Every finding on record at Suncrest Hospice LLC

Based on interview and record review, the hospice failed to include measurable outcomes anticipated from implementing and coordinating the plan of care for 1 of 2 patients receiving wound care (Patient #4). Specifically, the agency failed to ensure the patient's wound care had specific goals for wound care outcomes. This deficiency was cited previously during a recertification survey conducted on 6/21/21. Although the agency corrected the deficiency, based on the findings below, the agency had not maintained compliance with this regulatory requirement. --- Findings include: AGENCY POLICY According to an agency policy, dated May 2020, and titled, Prioritizing Patient Problems/Needs, (read in pertinent parts): "Using the data obtained during the initial, comprehensive and ongoing hospice assessments, the hospice interdisciplinary group members will develop a list of patient problems and needs, with corresponding goals and anticipated target dates for reaching those goals." 1. The clinical record for Patient #4 was reviewed on 12/29/22. The patient was admitted for hospice care and services on 7/26/22 with a terminal diagnosis of senile degeneration of the brain. The plan of care for the certification period dated 10/30/22 to 12/28/22 included orders for skilled nursing (SN) services three times a week for nine weeks and one as needed (PRN) visit for assessment and wound care; home health aide (HHA) services two times a week for six weeks, one time a week for four weeks for transfers, toileting, mobility, bathing, and personal care; medical social worker (MSW) services two times a month for three months for coping support; and spiritual counselor (SC) services two times a month for three months for spiritual care. The patient resided in an assisted living residence (ALR). Review of the plan of care for the certification period dated 12/29/22 to 2/26/23 included orders for SN services one time a week for one week and three times a week for nine weeks and one PRN visit for assessment and wound care; HHA services one time a week for ten weeks for transfers, toileting, mobility, bathing, and personal care; MSW two times a month for three months for coping support; and SC services two times a month for three months for spiritual care. a) The agency failed to ensure the plans of care for Patient #4 included specific goals for wound care. Review of the plans of care for the certification periods dated 10/30/22 to 12/28/22 and 12/29/22 to 2/26/23 revealed Patient #4 was receiving wound care for a cancerous ulcer to her right anterior pretibial (shin). Further review of the plans of care revealed in the section titled "22 Goals/Rehabilitation Potential/Discharge Plans," the SN goal was documented as "Fall risk interventions will remain in place to decrease potential for falls within cert [certification] period." There was no evidence of a wound care goal for Patient #4. During an interview on 12/29/22 at 11:07 a.m., registered nurse (RN) #8 confirmed she was the SN case manager for Patient #4. RN #8 stated the goal for Patient #4's right anterior pretibial wound care was that the wound would not get worse, but RN #8 confirmed Patient #4's plans of care failed to have a wound care goal documented. RN #8 stated the patient's plans of care she was responsible for were not up to date as she had a large number of patients to care for and she had not had the time to update every patient's plan of care. During an interview on 12/29/22 at 1:44 p.m., the executive director confirmed Patient #4's plans of care for the certification periods 10/30/22 to 12/28/22 and 12/29/22 to 2/26/23 failed to have a wound care goal. The executive director stated the agency expectation was that each intervention listed on a patient's plan of care should have a corresponding goal.

