Every finding on record at Spencer Municipal Hospital

Based on clinical record review and staff interview, the hospice failed to ensure hospice nurse members of the Interdisciplinary Group failed to update the comprehensive assessment with changes to the patient condition regarding wound description and measurements for 6 of 7 sampled patients with an open wound (Patients #1, #2, #5, #7, #8 and #10). Failure by the hospice Interdisciplinary Group (IDG) registered nurses to update the comprehensive assessment with complete wound descriptions and measurements placed the patient at risk for ineffective staff collaboration and communication regarding patient's wound status and effectiveness of treatments and interventions. Findings include: --- According to the hospice policy titled Skin and Wound Care-Assessment, dated 2017, basic wound assessment for all wounds includes dimensions: length, width and depth, presence of tunneling or undermining and shape. Wounds and patients change, therefore wounds need to be reassessed regularly and treated according to the changing needs of the patient and the wound. In home care, a professional reassessment of most wounds is indicated at least one a week. During an interview on 8/9/23 at 9:05 aM, the Clinical Manager stated staff are expected assess the wound measurements weekly, and include length by width by depth, drainage and signs and symptoms of infection. 1. Patient #1 had a hospice admission date of 6/13/22 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 6/8/23 to 8/6/23, included physician orders for skilled nursing services 3 times per week. b. The skilled nurse visit note, dated 6/28/23, included documentation The patient had a fluid filled blister to the left heel and non fluid filled blister to the right heel. The wounds lacked assessment of measurements. c. The skilled nurse visit note, dated 8/2/23, included documentation the right heel measured 4 centimeters(cm) by 3 cm with a dry area. The left heel measured 3 cm by 2 cm with no description of the wound. d. The skilled nurse visit note, dated 8/8/23, included documentation the right heel measured 5 cm by 5 cm and described flat purple area. The left heel improved since last seen on 8/2/23. e. During an observational home visit on 8/8/23 at 2:55 PM, Staff C, RN assessment the patients heels. She stated the left heel intact with no open area. She further stated the right heel had changed and measured the wound. The patient stated the heel area was sore when touching the area. Hospice staff failed to provide complete weekly assessments of the patient's wound. 2. Patient #2 had a hospice admission date of 6/26/23 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The POC, dated 6/26/23 to 9/23/23, included physician orders for skilled nursing services 2 times per week. b. The skilled nurse visit note, dated 6/26/23, included documentation the patient had a skin tear on the right arm and cleansed the wound with mepilex and gauze dressing. The document failed to include an assessment of the skin tear. Hospice staff failed to provide complete assessment of the patient's wound. 3. Patient #5 had a hospice admission date of 8/3/23 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The POC, dated 8/3/23 to 10/31/23, included physician orders for skilled nursing services 3 times per week. b. The initial skilled nurse visit note, dated 3/7/22, included documentation of no wounds identified. c. The skilled nurse visit note, dated 8/4/23, included documentation of pressure sores noted to the left and right buttock area and interventions are in place. The documentation failed to include assessment of the wounds. d. The skilled nurse visit note, dated 8/7/23, included documentation the wounds cleansed with wound cleanser and apply calazinc cream to the wound. The documentation failed to include assessment of the wounds. e. The skilled nurse visit note, dated 8/9/23, included assessment of he left buttock measurements included 1.5 cm by 1 cm and no depth assessed. Hospice staff failed to provide complete assessment of the patient's wound. 4. Patient #7 had a hospice admission date of 6/22/23 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The POC, dated 6/22/23 to 9/19/23, included physician orders for skilled nursing services 2 times per week. b. The skilled nurse visit note, dated 6/26/23, included documentation the patient noted to have a tegaderm (transparent dressing) on the right and left arm for skin tears. The documentation failed to include assessment of the wounds. Hospice staff failed to provide complete assessment of the patient's wound. 5. Patient #8 had a hospice admission date of 8/1/23 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The POC, dated 8/1/23 to 10/29/23, included physician orders for skilled nursing services every 14 days. b. The skilled nurse visit note, dated 8/1/23 included documentation of a skin tear to the right arm. The note failed to include documentation of an assessment of the wound. c. The skilled nurse visit note, dated 8/8/23, included documentation of a wound noted to the bottom right foot described with a callous. The document failed to include assessment of the wound Hospice staff failed to provide complete assessment of the patient's wounds. 