Every finding on record at St. Luke's Episcopal-Presbyterian Hospitals

Observed in Patient Home. In 1 of 3 home visits conducted, it was observed by the Nurse Surveyor that the organization did not implement the infection prevention and control activities it had planned per their Bag Technique Procedure. For example, during HOSHV#3/RR#3 the skilled nurse laid out a barrier and took her clean equipment (blood pressure cuff, stethoscope, thermometer) out of her nursing bag and placed it on the barrier. As she used the equipment, she put it on top of/right up against the clean equipment on the barrier. At one point she took out a measuring tape out of her nursing bag and placed it next to the used equipment on the now dirty barrier before she used it on the patient. Once done with her assessment of the patient, she cleaned all her equipment and placed it on a clean barrier to dry. The Hospice Clinical Supervisor was present during the home visit and observed the breaks in technique per agency policy.

Based on policy review, record review, and interview, the agency failed to ensure the patient's right to receive effective pain management in one (Record/Patient #3) of five full records reviewed. This deficiency has the potential to adversely affect pain management for all the agency's patients with pain. Findings included: Review of the agency's policy titled, "Pain management," dated 06/2021, showed : - The patient has the right to appropriate assessment and management of pain and symptoms; and - If the patient reports inadequate pain control, appropriate interventions will be implemented and/or the patient's physician will be contacted. RECORD/PATIENT #3: Review of the clinical record, plan of care (POC) showed under "pain control", to "call the physician for a pain level ?". Review of the Skilled Nurse (SN) visits showed: - 04/18/2022 patient stated current pain of seven of ten, using pain intensity rating scale ( 0 - 10: 0 = no pain, 10 = unbearable pain). No documentation in the clinical record that showed physician notification of this pain level; - 04/25/2022 patient stated current pain level of nine of ten. No documentation in the clinical record that showed physician notification of this pain level; - 05/02/2022 patient stated current pain of eight of ten. No documentation in the clinical record that showed physician notification of this pain level; and - 05/05/2022 patient stated current pain of seven of ten. No documentation in the clinical record that showed physician notification of this pain level. During an interview on 05/12/2022 at 10:30 AM, the administrator stated that he/she would expect that staff would notify the patient's physician of high pain scores. The administrator stated also that the staff would perform a correction entry for the POC to read "call physician for a pain score of seven or greater".

Based on policy review, record review, and interview, the agency failed to ensure the hospice registered nurse (RN) completed the initial assessment within 48 hours after the election of hospice care in, but not limited to, one (Record/Patient #1) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy titled, "Initial and Comprehensive Assessment and Re-assessment of the Hospice Patient," revised 04/2020, showed in part that the hospice RN will complete an initial assessment within 48 hours after the election of hospice care. RECORD/PATIENT #1: Review of the hospice election statement showed the effective date of election was 04/04/2022. Review of the initial RN visit showed a visit date of 04/04/2022. The bottom of the visit note showed a created date of 04/04/2022 and a completed date of 04/21/2022. During an interview on 05/12/2022, beginning at 11:45 AM, the administrator stated that they could not show evidence that the initial assessment had been completed prior to 04/21/2022.