Based on interview and record review, the hospice failed to ensure care and services were provided in accordance with the plan of care for 1 of 2 patient records reviewed who received wound care (Patient #4). --- Findings include: AGENCY POLICY According to the agency policy, dated May 2020, titled, Missed Visits, (read in pertinent parts): "If a visit is missed for any reason, the clinician should attempt to reschedule it for the same week so that the physician ordered frequency is maintained and would not be considered a missed visit." "If a visit is missed and not rescheduled the clinician will: -Notify the IDG [Interdisciplinary Group] and Director of Patient Care Services/Clinical Supervisor of the missed visit and reason for missed visit." According to the agency policy, dated May 2020, titled, Monitoring Patient's Response/Reporting to Physician, (read in pertinent parts): "Clinicians will establish and maintain ongoing communication with the patient's Attending Physician and the Hospice Medical Director to ensure safe and appropriate care for the patient." "The patient's Attending Physician and/or the Hospice Medical Director will be contacted on the same day when any of the following occur: -Changes occur regarding diagnosis, prognosis, or treatment (including procedures, medications, precautions, and limitations)." According to the agency policy, dated May 2020, titled, Ongoing Comprehensive Assessment, (read in pertinent parts): "Based on the assessments, the plan of care-including problems, needs, goals, and outcomes-will be reviewed and updated by the interdisciplinary group members responsible for the case." "Based upon the findings of the assessment change/verbal orders will be generated and forwarded to the physician (or other authorized independent practitioner) as needed." 1. The clinical record for Patient #4 was reviewed on 12/29/22. The patient was admitted for hospice care and services on 7/26/22 with a terminal diagnosis of senile degeneration of the brain. The plan of care for the certification period dated 10/30/22 to 12/28/22 included orders for skilled nursing (SN) services three times a week for nine weeks and one as needed (PRN) visit for assessment and wound care; home health aide (HHA) services two times a week for six weeks, one time a week for four weeks for transfers, toileting, mobility, bathing, and personal care; medical social worker (MSW) services two times a month for three months for coping support; and spiritual counselor (SC) services two times a month for three months for spiritual care. The patient resided in an assisted living residence (ALR). Further review of the plan of care for the certification period dated 10/30/22 to 12/28/22 revealed SN interventions included the following wound care protocol for Patient #4's cancerous right anterior pretibial (shin) wound: "1. Cleanse wound and surrounding broken down skin with wound cleanser; 2. Pat dry; 3. Apply UNNA -Z boot with zinc (a wound care bandage that maintains a moist healing environment and provides light compression impregnated with zinc oxide) (zinc oxide keeps wounds moist and clean while facilitating wound healing) to right leg and cover with ace bandage. Review of a SN recertification visit summary completed on 10/26/22 by registered nurse (RN) #8 showed Patient #4 had a cancerous right anterior pretibial wound that was identified on 7/26/22. a) The agency failed to ensure wound care was provided as ordered on the plan of care for Patient #4. Review of SN notes from 11/2/22 to 12/28/22 revealed on 12/21/22, RN #8 documented she provided wound care to Patient #4 as follows: "Cleaning/Irrigation Method: NS [normal saline]; Dressings: 4x4 gauze Non-adherent Kerlix (a bandage roll made of gauze that provides wicking action and absorbency)" Further review of Patient #4's chart including verbal orders and communication notes revealed no evidence RN #8 had communicated with or received orders from the physician to change Patient #4's wound care orders. During an interview on 12/29/22 at 11:25 a.m., LPN # 9 stated she provided care to Patient #4 including wound care to her right anterior pretibial wound. LPN #9 stated the wound care she provided was as follows: remove the old dressing, clean the wound with wound cleanser, pat the wound dry, put a new xeroform dressing (a petroleum based wound care dressing used to cover and protect the wound while promoting a moist environment for healing) on, cover the xeroform dressing with sterile gauze, cover the gauze with kerlix wrap, and finally apply a layer of Coban (a self-adherent wrap that functions like a tape but sticks to itself). LPN #9 acknowledged this was the wound care she provided to Patient #4 the 12 times she provided care to Patient #4 (11/2/22, 11/4/22, 11/8/22, 11/11/22, 11/14/22, 11/23/22, 11/28/22, 12/2/22, 12/7/22, 12/12/22, 12/19/22 and 12/28/22) from 11/2/22 through 12/28/22. During continued interview, LPN #9 acknowledged the wound care she provided to Patient #4 was not the wound care protocol ordered on Patient #4's plan of care and acknowledged she did not have a physician order for the wound care she provided. LPN #9 stated she had discussed with RN #8 the wound care for Patient #4 and RN #8 stated the hospice agency did not have the "Unna Z boot" product ordered for Patient #4's wound care, thus advised LPN #9 to use the wound care technique described above as this was the protocol RN #8 used for Patient #4's right anterior pretibial wound, and RN #8 felt Patient #4's wound was doing well with this protocol. During an interview on 12/29/22 at 11:07 a.m., RN #8 stated the wound care she provided to Patient #4 was as follows: she would clean the wound with wound cleanser, dry the wound and use an "Unna type wrap". RN #8 stated by "Unna type wrap" she meant she used a petroleum dressing, covered the petroleum dressing with an absorbent dressing (such as sterile gauze) , wrapped the absorbent dressing with kerlix and covered the kerlix with Coban. RN #8 stated she had used that wound care protocol for Patient #4 since she took over as Patient #4's RN case manager on 10/5/22. During continued interview, RN #8 stated the hospice agency did not have the "Unna Z boot" product ordered for Patient #4 so RN #8 used the petroleum dressing, absorbent dressing, kerlix and Coban as she had those supplies on hand. RN #8 stated agency expectation was that the SN called the patient's physician if they had to vary from plan of care orders to receive new orders for the care provided, but she failed to communicate with Patient #4's physician when LPN #9 and RN #8 varied from Patient #4's plan of care wound protocol orders. RN #8 stated she would have called if she had to change the type of medication being applied to a wound bed, but since she substituted similar products for the ordered wound care for Patient #4, RN #8 did not feel she needed to call Patient #4's physician for new orders. During an interview on 12/29/22 at 1:41 p.m., the executive director stated the agency had "Unna Z boot" products on hand. The executive director stated if the hospice agency did not have the wound care supplies ordered on a patient's plan of care, the procedure the hospice agency expected the SN to follow was the SN was to inform the hospice agency of the wound care supplies ordered for a patient and the hospice agency would order the supplies. The executive director also stated the hospice agency expectation was any time a SN had to vary from orders on a patient's plan of care, the SN was to call the patient's physician to inform the physician of the change and to be provided with new orders. If the new orders were to become the patient's permanent orders, the patient's plan of care should be updated to reflect this change. b) The hospice failed to provide SN services to meet the patient's needs in accordance with the plan of care orders. Review of Patient #4's November and December 2022 schedule revealed SN visits were conducted Monday, Wednesdays and Fridays except for the week of 11/6/22 to 11/12/22 when Patient #4 was seen by SN on Monday 11/7/22, Tuesday 11/8/22 and Friday 11/11/22. Review of completed SN visit notes for Patient #4 failed to show SN services were provided in accordance with the plan of care. Specifically, the clinical record for Patient #4 failed to reveal SN visits were conducted on 11/25/22, 12/14/22, and 12/26/22. Documentation showed RN #8 completed a missed visit note for these visits, but failed to show how the patient's needs were met including her wound care needs. Record review failed to show wound care was provided to Patient #4 on these three missed visits. Review of a missed visit note written by RN #8, on 11/22/22, stated Patient #4's SN visit for 11/25/22 was canceled because "Not Necessary." The missed visit note failed to state how Patient #4's needs were met, specifically her wound care needs. Review of a missed visit note written by RN #8, on 12/13/22, stated Patient #4's SN visit for 12/16/22 was canceled because "Not Necessary." However, record review revealed RN #8 provided care, including wound care, to Patient #4 on 12/16/22. Review of visit notes for the week of 12/11/22 to 12/17/22 showed: licensed practical nurse (LPN) #9 provided a SN visit, which included wound care, on 12/12/22; and RN #8 provided a SN visit, which included wound care, on 12/16/22. Documentation review failed to show that Patient #4 was provided with three days of wound care during the week of 12/11/22 to 12/17/22, with the record failing to show a visit was conducted on Wednesday 12/14/22. Review of the missed visit note written by RN #8, on 12/28/22, stated Patient #4's SN visit for 12/26/22 was canceled because "Not Necessary. The missed visit note failed to state how Patient #4's needs were met, specifically her wound care needs. During an interview on 12/29/22 at 11:07 a.m., RN #8 stated she was Patient #4's RN case manager and Patient #4 received SN visits Mondays, Wednesdays, and Fridays for assessments and wound care to her right anterior pretibial wound. RN #8 acknowledged Patient #4 did not have SN visits on 11/25/22, 12/14/22 and 12/26/22. RN #8 stated the hospice agency expectation when a SN could not provide services as scheduled was the SN was to either arrange for the ALR to have their SN, if the ALR had a SN on staff, provide the wound care for the missed SN visit and/or the hospice agency would send an on-call nurse to provide the SN visit so the patient did not go without wound care. RN #8 could not recall if Patient #4's ALR provided wound care for the three missed visits or if the hospice agency sent an on-call SN, and stated she felt Patient #4 did not have wound care three times a week during the weeks of those missed visits. RN #8 also stated she failed to contact Patient #8's attending physician or the hospice medical director to inform either of them that Patient #4 went three to five days without wound care each time Patient #4 had a missed visit. During an interview on 12/29/22 at 1:14 p.m., Clinical Manager #2 stated when a hospice SN was unable to make a scheduled visit, the agency expectation was the SN should call and/or email a clinical manager to inform the clinical manager that the SN would be unable to make the scheduled visit. Additionally, the SN should add the visit that he/she would not be able to provide patient care to a report titled, "Shift Report." Clinical Manager #2 explained the "Shift Report" was an internal document used by hospice management to track patient needs including but not limited to coverage for scheduled visits. If a patient was added on the Shift Report as not having coverage for an upcoming scheduled visit, the hospice management team would contact an on-call SN to ensure the patient did not go without a visit. During continued interview, Clinical Manager #2 stated this was especially important for patients with wound care as it was the hospice agency's policy that if a scheduled SN could not provide care to a patient receiving wound care, that an on-call SN provide the wound care to the patient. Clinical Manager #2 checked the "Shift Report" for Patient #4's missed visits and stated RN #8 had not reported the three missed visits from 11/25/22 through 12/26/22. Additionally, Clinical Managers #2 and #3 both stated RN #8 had not reached out to either of them via a telephone call or email to inform them of her inability to complete the visits as scheduled for Patient #4. Clinical Managers #2 and #3 and the executive director were not aware that Patient #4 had missed visits until the surveyor interviewed them. All three of them stated RN #8 failed to follow agency protocol and Patient #4 should not have had any missed visits.

