Every finding on record at Presbyterian Hospice Inpatient Unit

Based on observation, record review, and interviews, the facility failed to ensure that Hospice staff were completing hand hygiene in accordance with company policy for 1 (P (patient) 15) out of 6 (P15-P20) patients reviewed. This deficient practice could possibly lead to patients being at risk for infections. --- The findings are: A. Review of the facility's policy titled, "Hand Hygiene" dated 06/30/2022 indicated "Before an Aseptic Task: Perform hand hygiene immediately before any aseptic task such as preparing or administering medication, accessing an IV (intravenous- plastic line in a vein) port, or performing wound care. Gloves alone do not prevent contamination." B. During an observation on 10/17/24 at 3:20 PM, S (Staff)10, Clinical staff member, removed the old dressing from P15's wound and discarded it, cleaned the wound and did not change their gloves or perform hand hygiene after the old dressing was removed and discarded. C. During an interview with S3 clinical staff member, on 10/18/24 at 12:49 PM, S3 confirmed that after the dressing is removed gloves should be discarded, and hands should be washed

Based on observation, record review, and interviews, the facility failed to ensure that Hospice aides were providing patient care as directed by and included in the hospice aide plan of care for 1(P (Patient) 20) out of 6 (P15-P20) patients reviewed. This deficient practice could possibly lead to patients personal care needs being unmet. --- The findings are: A. Record review of the facilitys undated job summary for hospice aides, no date, stated ";All procedures, duties and tasks are to be completed under the patients care plan as ordered. . ." B. Record review of P20s Hospice Aide Plan of Care under the section ";Aide Other tasks" under ";Interventions" stated ";Aide assist with Shampoo- Assist patient with shampooing hair" the frequency was ordered as ";Each Visit." Indicating P20s hair should be shampooed on each visit by the aide. C. During an observation on 10/18/24 at 11:00 AM with S (staff)9, clinical staff member, on a home visit. S9 did not shampoo P20s hair and did not offer P20 a hair shampooing. D . During an interview on 10/18/24 at 12:20 PM with S2, non-clinical staff member, when asked if all the aide tasks on the section ";Other Aide Tasks" should be performed. S2 confirmed that all aide tasks should be completed that are under this section. E. During an interview with S9 clinical on 10/18/24 at 11:20 AM, S9 stated ";I wont be washing her hair because I washed it yesterday.

Based on record review and interview, the facility failed to maintain and update the Emergency Preparedness manual (binder) with a current staff and patient list. This deficient practice can delay the ability to offer continued patient care by not having a staff list readily available to contact in and knowing which patients are receiving care in an emergent (unpredictable or unforeseen) situation. The findings are: A. Record review of the Emergency Preparedness Manual, undated, revealed the following: 1. No current copy of a dated staff list 2. No current copy of a dated patient list. B. On 10/19/2021 at 3:15 pm during an interview, Staff (S)#1 (Administrator) confirmed there was not a current staff or patient list in the Emergency Preparedness binder.

Based on record review and interview, the agency failed to make sure a consistent method is in place to provide samples of complaints and grievances to the Quality Assessment and Performance Improvement (QAPI) committee which shows what complaints the facility received, investigated, and resolved. This deficient practice prevents the facility the ability to track and trend complaints and grievances from patients and family members to identify if the complaints require patient or staff education to minimize the complaints and patients are free from any mistreatment. The findings are: A. Record review of a binder (a cover for holding loose sheets of paper), titled Complaints revealed the following: 1. Copies of Complaints the facility received for dates 10/01/2020- 09/30/2021. On the log it indicated which staff contacted the patient or family member and what was done to resolve the complaint. 2. Record review of Quality Assessment and Performance Improvement (QAPI) documents dated 10/01/2020 through 09/30/2021, revealed, no information of any complaints. B. On 10/19/21 at 2:20 pm during an interview, Staff (S)#2 (Patient Care Manager) confirmed does not include complaint/grievances in QAPI meetings since they are resolved did not feel the need to include them.

Based on record review and interview, the facility failed to maintain an ongoing program to inform the Governing Body (professional advisory committee) of issues within the Quality Assessment and Performance Improvement (QAPI) to continue adequate and effective operations in the areas of clinical care and to discuss concerns that will improve the quality of care and patient safety. This deficient practice increases the likelihood of the facility not having a process for improving the quality and performance of patient care practices. The findings are: A. Record review of Quality Assessment and Performance Improvement (QAPI) documents dated 10/01/2020 through 09/30/2021, did not show any information of complaints received, investigated, and resolved. Or complaints being monitored or discussed with the governing body to implement resolutions to minimize the complaints/grievances to include patient or staff education. B. On 10/19/2021 at 2:30 pm during an interview, Staff (S)#2 (Patient Care Manager) confirmed, in the governing body meeting agenda there is a section for QAPI, and it does not show any complaints or what steps were taken to resolve any concerns. S#2 confirmed the QAPI committee does not identify problems or develop solutions about complaints and does not track and trend indicators or outcomes.

Based on observation and interview, the facility failed to ensure that items utilized for direct patient care are furnished appropriately by not using items past expiration dates and not identified as being under an extended use authorization by the United States Food and Drug Administration. This failed practice is likely to lead to poor patient treatment and delayed progression to goals. The findings are: A. On 10/19/2021 at 11:30 am, observation of the medical supply room revealed the following expired (exp) products used in direct patient care: 1. Five (5) bags of Baxter (product name) 0.9% Sodium Chloride Irrigation USP (used to wash and clean wounds): exp 11-2019 2. Three (3) Convatec (product name) Aquacel ribbon dressing (helps reduce wound pain and supports wound healing by providing a moist wound healing environment): exp (2) 06-2020 and (1) 10-2020. B. On 10/19/2021 at 11:45 am during an interview, Staff (S)#7 (Patient Care Manager) acknowledged the expired products in the supply room. S#7 reported there is not a set log to ensure that all product(s) is up to date. S#7 stated, "I check the supply room once a month or as needed to make sure there's nothing expired being used."

Based on observation and interview, the facility failed to maintain a safe physical environment by identifying and managing the integrity (condition) of patient rooms to minimize the spreading of infections or communicable diseases. This failed practice is likely to expose patients to infectious diseases. The findings are: A. On 10/19/2021 at 10:00 am during observation of the Hospice In-patient Unit the following was revealed: 1. Patient room 706, in the closet there was a linoleum (natural materials that are much more susceptible to damage from water and cleaning products) molding approximately 4 feet long 2. Patient room 707, in the restroom, the paint underneath the soap dispenser peeling from the wall 3. Patient room 708, in the restroom, the paint underneath the soap dispenser peeling from the wall. B. On 10/19/2021 at 10:20 am, during an interview Staff (S)#7 (Patient Care Manager) confirmed the linoleum molding in the closet and confirmed the molding belonged on the wall behind the patient bed. S#7 confirmed had not been informed by EVS (Environmental Services) to submit a work order to have it fixed. S#7 confirmed the paint peeling from the wall underneath the soap dispensers.