Every finding on record at Our Lady of Peace

Based on observation, a review of available documentation, and staff interviews, the facility failed to maintain and test the fire sprinkler system per NFPA 101 (2012 edition), Life Safety Code, section(s) 9.7.5, and NFPA 25- 2011 section 4.5. These deficient findings could have a widespread impact on the residents within the facility. Findings include: 1. On 10/25/2023 between 12-2 PM, it was revealed by a review of available documentation that the facility did not complete the required quarterly inspections and testing on the fire sprinkler system. 2. On 10/25/2023 between 12-2 PM, it was revealed by observation that a fire sprinkler head in the tunnel area had been painted white located above the piping. An interview with the maintenance director verified these deficient findings at the time of discovery.

Based on a review of available documentation and staff interviews, the facility failed to maintain the Smoking policy per NFPA 101 (2012 edition), Life Safety Code, section 19.7.4. These deficient findings have a widespread impact on the residents within the facility. Findings include: On 10/25/2023 between 12-2 PM, it was revealed by a review of available documentation that the facility has not updated its smoke policy since 2009. An interview with the maintenance director verified this deficient finding at the time of discovery.

Based on observation and staff interviews, the facility failed to maintain fire doors per NFPA 101 (2012 edition), Life Safety Code, section(s) 19.7.6, and NFPA 80-2010 section 5.2. These deficient findings could have a patterned impact on the residents within the facility. Findings include: On 10/25/2023 between 12-2 PM, it was revealed by observation the fire-rated door in the lower level tunnel area could not close due to the hinge being missing. The door is a separation between the I-1 and R-2 occupancies. An interview with the maintenance director verified this deficient finding at the time of discovery.

Based on observation and staff interviews, the facility failed to maintain Electrical equipment per NFPA 99 (2012 edition), Health Care Facilities Code Code, section 10.2.4. This deficient finding could have an isolated impact on the residents within the facility. Findings include: On 10/25/2023 between 12-2 PM, it was revealed by observation an extension cord was plugged into a power strip supplying an AC unit for the window located in the lower level conference room. An interview with XXX verified this deficient finding at the time of discovery.

Based on observation, interview, and document review, the agency failed to ensure proper hand hygiene, use of a barrier between the floor and staff clothing while kneeling and failed to ensure reusable equipment was properly sanitized following use for 1 of 4 patients (P13) observed for cares. --- P13's hospice plan of care indicated a diagnosis of hemiparesis (muscle weakness) of the left dominant side as a late effect of cerebral infarction (stroke), resided at a nursing facility, and received skilled nursing visits one to two times a week. During interview and observation on 10/23/23 between 2:01 p.m., and 2:23 p.m., observed signage on the facility doors alerting visitors to a COVID outbreak status. Registered nurse (RN)-A sanitized her hands and placed a barrier on the floor in P13's room to place her bag on and applied gloves. At 2:05 p.m., RN-A grabbed P13's lotion and placed it in the bathroom and doffed her gloves and grabbed a new set of gloves from inside RN-A's bag but did not sanitize hands in-between removing and applying the new set of gloves. At 2:08 p.m., RN-A took out a stethoscope and a thermometer and checked P13's temperature and put the thermometer back into the plastic bag located inside RN-A's nursing bag without first sanitizing the equipment. RN-A took out an oximeter out of the plastic bag and placed it on P13's left middle finger and without sanitizing, put the oximeter back into the plastic bag. RN-A took out a wrist blood pressure monitor and placed it on P13's left wrist and then took the thermometer and oximeter and plastic bag out of her nursing bag and set the plastic bag on the barrier and took the blood pressure monitor off P13's wrist and placed it in its container in the plastic bag on the floor without sanitizing. RN-A placed the stethoscope in the plastic bag but did not sanitize the equipment after listening to P13's lungs and bowel sounds. RN-A then took out a sanitizing wipe and cleaned the oximeter and put it back in its case and wiped down the thermometer and placed both items back into the plastic bag and wiped down the stethoscope and put it back into the same plastic bag and placed the same plastic bag into the nursing bag and removed gloves. At 2:23 p.m., RN-A stated she should have sanitized her hands after applying the lotion and further stated she should have cleaned the stethoscope, oximeter, blood pressure monitor, and thermometer before placing them in the bag. During interview on 10/25/23 at 12:04 p.m., the director of community hospice (DOCH) stated she expected hands to be sanitized in between glove use, and reusable equipment be sanitized. A policy, Hand Hygiene, dated April 2017, indicated the purpose of hand hygiene was to prevent cross contamination and home care acquired infections. Additionally, the policy indicated hand decontamination using an alcohol-based hand rub should be performed after removing gloves. A policy, Bag Technique, dated January 2016, indicated the purpose of the policy was to maintain a clean nursing bag and computer bag and prevent cross contamination. Further, the bag will be placed on a clean surface or a clean disposable surface. After hand washing, the supplies and or equipment needed for the visit will be removed from the bag. When the visit is completed, reusable equipment will be cleaned using alcohol, soap and water, or other appropriate solution, hands will be washed, and equipment and supplies will be returned to the bag. Hands will be decontaminated prior to returning clean equipment to the bag.

