Every finding on record at St Joseph Hospice of Bayou Region, LLC

Based on interviews and record reviews, the agency failed to ensure all interdisciplinary assessments were completed within 5 calendar days of the patient’s start of care date for 5 (Patient #1, Patient #3, Patient #13, Patient #15, Patient #19) of 20 (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, Patient #19, Patient #20) sampled patients reviewed for interdisciplinary comprehensive assessment requirements. Findings: --- On 11/05/2025 at 4:15PM, S1Administrator and S2Director of Nursing (DON) were presented with the below findings, and the surveyor requested that if they wanted to present any additional evidence to dispute the deficient practice to do so by 11/06/2025.  Patient #1Review of Patient #1’s Plan of Care revealed a start of care date of 05/31/2025. Review of Patient #1’s record revealed a spiritual assessment was not completed within 5 calendar days of Patient #1’s start of care. In an interview on 11/06/2025 at 2:43PM, S2DON indicated he had nothing to present to dispute the above mentioned deficient practice.  Patient #3Review of Patient #3’s Plan of Care revealed a start of care date of 06/18/2025. Review of Patient #3’s record revealed a spiritual assessment was not completed within 5 calendar days of Patient #3’s start of care. In an interview on 11/06/2025 at 2:43PM, S2DON indicated he had nothing to present to dispute the above mentioned deficient practice. Patient #13Review of Patient #13’s Plan of Care revealed a start of care date of 10/13/2025. Review of Patient #13’s record revealed a bereavement assessment was not completed within 5 calendar days of Patient #13’s start of care. In an interview on 11/06/2025 at 2:57PM, S2DON indicated he had nothing to present to dispute the above mentioned deficient practice. Patient #15Review of Patient #15’s Plan of Care revealed a start of care date of 02/02/2024. Review of Patient #15’s record revealed a bereavement assessment was not completed within 5 calendar days of Patient #15’s start of care. In an interview on 11/06/2025 at 2:57PM, S2DON indicated he had nothing to present to dispute the above mentioned deficient practice. Patient #19Review of Patient #19’s Plan of Care revealed a start of care date of 01/29/2025. Review of Patient #19’s record revealed a bereavement assessment was not completed within 5 calendar days of Patient #19’s start of care. In an interview on 11/06/2025 at 3:03PM, S2DON indicated he had nothing to present to dispute the above mentioned deficient practice.

Based on interviews and record reviews, the agency failed to complete an initial bereavement assessment for 2 (Patient #13, Patient #19) of 20 (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, Patient #19, Patient #20) sampled patients reviewed for initial bereavement assessment requirements. Findings: --- On 11/05/2025 at 4:15PM, S1Administrator and S2Director of Nursing (DON) were presented with the below findings, and the surveyor requested that if they wanted to present any additional evidence to dispute the deficient practice, to do so by 11/06/2025. Review of the agency’s Bereavement Assessment policy, revised on 10/2025, revealed, in part, upon admission, the social worker or registered nurse will complete a bereavement risk assessment.  Patient #13 Review of Patient #13’s Plan of Care revealed Patient #13 was admitted to the agency on 10/13/2025.   Review of Patient #13’s record revealed no documented evidence an initial bereavement assessment was not on Patient #13 since admit.  In an interview on 11/06/2025 at 2:57PM, S2DON indicated the agency did not complete an initial bereavement assessment, as required.  Patient #19Review of Patient #19’s Plan of Care revealed Patient #19 was admitted to the agency on 01/29/2025.   Review of Patient #19’s record revealed an initial bereavement assessment was not completed on Patient #19 since admit.  In an interview on 11/06/2025 at 3:03PM, S2DON indicated the agency did not complete an initial bereavement assessment as required.

