Every finding on record at Seasons Hospice & Palliative Care of Wisconsin, LLC

Observed in Record Review. On 2 of 16 active patient records reviewed, wound assessments were not completed per policy. Agency wound assessment policy states that wounds will be assessed at least once per week. On RRNHV #9 it was noted that patient had multiple wounds that were not being assessed weekly per policy. In particular a heel wound that was not assessed weekly over a 2-month period. On RRNHV #10 it was noted on admit nearly 2 months ago that patient had a wound but there has been no assessment since day two on service. This issue was discussed was discussed with Hospice leaders.

Observed in Record Review. In 3 of 16 active patient records reviewed, the organization failed to plan the patient's care. On RRNHV #3 and RRNHV #9, the goals were not measurable with an example of pain will be managed at acceptable level. On RRNHV #6, it was noted that patient had no goals developed until a few weeks into the second certification. This was discussed and reviewed with the Hospice Leadership Team.

Observed in Record Review. In 3 of 16 active patient records reviewed, the organization did not ensure the care and services necessary to meet the needs identified in the comprehensive assessment were specified on the patient's plan of care. For example, RRHV #1, it was noted that the comprehensive assessment identified that the patient was at risk for skin breakdown and had recent pressure ulcers but the patient’s plan of care did not include goals and interventions to maintain the integrity of the skin. On RRIP #2, it was noted that the patient had been started on methadone but no goals developed for this medication. On RRNHV #6, it was noted that patient is incontinent using incontinent briefs but there was not goals addressing the incontinence or the skin breakdown risk associated with incontinence. This was reviewed with hospice leadership.

Observed in Record Review. In 8 of 16 active patient records reviewed, the hospice nurse surveyor noted medication orders were not clear and accurate. On RRHV # 1 and RRHV #4, it was noted that the plan of cares had duplicate PRN constipation drugs of Senna and Bisacodyl with no indication when to use duplicate therapy. On RRHV #2 and RRNHV #7 it was noted that the plan of cares had duplicate PRN constipation drugs of Milk of Magnesia and Bisacodyl with no indication of how to handle each duplicate therapy. On RRHV #3 it was noted that the plan of care had duplicate PRN constipation drugs of Milk of Magnesia, docusate and Bisacodyl with no indication of how to handle each duplicate therapy. On RRNHV #1, it was noted that patient had multiple PRN pain medications of Morphine, Oxycodone, and extra strength Tylenol with no indication how to handle duplicate therapy. On RRNHV #4, it was noted that patient had multiple PRN constipation medications of Magnesium Hydroxide and Bisacodyl with no indication when to use the duplicate therapy. On RRNHV #5, it was noted that patient had multiple PRN pain medications of Morphine, Tylenol supp and Tylenol PO with no indication how to handle duplicate therapy. This finding was discussed with Hospice leadership.

Observed in Record Review. In 2 of 16 active patient records reviewed, the plan of care did not include medical supplies and appliances necessary to meet the patient's needs. On RRHV #2, it was noted that the plan of care did not include all equipment need to care for the patient including the walker, wheelchair and hospital bed. On RRHV #3 it was noted that the plan of care did not include all equipment needed to care for the patient including, air mattress, hospital bed, and Hoyer lift. This finding was reviewed with Hospice leadership.

Observed in Record Review. In 2 of 16 active patient records reviewed, the organization failed to plan the patient's care. On review of RRHV #4 and RRNHV #1 it was noted that patient had goals from start of care that were not updated or achieved such as a goal complete SOC assessment and initiate hospice plan by end of admission. This was discussed and reviewed with the Hospice Leadership Team.

Observed in Patient Home. In 1 of 4 home visits conducted, the organization did not implement appropriate infection control procedures. On RRHV #2, the nurse cleaned her equipment with SaniWipes that had an expiration date of 2023. This finding was reviewed with the Director of Clinical Operations who was present for the visit.

Observed in Record Review. In 1 out of 16 active records reviewed, the organization failed to assess and reassess the patient. Organization policy states that the comprehensive assessment will include spiritual orientation of the patient. On RRNHV #1, the Hospice Nurse Surveyor noted that the spiritual assessment was not completed to include spiritual orientation which would include desire for involvement of a religious group the RN only answered the HIS data question but no actual assessment documented. This was discussed and reviewed with the Hospice Leadership Team.

Observed in Record Review. In 2 out of 4 home visits conducted that had ordered aide services, the Aide Care Plan did not have specific instructions for the aide. During the home visit for RRHV #1, the assigned tasks did not include specific instructions for care of the patient. For example, the patient is bedbound and told me that when the aide comes she is placed in a Hoyer lift to transfer. In addition patient states that she is transferred from bed to a chair but there was no instructions for this on the aide plan of care. On RRHV #3 it was noted that the patient was incontinent and the aide is using incontinence briefs and this should be noted on the aide plan of care. This finding was reviewed with Hospice leadership. .

