Every finding on record at Passages Hospice North-Northeast, LLC

Based on record review, observation, and interviews, the Hospice provider failed to ensure accepted standards of practice was exercised by nursing staff for 1 (#3) of 1 (#3) patients observed during wound care. The failed practice was evidenced by S6Registered Nurse (RN) failing to change her gloves when she provided wound care for patient #3. --- Findings: Hand Washing Policy and Procedures: Review of the hospice hand washing policy and procedures revealed the following the purpose was to provide guidelines for effective hand hygiene, in order to prevent the transmission of bacteria, germs, and infections. Further review revealed the following: · Always follow Standard Precautions. · Gloves are to be worn when contact with blood, bodily fluids, mucous membranes, dressings, non-intact skin, ect., is anticipated and, · Change gloves when moving from a contaminated body site to a clean body site on the same patient. Review of patient #3s medical record revealed a plan of care (POC) start date of 04/16/2024. Further review of the POC revealed the certification period was from 04/16/2024 to 07/14/2024. Resident #3 had a documented primary diagnosis of trauma subdural hematoma with loss of consciousness of unspecified duration, initial encounter. Review of the orders for the discipline and treatments included an addendum physicians order dated 04/16/2024 for a skilled nurse two times a week for thirteen weeks. Review of the plan of care revealed patient #3 resided in a nursing facility. A home visit was made at the nursing facility with S6RN on 05/07/2024 at 9:00 a.m. During the visit, she revealed that patient #3 had a stage 2 pressure wound to his buttocks and further reported that she would perform wound care during the visit. During the visit, an observation revealed S6RN donning a pair of clean disposable gloves. Further observation revealed S6RN handling the patients legs by touching the legs with her gloved hands during her assessment of his skin. She then handled patient #3s feet while palpating for pedal pulses, using the same pair of gloves. After her assessments, S6RN positioned the patient on his right side with staff assistance and in preparation for the wound care procedure. After the patient was positioned, an observation revealed patient #3 had a large dressing that partially covered his buttocks. S6RN removed the dirty dressing from the buttocks area. S6RN then retrieved some clean gauze, applied DermaKlenz wound cleanser to the gauze, and began cleaning the wound. After she finished cleaning the wound, S6RN retrieved a clean boarded gauze dressing and covered the pressure wound and buttocks. S6RN did not change her gloves and /or perform hand hygiene after handling patient #3s legs, feet, and prior to performing wound care or during wound care. During an interview with S3Director of Nursing (DON) on 05/07/2024 at 11:30 a.m., she was notified of the findings during the wound care observation of S6RN not changing her gloves and /or performing hand hygiene during the wound care observation for patient #3. S3DON confirmed that S6RN did not perform effective hand hygiene practices when providing wound care for patient #3 to in accordance with the providers written policies and procedures.

Based on record review and interview the facility failed to provide volunteer services on a day to day administrative and or direct patient care services in an amount that at a minimum, equals 5% of the total patient care hours of all paid hospice employees and contract staff. --- Findings: Review of the 2023 volunteer statistics revealed volunteers provided 235 hours of administrative and or direct patient care services for the provider. The provider rendered 8742.14 total hours for patient care in the year 2023. Volunteers provided approximately 2.69 % of the total patient care hours of all paid hospice employees and contract staff. On 05/08/2024 at 11:30 a.m., an interview with S2 Director of Nurses (DON) confirmed the facility failed to provide volunteer services on a day to day administrative and or direct patient care services in an amount that at a minimum, equals 5% of the total patient care hours of all paid hospice employees and contract staff.