Based on policy review, record review, and interview, the agency failed to ensure the social worker's (MSW) comprehensive assessment and the spiritual assessment were completed within five days of election of hospice care in, but not limited to, three (Records/Patients #2, #3 and #5) of five records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy titled, "Initial and Comprehensive Assessment and Re-assessment of the Hospice Patient," revised 04/2020, showed in part: - The hospice registered nurse (RN) will complete an initial assessment within 48 hours after the election of hospice care; - The RN will review and document the patient/family spiritual history and practices to determine if there is any spiritual distress that would require immediate attention by the hospice chaplain; - The hospice chaplain will do an initial spiritual assessment as part of the comprehensive plan of care (POC); - The RN will assess if there are anticipatory grieving issues that would require immediate attention by the MSW. The MSW will assess the anticipatory grieving of the patient/family during the initial psychosocial assessment as part of the comprehensive POC; - The RN will assess if there are any coping issues that would require immediate attention by the MSW. The MSW will assess the patient and family coping mechanisms and needs during his/her initial psychosocial as part of the comprehensive assessment POC; - The interdisciplinary group (IDG) will complete a comprehensive assessment no later than five days after the election of hospice care; and - The comprehensive assessment will consist of a comprehensive assessment by the MSW and spiritual assessment by the spiritual counselor (chaplain). RECORD/PATIENT #2: Review of the hospice election statement showed the effective date of election was 04/14/2022. Review of the initial MSW evaluation visit showed a date of 04/20/2022 (six days after election of hospice care). Review of the record showed the initial spiritual assessment evaluation visit showed a date of 04/22/2022 (eight days after the election of hospice care). During an interview on 05/11/2022, at 9:50 AM, the administrator stated that he/she would expect the MSW and the spiritual counselor to visit the patient within five days to complete the comprehensive assessment. During an interview on 05/11/2022, at 10:50 AM, with the spiritual counselor and administrator, the spiritual counselor stated that he/she remembered they were wanting a longer visit. The spouse was forgetful, and he/she waited to call to confirm the visit. He/she remembered the visit being outside the time of what he/she normally did. The administrator stated that the spiritual counselor should have attempted a visit within the five day window. RECORD/PATIENT #3: Review of the hospice clinical record showed the effective date of election was 03/25/2022. Review of the clinical record showed the initial MSW evaluation visit was completed by the MSW on 04/13/2022 (19 days after the election date). During an interview on 05/11/2022 at 10:00 AM, the Clinical Manager stated that he/she would expect the MSW to complete the visit with the patient within five days to complete the comprehensive assessment. RECORD/PATIENT #5: Review of the hospice clinical record showed the effective date of election was 04/21/2022. Review of the clinical record showed the initial MSW evaluation visit was completed by the MSW on 05/10/2022 (19 days after the election date). During an interview on 05/11/2022 at 10:15 PM, the Clinical Manager stated that he/she would expect the MSW to complete the visit with the patient within five days to complete the comprehensive assessment.

Based on policy review, record review, home visit observation, and interview, the agency failed to maintain an accurate/updated medication profile in two (Records/Patients #1 and #2) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy titled, "Medication Reconciliation," revised 03/2020, showed in part: - At the time of admission, recertification, live discharge, and on an ongoing basis, a complete list of all prescription and over the counter medications taken by the patient will be maintained in the electronic medical record; - The clinician will ask the patient to describe or confirm any prescription, over the counter medications, vaccines, respiratory therapy treatment, vitamins, herbal remedies, neutraceuticals (parts of foods that have health benefits), or other supplements, as well as their perceptions about any side effects and efficacy; - This will be accomplished by requesting to see the bottles of medications or supplements the patient has in the home; and - Changes in the medication regimen will be documented in the clinical record. RECORD/PATIENT #1: Review of the record showed that the patient resided in a long term care facility (LTCF). Review of the hospice physician orders showed an order dated 05/06/2022, to discontinue Norco (narcotic pain medication) 5-325 milligrams (mg) one tablet every four hours. Review of the skilled nursing facility (SNF) medication administration record showed the SNF staff continued to administer the Norco through 05/09/2022. During an interview on 05/12/2022, beginning at 11:45 AM, the administrator stated that the hospice and SNF orders should match. RECORD/PATIENT #2: Observation on 05/11/2022 at approximately 1:15 PM, during the patient's home visit, showed the following discrepancies with the hospice medication profile: - The hospice medication profile showed an order for Atropine sulfate 1% administer two drops orally every four hours as needed for excess secretions. The medication label in the home showed to administer one to two drops under the tongue as needed for excess secretions; - The patient had an albuterol inhaler (for difficulty breathing) 90 micrograms (mcg) per actuation two inhalations every six hours as needed dated 01/07/2022. The patient stated that he/she had not used this recently but had it to use if needed. This was not included on the hospice medication profile; - The patient had a bottle of Prednisone (reduces inflammation) 20 milligrams (mg) one daily dated 05/02/2022. The patient stated this was for his/her rash (spot on skin). The patient had taken two tablets but then thought maybe he/she had a reaction in the past and had contacted his/her physician about it but had not heard back. This was not included on the medication profile; - The hospice medication profile showed an order for carbidopa-levodopa (for Parkinson's tremors/shaking) 100 mg one tablet three times a day. The patient stated that he/she took this depending on how shaky he/she is; - The hospice medication profile showed an order for ropinirole (can be used to treat Parkinson's disease or restless leg syndrome) 4 mg three times a day. The patient stated that he/she took this once a day, then when it is gone, he/she is going to wean him/herself off the medication; - The patient had nystatin powder (used to treat fungal/yeast skin infections) 100,000/gram apply to affected area daily as needed dated 05/02/2022. This was not included on the hospice medication profile; and - The hospice medication profile showed an order for oxygen two liters per nasal cannula as needed for shortness of breath. The patient stated that he/she used oxygen at three liters per nasal cannula. During an interview on 05/11/2022, at 4:40 PM, the administrator stated that the nurses reconcile the medications with the most current medication list and contact the physician with any discrepancies. The nurses do a medication reconciliation once a week to capture any changes that may have occurred. When a new medication is ordered, they add the medication to the medication profile.