Based on clinical record review and interviews, the hospice agency failed to prepare a plan of care (POC) that specifically identified which provider was responsible for performing the respective functions that have been agreed upon and included in the hospice POC in 4:4 records reviewed for patients residing in skilled facilities (Patients #1, #2, #3, and #4). --- Findings include: AGENCY POLICY According to agency policy titled, Care and Service Coordination, dated May 2020, (in pertinent parts): "Care coordination will include, but not be limited to: Clearly outlining each clinician's responsibilities to avoid duplication of services Integration of services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. When the patient requires more than one (1) service from the hospice, the Hospice Case Manager will be responsible for cooperative care planning in order to assure that goals, actions, and the interrelationship of services is not duplicated and to minimize the potential for missed or conflicting services." According to agency policy titled, Provision of care to residents of SNF/NF or ICF/IID, dated May 2020, (in pertinent parts): "A written plan of care must be established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided must be in accordance with this plan of care. The plan of care must: Identify the care and services that are needed and specifically identify which provider is responsible for performing the respective functions. Reflect the participation of the hospice, the SNF/NF or ICF/IID, and the patient and family to the extent possible" 1. The clinical record for Patient #1 was reviewed on 12/28/22. The patient was admitted to hospice care and services on 9/30/21, with a terminal diagnosis of senile degeneration of the brain. The POC for the certification periods dated, 9/25/22 to 11/23/22 and 11/24/22 to 1/22/23 included orders for skilled nursing (SN) services two times a week for 13 weeks, with two as needed (PRN) visits for falls or symptom management, for skilled assessment of integument status, mental neuro status, nutrition/hydration, pain status, and education of facility staff and family on fall prevention, mental status changes and nutritional needs, home health aide (HHA) services four times a week for nine weeks for, personal cares, bed making, tray setup, meal companionship, and to offer fluids every two hours and with meals; medical social worker (MSW) services three times a month for a comforting supportive environment, and clergy services monthly for spiritual support to patient and caregivers. The patient resided in an assisted living residence (ALR). a) Clinical record review revealed the hospice agency failed to include delineation of who was responsible for performing the different aspects of care required within the POC. Review of the Hospice Interdisciplinary Care Plan, for the certification periods dated 9/25/22 to 11/23/22 and 11/24/22 to 1/22/23, showed SN interventions were included to manage the patient's pain, integumentary and mental status, as well as skilled observation and assessment of nutritional and hydration status with swallow assessment; patient on pureed diet with honey thickened liquids and needing feeding assist. It was also noted that the patient was to receive HHA services to provide PO (per mouth) fluids every two hours and with each meal, however it failed to indicate who was responsible for what and when to complete it. Review of HHA routine visits dated; 9/1/22, 9/14/22, 9/19/22, 9/21/22, 9/22/22, 9/23/22, 9/29/22, 10/3/22, 10/4/22, 10/6/22, 10/7/22, 10/17/22, 10/26/22, 11/2/22, 11/3/22 and 12/28/22, stated the HHA assisted the patient with breakfast. A note dated 9/15/22 stated water was given. Review of SN notes revealed the SN assisted with a meal during a PRN visit on 9/1/22 at 12:55 p.m. Further review showed no documented evidence as to who was responsible for providing the pureed meal and honey thickened liquid, who was responsible for the swallowing assessment, and when the HHA was to assist with feeding meals, or offer fluids every two hours. During an interview on 12/28/22 at 3:58 p.m., HHA # 6 stated, she saw Patient #1 four times per week and assisted her with breakfast. She further stated that the food came to her prepared with the liquids already thickened. During an interview on 12/29/22 at 11:39 a.m., RN #4 stated, she saw Patient #1 one to two times a week and had been seeing her since the end of August 2022. She stated Patient #1 received a pureed diet with nectar thick liquids which was provided by the facility, hospice staff only assisted with breakfast and no other meals that she was aware of. She further stated she documented every two hour fluids for the facility staff to perform and was not sure why the POC did not reflect that. During an interview on 12/29/22 at 1:20 p.m., LPN #5 stated, she had been seeing Patient #2 for about one year. She stated she was on a pureed diet with nectar thick liquids, but did not assist her with meals. She further stated the order to offer fluids every two hours should be on the facility medication administration record (MAR) and that she had nothing to do with the hospice POC or updating it as that was the RNs responsibility. 