Based on interviews and record reviews, the agency failed to ensure the patients received services per the plan of care for 11 (Patient #1, Patient #2, Patient #3, Patient #5, Patient #8,  Patient #9, Patient #11, Patient #12, Patient #14, Patient #15, Patient #17) of 20 (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, Patient #19, Patient #20) sampled patients reviewed for services provided per the plan of care.  Findings: --- On 11/05/2025 at 4:15PM, S1Administrator and S2Director of Nursing (DON) were presented with the below findings, and the surveyor requested that if they wanted to present any additional evidence to dispute the deficient practice, to do so by 11/06/2025. Patient #1Review of Patient #1’s Plan of Care (POC) for the certification period of 08/29/2025 through 11/26/2025 revealed Patient #1 was to receive hospice aide services twice a week.  Review of Patient #1’s record revealed, in part,No hospice aide visits were completed for the week of 09/21/2025 through 09/27/2025; and, The only visit hospice visit completed the week of 10/19/2025 through 10/25/2025 was completed on 10/21/2025.   In an interview on 11/06/2025 at 2:34PM, S2DON indicated Patient #1 did not receive the required hospice aide visits per the POC. Patient #2 Review of Patient #2’s Plan of Care for the certification period of 08/15/2025 through 11/12/2025 revealed Patient #2 was to receive hospice aide services once a week for one week, and then three times a week. Further review revealed Patient #2 was to receive skilled nursing services twice a week.  Review of Patient #2’s record revealed, in part:The only hospice aide visit completed the week of 08/31/2025 through 09/06/2025 was completed on 09/05/2025;The only documented hospice aide visits completed the week of 09/21/2025 through 09/27/2025 were completed on 10/22/2025 and 10/25/2025; The only skilled nurse visit completed the week of 09/28/2025 through 10/04/2025 was completed on 10/02/2025; and, The only documented hospice aide visits completed the week of 10/19/2025 through 10/25/2025 were completed on 10/20/2025 and 10/21/2025.   In an interview on 11/06/2025 at 2:38PM, S1Administrator indicated Patient #2 did not receive services per the POC, and had nothing to present to dispute the above. Patient #3Review of Patient #3’s Plan of Care for the certification period of 09/16/2025 through 12/14/2025 revealed, in part, skilled nurse services effective 09/16/2025 five times a week for one week; and, hospice aide services effective 09/16/2025 twice a week for one week, and three times a week for 12 weeks. Review of Patient #3’s record revealed, in part:The only skilled nurse visits completed the week of 09/14/2025 through 09/20/2025 were completed on 09/16/2025 and 09/18/2025;The only hospice aide visits completed the week of 09/21/2025 through 09/27/2025 were completed on 09/22/2025 and 09/24/2025; and,The only hospice aide visits completed the week of 10/19/2025 through 10/25/2025 were completed on 10/20/2025 and 10/21/2025.   In an interview on 11/06/2025 at 2:39PM, S2DON indicated the above mentioned disciplines had not provided services per Patient #3’s Plan of Care.  Patient #5Review of Patient #5’s Plan of Care for the certification period of 09/16/2025 through 11/14/2025 revealed, in part, hospice aide services twice a week. Review of Patient #5’s record revealed, in part:The only hospice aide service completed the week of 10/05/2025 through 10/11/2025 was on 10/09/2025; and,The only hospice aide service completed the week of 10/19/2025 through 10/25/2025 was completed on 10/21/2025.  In an interview on 11/06/2025 at 2:44PM, S2DON indicated hospice aide services were not completed per the plan of care as required for Patient #5.  Patient #8Review of Patient #8’s Plan of Care for the certification period of 10/07/2024 through 01/04/2025 revealed, in part, hospice aide services once a week for one week, then three times a week for 12 weeks.  Review of Patient #8’s record revealed, in part:The only hospice aide service completed the week of 10/12/2025 through 10/18/2025 was completed on 10/13/2025;The only hospice aide service completed the week of 10/19/2025 through 10/25/2025 was completed on 10/24/2025;The only hospice aide visits completed the week of 10/26/2025 through 11/01/2025 were completed on 10/28/2025 and 10/30/2025; and,The only hospice aide visit completed the week of 11/02/2025 through 11/08/2025 was completed on 11/04/2025.  In an interview on 11/06/2025 at 2:52PM, S2DON indicated the agency failed to ensure services were provided per the plan of care for Patient #8.  Patient #9Review of Patient #9’s Plan of Care for the certification period of 08/19/2025 through 11/16/2025 revealed, in part, hospice aide services once a week for one week, then twice a week for 12 weeks.  Review of Patient #9’s record revealed, in part:No hospice aide visits were completed the week of 08/24/2025 through 08/30/2025; The only hospice aide visit completed the week of 08/31/2025 through 09/06/2025 was completed on 09/06/2025;The only hospice aide visit completed the week of 10/05/2025 through 10/11/2025 was completed on 10/07/2025; and,The only hospice aide visit completed the week of 10/19/2025 thorough 10/25/2025 was completed on 10/21/2025.  