Based on policy review, record review, and interview, the agency failed to provide/document education and training for the caregiver as appropriate to their responsibilities in one (Record/Patient #4) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy titled, "Education-Patient/Family-Resources," reviewed June, 2017, showed in part the hospice plans and provides patient education to promote and maintain health and improve care outcomes. RECORD/PATIENT #4: Review of the plan of care dated 04/28/2022, showed: - SN (skilled nurse) orders included an order for Jevity (liquid food) 1.2 per G-tube (a feeding tube inserted through the stomach) 70 milliliters (ml) per hour over 10 hours with 150 ml of water flush four times a day; - Wound care to the Stage 2 (partial thickness skin loss) pressure injury to the thoracic spine (mid back), cleanse with wound cleanser, apply foam dressing, change two times a week and as needed for excess drainage/soiling; - Teach wound care and dressing changes; and - An order dated 05/02/2022, to insert a Foley catheter (a tube inserted into the bladder to drain urine) 16 french (diameter of catheter) 10 ml balloon, change every 30 days and as needed for leaking or obstruction, may flush as needed with 30-60 ml of normal saline (salt solution) for blockage, and educate patient/caregiver regarding Foley catheter maintenance and care. Review of the initial nursing visit dated 04/28/2022: - Education provided on giving medication via the G-tube; - No documentation that education was provided regarding G-tube feedings, flushing, or care of the insertion site; and - No documentation of assessment or education regarding wound care for the Stage 2 pressure injury. Review of the nursing visits from 05/04/2022 through 05/09/2022, showed on 05/04/2022, the nurse educated the caregiver on emptying the catheter. No documentation that further education was provided regarding maintenance and care of the catheter. The findings were reviewed on 05/12/2022, beginning at 12:35 PM, with the administrator,, assistant administrator , clinical supervisor, and clinical manager. During the review, the assistant administrator stated that he/she would expect the nurse to document the education provided.