Observed in Building Tour. It was observed in the kitchen that the gas cooking equipment was equipped with tethers, but they had been disconnected. This was verified by the Director of Plant Operations. The surveyor discussed the Life Safety deficiency with the organization, and it was determined that the following ILSMs will be implemented until the deficiency has been resolved and according to the organization's ILSM policy: Observed in Building Tour. It was observed above the ceiling outside the soiled utility room that there were several data cables supported by the fire main piping. This was verified by the Director of Plant Operations. This finding was observed during survey activity, but corrected onsite prior to the surveyor's departure. The corrective action taken needs to be included in the organization's Evidence of Standards Compliance submission. Observed in Building Tour. It was observed in the med room which was one hour rated that there was an unsealed penetration in the fire barrier. This was verified by the Director of Plant Operations. This finding was observed during survey activity, but corrected onsite prior to the surveyor's departure. The corrective action taken needs to be included in the organization's Evidence of Standards Compliance submission. Observed in Building Tour. It was observed that the Hospice med room was one hour rated and the door label fire rating had been painted over and could not be read. This was verified by the Director of Plant Operations. The surveyor discussed the Life Safety deficiency with the organization, and it was determined that the following ILSMs will be implemented until the deficiency has been resolved and according to the organization's ILSM policy: Observed in Building Tour. It was observed that the fire pump room door which was in a one hour fire barrier did not have a fire rating label. This was verified by the Director of Plant Operations. The surveyor discussed the Life Safety deficiency with the organization, and it was determined that the following ILSMs will be implemented until the deficiency has been resolved and according to the organization's ILSM policy:

Observed in Document Review. It was observed that the fire extinguisher inspection documentation did not include the NFPA standard(s) referenced for the activity. This was verified by the Director of Plant Operations.

Based on record review and interview the hospice staff failed to ensure all patients were kept clean and well-groomed in 1 of 10 patient records reviewed (Patient #1). --- Findings include: Review of Patient #1s ";Hospice Daily Encounter Report" on 7/23/2022 at 8:22 a.m. revealed in part, ";Has thick secretions in mouth." There was no documentation within the Plan of Care or Daily Encounter Report of measures to alleviate/treat the secretions nor if any oral care was provided at that time. Review of Patient #1s ";Hospice Daily Encounter Report" dated 7/25/2022 at 9:56 a.m. revealed in part, ";Oral care performed." There was no other documentation to indicate that oral cares and/or oral assessment was specifically completed at any other time for the rest of the patients respite stay. Patient #1 was discharged from respite on 7/27/2022. Photographs submitted as part of the complaint, dated 7/27/2022, of the patients groin/peri area which showed dried fecal smears on buttock and genital areas. Review of Patient #1s ";Hospice Certification and Plan of Care" dated 7/22/2022 revealed in part ";Need for skilled teaching related to urinary incontinence." A telephone interview was conducted with Complainant A on 4/25/2023 at 11:45 a.m. Complainant A stated that Patient #1 functions at approximately the level of a 2-year-old and is unable to complete any daily cares without total assistance. Upon admission for respite stay on 7/22/2022, it was noted that patient was having increased resistance to cares. These episodes increased when family was unable to visit to due COVID exposure from 7/23/2022 – 7/26/2022. Review of Patient #1s ";Hospice Daily Encounter Reports" during the patients 5-day respite stay revealed Patient #1 received incontinent skin care several times per day. During the three days that the family was unable to visit, Patient #1 became much more aggressive during these cares. As-needed lorazepam (anti-anxiety), haloperidol (anti-psychotic) and propanalol (cardiac medication also used for aggression) was given as ordered to help to deescalate behaviors (hitting and punching staff) and skin care continued to be given with each incontinent episode. There was no documentation within the record that the patient had a history of smearing his/her own fecal matter. Patient #1 wore incontinent briefs. The pictures submitted clearly showed smeared dried feces on the skin of patient's buttocks and peri area. These findings were confirmed during an interview with Director of Clinical Operations B on 4/26/2023 at 1:45 p.m.

