Every finding on record at Traditions Hospice of Indianapolis LLC

Based on record review and interview, the agency failed to ensure all falls were documented in an occurrence log to be included in their Quality Assurance Performance Improvement program for 5 of 8 active records reviewed (Patients #1, #3, #4, #6, and #8) with falls not documented on the occurrence log. Findings Include: --- 1. An agency policy titled " Occurrence/Violence Incident Reporting" reviewed 09/01/2024 indicated but was not limited to, "   …   The Hospice will document and report all occurrences   …   that deviate from routine Hospice operations and may result in injury or potential harm to a patient or Hospice staff.   …   I. Adverse Events include, but are not limited to: A. Provision of care errors such as   …   falls   …" 2. A review of Patient #1's clinical record evidenced "Client Episode Coordination Notes Report" from 08/23/2025 through 11/13/2025. The coordination note dated 08/23/2025 at 9:36 PM by the on-call triage company, Entity 13, by Person 14, indicated Patient #1 had fallen out of their wheelchair and hit the right side of their face and were currently bleeding. The note evidenced RN 3 was aware of the patient's fall and injury and an RN visit was scheduled. The coordination note dated 08/23/2025 at 11:49 PM by RN 3 revealed they had canceled the visit made at 9:36 PM on 08/23/2025 because the assisted living facility nurse had informed RN 3, Patient #1 had fallen asleep. Patient #1's clinical record evidenced the next RN visit was made by RN 3 on 08/24/2025 at 9:06 AM. The nurse indicated in their narrative, the patient had a bruise on their upper lip on the right side. A review of the agency's "QI (sic Quality Improvement) Event Summary" failed to evidence Patient #1's fall on 08/23/2025. During an interview with RN 3 on 11/14/2025 at 9:11 AM, they explained when a fall occurs, an occurrence log would be completed. 3. A review of Patient #3's clinical record evidenced "Client Episode Coordination Notes Report" from 09/16/2025 through 11/13/2025. The coordination note dated 09/16/2025 at 3:47 AM by the on-call triage company, Entity 13, by Person 15, they indicated in the note, Patient #3 had fallen while attempting to ambulate to the restroom and complained of pain in their hands, with no other injuries noted. The note evidenced the assisted living facility put an order in for an x-ray (a type of radiation used to see inside of the body) to be completed on the patient. Patient #3's clinical record evidenced the patient was seen by RN 2 on 09/30/2025 at 2:17 PM. The narrative revealed the x-ray taken of the patient's hands failed to reveal any injury. A review of the agency's "QI Event Summary" failed to evidence Patient #3's fall on 09/28/2025. During an interview with RN 2 on 11/14/2025 at 10:05 AM, they indicated they will then complete an incident report after a fall, which is separate from the communication notes. 4. A review of Patient #4's clinical record evidenced a coordination note dated 09/03/2025 at 9:46 PM by Person 16, from the on-call triage agency, Entity 13. The note evidenced the triage line received a call from Patient #4's assisted living facility at 8:57 PM on 09/03/2025 indicating the patient had an unwitnessed fall and hit their head. RN 2 was notified. Patient #4's clinical record revealed RN 2 saw the patient on 09/03/2025 at 9:45 PM. A review of the agency's "QI Event Summary" failed to evidence Patient #4's fall on 09/03/2025.   During an interview with RN 4 on 11/14/2025 at 3:09 PM, they explained after a fall, they were to complete an occurrence report even if it was an unwitnessed fall. 5. A review of Patient #6's clinical record evidenced an RN visit note dated 09/04/2025 at 12:04 PM. The visit note evidenced a communication note indicating the patient had fell on 09/04/2025 and had hit their head. A review of the agency's "QI Event Summary" failed to evidence Patient #4's fall on 09/03/2025.   During an interview with RN 1 on 11/14/2025 at 3:26 PM, they explained they will complete a client occurrence for any falls, will include what happened, how it was addressed, and determine what interventions needed to be changed. 