In an interview on 11/06/2025 at 2:55PM, S2DON indicated the agency did not ensure Patient #9 received hospice aide services per the plan of care.  Patient #11Review of Patient #11’s Plan of Care for the certification period of 09/23/2025 through 12/21/2025 revealed Patient #11 was to receive hospice aide services twice a week for one week, then three times a week for 12 weeks.  Review of Patient #11’s record revealed, in part:The only hospice aide visit completed the week of 09/21/2025 through 09/27/2025 was completed on 09/26/2025;The only hospice aide visit completed the week of 10/12/2025 through 10/18/2025 was completed on 10/15/2025;The only hospice aide visits completed the week of 10/19/2025 through 10/25/2025 were completed on 10/21/2025 and 10/24/2025; and,The only hospice aide visits completed the week of 10/26/2025 through 11/01/2025 were completed on 10/27/2025 and 10/29/2025.  In an interview on 11/06/2025 at 2:55PM, S2DON indicated the agency had not provided services per the plan of care for Patient #11.  Patient #12Review of Patient #12’s Plan of Care for the certification period of 07/25/2025 through 10/22/2025 revealed, in part, hospice aide services effective 07/27/2025 twice a week for 12 weeks. Further review revealed skilled nurse services twice a week for 13 weeks.  Review of Patient #12’s physician order dated 07/28/2025 revealed chaplain services once a month for one month, then twice a month for three months effective 07/25/2025.  Review of Patient #12’s record revealed, in part:No documented evidence a hospice aide visit was completed the week of 07/27/2025 through 08/02/2025; The only skilled nurse visit completed the week of 08/31/2025 through 09/06/2025 was completed on 09/02/2025;No documented evidence of a hospice aide visit was completed for the week of 08/31/2025 through 09/06/2025;The only skilled nurse visit completed the week of 09/21/2025 through 09/27/2025 was completed on 09/23/2025; The only hospice aide visit completed the week of 09/21/2025 through 09/27/2025 was completed on 09/26/2025;The only skilled nurse visit completed the week of 10/05/2025 through 10/11/2025 was completed on 10/09/2025; The only hospice aide visit completed the week of 10/05/2025 through 10/11/2025 was completed on 10/07/2025; and, No documented evidence of a chaplain visit completed in August 2025.  In an interview on 11/06/2025 at 2:56PM, S2DON indicated the agency had not ensured Patient #12 was provided the above mentioned services per the POC as required.   Patient #14Review of Patient #14’s Plan of Care for the certification period of 09/17/2025 through 12/15/2025 revealed Patient #14 was to receive hospice aide services once a week for one week then twice a week for 12 weeks effective 09/17/2025.  Review of Patient #14’s record revealed no evidence Patient #14 received hospice aide services the week of 10/19/2025 through 10/25/2025.  In an interview on 11/06/2025 at 2:58PM, S2DON indicated the hospice aide failed to provide services per the plan of care for the above mentioned week for Patient #14.  Patient #15Review of Patient #15’s Plan of Care for the certification period of 09/24/2025 through 11/22/2025 revealed, in part, hospice aide services twice a week for one week, then three times a week for eight weeks effective 09/24/2025.  Review of Patient #15’s record revealed, in part:The only hospice aide visits completed the week of 10/12/2025 through 10/18/2025 were completed on 10/15/2025 and 10/17/2025; and,The only hospice aide visits completed the week of 10/19/2025 through 10/25/2025 were completed on 10/20/2025 and 10/24/2025. In an interview on 11/06/2025 at 2:59PM, S2DON indicated the agency did not ensure Patient #15 received hospice aide services per the plan of care as required.  Patient #17 Review of Patient #17’s Plan of Care for the certification period of 05/28/2025 through 06/29/2025 revealed, in part, Patient #17 was to receive hospice aide services twice a week effective 06/01/2025. Review of Patient #17’s record revealed the only documented evidence of a hospice aide visit was completed during the period of 05/28/2025 through 06/29/2025 was the hospice aide visit completed on 06/10/2025. In an interview on 11/04/2025 at 1:48PM, S2DON indicated Patient #17 indicated she had nothing to present to dispute the above mentioned deficient practice and verified that Patient #17 did not receive services per the POC. In an interview on 11/06/2025 at 2:34PM, S2DON indicated the agency had an issue with the hospice aide not completing home visits and not notifying the office. In an interview on 11/06/2025 at 2:35PM, S1Administrator indicated the agency was aware of an issue with a hospice aide not completing the home visits per the patients’ plans of care, and the above mentioned patients did not receive services per their POC as required.

