Every finding on record at St. Catherine's Hospice, LLC

Based on record review and interview the agency failed to conduct initial bereavement assessments with the patients family and/or caregiver for 4 (Patient #5, Patient #7, Patient #9, Patient #13) of 19 (Patient #1, Patient #2, Patient #3, Patient #4, Patient #5, Patient #6, Patient #7, Patient #8, Patient #9, Patient #10, Patient #11, Patient #12, Patient #13, Patient #14, Patient #15, Patient #16, Patient #17, Patient #18, and Patient #19) sampled patients reviewed. Findings: --- Patient #5 Review of Patient #5s record revealed Patient #5 was admitted to the agency on 06/08/2023. Review of Patient #5s Initial Bereavement Assessment dated 06/12/2023 revealed an attempt was made to reach Patient #5s son for an assessment; however, the chaplain did not receive a call back. Review of Patient #5s record revealed no documented evidence and the agency presented no documented evidence Patient #5s family or caregiver had an initial bereavement assessment completed since admission on 06/08/2023. In an interview on 08/25/2023 at 3:45 p.m., S2Director of Nursing (DON) stated the agency did not have any documented evidence on the follow up for Patient #5s initial bereavement assessment. S2DON confirmed the initial bereavement assessment was not completed for Patient #5. Patient #7 Review of Patient #5s record revealed Patient #7 was admitted to the agency on 07/12/2023. Further review of Patient #5s record revealed no documented evidence and the agency presented no documented evidence of an initial bereavement assessment had been completed. In an interview on 08/24/2023 at 3:56 p.m., S2DON stated the agency had no documentation an initial bereavement assessment had been completed for Patient #7. Patient #9 Review of Patient #9s record revealed Patient #9 was admitted to the agency on 01/21/2023. Further review of Patient #9s record revealed no documented evidence and the agency presented no documented evidence of an initial bereavement assessment had been completed. In an interview on 08/24/2023 at 4:06 p.m., S2DON stated the agency had no documentation an initial bereavement assessment had been completed for Patient #9. Patient #13 Review of Patient #13s record revealed Patient #13 was admitted to the agency on 07/20/2023. Further review of Patient #13s record revealed no documented evidence and the agency presented no documented evidence of an initial bereavement assessment had been completed. In an interview on 08/24/2023 at 4:23 p.m., S2DON stated the agency had no documentation an initial bereavement assessment had been completed for Patient #13.

Based on record review and interview the agency failed to ensure patients received social worker visits per their plan of care for 2 (Patient #13 and Patient #16) of 19 (Patient #1, Patient #2, Patient #3, Patient #4, Patient #5, Patient #6, Patient #7, Patient #8, Patient #9, Patient #10, Patient #11, Patient #12, Patient #13, Patient #14, Patient #15, Patient #16, Patient #17, Patient #18, and Patient #19) sampled patients reviewed. Findings: --- Patient #13 Review of Patient #13s Physician Plan of Care for certification period of 07/20/2023 to 10/17/2023 revealed Patient #13 was admitted to the agency on 07/20/2023. Further review revealed Patient #13 was to receive social worker services once a month and as needed. Review of Patient #13s record revealed no documented evidence and the agency presented no documented evidence Patient #13 had a social worker visit since admit. In an interview on 08/24/2023 at 4:23 p.m., S2Director of Nursing (DON) stated the agency had no documented evidence of a social worker visit having been completed. Patient #16 Review of Patient #16s Physician Plan of Care for certification period of 10/13/2022 to 01/10/2023 revealed Patient #16 was to receive social worker services once a month and as needed. Review of Patient #16s record revealed no documented evidence and the agency presented no documented evidence Patient #16 had a social worker visit in the month of November 2022. In an interview on 08/24/2023 at 4:30 p.m., S2DON stated the agency had no documented evidence of a social worker visit having been completed in November 2022.