Based on record review and interview hospice staff failed to ensure that medications were not used as the least restrictive intervention for patient behaviors in 1 of 10 patient records reviewed (Patient #1). --- Findings include: Review of Patient #1s medical record revealed that Patient #1 was brought to the facility by a different hospice agency for respite care on 7/22/2023. Patient #1s primary hospice diagnosis was unspecified protein-calorie malnutrition. Patient #1 had parent as guardian. Patient #1 also had a diagnosis of Down's Syndrome. Patient #1 had lived with and been cared for by family since birth had never been parted from at least one family member being present. Review of Patient #1's "Client Coordination Note Report" dated 7/22/2022 revealed in part, "Patient was admitted to 'other hospice' on 7/14/2022 and was transferred to IPC (inpatient center) today for emergency respite. Patient was transferred from home where 'he/she' lived with 'family member'. 'Family member' experiencing caregiver burnout and is unable to care for 'patient' at this time. Patient had been having increased resistance to cares and taking medications. 'Other hospice' has added haloperidol (anti-psychotic) to help manage symptoms of agitation." Review of Patient #1s ";Hospice Daily Encounter Report" dated 7/23/2022 at 8:40 p.m. revealed in part, ";Discussion occurred about COVID and exposures. Determined best complainant get tested for the safety of the patient and for the safety of staff." Family members were unable to visit Patient #1 from 7/24/2022 - 7/27/2022 due to the exposure. Review of Patient #1s ";Medication Administration Record" revealed that the patient was prescribed lorazepam (anti-anxiety/sedative) 1mg (milligram) every hour as needed for anxiety. This was given on 7/24/2022 at: 2:45 a.m. ";Patient refusing to sleep, requesting where parent and family are." 4:00 a.m. ";Patient continued to be anxious. Other hospice contacted and they advised that if family will not be able to visit to assist with calming patient due to COVID issues, that current plan is to sedate patient so he/she will not fall nor be aggressive with staff." 6:16 p.m. ";Restless. Agitated." 7:57 p.m. ";Restless. Agitated." Review of Patient #1s ";Medication Administration Record" revealed that the patient was prescribed propranolol (heart medication also used for migraines, agitation) 10mg daily as needed for agitation. This was given on: 7/22/2022 at 8:30 p.m. ";Patient became aggressive when attempting to get blood pressure." 7/24/2022 at 4:20 a.m. ";Second dose of lorazepam not effective." 7/25/2022 at 4:00 a.m. ";Patient still restless after receiving lorazepam and behaviors seemed to escalate. Resistive to cares." Review of Patient #1s Medication Administration Record" revealed that the patient was prescribed haloperidol (anti-psychotic) 1mg every two hours as needed for agitation. This was given on 7/27/2022 at: 12:30 a.m. ";Patient restless and attempting to place legs off the bed. RN (Registered Nurse) attempted to change patient and he/she started saying no." 4:30 a.m. ";Patient air-picking (reaching out to grab things from the air that are not visible) and removing blanket. Warm blanket applied. Haloperidol administered for comfort." Review of Patient #1s ";Medication Administration Record" revealed that the patient was prescribed a new medication, Seroquel, 25 mg every morning and 50 mg every evening scheduled for agitation. This was given on 7/25/2022 25mg at 9:00 a.m. and 50 mg at 9:00 p.m., on 7/26/2022 25 mg at 9:00 a.m. and 50 mg at 9:00 p.m., and on 7/27/2022 at 9:00 a.m. There was no documentation in the Plan of Care or medical record of any alternate interventions to assist with calming the patient prior to administering any sedating/calming medication. These findings were reviewed with Director of Clinical Operations B on 4/26/2023 at 1:45 p.m.

Observed in Record Review. A review of 1 of 16 patient records revealed that the organization did not ensure that initial assessments by members of the interdisciplinary group included all required information. For example, a review of the medical record for HosInpt#1, revealed that the MAHC 10 Fall Risk Assessment questions were not answered with information gathered from the comprehensive assessment. The question related to Impaired functional mobility was answered 'No'. The clinician documented that the patient was dependent in all activities of daily living. The question related to Polypharmacy was answered 'No'. The patient had more that 14 prescribed medications listed on the medication profile at the start of care date. This observation was reviewed with the Director of Clinical Operations.

Observed in Record Review. A review of 1 of 16 patient's records revealed that the organization did not ensure the care and services necessary to meet the needs identified in the comprehensive assessment were specified on the patient's plan of care. For example, during a review of the medical record for RR#7, it was noted that the comprehensive assessment identified that the patient was at risk for falls and had experienced falls during the past 3 month period. The patient’s plan of care did not include interventions to maintain patient safety, strategies to prevent injury, and a goal statement to evaluate response to care, treatment and services related to fall prevention interventions. This observation was reviewed with the Director of Clinical Operations.

Observed in Competency Session. In 2 of 13 Human Resource files reviewed it was noted that the organization did not ensure that competence of all individuals furnishing care was assessed as required. For example, during a review of the Human Resource file for Registered Nurse #6, and Registered Nurse #7, it was noted that competence was not initially assessed and documented as a part of orientation. This observation was reviewed with the Director of Business Operations.

Observed in Building Tour. The surveyor observed that the piping for approved automatic sprinkler systems was supporting other items. For example, there were 2 gray cords resting on the sprinkler pipe. This observation was reviewed with the Director of Clinical Operations. This finding was observed during survey activity, but corrected onsite prior to the surveyor's departure. The corrective action taken needs to be included in the organization's Evidence of Standards Compliance submission.