2.The clinical record for Patient #2 was reviewed on 12/28/22. The patient was admitted for hospice care and services on 2/27/21 with a terminal diagnosis of vascular dementia. The plan of care for the certification period dated 10/20/22 to 12/18/22 included orders for SN services one time a week for one week and two times a week for nine weeks with PRN visit for assessment, monitoring effectiveness and side effects of drug therapy, activities of daily living (ADL)/mobility education, monitoring of bowel function, Covid-19 education, and feeding assisting; HHA services two times a week for one week and five times a week for nine weeks for personal care including monitoring bowel movements; bathing, Covid-19 screening, housekeeping, nourishment assistance, and care coordination with facility staff; MSW three times a month for three months and four times a month for three months for bereavement needs and psychosocial support; and spiritual counselor (SC) services one time a month for one month and three PRN visits for spiritual support and care. The patient resided in an ALR. Review of the plan of care for the certification period dated 12/19/22 to 2/16/23 for Patient #2 included orders for SN services two times a week for nine weeks for assessment, monitoring effectiveness and side effects of drug therapy, ADL/mobility education, monitoring of bowel function, Covid-19 education, and feeding assistance; HHA services five times a week for nine weeks for personal care including monitoring bowel movements; bathing, Covid-19 screening, housekeeping, nourishment assistance, and care coordination with facility staff; MSW services three times a month for three months for bereavement needs and psychosocial support; and SC services one time a month for three months and 6 PRN visits for spiritual support and care. a) Clinical record review revealed the hospice agency failed to include delineation of who was responsible for performing the different aspects of care required within the POC. Review of the Hospice Interdisciplinary Care Plan, for the certification periods dated10/20/22 to 12/18/22 and 12/19/22 to 2/16/23, showed SN interventions were included to manage drug therapy, bowel function, ADL and mobility education, and pureed diet with thin liquids as well as feeding assistance. It was also noted that the patient was to receive HHA services to provide tray set up and assist feed, as well as offer fluids every two hours. However, it failed to reveal who was responsible for what and when. Review of HHA routine visits dated; 10/25/22, 10/26/22, 10/31/22, 11/4/22, 11/7/22, 11/10/22, 11/11/22, 11/16/22, 11/17/22, 11/28/22, 11/29/22, 11/30/22, 12/2/22, 12/5/22, 12/7/22, 12/15/22, 12/16/22, 12/19/22, stated the HHA took Patient #2 out to breakfast. Review of HHA routine visits dated 10/27/22, 10/28/22, 11/3/22, 11/9/22, 11/14/22, 11/15/22, 11/18/22, 11/22/22, 12/13/22, 12/14/22, 12/20/22, 12/21/22, 12/26/22, and 12/27/22 stated the HHA provided companionship to Patient #2. A note dated 12/22/22 stated Patient #2 had breakfast. Further review showed no documented evidence as to who was responsible for providing the pureed meal and thin liquids, and when the HHA was to assist with feeding meals, or offer fluids every two hours. During an interview on 12/28/22 at 3:57 p.m., HHA #6 stated, she saw Patient #2, typically in the morning around 8:30 a.m. She set up her tray, opened cartons and cued her to eat but did not actually assist with feeding the meal. During an interview on 12/29/22 at 11:39 a.m., RN #4 stated, she saw Patient #2 two times per week since August 2022. She stated she was on a pureed diet with thin liquids. She further stated that the HHA was to assist with meals and offer fluids every two hours while visiting and needed to make that clearer on the HHA care plan. During an interview on 12/29/22 at 1:20 p.m. LPN #5 stated, she saw Patient #2 weekly, but