Every finding on record at Mercy Hospital Fort Smith

Based on a review of clinical records and staff interviews, it was determined that the agency failed to follow the written plan of care in four  (#1, #16, #18, and #19) of nineteen (#1-#19) clinical records reviewed. This failure had the potential to impact all patients currently on census and may result in missed or delayed symptom management, ineffective care delivery, and unmet physical, psychosocial, or emotional needs. Findings follow: --- A review of Clinical Record #1, with a start-of-care date of 04/28/25, identified a patient diagnosed with Parkinson’s disease. Review of the document titled “Hospice Plan of Care Update” indicated planned Medical Social Worker (MSW) visits to address psychosocial needs at a minimum frequency of once per month and Chaplain visits for spiritual support one to two times per month. There was no documentation to support that SW or Chaplain visits were completed during the period reviewed, from 09/21/25 through 11/18/25.A review of Clinical Record #16, with a start-of-care date of 11/24/25, identified a patient diagnosed with amyotrophic lateral sclerosis (ALS). Review of the Aide Care Plan had orders for the aide frequency of five times a week and indicated instructions for the hospice aide to obtain and record the patient’s weight at each visit. No documentation was found to support that weights were obtained or recorded by the aide. A review of Clinical Record #18, with a start-of-care date of 08/20/25, identified a patient diagnosed with diastolic congestive heart failure. Review of the “Hospice Plan of Care Update” indicated planned Chaplain visits for spiritual support once per month. There was no documentation to support that a Chaplain visit occurred during November 2025.A review of Clinical Record #19, with a start-of-care date of 11/25/25, identified a patient diagnosed with malignant neoplasm of the sigmoid colon. Review of the Aide Care Plan indicated instructions for hospice aide services to “assist with ambulation using a wheelchair” at each visit. No documentation was found to support that ambulation assistance was provided. An interview conducted on 12/10/25 during a home visit with Agency Personnel #5 revealed that the patient is bed- or chair-bound and unable to stand or ambulate.During an interview conducted on 12/12/25 at 9:30 a.m., Agency Personnel #1 and #2 confirmed that the agency failed to ensure that the care and services were provided in accordance with the plan of care.

Based on a review of clinical records, home visits, and staff interviews, it was determined that the hospice failed to ensure the provision of adequate social work services in six (#1, #6, #7, #10, #13, and #18) of nineteen (#1-#19) clinical records reviewed. The hospice social worker provided minimal services despite identified psychosocial needs, while psychosocial interventions typically within the scope of social work practice were performed by other members of the interdisciplinary team. This failure had the potential to affect all patients currently on census and may result in unmet psychosocial needs and a lack of discipline-specific care delivery. Findings follow: --- A review of Clinical Record #1, with a start-of-care date of 04/28/25, identified a patient diagnosed with Parkinson’s disease. Review of the document titled “Hospice Plan of Care Update” revealed documentation by the Medical Social Worker (MSW) stating, “Visits will be done at a minimum of once a month and increase visits as needed if possible since I am presently the only Social Worker and carry the whole caseload of our hospice,” indicating that visit frequency was determined by staff availability rather than patient needs. The MSW documented an attempted visit on 04/30/25, during which he was told to “go away” through the door. A telephone call was made on 05/02/25, at which time the patient’s spouse requested that the MSW “come next week.” No further attempts to contact or visits were documented after that date.A review of Clinical Record #6, with a start-of-care date of 11/13/25, identified a patient diagnosed with lung cancer. Review of the “Plan of Care Update” dated 11/13/25 revealed no social worker frequencies of visits, interventions or goals.A review of Clinical Record #7, with a start-of-care date of 10/27/25, identified a patient diagnosed with congestive heart failure. Review of a Chaplain initial visit note dated 10/29/25 revealed psychosocial concerns including the patient had an autistic son who lived in patient's home alone while patient resided in a nursing facility. Patient's nephew helped take care of the patient's autistic son but the nephew was unsure what would happen to the son after the patient's death. Review of the Social Worker initial note dated 10/30/25 revealed no assessment, interventions, or goals relating to the psychosocial issues the chaplain had identified.A review of Clinical Record #10, with a start-of-care date of 11/16/25, identified a patient diagnosed with cerebrovascular accident. Review of a Chaplain initial visit note dated 11/19/25 identified psychosocial concerns, including the patient’s reported feelings of disconnection and lack of communication with his daughter, by the following statement, “He is married to [named person]. She has her children and he has his. His children are twins, a girl and a boy. The girl [named person] stopped talking to him when he remarried…” Review of the Medical Social Worker (MSW) initial visit note dated 12/01/25 revealed no assessment, interventions, or goals relating to the psychosocial issues the chaplain had identified. A review of Clinical Record #13, with a start-of-care date of 11/06/25, identified a patient diagnosed with lung cancer. Observation of the Interdisciplinary Group (IDG) meeting on 12/09/25 revealed the identification of multiple psychosocial concerns, including the patient’s expressed fear of her daughter and the potential for financial exploitation by the daughter. The Skilled Nurse (SN) reported that upon the daughter’s release from jail, she removed the patient from the skilled nursing facility because she could not afford rent without access to the patient’s income. Despite the complexity of these psychosocial issues, the Medical Social Worker (MSW) provided minimal input, and the plan of care reflected a visit frequency of once per month.A review of Clinical Record #18, with a start-of-care date of 08/20/25, identified a patient diagnosed with diastolic congestive heart failure. Review of the document titled “Hospice Plan of Care Update” revealed documentation indicating “MSW declined at this time.” The Medical Social Worker (MSW) documented a telephone call on 08/22/25 with the patient’s niece, during which the niece stated that a visit was not needed at that time but requested that the MSW call back in a couple of weeks. The MSW documented agreement with this plan; however, no further contact attempts or visits were documented after that date. During a home visit conducted on 12/11/25, the patient’s niece was asked whether she would be agreeable to MSW visits and stated that she would be agreeable.During an interview conducted on 12/12/25 at 9:30 a.m., Agency Personnel #1 and #2 confirmed that the agency failed to provide psychosocial assessments, interventions, or goals related the patient and family needs.