Based on record review and interview the agency failed to ensure wounds were assessed weekly per professional standards to monitor for wound healing and/or deterioration for 3 (Patient #6, Patient #7, Patient #11) of 4 (Patient #4, Patient #6, Patient #7, Patient #11) sampled patients reviewed for wounds in a total sample of 19. Findings: --- Review of the Wound Ostomy and Continence Nurses Society's Guidelines revealed assessment and documentation of wound status, which includes comprehensive clinical data demonstrating evidence of progress in healing or failure to heal. Comprehensive wound assessment includes: dimensions and depth; presence, location and depth of any sinus tracts or undermining areas; status and characteristics of the wound bed; volume, color, and odor of exudates; evidence of infection in surrounding tissues. Further review revealed when recorded over time this information can be used to track the progress of wound healing. Patient #6 Review of Patient #6s Physicians Plan of Care for certification period of 06/28/2023 to 09/25/2023 revealed, in part, Patient #6 with a skin impairment due to disease processes. Interventions included a professional nurse to assess and monitor progress of wound/ulcer healing. Review of Patient #6s record revealed, in part, Patient #6 was admitted with an unstageable (unable to determine depth of wound to stage) pressure ulcer to the left buttock measuring 9.0 centimeters (cm) by 6.0cm. Further review revealed no documented evidence and the agency presented no documented evidence of wound care measurements having been obtained the week of 07/03/2023 through 07/09/2023. Review of Patient #6s Wound/Ulcer Assessment dated 07/13/2023 revealed, in part, Patient #6s wound to the left buttock was staged as a stage 4 (wound where the bone was exposed) measuring 4.5cm by 7.5cm by 3cm and Resident #6 had developed a stage 3 (wound that extends in the fat tissue) to the right posterior shoulder measuring 0.5cm by 0.5cm by 0.1cm. Review of Patient #6s record revealed no documented evidence and the agency presented no documented evidence of wound care measurements having been obtained on either of Patient #6s above mentioned wounds for the weeks of 07/17/2023 through 07/23/2023; 07/31/2023 through 08/06/2023; and 08/14/2023 through 08/20/2023. In an interview on 08/24/2023 3:49 p.m., S2Director of Nursing (DON) stated the facility was unable to present any documented evidence of wound assessments for the above mentioned weeks. S2DON further stated all wounds should be measured and documented on weekly. Patient #7 Review of Patient #7s Physicians Plan of Care for certification period of 07/12/2023 to 10/09/2023 revealed, in part, Patient #7 had a skin impairment due to disease processes. Interventions included a professional nurse to assess skin, tissue, and membrane integrity. Review of Patient #7s Wound Ulcer Assessment dated 07/12/2023 revealed, in part, Patient #7 had a stage 1 (area of red skin which does not lighten with pressure applied) measuring 2cm by 2 cm. Review of Patient #7s record revealed, in part, no documented evidence and the agency presented no documented evidence of wound care measurements were obtained the following weeks: 07/17/2023 through 07/23/2023; 07/24/2023 through 07/30/2023; and 07/31/2023 through 08/06/2023. In an interview on 08/24/2023 3:56 p.m., S2Director of Nursing (DON) stated the facility was unable to present any documented evidence of wound assessments for the above mentioned weeks. S2DON further stated all wounds should be measured and documented weekly. Patient #11 Review of Patient #11s Physicians Plan of Care for certification periods of 05/20/2023 to 08/17/2023 and 08/18/2023 to 11/15/2023 revealed, in part, Patient #11 with a skin impairment due to disease processes. Interventions included a professional nurse to assess skin, tissue, and membrane integrity. Review of Patient #11s Wound/Ulcer Assessment dated 05/20/2023 revealed, in part, Patient #11 had open wounds to the right anterior scalp; and the right posterior scalp. Further review revealed no measurements were obtained of either wound. Review of Patient #11s record revealed no documented evidence and the agency presented no documented evidence of wound care measurements had been obtained the week of 05/22/2023 through 05/28/2023. Review of Patient #11s record revealed no documented evidence and the agency presented no documented evidence of Patient #11s wounds were assessed the week of 06/19/2023 through 06/25/2023. Review of Patient #11s Wound/Ulcer Assessment dated 08/02/2023 revealed, in part, the following wounds were present, in part, right anterior scalp open wound; right posterior scalp open wound; left lower leg vascular wound; right outer ankle arterial wound; and right great toe arterial wound. Review of Patient #11s record revealed no documented evidence and the agency presented no documented evidence of Patient #11s above mentioned wounds were measured and assessed the weeks of 08/07/2023 through 08/13/2023; and 08/14/2023 through 08/20/2023. In an interview on 08/24/2023 at 4:15 p.m., S2DON stated the agency had no documented evidence of wound care measurements for the above mentioned timeframes. S2DON confirmed the wounds should have been assessed including measurements weekly.

Based on record review and interview the agency failed to ensure the nurses coordinated care with the patients nursing facility to ensure the patients catheter was changed monthly per the plan of care for 2 (Patient #6 and Patient #7) of 2 (Patient #6 and Patient #7) sampled patients with catheters who resided in a nursing facility in a total sample of 19. Findings: --- Patient #6 Review of Patient #6s Physicians Plan of Care for certification period of 06/28/2023 to 09/25/2023 revealed an order for, in part, insert Foley catheter, and change Foley catheter every 30 days and as needed. Review of Patient #6s record revealed no documented evidence and the agency presented no documented evidence the skilled nurse had coordinated care with the nursing facility to ensure Patient #6s catheter was changed every 30 days. In an interview on 08/24/2023 at 3:49 p.m., S2Director of Nursing (DON) stated the nursing facilities usually changed the patients catheter; however, the agency had no documentation to present of when the catheter was changed, or if the catheter had been changed. Patient #7 Review of Patient #7s Physicians Plan of Care for certification period of 07/12/2023 to 10/09/2023 revealed an order for, in part, insert Foley catheter, and change Foley catheter every 30 days and as needed. Review of Patient #7s record revealed no documented evidence and the agency presented no documented evidence the skilled nurse had coordinated care with the nursing facility to ensure Patient #7s catheter was changed every 30 days. In an interview on 08/24/2023 at 3:56 p.m., S2DON stated the nursing facilities usually changed the patients catheter; however, the agency had no documentation to present of when the catheter was changed, or if the catheter had been changed.