Based on interviews and record reviews, the agency failed to ensure patient’s wounds were measured weekly to assess for healing status for 3 (Patient #9, Patient #12, Patient #18) of 4 (Patient #9, Patient #10, Patient #12, Patient #18) sampled patients with identified wounds reviewed for weekly wound care measurements. Findings: --- Review of the Wound Ostomy and Continence Nurses Society's Guidelines revealed the assessment and documentation of wound status included comprehensive clinical data demonstrating evidence of progress in healing or failure to heal. Further review revealed, in part, comprehensive wound assessment included 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, and 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. Review of the agency’s undated Wound Care Protocol revealed, in part, the agency would require weekly wound care measurements by the registered nurse.   On 11/05/2025 at 4:15PM, S1Administrator and S2Director of Nursing (DON) were presented with the below findings, and the surveyor requested that if they wanted to present any additional evidence to dispute the deficient practice, to do so by 11/06/2025. Patient #9Review of Patient #9’s physician order dated 10/03/2025 revealed, in part, right medial great toe (the part of the right large toe which faces the other foot) wound clean with betadine and leave open to air. Review of Patient #9’s record for the period of 10/03/2025 through 11/05/2025 revealed Patient #9’s right great toe wound was not measured the weeks of 10/10/2025, the week of 10/17/2025, and the week of 10/24/2025.                                                                                                                       In an interview on 11/06/2025 at 2:55PM, S2DON indicated Patient #9’s right great toe wound was not measured weekly as required. Patient #12Review of Patient #12’s nurse’s note dated 09/02/2025 revealed, in part, Patient #12 had a right heel blister to the right heel which opened last night. Further review revealed Patient #12’s wound to the right hell was not measured on 09/02/2025.  Review of Patient #12’s nurse’s note dated 09/09/2025 revealed, in part, Patient #12 had a right heel blister which was now scabbed. Review of Patient #12’s record revealed no documented evidence of any wound care measurements for Patient #12’s right heel wound until 11/04/2025.  In an interview on 11/06/2025 at 2:56PM, S2DON indicated Patient #12’s right heel wound was not measured from 09/02/2025 through 11/04/2025.  Patient #18Review of Patient #18’s record revealed Patient #18 had an abdominal surgical wound on 10/22/2024. Review of Patient #18’s record for the period of 10/21/2024 through 11/06/2024 revealed Patient #18’s above mentioned wound was not measured since 10/26/2025. In an interview on 11/06/2025 at 3:02PM, S2DON indicated Patient #18’s abdominal surgical wound was not measured weekly as required.

Based on interviews and record reviews, the agency failed to conduct a spiritual assessment for 2 (Patient #1, Patient #3) of 20 (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, Patient #19, Patient #20) sampled patients reviewed for spiritual counseling requirements. Findings: --- On 11/05/2025 at 4:15PM, S1Administrator and S2Director of Nursing (DON) were presented with the below findings, and the surveyor requested that if they wanted to present any additional evidence to dispute the deficient practice, to do so by 11/06/2025. Patient #1Review of Patient #1’s Plan of Care revealed a start of care date of 05/31/2025. Review of Patient #1’s record revealed a spiritual assessment was not completed on Patient #1 since Patient #1’s start of care. In an interview on 11/06/2025 at 2:43PM, S2DON indicated he had nothing to present to show that a spiritual assessment was completed on Patient #1. Patient #3Review of Patient #3’s Plan of Care revealed a start of care date of 06/18/2025. Review of Patient #3’s record revealed a spiritual assessment was not completed on Patient #3 since Patient #3’s start of care. In an interview on 11/06/2025 at 2:43PM, S2DON indicated he had nothing to present to show that a spiritual assessment was completed on Patient #3.