6. Patient #10 had a hospice admission date of 4/27/23 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The POC, dated 7/26/23 to 10/23/23, included physician orders for skilled nursing services 2 times per week. b. The POC identified the patient had a wound to the buttocks and included a penrose drain. The POC included documentation the spouse provides wound care to the patient and cleansed the area 2 times a day and puts a 4 by 4 dressing around the site and covers the area with an abdominal pad and medical prep. c. Review of the medical record lacked documentation of the wound on the buttock or documentation of patient refusal to allow staff to observe. d, During and interview on 8/15/23 at 8:55 AM Staff F, RN stated the patient had a penrose drain on the lower bottocks. He/she lays ono the area and is resistant to staff looking at the area and he/she complains about the site. The patient's spouse is a retired nurse and very aware of what to look for and staff talk to him/her about signs and symptoms of infection. Hospice staff failed to provide complete assessment of the patient's wound. The Administrator received the above findings and hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, review of employee personnel files and hospice policy review, the hospice failed to ensure 1 of 2 sampled hospice aide (Staff G) satisfactorily demonstrated competency in the performance of any skills which exceed the level of basic hospice aide skills in the presence of a registered nurse with competency determined at a patient's bedside or using a real person (pseudo-patient) prior to being assigned to perform the task independently for 2 of 5 sampled patients who required an extra skill task to be performed (Patient #2 & 9). The hospice reported 13 current patients who required aide services at the time of the survey. The hospice employed a total of 2 aides at the time of the survey. Failure to ensure hospice aides have a competent ability to perform all skills above and beyond basic hospice aide skills increased the risk that patients received inadequate or inappropriate care. Findings include: --- The Medicare Conditions of Participation direct that the hospice aide may not independently provide any patient cares beyond the basic required skills without successful instruction and demonstration of competency in extra skills assigned on the aide care plan. According to the hospice policy titled Care Assistant/Aide Training, dated 8/16/23, observations must be made with a live patient or other individual, and must include but are not limited to: reading and recording temperatures, pulse and respiration; Bath; shampoos; nail and skin care; oral hygiene;toileting and elimination; safe transfer techniques and ambulation; normal range of motion and positioning and any other task that the hospice may choose to have the hospice aide perform. During an interview on 8/16/23 at 1:40 PM, the Administrator, reported Staff G, Hospice Aide did not have documentation of competency training for competency of patient shaving or EZ stand lift transfers. 1. Patient #2 had a hospice admission date of 6/13/23, and received hospice services while residing in a nursing home. The plan of care, dated 6/26/23 to 9/23/23, identified the patient required assistance with shaving. The aide care plan included Registered Nurse (RN) instructions to shave the resident. Review of the clinical record showed Staff G, Hospice Aide, provided aide services independently for Patient #2. Staff G, Hospice Aide, had a hire date of 4/18/23. Staff G's personnel file lacked documentation RN had observed Staff G competently perform the task of the use of shaving patients. 2. Patient #9 had a hospice admission date of 5/12/23, and received hospice services while residing in a nursing home. The plan of care, dated 5/12/23 to 8/9/23, identified the patient required assistance with use of an EZ stand lift for transfers. The aide care plan included RN instructions to transfer the patient with an EZ stand lift. Review of the clinical record showed Staff E, Hospice Aide, provided aide services independently for Patient #9. Staff G, Hospice Aide, had a hire date of 4/18/23. Staff G's personnel file lacked documentation RN had observed Staff G competently perform the task of the use of an EZ stand lift for patient transfers. The above findings were reviewed with the Administrator. Hospice staff provided no further information prior to the end of the survey.

Based on review of written contractual agreements, the hospice failed to ensure the written agreement between the hospice and 2 of 3 sampled services under arrangement included all of the required contract components. The hospice reported a total of 8 written agreements for services under arrangement with individuals/companies at the time of the survey. Failure to include the required contract components within the contractual agreement increased the potential that hospice management and oversight failed to occur and the patient would not receive services as specified on the plan of care. Findings include: --- 1. A hospice massage therapy contract, dated 1/9/12, failed to include the following contractual language: the hospice retains administrative management, the hospice retains financial management, oversight of staff and services and all services are authorized by the hospice. 2. A hospice durable medical equipment contract, dated 4/18/11, failed to include the following contractual language: the hospice retains administrative management, the hospice retains financial management, oversight of staff and services and all services are authorized by the hospice. The above findings were reviewed with the Administrator. Hospice staff provided no further evidence prior to the end of the survey.