6. A review of Patient #8's clinical record evidenced coordination notes dated 08/14/2025 through 10/31/2025. Patient #8's clinical record evidenced a coordination note dated 08/15/2025 at 10:30 PM by the on-call triage company, Entity 13, by Person 17, indicated the patient had fallen and had no injuries. The coordination note dated 08/25/2025 at 2:01 AM by Person 15, from the on-call triage agency, Entity 13 indicating Patient #8 had a new skin tear on their left arm and Emergency Medical Services had been called. The coordination note dated 08/25/2025 at 2:42 AM by Person 18, from the on-call triage agency, Entity 13, indicated Patient #8's skin tear was no longer bleeding. The wound was treated by Emergency Medical Services and it was no longer bleeding. An RN visit note was conducted on 08/26/2025 at 6:15 PM by RN 4 to treat Patient #8's new skin tear with the wound care orders. Patient #8's coordination note dated 09/14/2025 at 2:52 PM, by Person 19, from the on-call triage agency, Entity 13, indicated Patient #8 had fallen and had no visible injuries. The note revealed RN 3 was notified. Patient #8's coordination note dated 09/14/2025 at 8:35 PM, by Person 19, from the on-call triage agency, Entity 13, indicated Patient #8 had fallen and had no visible injuries. The note revealed RN 3 was notified. The coordination note dated 09/20/2025 at 2:37 AM, by Person 21, from the on-call triage agency, Entity 13, indicated Patient #8 had fallen and had no visible injuries. RN 3 was notified. An RN visit note was completed by RN 3 on 09/21/2025 at 8:34 AM for a follow-up visit for Patient #8's fall. The coordination note dated 10/04/2025 at 2:44 PM by Person 22, with Entity 13, indicating Patient #8 had fallen with no visible injuries and RN 3 was notified. The coordination note dated 10/25/2025 at 10:56 PM by Person 23, with Entity 13, indicating Patient #8 had fallen and had no injuries. RN 3 was notified. A review of the agency's "QI Event Summary" failed to evidence Patient #8's falls on 08/15, 08/25, 09/14, 09/20, 10/04, and 10/25/2025.   During an interview with RN 3 on 11/14/2025 at 9:11 AM, they explained when a fall occurs, an occurrence log would be completed. 7. During an interview with the Executive Director (Admin 1) and the Vice President of Quality (Admin 7) on 11/14/2025 at 3:45 PM, the Executive Director explained an occurrence report will be filed when a fall occurs.

Based on record review and interview, the agency failed to ensure all patients were seen in a timely manner after a fall for 3 of 3 active records reviewed (Patients #1, #3, and #8) and 1 of 1 inactive record reviewed (Patient #10) with patients who fell and were not seen in a timely manner. Findings Include: --- 1. An agency policy titled "On Call for Patient Care" with a reviewed date of 09/01/2024 indicated but was not limited to, "   …   Nursing and physician services will be available 24 hours, seven days a week   …   II. The Hospice will develop protocols and procedures for: A. Timely return of the call and back-up contingencies   …" 2. A review of the agency Admission packet evidenced on page 3 included but was not limited to, "   …   CALL HOSPICE FIRST   …   We are able to help you 24 hours a day, seven days a week, including holidays   …   Call us if there are any issues or concerns including:   …   You experience a fall   …". On page 19 of the Admission packet included but was not limited to, "   …   Your Rights and Responsibilities   …   11. To 24 hour/7 day/week availability of nursing services by calling the office number.   …" 3. A review of Patient #1's clinical record evidenced "Client Episode Coordination Notes Report" from 08/23/2025 through 11/13/2025. The coordination note dated 08/23/2025 at 9:36 PM by the on-call triage company, Entity 13, by Person 14, indicated Patient #1 had fallen out of their wheelchair and hit the right side of their face and were currently bleeding. The note evidenced RN 3 was aware of the patient's fall and injury and an RN visit was scheduled on 08/23/2025. The coordination note dated 08/23/2025 at 11:49 PM by RN 3 revealed they had canceled the visit made at 9:36 PM on 08/23/2025 because the assisted living facility nurse had informed RN 3, Patient #1 had fallen asleep. Patient #1's clinical record evidenced the next RN visit was made by RN 3 on 08/24/2025 at 9:06 AM. The nurse indicated in their narrative, the patient had a bruise on their upper lip on the right side. The clinical record failed to evidence Patient #1 was seen in a timely manner after the report of a fall with injury. During an interview with RN 3 on 11/14/2025 at 9:11 AM, they explained they were the weekend and on-call nurse. RN 3 indicated the agency had a triage line with nurses and if anyone called the on-call line it would go through the triage company and then to the on-call nurse with the agency. RN 3 would then call the individual who called the on-call line, determine the problem, and inquire whether they would want RN 3 to come see the patient. RN 3 indicated they would go to see the patient as soon as possible. If the patient had a fall with no injury, they determined if the patient needed any assistance or if they had a visit later in the day. They clarified if a patient had an injury from a fall, they will go out immediately to assess the patient even if the facility the patient lived in had already addressed the injury or wound. When queried regarding Patient #1's injury on 08/23/2025, which resulted in an injury. They explained they could not remember why they had not gone out immediately to see them. They confirmed they usually go out to see the patient within 24 hours after a fall without injury and an occurrence log would be completed. 