Based on a review of clinical records and staff interviews, it was determined the Registered Nurse (RN) failed to ensure that written instructions for hospice aide (HA) services were individualized to meet the specific needs of each patient in 10 ( #1, #2, #6, #8, #9, #10, #12, #14,  #15, and #16,) of 16 (#1, #3-#12, #14-#16, and #18-#19) patients receiving HA services. Specifically, review of HA care plans revealed that bathing tasks were listed as “Partial/Complete Bed Bath, Aide Tub/Shower Bath, and Partial/Complete Sponge Bath” without patient-specific instructions indicating which type of bath was appropriate, under what conditions each bathing method should be used, or how the aide was to determine the safest and most appropriate bathing approach for the individual patient. This failure had the potential to impact all patients currently on census receiving HA services for inconsistent care delivery and placing patients at risk for unsafe or inappropriate bathing practices. Findings follow: --- A review of Clinical Record #1, with a start-of-care date of 04/28/25, identified a patient diagnosed with Parkinson’s disease. Review of the Aide Care Plan revealed instructions for Hospice Aide (HA) services that included “Aide Partial/Complete Bed Bath,” “Aide Tub/Shower Bath,” and “Partial/Complete Sponge Bath” at each visit. The care plan lacked specificity regarding the type of bath to be provided and did not identify the level of patient participation that could be safely accommodated.A review of Clinical Record #2, with a start-of-care date of 10/24/25, identified a patient diagnosed with congestive heart failure. Review of the Aide Care Plan indicated instructions for HA services that included “Aide Partial/Complete Bed Bath,” “Aide Tub/Shower Bath,” and “Partial/Complete Sponge Bath” at each visit. The care plan lacked specificity regarding the type of bath to be provided and did not identify the level of patient participation that could be safely accommodated.A review of Clinical Record #6, with a start-of-care date of 11/13/25, identified a patient diagnosed with lung cancer. Review of the Aide Care Plan revealed HA service instructions that included “Aide Partial/Complete Bed Bath,” “Aide Tub/Shower Bath,” and “Partial/Complete Sponge Bath” at each visit. The care plan lacked specificity regarding the type of bath to be provided and did not identify the level of patient participation that could be safely accommodated.A review of Clinical Record #8, with a start-of-care date of 10/16/25, identified a patient diagnosed with pulmonary fibrosis. Review of the Aide Care Plan revealed HA service instructions that included “Aide Partial/Complete Bed Bath,” “Aide Tub/Shower Bath,” and “Partial/Complete Sponge Bath” at each visit. The care plan lacked specificity regarding the type of bath to be provided and did not identify the level of patient participation that could be safely accommodated.A review of Clinical Record #9, with a start-of-care date of 11/26/25, identified a patient with a diagnosis of atherosclerosis of native coronary artery. Review of the Aide Care Plan revealed HA service instructions that included, “Partial/Complete bed Bath” at each visit. The care plan lacked specificity regarding the type of bed bath to be provided and did not identify the level of patient participation that could be safely accommodated.A review of Clinical Record #10, with a start-of-care date of 11/16/25, identified a patient with a diagnosis of Cerebrovascular accident. Review of the Aide Care Plan revealed HA service instructions that included, “Partial/Complete bed Bath” and “Partial/Complete sponge bath” at each visit. The care plan lacked specificity regarding the type of bed/sponge bath to be provided and did not identify the level of patient participation that could be safely accommodated.A review of Clinical Record #12, with a start-of-care date of 11/10/25, identified a patient with a diagnosis of senile degeneration of the brain. Review of the Aide Care Plan revealed HA service instructions that included, “Partial/Complete bed Bath” and “Perform complete bed bath, if unable to tolerate shower “at each visit. The care plan lacked specificity regarding the type of bed bath or shower to be provided and did not identify the level of patient participation that could be safely accommodated.A review of Clinical Record #14, with a start-of-care date of 11/20/25, identified a patient with a diagnosis of breast cancer. Review of the Aide Care Plan revealed HA service instructions that included, “Partial/Complete sponge Bath” at each visit. The care plan lacked specificity regarding the type of bed bath to be provided and did not identify the level of patient participation that could be safely accommodated.A review of Clinical Record #15, with a start-of-care date of 11/07/25, identified a patient diagnosed with chronic obstructive pulmonary disease (COPD). Review of the Aide Care Plan revealed instructions for HA services that included “Aide Partial/Complete Bed Bath” and “Aide Tub/Shower Bath” at each visit. The care plan lacked specificity regarding the type of bath to be provided and did not identify the level of patient participation that could be safely accommodated.A review of Clinical Record #16, with a start-of-care date of 11/24/25, identified a patient diagnosed with amyotrophic lateral sclerosis (ALS). Review of the Aide Care Plan indicated instructions for HA services that included “Aide Partial/Complete Bed Bath” and “Aide Tub/Shower Bath” at each visit. The care plan lacked specificity regarding the type of bath to be provided and did not identify the level of patient participation that could be safely accommodated.During an interview conducted on 12/12/25 at 9:30 a.m., Agency Personnel #1 and #2 confirmed the lack of specific and individualized written instructions documented regarding bathing services.

