Every finding on record at Tmc Hospice Care, Inc

Based on record review and staff interview it was determined the agency failed to include in a required discharge summary for five patients (P) (P#15, P#16, P#17, P#18 and P#19) of five discharged patients reviewed. --- Findings include: Review of P#15, P#16, P#17, P#18 and P#19 clinical records failed to have a discharge summary in the clinical record.  On 4/15/2025 at 11:30 am, during an office interview, the Clinical Supervisor (CS) acknowledged P#15, P#16, P#17, P#18 and P#19 did not have a discharge summary in the clinical records. Furthermore, the CS acknowledged the agency did not have a policy for patient discharge summary.

Based on review of clinical records, it was determined the interdisciplinary group failed to ensure the initial comprehensive assessment was completed within 5 days of admission for two (2) of fourteen (14) sampled patients. (P#10, and P#11). The findings include: 1. Review of the clinical record for P#10 admitted on 11/12/21, with a diagnosis of severe protein calorie malnutrition, depression, and atrial fibrillation, revealed the initial spiritual assessment was not done. The clinical record lacked documentation regarding the staff's delay in completing the assessments. 2. Review of the clinical record for P#11 admitted on 11/23/21, with a diagnosis of malignant neoplasm of intrahepatic bile duct, pain, hypertension, and bone metastasis, revealed the initial spiritual assessment was not done. The clinical record lacked documentation regarding the staff's delay in completing the assessments. In an interview on 4/20/22, at 3:15 p.m., the Administrator said she did not know how they missed it. The Administrator also confirmed that the surveyor has been provided with all available documentation for the patients' record.

Based on review of clinical records, it was determined the interdisciplinary group failed to ensure that the initial bereavement assessment was completed within 5 days of admission for two (2) of fourteen (14) sampled patients. (P#10, and P#11). The findings include: 1. Review of the clinical record for P#10 admitted on 11/12/21, with a diagnosis of severe protein calorie malnutrition, depression, and atrial fibrillation, revealed that the initial bereavement assessment was not done. The clinical record lacked documentation regarding the staff's delay in completing the assessments. 2. Review of the clinical record for P#11 admitted on 11/23/21, with a diagnosis of malignant neoplasm of intrahepatic bile duct, pain, hypertension, and bone metastasis, revealed the initial bereavement assessment was not done. The clinical record lacked documentation regarding the staff's delay in completing the assessments. In an interview on 4/20/22, at 3:15 p.m., the Administrator said she did not know how they missed it. The Administrator also confirmed that the surveyor has been provided with all available documentation for the patients' records.

Based on home visit observations 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#1). The findings include: During a home visit to P#1 on 4/20/22, at 9:25 a.m., the surveyor observed Certified Nursing Aide (CNA) AA perform a bed bath to P#1. During the entire bathing procedure CNA AA did not change gloves or the water and she did not use sanitizer or wash hands between and after the bed baths. On 4/20/22, at 9:40 a.m., an interview was conducted with CNA AA, confirmed that she did not change gloves and did not change the bathing water. During an interview on 4/20/21, at 4:50 p.m., the Administrator acknowledged CNA AA did not follow acceptable standards for infection control to prevent transmission of infectious and communicable diseases.

Based on observation, clinical record review, and staff interviews, it was determined that the agency failed to order patients' medication: Flagyl (Antibiotic), drugs must be made routinely available on 24 hours basis 7 days a week for all patients. The hospice agency failed to comply with this regulation for one (1) of thirteen (13) sampled patients (P#1). The finding include: During a home visit observation for Patient #1 on 4/20/22, at 9:25 a.m., revealed P#1 was admitted on 7/23/21, with a diagnosis of Parkinson's disease, dysphagia, and hypertensive heart disease. The surveyor compared P#1's current medication list at home to the hospice agency's medication profile and discrepancies were found for Flagyl 500milligrams (MG), crush one tablet mix with jelly and apply to wound bed of sacral daily. During interview on 4/20/22, at 4:40 p.m., with RN BB she stated that she was not aware the Flagyl 500mg tablet had finished.