Based on clinical record review, policy review and staff interview, the hospice failed to ensure patient clinical records included a physician order for all treatments for 3 of 14 sampled patients (Patients #5, #11 and #14) with a record review. Failure to have physician order for all medications and treatments created the potential for patients to receive incorrect or ineffective treatment to meet assessed needs. Findings include: --- According to the hospice policy titled Physician Orders, dated 9/29/22, a registered nurse or other qualified practitioner licensed to practice by the state must document a verbal/telephone order in writing in the patient's clinical record, with the source of the order, date, time, signature and read back notation. 1. Patient #5 had a hospice admission date of 8/3/23 and received hospice services while residing in a nursing home. The POC, dated 7/11/23 to 10/8/23, included medication and treatment orders. a. The skilled nurse visit note, dated 8/7/23 included documentation the patient had a pressure wound on the left and right buttock. The treatment provided included cleanse with wound cleanser and apply clazinc cream 2 times daily. b. The skilled nurse visit note, dated 8/9/23 included documentation the treatment for the pressure wounds to the right and left buttock included cleanse with wound cleanser and apply clazinc cream. c. The verbal order, dated 8/9/23, included order to cleanse the right and left buttock pressure wound with wound cleanser, apply calazinc cream 2 x daily and as needed. The hospice failed to notify the physician of wound care treatments and receive specific orders for patient care in a timely manner. 2. Patient #11 had a hospice admission date of 11/10/22 and date of discharge of 11/22/22 and received hospice services while residing in a nursing home. The POC, dated 11/10/22 to 2/7/23, included orders for medications and treatments. The skilled nurse visit note, dated 11/15/22, included documentation the patient had a pressure wound on the buttock. The note included documentation the nurse applied healing ointment and optifoam to the wound. Review of the clinical record lacked physician order for healing ointment or optifoam. 3. Patient #14 had a hospice admission date of 11/15/22 and date of death pf 11/24/22 received hospice services while residing in a nursing home. Clinical record review revealed: The POC, dated 11/15/22 to 2/12/23, included orders for medications and treatments. The skilled nurse visit note, dated 11/22/22, included documentation of a wound on right outer heel described black-blue area. The note included documentation the area cleaned with alcohol and skin prep applied. A 4 by 4 dressing and soft wrap applied. Review of the clinical record lacked physician order . to cleanse with alcohol, apply skin prep and the 4 by 4 dressing with soft wrap. The Administrator received the above findings. Hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, policy review and staff interview, the hospice failed to ensure the hospice staff sent a copy of a discharge summary to the attending physician for 2 of 2 sampled (live) discharged patients (Patients #11 and #12). The hospice reported a total of 2 live discharge for patients who revoked hospice services in the past 12 months. Failure to ensure the hospice staff included the attending physician in the process for imminent discharge placed the patient at risk for not receiving ongoing medical care and services to meet the needs of the patients. --- According to the hospice policy, titled Discharge for Reasons Other than Death, dated 11/2008, when the patient is discharged from hospice, the hospice provides a copy of the clinical record (if requested) and the hospice discharge summary to the patients attending physician. During an interview on 8/16/23 at 1:40 PM the Administrator stated the Electronic Medical Record did not have a discharge summary built in. The nurses did not have prompts to complete a discharge summary. 1. Patient #11 was admitted to hospice on 11/10/22, received services while residing in a nursing home and revoked hospice services and had a discharge date of 11/22/22. Clinical record review lacked documentation the discharge summary was completed or forwarded to the patient's attending physician. 2. Patient #12 had a hospice admission date of 9/20/22, received routine home care hospice services while residing in a private residence and revoked hospice services and had a discharge date of 11/17/22. Clinical record review lacked documentation the discharge summary was completed or forwarded to the patient's attending physician. The Administrator received the above findings and hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, hospice policy review, nursing home medication administration records and hospice staff interview, the hospice failed to ensure hospice staff provided overall coordination of the hospice care in regards to the patient's medications with the nursing home for 1 of 1 sampled patients (Patient #1) with a nursing home medication review. The hospice reported 