Based on interview and record reviews, the agency failed to ensure a registered nurse made an on-site visit to the patient’s home at least every 14 days to assess the quality of care and services provided by the hospice aide for 1 (Patient #8) of 12 (Patient #1, Patient #2, Patient #3, Patient #5, Patient #8, Patient #9, Patient #11, Patient #12, Patient #14, Patient #15, Patient #17, Patient #20) sampled patients receiving hospice aide services reviewed for supervisory visits.   Findings: --- On 11/05/2025 at 4:15PM, S1Administrator and S2Director of Nursing (DON) were presented with the below findings, and the surveyor requested that if they wanted to present any additional evidence to dispute the deficient practice, to do so by 11/06/2025. Review of the agency’s undated Supervision policy revealed, in part, a registered nurse was to ensure all hospice aide services were supervised every 14 days.   Review of Patient #8’s Plan of Care for the certification period of 10/07/2025 through 01/04/2025 revealed Patient #8 was to receive hospice aide services. Review of Patient #8’s record revealed Patient #8 received hospice aide services on 10/10/2025, 10/13/2025, 10/24/2025, 10/28/2025, and 10/30/2025. Further review revealed a hospice aide supervisory visit was not completed by a registered nurse for the time period of 10/07/2025 through 10/30/2025.  In an interview on 11/06/2025 at 2:52PM, S2Director of Nursing (DON) indicated the agency failed to ensure the registered nurse completed a hospice aid supervisory visit every 14 days as required.

Based on interviews and record reviews, the agency failed to:1. Document signs and symptoms of infection on a patient’s assessment (Patient #4); and,  2. Accurately document the services a patient received (Patient #7).This deficient practice was identified for 2 (Patient #4, Patient #7) of 20 (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, Patient #19, Patient #20) sampled patients reviewed for documentation requirements.  Findings: --- On 11/05/2025 at 4:15PM, S1Administrator and S2Director of Nursing (DON) was presented with the below findings, and the surveyor requested that if they wanted to present any additional evidence to dispute the deficient practice, to do so by 11/06/2025. Review of the agency’s Clinical Record Review policy, revised on 10/2015, revealed, in part, clinical records were to be reviewed for completeness and accuracy.  Patient #4Review of Patient #4’s physician order dated 09/04/2025 revealed Patient #4 was prescribed Keflex (antibiotic a medication used to treat infections) for a toe infection. Review of Patient #4’s record revealed no documented evidence of an assessment of Patient #4’s toe had been documented, nor any documented evidence of an assessment of Patient #4’s response to the infection. In an interview on 11/06/2025 at 2:43PM, S2DON indicated Patient #4’s record did not include the required documentation related to Patient #4’s toe infection assessment. Patient #7Review of Patient #7’s Plan of Care for the certification period of 07/29/2025 through 10/26/2025 revealed no documented evidence hospice aide services were ordered for Patient #7.  Review of Patient #7’s record for the certification period of 07/29/2025 through 10/26/2025 revealed no documented evidence hospice aide services had been provided to Patient #7. Review of Patient #7’s skilled nursing notes dated 09/15/2025, 09/21/2025, and 09/25/2025 revealed the skilled nurse had completed hospice aide supervisory visits.  In an interview on 11/06/2025 at 2:50PM. S2DON indicated the above mentioned hospice aide supervisory visits were inaccurate because Patient #7 had not received hospice aide services.

