wound care. (Patients #10 and #12) --- Findings include: On October 5, 2023 at approximately 3:11 PM, review of the hospice policy wound assessment policy revealed the following: 1. If you are not using SWIFT (wound assessment software) for wound documentation, you must describe the wound fully in your narrative...Include the following in your narrative: a. Measurements (once a week) b. Wound bed c. Exudate d. Peri-wound (skin surrounding the edge of the wound)... On October 5, 2023 at approximately 4:53 PM, review of the Cleveland Clinic website revealed the following under the article titled ";Bedsores (Pressure Injuries)": What parts of your body do bedsores affect?... Bedsores can begin anywhere...But bedsores are most likely to develop on the parts of your body where your bones sit closest to your skin, such as your...heels... What are the signs of bedsores?...What a bedsore looks like and what symptoms it causes varies depending on the stage of the wound. What are the stages of bedsores? Healthcare providers use a staging system to determine the severity of a pressure ulcer. Stages of bedsores or pressure ulcers include...Stage 2: A shallow wound with a pink or red base develops. You may see skin loss, abrasions and blisters... Patient #10: On October 5, 2023 at approximately 10:30 AM, review of the clinical record revealed the start of care was 08/20/2023, the primary diagnosis is Alzheimer's disease, that the patient is chair or bedbound and that SN is to assess skin integrity as documented on the hospice plan of care for the initial certification period of 08/20/2023 through 11/17/2023. Review of SN integumentary (skin) assessment findings documented on the 09/07/2023 SN visit note revealed there were no open areas. Review of SN visit notes dated 09/15/2023 and 09/19/2023 revealed a left heel blister no longer contained fluid and that the area was clean/dry and resolving as documented by the licensed practical nurse (LPN-Employee #10). Review of SN visit notes dated 09/22/2023 and 09/26/2023 revealed the left heel blister wound measured 6 centimeters (cm) by 5 cm and that the blister was filled with serosanguineous drainage (yellow with some blood) and that the LPN (Employee #10) performed wound care. There was no documentation which provided evidence the LPN measured the left heel blister nor assessed the wound bed and the peri-wound on 09/15/2023 and 09/19/2023, nor was documentation present which provided evidence the LPN assessed the peri-wound on 09/22/2023 and 09/26/2023. Patient #12: On October 5, 2023 at approximately 1:10 PM, review of the clinical record revealed the start of care was 09/15/2023, other pertinent diagnoses include peripheral vascular disease and that SN is to assess for skin integrity risk factors as documented on the hospice plan of care for the initial certification period of 09/15/2023 through 12/13/2023. Review of SN integumentary (skin) assessment findings documented on the 09/15/2023 start of care SN visit note revealed skin was intact. Review of SN visit note dated 09/19/2023 revealed a new wound of the left fifth toe wound was assessed by the LPN (Employee #11) and that the wound measured 1.8 cm by 0.5 cm by 0.1 cm, the area surrounding the wound appeared purple and red, serous/bloody drainage was noted from the wound and that the LPN provided wound care. Review of SN visit note dated 09/26/2023 revealed the LPN (Employee #11) assessed the color of the left foot and the change in appearance of the second and fourth toes and that the LPN provided wound care. The LPN documented that a necrotic (dead tissue) area of the left fourth toe was now present. There was no documentation in the clinical record which provided evidence the LPN assessed the appearance of the left fifth toe wound bed nor the size of the left fourth toe necrotic area on 09/26/2023. During interview conducted on October 5, 2023 at approximately 3:40 PM, the administrator and the hospice director confirmed there was no documentation in the clinical record which provided evidence wound assessment was completed per agency policy and procedure for the above identified patients.

Based on review of hospice policies/procedures and clinical records and based on interview with the administrator and the hospice director, the hospice failed to ensure the hospice plan of care included physician's orders for the oxygen flow rate, method of oxygen administration and/or the Foley (urinary) catheter size for five (5) of ten (10) active hospice patients. (Patients #9, #10, #11, #13 and #14) --- Findings include: On October 5, 2023 at approximately 3:05 PM, review of the hospice policy titled "Plan of Care" revealed the following: "Policy: Maylath Valley Health Systems, Inc., the patient, family/caregiver(s), the physician (medical director/attending physician), RN (registered nurse), social worker, spiritual counselor and others as appropriate will develop a written plan of care and implement an individualized plan of care for each hospice patient. "Procedure: 2. Developing, coordinating, reviewing, and as necessary revising the plan of care to include pain management, symptoms and a drug profile which assesses current medications for redundance or ineffectiveness upon admission, at IDG review and discharge. 7. The written plan of care will include... (f) Treatment Modalities/Services and Equipment." Patient #9: On October 5, 2023 at approximately 10:30 AM, review of the clinical record revealed physician orders included oxygen therapy as documented on the hospice plan of care for the recertification period of 09/18/2023 through 12/16/2023. Review of the 09/19/2023 skilled nursing (SN) visit note revealed oxygen therapy is to be administered at 2 liters per minute as needed. There was no documentation which provided evidence that physician orders for the oxygen flow rate and method of administration had been included on the hospice plan of care for the recertification period of 09/18/2023 through 12/16/2023. Patient #10: On October 5, 2023 at approximately 10:30 AM, review of the clinical record revealed physician orders included oxygen therapy and urinary catheter care as documented on the hospice plan of care for the initial certification period of 08/20/2023 through 11/17/2023. Review of the 08/20/2023 SN visit note revealed oxygen therapy is to be administered at 2 liters per minute as needed and that a 16 Fr (French) Foley catheter with a 10 milliliter (ml) balloon was in place. There was no documentation which provided evidence that physician orders for the oxygen flow rate/method of administration nor Foley catheter size had been included on the hospice plan of care for the initial certification period of 08/20/2023 through 11/17/2023. Patient #11: On October 5, 2023 at approximately 12:05 PM, review of the clinical record revealed physician orders included oxygen therapy as documented on the hospice plan of care for the initial certification period of 09/29/2023 through 12/27/2023. Review of the 09/29/2023 SN visit note revealed oxygen therapy is to be administered at 2 liters per minute as needed. There was no documentation which provided evidence that physician orders for the oxygen flow rate and method of administration had been included on the hospice plan of care for the initial certification period of 09/29/2023 through 12/27/2023. Patient #13: On October 5, 2023 at approximately 1:54 PM, review of the clinical record revealed physician orders included oxygen therapy as documented on the hospice plan of care for the recertification period of 09/25/2023 through 12/23/2023. Review of the 09/25/2023 SN visit note revealed oxygen therapy is to be administered at 2 liters per minute as needed. There was no documentation which provided evidence that physician orders for the oxygen flow rate and method of administration had been included on the hospice plan of care for the recertification period of 09/25/2023 through 12/23/2023. Patient #14: On October 5, 2023 at approximately 2:12 PM, review of the clinical record revealed physician orders included oxygen therapy and urinary catheter care as documented on the hospice plan of care for the recertification period of 08/22/2023 through 10/20/2023. Review of the 08/22/2023 SN visit note revealed oxygen therapy is to be administered at 2 liters per minute as needed and that a 16 Fr Foley catheter with a 10 ml balloon was in place. There was no documentation which provided evidence that physician orders for the oxygen flow rate/method of administration nor the Foley catheter size had been included on the hospice plan of care for the recertification period of 08/22/2023 through 10/20//2023. During interview conducted on October 5, 2023 at approximately 3:40 PM, the administrator and the hospice director confirmed that the hospice plan of care did not include physician orders for the oxygen flow rate, method of oxygen administration nor the Foley catheter size for the above referenced patients.