11 patients who received hospice services in a nursing home setting. Failure to ensure the hospice staff provided overall coordination of the patient's medications with the nursing home placed the patient at risk for receiving inadequate care and/or treatments needed to meet the individual needs of the patient. Findings include: --- According to the Nursing Home Contract Regarding Hospice Care, dated 8/16/23, the hospice with designate a Primary Nurse who is responsible for a patient who is a resident of the Skilled Nursing Facility. The designated member is responsible for: providing overall coordination of hospice are of the resident with the facility representatives. Communicating with the facility representatives and other health care providers participating in the provision of care for the terminal illness and related conditions and other conditions to ensure quality of care for the patient and family. During an interview with Staff C, Registered Nurse on 8/14/23 at 8:38 AM she stated the facility staff call the hospice and communicate patient changes. The hospice staff go to the facility and sees the patient. Patient #1 had a hospice admission date of 6/13/22 and received routine home care hospice services while residing in a nursing home. Review of the clinical record revealed the following: The Plan of Care (POC), dated 6/8/23 to 8/6/23, included Interdisciplinary group (IDG) orders for skilled nursing services 3 times per week and included physician orders for medications. Review of the patient's nursing home Medication list for August 2023 identified the following medication discrepancies with the hospice's POC and Medication Profile, dated 8/8/23, for the patient: a. The hospice POC had an order for Furosemide (diuretic) 80 mg every morning. The hospice's Medication Profile identified a start date for the medication, dated 6/13/22. The nursing home's Medication Administration Record (MAR) included an order for Furosemide 80 mg every morning and 40 mg at noon, dated 4/7/23. b. The hospice POC had an order for Acetaminophen 325 mg every 8 hours as needed for pain/fever, not to exceed 4 grams in 24 hours. The hospice's Medication Profile identified a start date for the medication, dated 6/13/22. The nursing home's MAR included an order for Acetaminophen 1000 mg every 8 hours as needed for pain/discomfort, dated 9/5/21. Hospice staff failed to ensure the coordination of the patient's medications with the patient's nursing home. The Administrator received the above findings and hospice staff provided no further information prior to the end of the survey.

The Iowa Code, Chapter 135C.33 requires hospice agencies to complete a criminal history, a dependent adult abuse, and child abuse record check on all prospective direct or contracted employees with the potential for direct patient contact, within 30 days prior to the date of hire, using either the Iowa Single Information Repository (SING), or using both the Iowa Department of Criminal Investigation (DCI) to conduct the criminal background check, and using the Iowa Department of Human Services to conduct the dependent adult abuse and child abuse background checks. The Iowa Administrative Code, Chapter 119, requires the hospice agency to obtain authorized clearance from the Department of Human Services (DHS) prior to hiring any prospective employee who DCI has reported has a criminal record for any conviction more severe than a simple misdemeanor. Based on review of employee personnel files and staff interview, the hospice failed to ensure completion of a criminal background check for 1 of 5 sampled employees (Staff H) who began serving hospice patients since their last survey, dated 10/22/2020. The hospice reported hiring 11 employees and 2 volunteers since the last survey. Failure to complete criminal background checks as required by Federal regulation, increased the potential risk of harm to agency patients from hospice employees who had direct patient contact. Findings include: --- According to the undated hospice policy titled Staff Selection and Hiring Policy, before performing duties, applicants that have a criminal background report on SING will need to complete the appropriate paperwork to be submitted to DHS for evaluation. Offers will be pended for applicants who have a criminal background report awaiting a disposition from DHS. Offers will be withdrawn if the applicant is not approved by DHS. During an interview on 8/16/23 at 9:05 AM, the Human Resource manager stated the hospice did not have documentation of authorized clearance from DHS. Staff H, Volunteer, had a hire date of 5/24/23. Staff H's personnel file included a criminal history background check completed by the hospice through the Iowa Single Information Repository (SING). The criminal history included documentation of a positive criminal history. The personnel file failed to include authorized clearance from the DHS. The above findings were reviewed with the Hospice Administrator and Human Resource Manager. Hospice staff provided no further information prior to the end of the survey.