Every finding on record at Regional Hospice & Palliative Services-Southeast

Based on record review and interview, the provider failed to maintain a system of communication and integration as evidenced by the RN (Registered Nurse) failing to notify the physician that orders to start an IV (Intravenous) infusion was not initiated for 1 (Patient #11) out of 14 (#1-#14) sampled patients. --- Patient #11.  Review of the patient’s electronic clinical record revealed a start of care date of 10/22/2024.  The patient’s admitting diagnosis was Alzheimer’s disease.  The benefit period reviewed was 10/22/2024 to 01/19/2025.  Review of the patient's POC (Plan of Care) for benefit period 10/22/2024 to 01/19/2025 revealed an order for SN visits 1x week and prn for certification period (skilled nurse visit one time a week and as needed for  certification period). Review of the progress note dated 11/05/2024 at 10:55 a.m. revealed, “Progress Note Summary: Phone call made during IDG (Interdisciplinary Group) to pt.’s PCG (primary care giver)… Pt’s plan of care discussed with all. New orders received… NaCl (sodium chloride) 0.9% 1 liter via IV over 6 hours.  Orders faxed to facility (nursing home where patient reside)… spoke with (the nurse at the nursing home) and she is aware of orders.  Pt’s (patient’s) daughter… agreed with new care plan.” Review of Patient #11’s physician’s orders dated 11/05/2024 at 10:56 a.m. revealed, “…MD (Medical Doctor) approved the following med order… Started prescription sodium chloride 0.9% solution: Facility nurse to start peripheral IV and administer 1,000 ml (milliliters) NS (normal saline) over 6 hours for dehydration.” Review of Patient #11’s progress note dated 11/6/2024 at 10:54 a.m. revealed, “…Progress Note Summary: RN (Registered Nurse) notified… pt. daughter … requested phone call.  RN called (pt daughter) and she stated pt. did not receive fluids last night… She wanted to have pt. sent to ER (Emergency Room)… Facility nurse (nursing home) stated last night pt. is hard stick and three attempts were made to start IV… DON (Director of Nursing) at hospice called by (hospice) RN to update her on IV fluids not being given and (the pt.’s daughter) concerns.” Review of the patient’s addendum note dated 11/06/2024 at 12:00 p.m. revealed, “Daughter called and spoke to MSW (Medical Social Worker)… stating that she really wants her (the patient) to go to the ED (Emergency Department) for evaluation and fluid for dehydration… Call made to patient’s daughter to update her that the facility will have patient transported (to the hospital ER)… we have to discharge patient from hospice services…”  There was no evidence the patient’s physician was notified that 1,000 ml of Normal Saline was not initiated intravenously over 6 hours as ordered. On 05/08/2025 at 9:00 a.m., an interview and record review was conducted with S1DON (Director of Nursing).  She confirmed there was no evidence in the patient’s clinical record the physician was notified that 1,000 ml of Normal Saline was not initiated intravenously over 6 hours as ordered.

Based on record review and interview, the agency failed to ensure the patient's written individualized POC (plan of care) was followed as evidenced by the agency failing to ensure the SN (skilled nurse) followed physicians orders for wound care for 1 patient (#2) out of 2 (#2, #3) patients with wounds out of a total sample of 5 patients. --- Patient #2. Review of the patients electronic clinical record revealed a start of care date 2/25/2022. The patients admitting diagnosis was Alzheimers Disease. The benefit period reviewed was 11/22/2022 to 1/20/2023. Review of the patient's POC for benefit period 11/22/2022 to 1/20/2023 revealed an order for SN visits 1x week and prn for cert period 6 (skilled nurse visit one time a week and as needed for certification period six). Review of the patients physicians orders dated 12/15/2022 revealed, ";Apply Aquaphor to stage 2 left buttock wound w (with) each brief change." Review of the physicians orders dated 12/16/2022 revealed, ";Cleanse venous ulcer to left ankle w/mesalt and cover w/border gauze every 2-3 days." Review of the patients nursing visit note dated 12/23/2022 at 12:00 p.m. revealed, ";...Upon arrival patient was in bed being fed by sitter. Wounds reassessed by this RN (S3RNCM)... Sitter reeducated on turning and barrier creams..." Further review of the note revealed that there was no evidence that wound care was performed as ordered to the ankle of left foot. Review of the patients nursing visit note dated 12/30/2022 at 1:15 p.m. revealed, ";...Wounds reassessed by this RN (S3RNCM)... Sitter reeducated on turning and barrier creams. Further review of the note revealed that there was no evidence that wound care was performed as ordered to the ankle of left foot. On 3/15/2023 at 9:00 a.m., an interview was conducted with S3RNCM (Registered Nurse Case Manager). S3RNCM stated that she taught the sitter how to perform wound care. S3RNCM stated that whatever she did during the skilled nurse visit was documented in the physical information section of nursing visit note. S3RNCM confirmed that she did not document wound care in the skin section of the nursing visit note for the skilled nurse visits she made on 12/23/2022 and on 12/30/2022. On 3/15/2023 at 10:10 a.m., an interview was conducted with S2DON (Director of Nursing). S2DON stated that the nurses should be documenting wound care in their nursing visit notes if wound care was done. On 3/15/2023 at 10:45 am, an interview was conducted with S1CCO (Chief Clinical Officer). S1CCO confirmed that the skilled nurses should be documenting wound care in the nursing visit notes if wound care was done.