Based on record review and interview the agency failed to ensure a patient received volunteer services as requested per the volunteer assessment for 1 of 1 patients (Patient #10) who requested volunteer services in a total sample of 15. Findings: --- Review of Patient #10s record revealed Patient #10 was admitted on 12/23/2021 with diagnoses of, in part, Metastatic Cancer (cancer which has spread from the original area), Cirrhosis of the Liver (liver is scarred and permanently damaged), Hepatitis C (viral infection which affects the liver), and Chronic Kidney Disease (kidneys are damaged). Review of Patient #10s Volunteer Coordinator Initial Assessment dated 12/28/2021 and updated on 01/04/2022 revealed Patient #10s son stated they would be interested in a volunteer as Patient #10 was home alone all day. Further review revealed no documented evidence and the agency did not present any documented evidence of a date a volunteer was assigned or the name of a volunteer assigned to Patient #10. In an interview on 11/16/2022 at 2:45pm, S5Volunteer Coordinator stated the only documentation about Patient #10s volunteer needs would have been on the initial assessment. In an interview on 11/16/2022 at 2:46pm, S2Regional RN (Registered Nurse) stated she thought the patient had refused volunteer services. On 11/16/2022 at 2:55pm, a hand written Initial Volunteer Assessment was presented which documented yes, Patient 10s son was interested in receiving volunteer services since his mom stays home alone all day. Further review revealed a note above with no date or time documented of, spoke with Patient #10 who stated not at this time. In an interview on 11/16/2022 at 3:27pm, Patient #10 stated the agency had never called her to discuss volunteer services, and she would like a volunteer to visit with her in the daytime since she was home alone during the day. In an interview on 11/16/2022 at 3:35pm, S2Regional Director stated she was unable to explain the discrepancy in the above interview versus the documentation.

Based on record review and interview the agency failed to have an effective infection control program which tracked and trended all patient infections for 2 (Patient #1 and Patient #8) of 5 patients (Patient #1, Patient #2, Patient #4, Patient #8, and Patient #10) reviewed for infection tracking and trending in a total sample of 15. Findings: --- Patient #1 Review of Patient #1s Visit Note Report dated 09/06/2022 revealed genitourinary (bladder/urinary) system findings of, in part, pain, abnormal urine clarity, clarity was cloudy, and an abnormal urine odor. Review of Patient #1s Physician Orders dated 09/06/2022 revealed an order for Bactrim DS (Double Strength) 800mg/160mg (milligrams) one tablet by mouth daily for a urinary tract infection (bladder infection). Review of Patient #1s Infection Report with Date of Onset of 09/06/2022 revealed suspected site of infection was urinary, with signs/symptoms of cloudy foul smelling urine. Further review revealed the S2Regional Registered Nurse (RN) completed the report and follow-up documentation on 11/16/2022. Patient #8 Review of Patient #8s Visit Note Report dated 08/30/2022 revealed, in part, Patient #8s right hand was swollen and red causing pain. Further review revealed care coordinated and S2Regional RN (Registered Nurse) nurse of new physician orders for, in part, Cephalexin (medication used to treat infections) by mouth times one week. Review of Patient #8s Physician Order dated 08/30/2022 revealed an order for Cephalexin 500mg one tablet by mouth twice a day for infection. Review of Patient #8s Infection Report with Date of Onset of 08/30/2022 revealed suspected site of infection was a skin lesion with signs/symptoms of redness and warmth. Further review revealed S2Regional RN completed the report and completed the follow-up documentation on 11/16/2022. Review of Patient #8s Visit Note Report dated 10/06/2022 revealed Patient #8 was started on Bactrim DS yesterday for increased confusion and burning upon urination. Review of Patient #8s Physician Order dated 10/05/2022 revealed an order for Bactrim DS 800mg/160mg one tablet by mouth twice daily for urinary tract infection. Review of Patient #8s Infection Report with Date of Onset of 10/06/2022 revealed the suspected site of infection was urinary, and signs/symptoms was cloudy foul urine. Further review revealed the S2Regional RN completed the report and follow-up documentation on 11/16/2022. Review of the agencys Infection Control Report for the third quarter (July-September 2022) revealed no documented evidence and the agency did not present any documented evidence of Patient #1s 09/06/2022 urinary tract infection, nor Patient #8s 08/30/2022 skin lesion infection having been tracked and reviewed for trends in infections. In an interview on 11/16/2022 at 2:27pm, S2Regional RN stated the process for tracking and trending infections was each nurse was to contact the physician for orders then start an Infection Report on the infection when signs and symptoms of an infection were identified. S2Regional RN stated the report would then go into her workflow to ensure there was adequate follow-up and resolution to the infection. S2Regional RN stated she was responsible for tracking and trending the infections and confirmed Patient #1s 09/06/2022 urinary tract infection and Patient #8s 08/30/2022 skin lesion infection were not tracked and trended on the Infection Control Report for the third quarter and should have been identified. S2Regional RN further stated Patient #8s 10/06/2022 urinary tract infection should have been follow-up for resolution and an Infection Report completed prior to today, 11/16/2022.

