Every finding on record at Tift Regional Health System, Inc.

Based on record reviews, review of policy “Physician Orders,” and staff interviews, it was determined that the facility failed to ensure the management of all hospice operations and provision of hospice services as evidenced by failure to ensure Medical Doctors orders for wound care were included in the patient’s clinical record for one patient (P) (P#9) of 19 sampled patient charts reviewed. --- Findings include: Review of policy titled “Physician Orders,” dated April 22, 2024, revealed the following:Procedure:C. Diagnostic and therapeutic orders, including verbal orders, are signed and dated by the physician within seven (7) days and incorporated into the clinical record within seven (7) working days. Review of records revealed P#9 was admitted on 4/20/2023 with pressure ulcers (localized injury to the skin and/or underlying tissue caused by pressure). Review of Registered Nurse (RN) AA visit note dated 7/9/2025 revealed wound care was provided during the home visit without a medical doctor’s order. On 7/15/2025 at 11:00 a.m., during an office interview, the Administrator confirmed the agency’s policy was to have a Medical Doctor’s (MD) order in the clinical records before administering wound care to patients. On 7/16/2025 at 10:00 a.m., during an office interview, the Administrator provided a written order for P#9’s wound care signed by a MD dated 7/15/2025.

Based on record reviews, and staff interviews, and policy “Physician Orders," it was determined the agency failed to maintain patient clinical records with physician orders for one patient (P) (P#9) of 19 sampled patient charts reviewed. --- Findings include: On 7/16/2025 at 10:20 a.m., during a phone interview, RN AA confirmed P#9’s wound care was administered without an order from a physician. RN AA admitted she was aware of a Medical Doctor’s (MD) verbal order given to another RN for P#9’s wound care. RN AA admitted she was not aware the wound care orders were never put into the patient’s clinical records. RN AA admitted she never looked in the patient’s clinical records to see if the order had been added to the patient’s plan of care. Cross refer to L0651 relating to Governing Body and Administrator.

Based on review of clinical records, it was determined that the hospice Registered Nurse (RN) CC, failed to ensure that the initial comprehensive assessment was completed within 48 hours after the election of hospice care for one (1) of thirteen (13) sampled patients (P#6). The Findings Include: Review of the clinical record for (P#6), who was admitted on 3/18/22, with a diagnosis of abdominal aortic aneurysm, type 2 diabetes, and hypertension, revealed that the admission was done on 3/18/22, but the initial skilled nurse assessment was completed on 3/22/22, (four days) after the election of hospice care. The clinical record lacked documentation regarding the staff's delay in completing the assessments. In an interview on 9/22/22 at 12:35 p.m., the Coordinator Nurse said that she did not know why the admission nurse (RN) CC completed the admission on 3/22/22. The Administrator also confirmed that the surveyor has been provided with all available documentation for the patient's record.

Based on observation, record review, and staff interviews, it was determined that the agency failed to ensure that patient medication profiles were updated to reflect current medications at the time of the comprehensive assessment for one (1) of thirteen (13) sampled patients (P#1). The Findings include: During a home visit observation conducted on 9/21/22 at approximately 9:45a.m., with Registered Nurse (RN) AA, for (P#1), it was revealed that (P#1) was admitted on 8/9/22, with a diagnosis of Metastatic Uterine, Coronary Artery Disease, Gastroesophageal Reflux Disease, Fibromyalgia. The surveyor compared P#1's current medication list at home to the hospice agency's medication profile. Discrepancies were found. 1. Docusate Sodium 250mg take one capsule oral every day as needed for constipation the medication expired on 6/2021, Unfortunately P#1 continued to take the medication and she took on 9/20/22, because she was constipated. Registered Nurse (RN) AA did not aware that docusate sodium 250mg expired since last year June (6/2021). 2. The following medications were missing from P#1's hospice medication profile and plan of care: Lasix 20milligrams (MG), take one tablet oral everyday as needed for edema: P#1 has been taking Lasix for two years, re-filled by pharmacy on 7/11/22, but it was missing in the hospice medication profile and plan of care. 3. Pepto-Bismol 525mg/15milliliters (ML), oral suspension takes 30ml oral every thirty minutes as needed for diarrhea: P#1 has been taking this medication since over one year, but it was missing in hospice medication profile and plan of care. On 9/21/22 at 9:40 a.m., an interview was conducted with (RN) AA, who confirmed that she was not aware that P#1 was taking expired docusate sodium 250mg; she did not check the medications; and did not update the medication profile and plan of care.

Based on observation, record review, and staff interviews, it was determined that the agency failed to ensure that patient medication profiles were updated to reflect current medications at the time of the comprehensive assessment for one (1) of thirteen (13) sampled patients (P#1). The Findings include: During a home visit observation conducted on 9/21/22 at approximately 9:45a.m., with Registered Nurse (RN) AA, for (P#1), it was revealed that (P#1) was admitted on 8/9/22, with a diagnosis of Metastatic Uterine, Coronary Artery Disease, Gastroesophageal Reflux Disease, Fibromyalgia. The surveyor compared P#1's current medication list at home to the hospice agency's medication profile. Discrepancies were found. 1. Docusate Sodium 250mg take one capsule oral every day as needed for constipation the medication expired on 6/2021, Unfortunately P#1 continued to take the medication and she took on 9/20/22, because she was constipated. Registered Nurse (RN) AA did not aware that docusate sodium 250mg expired since last year June (6/2021). 2. The following medications were missing from P#1's hospice medication profile and plan of care: Lasix 20milligrams (MG), take one tablet oral everyday as needed for edema: P#1 has been taking Lasix for two years, re-filled by pharmacy on 7/11/22, but it was missing in the hospice medication profile and plan of care. 3. Pepto-Bismol 525mg/15milliliters (ML), oral suspension takes 30ml oral every thirty minutes as needed for diarrhea: P#1 has been taking this medication since over one year, but it was missing in hospice medication profile and plan of care. On 9/21/22 at 9:40 a.m., an interview was conducted with (RN) AA, who confirmed that she was not aware that P#1 was taking expired docusate sodium 250mg; she did not check the medications; and did not update the medication profile and plan of care.

Based on home visit observation, and staff interviews, it was determined that the hospice agency staff failed to follow standard precautions to prevent the transmission of infectious and communicable diseases during bed bath for one (1) of thirteen (13) patients sampled (P#2). The Findings include: During a home visit with P#2 on 9/21/22 at 10:55 a.m., this surveyor observed Certified Nursing Aide (CNA) BB, perform bed bath care to the patient. During the bathing procedure, patient had bowel movement, and (CNA) BB wiped P#2 from back to front twice. On 9/21/22 at 11:15 a.m., an interview was conducted with (CNA) BB, who confirmed that she did wipe P#2 from back to front twice. (CNA) BB said that she was nervous during the bathing procedure. During an interview on 9/21/22 at 1:30 p.m., the Administrator acknowledged that (CNA) CC did not follow acceptable standards for infection control to prevent transmission of infectious and communicable diseases.