Based on policy review, record review, and interview, the agency failed to develop and/or revise an individualized plan of care (POC) in, but not limited to, one (Record/Patient #1) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy titled, "Patient's Plan of Care," revised 05/2021, showed in part: - A POC is developed to ensure individualized care, treatment, and services to the hospice patient; - The POC is appropriated to each individual hospice patient's needs, strengths, limitations, and goals; - All hospice care and services furnished to the patient's/families will follow an individualized written POC established by the hospice interdisciplinary group (IDG); - The individualized POC will reflect patient and family goals and interventions based on the problems identified in the initial and updated comprehensive assessments; - The IDG will review, revise and document the individualized POC as frequently as the patient's condition requires, but no less frequently than every 15 days; and - A revised individualized POC will include information from the updated comprehensive assessments and will reflect the changing needs of the patient/family and the services required to meet those needs. RECORD/PATIENT #1: Review of the registered nurse (RN) initial assessment dated 04/04/2022, showed: - The patient resided in a long term care facility (LTCF); - Diagnoses included heart failure (hearts pumping ability is impaired), cardiomyopathy (enlarged heart), ventricular tachycardia (abnormal heart rhythm), and atrial fibrillation (abnormal heart rhythm); - Had an active pacemaker (a device placed in the chest to help control the heartbeat); - On Eliquis (blood thinning medication that can increase the risk of bleeding and bruising); and - The patient had chronic pain in both feet. Review of the POC dated 04/04/2022, showed: - No interventions and goals related to the pacemaker; - No interventions and goals related to diagnoses of heart failure, cardiomyopathy, ventricular tachycardia, and atrial fibrillation - No interventions and goals related to the use of Eliquis; and - No specific interventions and goals related to the chronic pain in the patient's feet. Review of the case conference summary (IDG notes) dated 04/06/2022, showed no information regarding the patient's pacemaker, or the chronic pain in both feet. Review of the nursing visit dated 04/26/2022, showed: - The patient had bruising to his/her arms; and - No documentation the new bruising was reported to the physician. Review of the case conference summary dated 04/27/2022, showed no information regarding the bruising noted to the patient's arms on 04/26/2022. Review of the nursing visit dated 04/28/2022 showed the patient had acute pain in the left leg and received a new order for pain medication. Review of the POC dated 04/04/2022, showed no revision to the POC for the acute pain in the left leg. Review of the nursing visit dated 05/03/2022, showed the patient continued to have pain in his/her legs/feet. The nurse received an order for gabapentin (used for nerve pain) 100 milligrams (mg) nightly. Review of the POC dated 04/04/2022, showed no revision to the POC for the pain to the legs/feet. During an interview on 05/12/2022, at 12:15 PM, the administrator stated that he/she would expect the POC to be individualized and revised as needed.

Based on policy review, record review, and interview, the agency failed to ensure the interdisciplinary group (IDG) discussed/documented changes regarding the patient's status, in three (Records/Patients #1, #2 and #4) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy titled, "Patient's Plan of Care," revised 05/2021, showed in part: - All hospice care and services furnished to the patient's/families will follow an individualized written POC established by the hospice interdisciplinary group (IDG); - The individualized POC will reflect patient and family goals and interventions based on the problems identified in the initial and updated comprehensive assessments; - The IDG will review, revise and document the individualized POC as frequently as the patient's condition requires, but no less frequently than every 15 days; and - A revised individualized POC will include information from the updated comprehensive assessments and will reflect the changing needs of the patient/family and the services required to meet those needs. RECORD/PATIENT #1: Review of the registered nurse (RN) initial assessment dated 04/04/2022, showed: - The patient resided in a long term care facility (LTCF); - Diagnoses included heart failure (hearts pumping ability is impaired), cardiomyopathy (enlarged heart), ventricular tachycardia (abnormal heart rhythm), and atrial fibrillation (abnormal heart rhythm); - Had an active pacemaker (a device placed in the chest to help control the heartbeat); - On Eliquis (blood thinning medication that can increase the risk of bleeding and bruising); and - The patient had chronic pain in both feet. Review of the POC dated 04/04/2022, showed: - No interventions and goals related to the pacemaker; - No interventions and goals related to the use of Eliquis; and - No specific interventions and goals related to the chronic pain in the patient's feet. Review of the case conference summary (IDG notes) dated 04/06/2022, showed no information regarding the patient's pacemaker or the chronic pain in both feet. Review of the nursing visit dated 04/26/2022, showed: - The patient had bruising to his/her arms; and - No documentation the new bruising was reported to the physician. Review of the case conference summary dated 04/27/2022, showed no documented discussion regarding the bruising noted to the patient's arms on 04/26/2022. During an interview on 05/12/2022, beginning at 11:45 AM, the administrator stated that depending on what the bruising looked like, it should have at least been discussed in case conference. RECORD/PATIENT #2: Review of the nursing visits showed: - On 04/16/2022, the patient complained of itching related to an extensive blister (raised area of the skin that contains fluid derived from blood serum) like rash (spot on skin) on his/her neck and across the torso (trunk of the human body) which appeared a month ago. The patient stated that the rash was not diagnosed/resolved while in the hospital. The plan for next visit was to assess the rash. No documentation showed that the physician was notified of the rash; - On 04/18/2022, the documentation showed no documented assessment of the rash. The plan for next visit was to assess the rash under the breasts and right neck area. A call was placed to the physician for possible fungal rash. Awaiting call back. The physician's office reported that the physician was off this day; and - On 04/19/2022 the patient has skin concerns in moist areas, neck, under breasts. No documented assessment of the rash or follow up with the physician regarding the rash. Review of the case conference note dated 04/20/2022, showed the patient complained of itching due to a rash. No further documentation regarding follow up with the patient's physician or interventions to address the rash. During an interview on 05/11/2022, beginning at 4:22 PM, the administrator stated that he/she would expect documentation in the case conference note if they addressed the rash. RECORD/PATIENT #4: Review of the POC dated 04/28/2022, showed: -Wound care to Stage 2 (partial thickness skin loss) pressure injury to the thoracic spine (mid back), cleanse with wound cleanser, apply foam dressing, change two times a week and as needed for excess drainage/soiling; and - Measure wound weekly and assess for signs and symptoms of infection. Review of the nursing visits showed: - On 04/30/2022, the Stage 2 pressure injury to the thoracic spine measured 1.0 x 1.0 x 0.2 (wounds are measured by length x width x depth) centimeters (cm) with scant serosanguineous (thin, watery pink colored) drainage, wound bed pink/silver epithelial cells (healing tissue) with no odor; and - On 05/02/2022, the Stage 2 pressure injury to the thoracic spine measured 1.0 x 2.0 x 0.1 cm, with a small amount of serosanguineous drainage, wound bed with loose yellow/tan slough (dead tissue) and had odor after irrigation (cleaning) of wound (this showed a change in the wound from the previous assessment). The note showed care was coordinated with the attending physician but failed to include what was discussed. No documentation that the nurse discussed the change in the wound with the physician. Review of the case conference summary (IDG note) note dated 05/04/2022, showed the patient had a stage 2 pressure injury to the thoracic spine with serosanguineous drainage noted with dressing removal, but failed to include the change in wound status documented by the nurse on 05/02/2022. During an interview on beginning at 12:35 PM. The administrator stated that he/she would expect the change in the wound to be discussed in case conference.