Based on interview and document review, the agency failed to ensure a verbal certification of terminal illness (VCTI) was obtained within two calendar days if a written certification could not be obtained within two calendar days after a benefit period began for 2 of 2 patients (P7, P11) reviewed. --- P7's Patient Information form indicated P7 was admitted to hospice on 3/31/23 with a primary diagnosis of hypertension in stage three chronic kidney disease due to type two diabetes mellitus. P7's written certification for the first 90-day benefit period 3/31/23, to 6/28/23, was not signed by the hospice medical director until 4/12/23, additionally, there was no signature or date next to the signature line and date for P7's attending physician. P7's written recertification for the second 90-day benefit period 6/29/23, to 9/26/23, was not signed until 8/1/23. P7's clinical notes were reviewed and lacked information a verbal certification of terminal illness was obtained following the first and second benefit periods. P11's Patient Information form indicated P11 was admitted to hospice on 10/17/23 and had a primary diagnosis of non-small cell cancer of the left lung. P11's Team Care Plan note indicated the hospice medical director verbally certified P11 as terminally ill with a life expectancy of 6 months or less on 10/17/23. P11's Certification Statement for First 90-Day Period form indicated a written CTI was completed by the hospice medical director on 10/24/23, however there was no signature or date next to the signature line and date for P11's attending physician. P11's Team Care Plan form dated 10/25/23, notes were reviewed and lacked information a verbal CTI was obtained from P11's attending physician within two calendar days after P11's benefit period began. During interview on 10/24/23 at 11:18 a.m., the performance improvement coordinator and community hospice nursing supervisor (PICCHNS) verified the medical director did not complete the written certification for terminal illness (CTI) for the second benefit period until 8/1/23 and verified the intradisciplinary team did not identify P7 would be verbally recertified and further stated they would have discussed P7 on 6/15/23. During follow up interview on 10/25/23, PICCHNS verified P11 did not have a verbal CTI and stated it should be documented in the admission note and stated if the verbal CTI is not documented in the admission note then the verbal CTI was missing. During interview on 10/25/23 at 12:06 p.m., the director of community hospice stated they just completed a PIP (process improvement project) and stated the CTIs were on their radar and expected the CTI to be completed per the requirements. A policy, Certification of Terminal Illness dated 12/28/16, indicated at the time a patient and family or caregiver chooses hospice care, the hospice medical director and the patient's attending physician, if any will certify the patient's terminal illness. Further, at the time of admission to hospice the hospice medical director or the patient's attending physician will complete a certification narrative. The hospice medical director and the patient's attending physician will sign the certification of terminal illness and authorization for hospice. The certification may be completed no more than fifteen calendar days prior to the effective date of the hospice election statement. If written certification cannot be obtained within two calendar days following the start of care, verbal certification must be obtained and documented in the clinical record within two days following initiation of care and written certification must be obtained before the hospice submits a claim for payment. Both the attending physician's and medical director's signed and dated initial certification forms must be on file prior to billing the first claim. Further, at recertification, the hospice medical director must compose and sign the narrative. A verbal or written certification statement must be obtained from the medical director or the attending physician no more than two calendar days after the first day of each period. A request for additional information regarding verbal certifications and written certifications was requested, but no additional information was provided.

Based on observation, interview and document review, the hospice failed to ensure a thorough investigation was completed for 1 of 1 patient (P1) reviewed for allegations of abuse. --- Findings include: A communication from a registered nurse (RN)-A to the assistant director of nursing (ADON), dated 9/27/22, indicated RN-A reported a concern via email from a patient (P1) who reported P1 "was sensitive to her nurse's energy/mood on Sunday evening, and did not feel respected." An interview form, dated 9/28/22, revealed P1 informed ADON a nurse (RN)-B, "was forceful and impatient. I felt disrespected" related to a rectal medication administration and "was left uncovered" and "did not have my call light" while waiting for RN-B to come to return to her room and administer medications. P1 noted "words were exchanged" between RN-B and a nursing assistant (NA)-A while in her room Two investigation documents, dated 10/5/22 and 10/6/22, indicated a maltreatment report was filed per P1's request due to concerns of maltreatment related to rectal medication administration. P1 noted the RN-B "moved too quickly." The documentation noted an interview with P1 and FM-A. No other patient or family interviews were noted to determine if there were additional concerns with patient treatment by staff or medication administration. The documentation noted ADON, NA-B and RN-B were interviewed. No other staff interviews were noted regarding staff treatment or patients, abuse reporting or medication administration. On 10/18/22 at 10:49 a.m., P1 and family member (FM)-A were interviewed together in P1's room. P1 was observed to have tense body posture, spoke in a strained voice and teared up. P1 noted she had arranged with RN-B for P1 to squeeze RN-B's hand when she was ready for each rectal medication administration. P1 explained RN-B waited for P1 to squeeze RN-B's hand for the first two capsules but did not wait for P1's hand squeeze for the remaining 2-4 capsules of medication. P1 explained the administration hurt and she felt RN-B was "impatient." P1 and FM-A noted RN-B and NA-A were arguing with each other on opposite sides of her bed. P1 and FM-A noted concerns about not being informed of follow up by hospice staff and worried if other vulnerable patients might be at risk. On 10/18/22 at 2:41p.m., ADON reported no additional family or patient interviews were completed regarding staff treatment of patients or medication administration outside of P1 and FM-A. ADON reported no other staff interviews were completed about staff treatment and medication administration, outside of the statements from NA-B, RN-B and RN-A. ADON reported she was new to her position and was not experienced in investigating abuse allegations at the hospice, as they seldom occurred. ADON reported it could be part of the protocol. The Complaint/Grievance Process, dated April 2017, directed staff "The organization will investigate complaints regarding treatment or care, mistreatment or neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and/or misappropriation of patient property by anyone furnishing services on behalf of the organization."