Based on clinical record review and staff interview, it was determined the Agency failed to perform an Initial Bereavement Assessment in 2 ( #7 and #10) of 16 ( #1 - #16) clinical records reviewed. This failed practice had the potential to negatively impact the grieving process for the patient and family in that social, spiritual and cultural factors which could interfere with coping mechanisms might not be discovered and/or addressed. Findings follow: --- Review of clinical record #7, with a start of care (SOC) of 09/23/22 and a diagnosis of Prostate Cancer revealed no evidence an Initial Bereavement Assessment had been conducted. Review of clinical record #10, with a SOC of 03/31/22 and a diagnosis of Lung Cancer revealed no evidence an Initial Bereavement Assessment had been conducted. An interview with Agency Personnel #1 and #2 on 11/10/22 at 10:45 AM confirmed no Initial Bereavement Assessment was performed.

Based on Interdisciplinary Group (IDG) meeting observation and staff interview, it was determined the Agency failed to maintain coordination between all disciplines providing care to all patients on census. This failed practice had the potential to leave patient and family needs unidentified and unmet. Findings follow: --- On 11/08/22 at 8:30 through 9:30 AM, an IDG meeting was observed. The Registered Nurse (RN) was the only discipline observed giving oral report on each patient. No care plan review or oral report given by Medical Social Worker or Chaplain. On 11/10/22 at 10:45 AM Agency Personnel #1 and #2 confirmed the lack of sharing of information by all disciplines in the IDG meetings.

Based on clinical record review and staff interview, it was determined the Registered Nurse (RN) failed to supervise and assess the quality of care and services through supervisory aide visits (SAV) every 14 days in 4 (#1, #3, #8 and #14) of 10 (#1, #3, #4, #5, #7, #9, #11, #13, #14 and #16) current patients records reviewed with Hospice Aide (HA) services. This lack of supervision by the RN had the potential to place all patients receiving HA services at risk for adverse outcomes due to possible delays in the discovery of noncompliance with the Plan of Care by the HA or possible changes in the needs of the patient and family. Findings follow: --- Review of clinical record #1, with a start of care (SOC) of 09/08/22 and a diagnosis of Alzheimer's revealed orders for HA services two times per week. The RN documented on a form titled, "supervisory visit" SAVs conducted on 09/20/22 and on 10/13/22 (9 days late). Review of clinical record #3, with a SOC of 10/04/22 and a diagnosis of Chronic Obstructive Pulmonary Disease revealed orders for HA services two time per week. The RN documented on a form titled, "supervisory visit" SAVs conducted on 10/18/22 and 11/02/22 (1 day late). Review of clinical record #8, with a SOC of 09/09/22 and a diagnosis of Lung Cancer revealed orders for HA services five times per week. The RN documented on a form titled, "supervisory visit" SAVs conducted on 09/13/22 and 09/28/22 (1 day late). Review of clinical record #14, with a SOC of 05/19/22 and a diagnosis of Colon Cancer revealed orders for HA services five times per week. The RN documented on a form titled, "supervisory visit" SAVs conducted on 07/18/22 and 08/02/22 (1 day late), and on 09/12/22 and 09/27/22 (1 day late). An interview on 11/10/22 at 10:45 AM with Agency Personnel #1 and #2 confirmed the late SAVs.

Based on a tour of the Agency's In-Patient Unit (IPU) and staff interview, it was determined the Agency failed to identify infection control risks and failed to use standard infection prevention precautions in 1 of 1 tour of the IPU. This lack of following standard infection control preventions had the potential to place patients, families and staff at risk for contact with potentially infectious material and limited the patients, families and staff's provision for safe care. Findings follow: --- During an IPU tour of a clean and empty patient room on 11/09/22 at 3:00 PM with Agency Personnel #1 and the Agency IPU Director, a soiled washcloth was found under the hospital bed mattress which could harbor microorganisms and pose an infection control risk to new patients. During an interview on 11/10/22 at 10:45 AM, Agency Personnel #1 who was present during the IPU tour, confirmed the observation listed above.