Based on home visit observation, home health standards, and interview, the agency failed to ensure that accepted standards of practice to prevent the transmission of infections and communicable diseases was followed in one (Record/Patient #2) of three home visits. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of official reference: McGoldrick, M. (2015). Home Care Infection Prevention and Control Program. Saint Simons Island, GA: Home Health Systems, Inc. showed that equipment that had direct contact with environmental surfaces should be cleaned and disinfected before use on another patient. Review of McGoldrick, M. Home Care Infection Prevention and Control Program showed also that staff should use a surface barrier of a water-resistant material (e.g., plastic bag [tall kitchen size] on a roll, wax paper, disposable underpads [chux], etc.) under the bag and/or equipment used in patient care. Observation on 05/11/2022, beginning at approximately 1:15 PM, during the patient's home visit, showed the hospice nurse placed his/her laptop on a table in the patient's home without a barrier underneath. At various times during the visit, the nurse picked up his/her laptop and placed it on his/her lap then placed the laptop back on the table without a barrier. At the end of the visit, the nurse left the patient's home without cleaning the laptop. During an interview on 05/11/2022, at 4:50 PM, the administrator stated that it is recommended, but is not the agency policy to place a barrier under the laptops or clean the laptops before leaving the home. Their recommendations are to place the laptops on a hard, clean, dry, non-porous surface in the home.