did not assist with meals. She stated the facility staff was responsible for assisting with meals, and did not know why it was not listed on the POC that way. 3. The clinical record for Patient #3 was reviewed on 12/28/22. The patient was admitted to hospice care and services on 1/22/21, with a terminal diagnosis of Alzheimer's disease. The POC for the certification period dated 11/13/22 to 1/11/23 included orders for SN services two times a week for nine weeks, with two PRN visits for symptom management and one PRN visit for falls, skilled assessment, pain management, COVID-19 education, feeding assistance related to dysphagia and nutritional/hydration management, HHA services five times week for nine weeks for, bright moments (an agency program to promote a calming comfortable environment with the use of essential oils and soft light touch), personal cares, bed making, mobility assistance with two persons and Hoyer lift, to apply Tubigrips to bilateral lower extremities (BLE) daily and remove at night; MSW services three times a month to encourage patient and family to verbalize feelings and assessment of psychosocial needs, and clergy services monthly, and once as needed spiritual care, to offer listening presence and emotional support to patient and caregivers. The Patient resided in an ALR a) Clinical record review revealed the hospice agency failed to include delineation of who was responsible for performing the different aspects of care required within the POC. Review of the Hospice Interdisciplinary Care Plan, for the certification period dated 11/13/22 to 1/13/23, showed SN interventions were included to provide skilled observation and assessment and feeding assistance related to dysphagia and nutritional/hydration management patient on pureed diet with thickened liquids and needing feeding assist. It was also noted that the patient was to receive HHA services to apply Tubigrips to BLE daily and remove at night. However, it failed to reveal who was responsible for what and when. Review of HHA routine visits dated and time stamped; 11/14/22 9:05 a.m. to 10:11 a.m., 12/16/22 8:03 a.m. to 9:06 a.m., 12/19/22 8:25 a.m. to 9:10 a.m., and 12/20/22 8:51 a.m. to 9:55 a.m., showed documentation of applying Tubigrips. Further review showed no documented evidence as to who was responsible for providing the pureed meal and thickened liquid, or who was to apply and remove the Tubigrips. During an interview on 12/29/22 at 9:38 a.m., HHA #7 stated, he applied the Tubigrips every morning if he provided am cares to Patient #3 but he was not aware of who took them off at night. During an interview on 12/29/22 at 11:39 a.m., RN #4 stated she needed to be more specific with tasks assigned to the POC. 4.The clinical record for Patient #4 was reviewed on 12/29/22. The patient was admitted for hospice care and services on 7/26/22 with a terminal diagnosis of senile degeneration of the brain. The POC for the certification period dated 10/30/22 to 12/28/22 included orders for SN services three times a week for nine weeks and one PRN visit for assessment and wound care; HHA services two times a week for six weeks, one time a week for four weeks for transfers, toileting, mobility, bathing, and personal care; MSW services two times a month for three months for coping support; and SC services two times a month for three months for spiritual care. The patient resided in an ALR. a) Clinical record review revealed the hospice agency failed to include delineation of who was responsible for performing the different aspects of care required within the POC. Review of the Hospice Interdisciplinary Care Plan, for the certification period dated 10/30/22 to 12/28/22, showed SN interventions were included to provide skilled assessment and wound care. It failed to reveal who was to provide the wound care and when. During an interview on 12/29/22 at 11:07 a.m., RN #8 stated, she had been providing care to Patient #4 for a few months. She further stated she did wound care every visit and if she was not there, the facility staff was responsible for it. She also stated she did not state on the POC who was to do what and when. During an interview on 12/29/22 at 11:25 a.m., LPN #9 stated she had been caring for Patient #4 for several months. She stated she did the wound care every visit but was not responsible for the POC or its contents. 5. During an interview on 12/29/22 at approximately 1:15 p.m., LPN #1, RN and RN #3 all stated the POC needed to be clear as to who was doing what and when for all patients residing in skilled facilities.