Based on record review and interview the agency failed to ensure patients wounds were measured and assessed weekly for 3 (Patient#2, Patient #5, and Patient #6) of 4 patients (Patient#2, Patient #5, Patient #6, and Patient #7) reviewed for weekly wound assessment in a total sample of 15. 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 included: 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; and 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. Review of the agencys Wound Care Protocol revealed weekly wound care measurements were to be completed by the RN in coordination with the facility staff, if under contract. Further review revealed wound care assessments would include measurements which included the length, width, and depth of the wound measured in centimeters and if there was any tunneling or undermining. Patient #2 Review of Patient #2s Hospice Certification and Plan of Care for certification period of 10/11/2022 to 01/08/2023 revealed Patient #2 had a stage II pressure ulcer of the left buttock (wound that causes break in the first layer of skin) and an unstageable (wound which nonviable tissue obscuring the depth of the wound) pressure ulcer. Review of Patient #2s Admit Visit Note report dated 10/11/2022 revealed Patient #2s integumentary (skin) was assessed as pale with poor turgor (elasticity). Review revealed the only other documentation of Patient #2s skin assessment was Patient #2 wounds to the right and left heel, sacrum, right lower buttock, and right medial foot. Further review S4RN (Registered Nurse) documented Patient #2s wounds were dressed by caregiver so only assessment was of dressings being intact. Review of Patient #2s Wound Record Report revealed no data had been returned for your selections (no wounds charted for the patient). Review of Patient #2s record revealed no documented evidence and the agency presented no documented evidence of a comprehensive assessment having been completed by the nurse on all above mentioned wounds. In an interview on 11/16/2022 at 9:37am, S4RN stated on admission the caregiver had performed the dressing change and she did not remove the dressings to assess the above mentioned wounds. S4RN stated the following week Patient #2 was admitted to the nursing home and she gave control of the wound care to the nursing home, and the wounds were dressed prior to her visits; therefore, she had not measured and assessed the wounds. Patient #5 Review of Patient #5s record revealed Patient #5 was assessed as having a skin tear to the right elbow upon admission on 10/21/2022 with no documented assessment of the wound characteristics charted. Further review of Patient #5s record revealed no documented evidence and the agency did not present any documented evidence the nurse had assessed the wound from admission till present. Review of Patient #5s Wound Record Report with the wound assessed section having revealed, in part, on 10/21/2022 wound was not assessed due to being covered by a non-removable dressing or device. Further review revealed the above mentioned wound was not assessed because the caregiver performed the dressing change on the following dates: 10/26/2022, 11/02/2022, 11/05/2022, 11/08/2022, 11/09/2022, and 11/15/2022. In an interview on 11/16/2022 at 9:46am, S4RN stated the nursing home nurses take care of the wound; therefore, she had never seen or assessed the wounds. S4RN stated the only information she was aware of the wounds was the information she received when speaking with the nurses from the nursing home. In an interview on 11/16/2022 at 9:47am, S2Regional RN stated she had trained the nurses for the hospice agency not to assess the wounds if the wounds had already been dressed prior to the visit, and instead document wound unable to be assessed due to caregiver had completed care. Patient #6 Review of Patient #6s Hospice Certification and Plan of Care for certification period of 10/25/2022 to 01/22/2023 revealed Patient #6 was admitted on 10/25/2022 with a pressure ulcer to the sacral region of an unspecified stage. Review of Patient #6s Admit Visit Note Report dated 10/25/2022 revealed the above mentioned wound was not assessed because the caregiver had performed the wound care already. Review of Patient #6s Wound Record Report revealed no wound measurements were obtained on Patient #6s sacral wound on 10/25/2022, 10/26/2022, 10/31/2022, 11/02/2022, 11/07/2022, 11/09/2022, and 11/16/2022. In an interview on 11/16/2022 at 9:57am, S3DON (Director of Nursing) stated he had never seen and/or provided care to Patient #6s sacral wound, and therefore he had not assessed Patient #6s wound. S3DON stated the family would take pictures to show him the wound, and the wound always appeared to have slough (non-viable tissue). S3DON stated the caregiver would state the wound was getting better but from the pictures it did not appear to be improving. S3DON stated per agency policy wounds should be looked at and assessed by the registered nurse weekly.