Based on policy review, record review, home visit observation, and interview, the agency failed to ensure the nursing needs of the patient were met in three (Records/Patients #1, #2, and #4) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy titled, "Initial and Comprehensive Assessment and Re-assessment of the Hospice Patient," revised 04/2020, showed in part: - The comprehensive assessment will identify the physical, psychosocial, emotional and spiritual needs related to the terminal illness that must be addressed in order to promote the patient's well being, comfort and dignity; and - The comprehensive assessment will be updated by the hospice interdisciplinary group (IDG) and will consider changes that have taken place since the initial assessment. RECORD/PATIENT #1: Review of the registered nurse (RN) initial assessment dated 04/04/2022, showed: - The patient resided in a long term care facility (LTCF); and - On Eliquis (blood thinning medication that can increase the risk of bleeding and bruising). Review of the plan of care (POC) dated 04/04/2022, showed no interventions and goals related to the use of Eliquis. Review of the nursing visit dated 04/26/2022, showed: - The patient had bruising to his/her arms (no prior documentation of bruising and no further description or extent of the bruising); and - No documentation the new bruising was reported to the physician. During an interview on 05/12/2022, beginning at 11:45 AM, the administrator agreed the documentation of the bruising should have been more descriptive. Depending on what the bruising looked like, it should have been reported to the physician. RECORD/PATIENT #2: Review of the nursing visits showed: - On 04/16/2022, the patient complained of itching related to an extensive blister (raised area of the skin that contains fluid derived from blood serum) like rash (spot on the skin) on his/her neck and across the torso (trunk of the human body) which appeared a month ago. The patient stated that the rash was not diagnosed/resolved while in the hospital. The plan for next visit was to assess the rash. No documentation showed that the physician was notified of the rash; - On 04/18/2022, no documented assessment of the rash. The plan for next visit was to assess the rash under the breasts and right neck area. A call was placed to the physician for possible fungal rash. Awaiting call back. The physician's office reported that the physician was off this day; and - On 04/19/2022 the patient has skin concerns in moist areas, neck, under breasts. No documented assessment of the rash or follow up with the physician regarding the rash. Review of the case conference (IDG notes) note dated 04/20/2022, showed the patient complained of itching due to a rash. No further documentation regarding follow up with the patient's physician or interventions to address the rash. Review of the nursing visits showed: - On 04/22/2022 the nurse documented the patient had a rash but no assessment of the rash or follow up with the physician regarding the rash; and - On 04/26/2022, 04/29/2022, and 05/03/2022 no documented assessment of the rash or follow up with the physician. Review of the case conference note dated 05/04/2022, showed the patient complained of itching due to a rash. Calmoseptine (skin barrier ointment) and nystatin powder to help resolve rash. The patient's record showed no order for this treatment. Observation on 05/11/2022 beginning at approximately 1:15 PM, during the patient's home visit, the hospice nurse asked the patient about his/her rash. The rash to the neck and under breasts appeared dry and pink colored. The patient stated that the nurse had been working on it and was better. He/she had a tube of nystatin (anti-fungal) powder dated 05/02/2022 apply to affected area daily. The patient also had a bottle of Prednisone (decreases inflammation) 20 mg one daily dated 05/02/2022 (no order in the record for this medication). The patient stated that was started because of the rash. During an interview on 05/11/2022, beginning at 4:22 PM, the administrator stated that he/she would expect the nurse to assess and address the rash the day it was identified. He/she would expect follow up with the physician for interventions for the rash. During an interview on 05/12/2022, at 11:22 AM, the administrator stated that the nurse contacted the hospice physician about the rash on 04/29/2022. He/she asked the nurse to document a late entry and order for the nystatin, Calmoseptine, and Prednisone. RECORD/PATIENT #4: Review of the POC dated 04/28/2022, showed: -Wound care to Stage 2 (partial thickness skin loss) pressure injury to the thoracic spine (mid back), cleanse with wound cleanser, apply foam dressing, change two times a week and as needed for excess drainage/soiling; and - Measure wound weekly and assess for signs and symptoms of infection. Review of the nursing visits showed: - On 04/30/2022, the Stage 2 pressure injury to the thoracic spine measured 1.0 x 1.0 x 0.2 (wounds are measured by length x width x depth) centimeters (cm) with scant serosanguineous (thin, watery pink colored) drainage, wound bed pink/silver epithelial cells (healing tissue) with no odor; and - On 05/02/2022, the Stage 2 pressure injury to the thoracic spine measured 1.0 x 2.0 x 0.1 cm, with a small amount of serosanguineous drainage, wound bed with loose yellow/tan slough (dead tissue) and had odor after irrigation (cleaning) of wound (this showed a change in the wound from the previous assessment). The note showed care was coordinated with the attending physician but failed to include what was discussed. No documentation that the nurse discussed the change in the wound with the physician. Review of the case conference summary note dated 05/04/2022, showed the patient had a stage 2 pressure injury to the thoracic spine with serosanguineous drainage noted with dressing removal, but failed to include the change in wound status on 05/02/2022. Review of the nursing visits showed: - On 05/05/2022, the Stage 2 pressure injury to the thoracic spine had a small amount of serosanguineous drainage, pink/red granulation (red, moist) tissue with odor after irrigation. The note showed care was coordinated with the attending physician but failed to include what was discussed. No documentation the nurse discussed the continued odor after irrigation with the physician; and - On 05/09/2022, the Stage 2 pressure injury to the thoracic spine measured 1.0 x 2.0 x 0.1 cm with scant amount of serosanguineous drainage, wound bed with pink/silver epithelial cells with no odor after irrigation. During an interview on 05/12/2022 beginning at 12:35 PM with the administrator, assistant administrator, clinical manager and clinical supervisor the findings were reviewed, the administrator stated that he/she would expect the change in the wound to be discussed in case conference. During an interview on 05/12/2022, at 3:30 PM, the administrator stated that they talked with the nurse. The nurse stated that the wound did not have odor. He/she was clicking the button in their computer system on the wrong side which showed odor. The clinical manager stated that the nurse said there was just a little bit of slough. The clinical manager stated that he/she instructed the nurse that he/she should call the physician even if there was just a little slough in a wound.

