Every finding on record at Riverside Hospital Inc

Based on a review of clinical records and staff interviews, it was determined the agency failed to ensure that there was ongoing sharing of information between all disciplines providing care and services in all settings, whether the care and services were provided directly or under arrangement. Specifically, the clinical records for one (1) of six (6) patients whose pressure injury worsened during the review period failed to contain evidence that the interdisciplinary group was notified of the change in patient status: (Clinical record #1). --- The findings: Six (6) clinical records were reviewed in the agency October 25, 2022 with the hospice Director assisting in the navigation of the electronic medical record. The clinical record of patient #1 was reviewed for the certification period of 08/18/2022. The patients primary diagnosis was cerebrovascular disease and other related diagnosis that included a stage IV sacral wound. The hospice care plan contained orders for SN (Skilled Nurse) to assess wound/incision/drain site every visit for presence of redness, odor, and/or changes in amt/characteristics of drainage, and for increased new pain. Wound measurements will be obtained weekly. Notify physician as needed. The clinical record contained a LPN (Licensed Practical Nurse) note from 09/14/2022 that read in part as follows: "This nurse and CG (Caregiver) observed a malodorous smell with CG asking where is this coming from. This nurse educated btw [sic] the wound and patient dying there is a certain smell of death". The clinical record failed to contain evidence that the LPN notified the physician or the registered nurse case manager of the presence of a malodorous smell from the wound. On 10/25/2022, this Medical Facilities Inspector asked the hospice Director if the odor noted to the wound was reported to the interdisciplinary group. The hospice Director stated, no but the nurse did obtain an order from the physician to increase the Morphine dosage. The hospice director confirmed the above noted deficiency during the exit conference on 10/25/2022, along with the Regional Director of Clinical Operations, Executive Director and the Quality Assurance Manager.