Based on observation, interview and document review, the hospice failed to develop an individualized and comprehensive care plan to address trauma and psychosocial concerns for 1 of 1 patient, (P1). Findings include: --- A social work assessment, dated 9/21/22, revealed P1 had "strong anxiety" which increased with bathing and wound care. P1 was estranged from all but one family member, FM-A. P1 experienced abuse from family members (not FM-A) in the past. P1 was noted as having lived with a chronic illness her whole life. The assessment noted the importance of FM-A's regular involvement in care, with plans for FM-A to always be present at the hospice home with P1. Facility investigation report, dated 9/28/22, described P1's concern a nurse (RN)-B was "forceful and impatient" during rectal medication administration and P1 felt "disrespected." P1 noted prior to rectal medication administration RN-B and a nursing assistant (NA)-A were arguing with each other on opposite sides of her bed. P1 reported while waiting for rectal medication administration she was left alone and uncovered without a call light. P1 noted, "I did not like the energy in the room." P1's team care plan, dated 9/20/22 to 10/18/22, included P1's preferred bathing methods. The team care plan did not include other individualized problems, goals or interventions related to P1's trauma history prior to entering hospice or care concerns that caused distress at the hospice home. On 10/18/22, at 10:49 a.m.P1 and family member (FM)-A were interviewed together in P1's room. P1 and FM-A was observed to have tense body posture, spoke in a strained voice and teared up. P1 noted she had told staff she shared with staff at admission she was a survivor of abuse. P1 noted an uncomfortable incident at the hospice house at the end of September. P1 noted a nursing assistant (NA)-A and nurse (RN)-B were arguing over her bed and made her feel uncomfortable. P1 noted she was left without her call light and was uncovered except a gown, and she felt very cold. P1 required rectal medications at that time due to health condition. P1 explained she felt the nurse working with her (RN-B) did not get full consent for third and subsequent capsules and felt rushed and experienced pain. P1 expressed anxiety over staff not believing her concerns and might ask her to leave. P1 and FM-A noted they had no other options for receiving care, outside of the hospice home. P1 noted she felt uncomfortable when male volunteers entered her room as she did not always know who they were right away. P1 and FM-A noted it was important to P1 for FM-A to be in the room with cares as it provided comfort. P1 expressed distress if the call light was not in place for her and FM-A had put up signs to remind staff to make sure call light was in place. P1 and FM-A explained they had discussed concerns with hospice staff. On 10/18/22, at 2:41p.m. the assistant director of nursing (ADON) reviewed the care plan and noted P1's bathing preferences were tailored to her comfort level, but no other problems goals, or interventions were included to direct staff related to her trauma history or P1's recent care concerns that caused her distress. ADON noted she wanted to ensure P1's privacy was respected in information shared on the team care plan. ADON explained there were interventions and concerns related to P1's trauma history and recent distressing experience at the residential hospice that could be included on the team care plan and respect P1's privacy. ADON noted, following the care concerns expressed by P1 on 9/28/22, FM-A was allowed to stay in the room for P1's cares to enhance P1's comfort, which was not generally recommended for other patients at the residential hospice. ADON noted male staff were no longer allowed in P1's room. These interventions were not on the team care plan. ADON explained there were no problems, concerns or interventions related to increasing P1's comfort with medication administration. On 10/18/22, at 3:57p.m. P1's hospice clinical social worker, (LICSW)-A, explained she assessed P1 shortly after admission and determined P1 had a history of trauma, including chronic lifelong illness, estrangement from family, and abuse from family. LICSW-A noted P1 was triggered easily and experienced sweat, anxiety and panic. LICSW-A noted personal cares, wound cares and bathing triggered P1's increased anxiety and panic. LICSW noted general interventions about anxiety but did not include trauma specific interventions as it was not a clinical concern, she was addressing with P1 during social work visits. LICSW was not sure how P1's direct care staff would be aware of problems, goals and interventions P1 required related to her history of trauma and anxiety. On 10/20/22 at 3:53 p.m. RN-B noted he was aware of P1's history of trauma but was not educated or directed on appropriate interventions related to P1's trauma history. RN-B noted rectal medications would be a potential trigger related to P1's trauma history. A policy on care plans was requested but not provided by the residential hospice.