Based on policy review, record review, and interview, the agency failed to ensure the hospice aide supervisory visits included all the required components in, but not limited to, one (Record/Patient #1) of five full records reviewed. This deficient practice has the potential to affect all patients that receive aide services. Findings included: Review of the agency's policy titled, "Aide and Homemaker Services," revised September, 2021, showed in part: - The supervising nurse must assess an aide's ability to demonstrate initial and continued satisfactory performance in meeting outcome criteria that include, but is not limited to: *Demonstrating competency with assigned tasks; *Complying with infection control policies and procedures; and *Reporting changes in the patient's condition. RECORD/PATIENT #1: Review of the hospice aide supervisory visits dated 04/26/2022 and 05/03/2022, failed to address whether the aide demonstrated competency with assigned tasks, complied with infection control policies and procedures, and reported changes in the patient's condition. During an interview with the administrator on 05/11/2022, at 4:25 PM, the findings were reviewed regarding the hospice aide supervisory visit. No further information was provided.

Based on policy review, record review, and interview, the agency failed to ensure physician orders were obtained in one (Record/Patient #2) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy titled, "Acceptance of Physician Orders," revised July, 2021, showed in part a verbal or telephone order should be documented appropriately in the clinical system. Review of the agency's policy titled, "Submission of Patient Documentation," revised 07/2020, showed in part physicians' orders must be documented the same day orders are received. RECORD/PATIENT #2: Review of the plan of care dated 04/14/2022, showed an order for oxygen two liters per nasal cannula as needed for shortness of breath. Review of the nursing visits showed from 04/19/2022 through 05/03/2022, the nurses documented the patient wore oxygen at three liters per minute. Review of the case conference summary (interdisciplinary group notes) note dated 04/20/2022, showed an order for oxygen two liters per nasal cannula as needed for shortness of breath. Review of the record showed no order for oxygen at three liters per minute. Review of the case conference summary note dated 05/04/2022, showed the patient wore oxygen at three liters continuously. Observation on 05/11/2022 at approximately 1:15 PM, during the patient's home visit showed: - The patient had a bottle of Prednisone (reduces inflammation) 20 milligrams (mg) one daily dated 05/02/2022; - The patient had nystatin powder (used to treat fungal/yeast skin infections) 100,000/gram apply to affected area daily as needed dated 05/02/2022; and - There were no physician orders for these medications. During an interview on 05/11/2022 at 4:22 PM, the administrator stated that he/she would expect there to be a physician order for the oxygen at three liters per minute. During an interview on 05/12/2022, at 11:20 PM, the administrator stated that the nurse was going to see the patient today for a medication reconciliation. The nurse had contacted the physician about the patient's rash on 04/29/2022. The administrator asked the nurse to document a late entry and put in the order for the nystatin and Prednisone. The first visit, the nurse contacted the physician about the oxygen due to a low oxygen saturation (level of oxygen in the blood) but did not document it. The nurse was going to put the oxygen order in the patient's record.

