Every finding on record at Park Hosptial District

Based on interview and record review, the hospice failed to ensure services were provided in accordance with the individualized written Plan of Care established by the hospice interdisciplinary group (IDG) in collaboration with the attending physician for 2 of 4 patient records reviewed who had wound care (Patient #6 and #7). Findings include: 1. The clinical record for Patient #7 was reviewed on 10/27/21. The patient was admitted for hospice care and services on 8/31/21, with a terminal diagnosis of malignant neoplasm of the bladder. The plans of care (POC) for the certification period, dated 8/3/21 to 10/31/21 included orders for skilled nursing services one time a week for 12 weeks, two times a week for seven weeks, and three times a week for two weeks, daily for three weeks and five as needed (PRN) visits, social work services one time per week for 12 weeks with six PRN visits, chaplain services once a week for 12 weeks with four PRN visits, volunteer services two times a week for three months with four PRN visits and hospice aide services one time a week for three weeks. Review of Patient #7's physician order dated 8/4/21 revealed wound care orders which included:"for Stage 1 wound (skin redness)- pressure reduction mattress overlay, alternating pressure mattress and Calazime ointment to reddened area daily and PRN, transparent film dressing to reduce friction/shear; for Stage 2 wound (superficial, partial thickness wounds)- cleanse with saline, apply transparent film dressing, change every 72 hours or PRN; for Stage 2-3 wound (superficial, partial thickness to shallow full thickness wounds)- cleanse with saline apply hydrocolloid dressing, change every three - seven days or PRN; for Stage 3-4 wound (partial or full thickness wounds with minimal to moderate exudate)- cleanse areas around wound with saline apply polyurethane foam dressing, change one to five days when the dressing was 75% saturated." Further review of Patient #7's physician orders revealed no evidence of any further wound care orders for Patient #7. a) The agency failed to obtain orders for wound care from the physician for Patient #7's lower abdomen suprapubic wound (previous drain site). Review of SN notes from 8/3/21 to 10/15/21 revealed wound care was provided to Patient #7's abdominal wound on 8/10/21 and 8/17/21. Specifically; On 8/10/21, RN # 6 documented "Abdominal drain site bandage change. Small serosanguinous drainage on old dressing, site cleaned with chloraprep swab, absorbent foam applied, extra bandages left, pt [patient] and spouse educated on changing dressing if saturated or soiled. No s/s [signs or symptoms] of infection noted." There was no evidence of communication and wound care orders received with Patient #7's physician documented in the 8/5/21 SN note, in the communication section of Patient #7's clinical record, nor was there evidence of a verbal order (VO) for the wound care provided. Review of the 8/18/21 IDG updated POC did not reveal evidence of wound care orders for Patient #7's abdominal wound. On 8/17/21, RN #7 documented in the wound assessment and care section of her SN note, Patient #7's lower abdomen suprapubic old drain site/surgical incision the wound was clean, left open to air, presence of a small scab with no drainage and no infection noted. Further review revealed in the narrative section of her documentation she wrote "The abdominal dressing he has been wearing from the removed drain is dry and intact. It is left open to air at his request." There was no evidence of communication and wound care ordered from Patient #7's physician documented in the 8/17/21 SN note or in the communication section of Patient #7's clinical record nor was there evidence of a VO for the wound care provided. Review of the 8/18/21 IDG updated POC did not reveal evidence of wound care orders for Patient #7's abdominal wound. During an interview on 10/27/21 at 2:34 p.m., RN #6 stated that she could recall specifics of the orders for wound care to Patient #7's abdominal drain site wound when he was on home health care, but she could not recall specifics about the orders for this wound when Patient #7 received hospice care. An interview with RN #7 was attempted on 10/27/21 at 1:48 p.m. but she was unavailable. b) The agency failed to obtain orders for wound care from the physician for Patient #7's upper pubic wound. Review of SN notes from 8/3/21 to 10/15/21 revealed wound care was provided to Patient #7's upper pubic area wound on 10/8/21, 10/11/21, and 10/12/21. Specifically; On 10/8/21 RN #4 documented in the narrative section of her note " Pus filled abscess at pubis was cleansed and re bandaged, spouse instructed to check each time she gives meds to see how much drainage is on gauze and to replace to maintain skin integrity. Copious amount of gray green discharge was expressed simply by pressing gently on area." RN #4 documented her communication with Physician #8 and documented a VO for increasing SN frequency to daily visits but there was no evidence of a VO documented for the wound care provided. Further review revealed no evidence of wound care orders for the abdominal wound on the 10/13/21 IDG updated POC. On 10/11/21 RN #9 documented in the wound assessment and care section of her note Patient #7's upper pubic wound was clean with scant serosanguinous (fluid that contains blood) drainage and covered with gauze. There was documentation of communication between RN #9 and the physician, however, no VO for wound care was found and no wound care orders for Patient #7's upper pubic wound were found on the 10/13/21 IDG updated POC. On 10/12/21 RN #9 documented in the wound assessment and care section of he SN note Patient #7's upper pubic wound had scant serous(fluid that is thin and watery) drainage and the wound was cleansed and dressing changed "Per Care Plan." In the narrative portion of her note she documented "Open blister to lower abdomen with scant drainage at times, no sxs (signs or symptoms of) infection noted, appeared dry during assessment." Further review revealed she documented in the communication section of this note "No one contacted as a result of this visit." There was no evidence a VO for the wound care was obtained for the wound care provided at this visit, and no evidence of wound care orders was found on the 10/13/21 IDG updated POC. Attempted to interview RN #4 on 10/27/21 at 1:51 p.m. but she was unavailable for an interview. During an interview on 10/27/21 at 1:22 p.m. the director of clinical services (DCS) stated there were no wound care orders for Patient #7 besides the standing orders for skin care in Patient #7's clinical record. She stated the agency was only "assessing the abdominal mass, not dressing the wound. The DCS stated she was unaware the mass was filled with pus or that the mass was near the original abdominal drain site. c) The nurse failed to follow standing physician orders for skin care for Patient #7's reddened coccyx. Review of SN notes from 8/3/21 to 10/15/21 revealed RN #6 provided wound care to Patient #7's stage 1 wound discovered on Patient #7's coccyx on 9/28/21 and 10/1/21. Specifically; On 9/28/21 RN #6 documented in the narrative section of the visit note, "Red blanchable area on coccyx, foam applied, pt (patient) and spouse educated on weight shifting and pressure injury prevention." RN #6 documented in the communication section of the visit note "No one contacted as a result of this visit." There was no evidence RN #6 communicated with a physician to use the standing treatment orders for a stage 3-4 wound for reddened skin on Patient #7 coccyx. There was no evidence of a VO and there was no evidence of wound care orders found on Patient #7's 9/29/21 updated IDG POC. On 10/1/21 RN #6 documented in the narrative section of the visit note "Red blanchable area to coccyx, Duoderm (type of hydrocolloid dressing) in place, foam placed over bony prominence, pt [patient] educated on pressure reducing weight shifting, rolled onto his side unassisted, stated he was comfortable lying on side." RN #6 documented she communicated with the physician to update him on Patient #7's condition, however there was no evidence RN #6 received wound care orders from the physician for applying the duoderm or foam on bony prominences, and no evidence of wound care orders on the 10/13/21 updated IDG POC. During an interview on 10/27/21 at 2:34 p.m. RN #6 stated she could not recall the specifics of the update she provided to the physician on 10/1/21. RN #6 stated "I typically get orders any time I change care." RN #6 could not recall the specifics of the wound care she provided to Patient #7's reddened coccyx. During an interview on 10/27/21 at 1:22 p.m. the DCS stated per the notes it appeared Patient #7 had a stated a Stage 1 wound on his coccyx and RN #6 was "staging up per standing orders on dressing choice." During an interview at 2:50 p.m. the DCS clarified her statement of "staging up per standing orders" to mean RN #6 was following standing orders for skin care but did not follow the correct orders for the stage of the wound RN #6 assessed on the patient's coccyx wound. During an interview on 10/27/21 at 2:53 p.m., the administrator reviewed the orders for Patient #7 and acknowledged there were no wound care orders besides the standing skin care orders found in Patient #7's clinical record. She stated RN #6 should have sought orders to vary from the standing skin care orders and she stated the agency should consider trying to get their standing orders modified to reflect the use of duoderm/foam dressing for reddened skin/skin protection as these are commonly used dressings for reddened skin. The administrator stated she felt the agency nurses knew Patient #7 well from treating him as a Home Health patient that when he transitioned over to Hospice the orders for wound care just got missed. 2. The clinical record for Patient #6 was reviewed on 10/26/21 and 10/27/21. The patient was admitted for hospice care and services on 5/6/21, with a terminal diagnosis of chronic diastolic heart failure. The plan of care (POC) for the certification period dated 5/16/21 to 8/13//21 included orders for skilled nursing two times a week for one week, one time a week for 12 weeks, two times a week for two weeks, one time a week for one week, and four PRN visits, social work services two time per week for 12 weeks and four PRN visits, and chaplain services once a week for 12 weeks and four PRN visits. a) The RN #9 failed to ensure wound care was provided as ordered on the POC for Patient #6. Review of a physician order dated 6/1/21 revealed RN #10 documented she received a VO for wound care to the left great toe to "cleanse the wound with normal saline (NS), pat dry, apply honey, cover with and absorbent dressing and change the dressing PRN." RN #10 also received orders for the right ankle to, "cleanse as needed with NS, pat dry, and cover with Tegaderm absorbent dressing changing the dressing as needed," as well as an order for the right ankle to, "cleanse as needed with NS, apply med honey into the wound and cover with ordered gauze or other absorbent dressing." Review of an order dated 6/3/21 revealed RN #10 documented she received a VO to discontinue the wound care order for the right ankle which stated "cleanse with NS, apply med honey into wound and cover with bordered gauze or other absorbent dressing." Review of an order dated 6/10/21 revealed RN #10 documented she received a new verbal order to change the wound care to the left great toe to "cleanse with NS, pat dry, apply medihoney and cover with absorbent dressing." Review of SN notes 5/16/21 to 7/19/21 revealed on 7/6/21 RN #9 documented in the wound care section of the visit note Patient #6's left lower medial foot wound was cleansed with normal saline, applied/packed with calcium alginate and covered with a band-aid, and Patient #6's right upper lateral foot was cleansed with normal saline applied/packed with calcium alginate and covered with a tegaderm foam dressing. In the narrative section of the visit note RN #9 documented "Wound care performed to bilateral feet, pt [patient] tol. [tolerated]. No sxs [signs or symptoms] infection noted." Review of VOs and communication notes revealed no evidence RN #9 had communicated with or received orders from the physician to change Patient #6's wound care orders. During an interview on 10/27/21 at 2:42 p.m., RN #9 stated when she treats a patient that she is not the primary RN for, she reviews the patient's POC to find out what treatments she is to provide for that patient. RN #9 reviewed her note on Patient #6 and stated "Oh, this says apply medihoney. I don't know why I did something completely different than the order. Unless there was excessive drainage maybe. Well it's not appropriate to do that without an order." RN #9 also stated she had no real explanation of why she did not follow the wound care orders as stated on Patient #6's POC as she could not remember exactly what happened. RN #9 stated "I know that I should be getting an order if I need to change the dressing."