Every finding on record at Sanford Fargo Hospice

Based on observation, record review, policy review, and staff interview, the agency failed to update the plan of care for 2 of 14 sampled patients (Patient #1 and #9) currently receiving Hospice services. Failure to review and revise the plan of care with information from the patient's updated comprehensive assessment limited the staff's ability to communicate treatment approaches and interventions to ensure continuity of care. --- Findings include:Review of the facility policy titled "Plan of Care, Hospice" occurred on 01/15/26. This policy, dated 07/30/25, stated, ". . . The POC [plan of care] identifies the care, treatment, and services provided to the patient based on his/her needs identified by the IDG [interdisciplinary group] and Comprehensive Assessments and reassessments. . . . PROCEDURE: . . . 4. The POC, treatment, services, and goals are revised based on the patient's needs. 5. The review of and revisions to the POC by the IDG occurs at least every 15 days. . . . 8. Factors which contribute to reviewing/updating the POC and therapeutic orders are, but not limited to: * Changes in the patient's physical and/or psychosocial condition * Outcomes/treatments have changed and/or been achieved . . ."- Observation on 01/12/26 at 2:50 p.m. showed a sign for "Enhanced Barrier Precautions" on the door to Patient #1's room. The sign directed staff to wear gloves and a gown when changing briefs or assisting with toileting, changing linens, or with wound care. During the visit with Patient #1, the hospice nurse (#1) performed hand hygiene, applied a gown and gloves, provided perineal care/wound care, and changed the soiled bottom sheet following the patient's incontinence with stool.Review of Patient #1's medical record occurred on January 12-13, 2026. The current plan of care included ". . . Problem: Orders and Wound Therapy . . . Wound care provided by SNF [skilled nursing facility] nursing staff, location of wound [:] coccyx, type of wound [:] pressure injury, dressing instructions [:] apply mepelix [type of foam dressing], frequency every three days and PRN [as needed]. . . ." The plan of care failed to include the need for enhanced barrier precautions. The Hospice staff failed to revise Patient #1's plan of care for wound therapy with interventions related to infection control and the use of enhanced barrier precautions. -Review of Patient #9's medical record occurred on 01/14/26. The nursing assessment, dated 10/28/25, indicated Patient #9 utilized oxygen at 2 liters/minute and stated, "[Patient #9] reports using the supplemental oxygen when taking her daily afternoon nap and while sleeping at night. . . ." The current plan of care, stated, ". . . Problem: Physical . . . [Name of Patient #9 and daughter's name] decline wanting oxygen in the home. They feel they do not need [oxygen]. . . ." The Hospice staff failed to revise Patient #9's plan of care to include the use of oxygen.During an interview on 01/15/26 at 10:45 a.m., an administrative nurse (#2) agreed staff should have updated Patient #9's care plan with the use of oxygen.