Based on record review and interview, the provider failed to maintain a system of communication and integration as evidenced by the RN (Registered Nurse) failing to assess and notify the physician of a wound after responding to the MSWs (Medical Social Workers) report that 1 patient (#2) acquired a wound for 1 out of 2 (#2, #3) patients with wounds out of 5 sampled patients. --- Patient #2. Review of the patients electronic clinical record revealed a start of care date 2/25/2022. The patients admitting diagnosis was Alzheimers Disease. The benefit period reviewed was 11/22/2022 to 1/20/2023. Review of the patient's POC for benefit period 11/22/2022 to 1/20/2023 revealed an order for SN visits 1x week and prn for cert period 6 (skilled nurse visit one time a week and as needed for certification period six). Review of the patients psychosocial visit note dated 12/12/2022 at 2:30 p.m. revealed, ";... (the patients sitter) reports that patient has a bed sore on her left butt cheek... SW (social worker) notified office..." Review of the patients nursing visit note dated 12/15/2022 at 2:10 p.m. revealed, ";...Patient has bedsore on left buttock stage 2..." This was the first note concerning the wound on the patients buttocks since the patients sitter reported it to the social worker on 12/12/2022. The wound was not assessed until 12/15/2022, which was 3 days after 12/12/2022. On 3/14/2023 at 12:20 p.m., an interview was conducted with S3RNCM (Registered Nurse Case Manager). S3RNCM stated that she discovered the stage 2 ulcer to the patients buttocks and stasis ulcer to the patients left foot during a routine skilled nurse visit that she made on 12/15/2022. On 3/14/2023 at 2:35 p.m., an interview was conducted with S4MSW (Medical Service Worker). S4MSW stated the patients sitter told her the patient had a wound on her buttocks. S4MSW stated she called the office and reported it to the ADON (Assistant Director of Nursing). On 3/15/2023 at 8:13 a.m., an interview was conducted with S5ADON. S5ADON confirmed that S4MSW did leave a message with the office that the patients sitter reported the patient having a wound on the buttocks on 12/12/2022. S5ADON stated that the other ADON had responded to the message and that the ADON was no longer an employee with the agency. S5ADON stated that he reviewed the patients clinical records and confirmed that there was no evidence that the other ADON made a visit to assess the wound or notified the physician of the wound. He confirmed that the wound was not assessed until 12/15/2022, which was 3 days after it was reported by S4MSW.

Based on record review and interview, the agency failed to ensure the patient's written individualized POC (plan of care) was followed as evidenced by the agency failing to ensure the SN (skilled nurse) weighed 1 patient (#3) as ordered per the POC for 1 out of 11 sampled patients and failing to ensure HA (hospice aide) visits were made as ordered per the POC for 1 (#4) out of 11 sampled patients. --- 1. Patient #3. Review of the patients electronic clinical record revealed a start of care date 8/18/2022. The patients admitting diagnosis was Alzheimers disease. The benefit period reviewed was 8/18/2022 to 11/15/2022. Review of the patient's POC for benefit period 8/18/2022 to 11/15/2022 revealed an order for SN visits 1x week and prn for cert period 1 (skilled nurse visit one time a week and as needed for certification period one). Further review of the patients POC revealed an order, ";...Weigh patient... weigh monthly..." Review of the patients SN visit notes for the month of September 2022 revealed no evidence that the patient was weighed for the month of September. On 11/1/2022 at 4:10 p.m., an interview was conducted with S1RCD (Regional Clinical Director). S1RCD reviewed the patients electronic clinical record and she verified that there was no evidence that the SN weighed the patient for the month of September 2022. 2. Patient #4. Review of the patient's electronic clinical record revealed a start of care date 10/7/2022. The patient's admitting diagnosis was Congestive Heart Failure. The benefit period reviewed was 10/7/2022 to 1/4/2023. Review of the patient's POC for the benefit period 10/7/2022 to 1/4/2023 revealed an order for HA visits 4x/week 1 then 5x week for cert 2 (hospice aide visits four times a week for one week then five times a week for certification period two). Review of the patient's HA visit notes revealed no evidence that HA visits were made for the week of 10/7/2022. Further review revealed there was no evidence that 5 HA visits were conducted for the week of 10/10/2022 as ordered per the patients POC. On 11/1/2022 at 8:45 a.m., S1RCD reviewed the patient's electronic clinical records and confirmed that there was no evidence that HA visits were made for the week of 10/7/2022 and confirmed that there was no evidence that 5 HA visits were made for the week of 10/10/2022 as ordered per the patients POC.