Based on policy review, record review, and interview, the agency failed to ensure timely documentation was completed in, but not limited to, one (Record/Patient #1) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy titled: "Submission of Patient Documentation," revised 07/2020, showed in part that routine visits must be documented within 48 hours. RECORD/PATIENT #1: Review of the nursing visits showed: - On 05/07/2022, the nurse created the visit note on 05/07/2022 but failed to document when the visit was completed; and - On 05/08/2022, the nurse created the visit note on 05/08/2022 but failed to document when the visit was completed. During an interview on 05/12/2022, at 11:45 AM, the administrator stated that he/she would expect the visit notes to be completed within 48 hours.

Based on policy review, record review, and interview, the agency failed to document a complete discharge summary containing all the components required by this regulation in one patient who revoked hospice services (Record/Patient #9), and in one patient who was discharged from the agency (Record/Patient #8), who no longer met hospice criteria. This deficient practice has the potential to affect the post-hospice medical care of all the agency's live discharged patients. Findings included: Review of the agency's undated policy titled, "Discharge, Transfer, and Revocation from Hospice Care," showed agency staff involved in the patient's care, were to meet and discuss the patient discharge and anticipated needs for continued care or treatment to meet the patient and family needs by other sources after discharge. The Hospice case manger completes a Discharge Summary. The agency discharge summary must include: - A summary of the Hospice patient's stay (care) including treatments, symptoms and pain management; - The Hospice patient's current plan of care (POC); - The Hospice patient's latest Physician orders, and - Any other documentation that will assist in post-discharge continuity of care or that is requested by the attending physician or receiving facility. RECORD/PATIENT #9: Review of the clinical record showed the patient was admitted to hospice services on 02/08/2022 and revoked hospice on 02/14/2022 to seek further treatment. Review of the clinical record provided showed the following missing items; - No summary of the patient's stay including treatments, symptoms and pain management; - The patient's current plan of care; - The patient's latest physician orders; and - Any other documentation that will assist in post-discharge continuity of care or that is requested by the attending physician. During an interview on 05/11/2022 at 4:15 PM, the administrator stated that the agency record failed to show evidence of a discharge summary being sent after the patient's discharge. RECORD/PATIENT #8: Review of the clinical record showed the patient was admitted to hospice services on 02/05/2022 and discharged due to condition stabilization on 05/01/2022. Review of the clinical record provided showed the following missing items in the discharge summary; - The latest physician orders; and - Any other documentation that will assist in post-discharge continuity of care or that is requested by the attending physician. During an interview on 05/11/2022 at 4:35 PM, the administrator stated that the agency record failed to show evidence of a complete discharge summary being sent.

Based on clinical record review, and staff interview, the hospice agency failed to document that they supplied the inpatient provider with a copy of the patient's plan of care that specified the inpatient services to be furnished at the acute care facility, in one of one applicable case reviewed for inpatient acute care (Record/Patient #7). This deficient practice has the potential to affect all patients admitted for inpatient acute care while receiving hospice services from the agency. Findings included: RECORD/PATIENT #7: Review of the clinical record showed the patient was admitted to hospice services on 01/12/2022. The patient was admitted to inpatient acute care on 02/01/2022. The hospice record failed to show that the hospice agency provided the patient's current plan of care to the inpatient acute care facility on admission. During an interview on 05/11/2022 at 10:00 AM, the administrator said there was no documentation to show the patient's plan of care was provided to the inpatient acute care facility.

Based on policy review, record review, home visit observation, and interview, the agency failed to ensure the skilled nursing facility (SNF) hospice patient record contained a copy of all required hospice documents in one (Record/Patient #1) of one applicable record of patients that resided in a SNF . This deficient practice has the potential to affect all patients that resided in a SNF. Findings included: Review of the agency policy titled, "Hospice Care to Residents of a SNF/NF (Skilled Nursing Facility/Nursing Facility or ICF/IID (intermediate care facilities)," revised 05/2021, showed in part the hospice will provide the following information: - The most recent plan of care specific to each patient; - Physician certification and recertification; and - Hospice medication information specific to the hospice patient. RECORD/PATIENT #1: Review of the hospice record maintained at the SNF, during a home visit observation on 05/10/2022 beginning at 1:16 PM, showed it failed to contain the following required information: - Current hospice plan of care; - Physician certification; and - Current medication profile. During an interview on 05/12/2022 beginning at 11:45 AM, with the administrator, the findings were reviewed. The administrator provided no further information.