4. A review of Patient #3's clinical record evidenced "Client Episode Coordination Notes Report" from 09/16/2025 through 11/13/2025. A review of the coordination note dated 09/28/2025 at 3:47 AM by the on-call triage company, Entity 13, by Person 15. Person 15 indicated in the note, Patient #3 had fallen while attempting to ambulate to the restroom and complained of pain in their hands, with no other injuries noted. The note evidenced the assisted living facility put an order in for an x-ray (a type of radiation used to see inside of the body) to be completed on the patient. Patient #3's clinical record evidenced the patient was seen by RN 2 on 09/30/2025 at 2:17 PM. The narrative revealed the x-ray taken of the patient's hands failed to reveal any injury. The clinical record failed to evidence Patient #3 was seen in a timely manner after the report of a fall without injury. During an interview with RN 2 on 11/14/2025 at 10:05 AM, they indicated for the on-call process, the triage line will call them and would follow-up with the patient or the person who called. If a patient had a fall with an injury or change of condition they would immediately visit the patient. A fall with no injury will result in a visit the next day to complete a follow-up from the fall. They will then complete an incident report which is separate from the communication notes. 5. A review of Patient #8's clinical record evidenced coordination notes dated 08/14/2025 through 10/31/2025. The coordination note dated 08/25/2025 at 2:01 AM by Person 15, from the on-call triage agency, Entity 13 indicating Patient #8 had a new skin tear on their left arm and Emergency Medical Services had been called. The coordination note dated 08/25/2025 at 2:42 AM by Person 18, from the on-call triage agency, Entity 13, indicated Patient #8's skin tear was no longer bleeding. The wound was treated by Emergency Medical Services and it was no longer bleeding. A review of a RN visit note dated 08/26/2025 at 6:15 PM and signed by RN 4 to treat Patient #8's new skin tear on their left arm with the new wound care orders by cleaning the wound with wound cleanser, dried with gauze, applied vaseline gauze, covered with gauze, and secured with wrap and tape. The coordination note dated 09/20/2025 at 2:37 AM, by Person 21, from the on-call triage agency, Entity 13, indicated Patient #8 had fallen and had no visible injuries. RN 3 was notified. An RN visit note was completed by RN 3 on 09/21/2025 at 8:34 AM for a follow-up visit for Patient #8's fall. The clinical record failed to evidence Patient #3 was seen in a timely manner after the report of a fall with or without injury. During an interview with the Complainant on 11/12/2025 at 2:45 PM, they indicated patients' encountering changes in condition and falls, the clinicians were not going out to see the patients within 24 hours. They explained how the as needed RN 4 will inform the complainant the visit was taken care of, but will look and find no visits for the day the visit was needed. They explained Patient #8's Assisted Living Facility, Entity 2, had called the complainant and informed them the patient had fallen and sustained an injury on a Monday at 2:00 AM, and a clinician had not gone out to assess the patient. RN 4 will put in the notes, the patient had declined the services, but the patients were not being called or sending any clinicians out to assess the patients. The Complainant will message the Executive Director (Admin 1) and RN 4 through electronic mail informing them of injuries to patients, and they will not respond back to the Complainant informing them of the patient being seen by a clinician. During an interview with RN 4 on 11/14/2025 at 3:09 PM, they explained they helped cover visits when needed and will help with on-call. They indicated the agency's on-call process was the call would go through the triage line, they would notify the nurse on-call if appropriate and relay the information from the caller. It all was dependent on the situation, if there was a fall with no injuries or no symptoms, they would follow-up with the patient within 24 hours or by the next day. A fall with injury included the normal procedure of going out to the patient immediately, and would only wait if the patient, family/caregiver, or facility declined them going out at the time. They explained, if the patient was resting after the injury, the facility or family/caregiver would tell the agency not to come see the patient. They had not heard of any issues with the patients not receiving their MSW or Aide visits. RN 4 said they were unable to remember why they had not gone out to see Patient #10 after their fall on 09/01/2025. After a fall, they were to complete an occurrence report even if it was an unwitnessed fall. 6. A review of the inactive clinical record for Patient #10 evidenced a coordination note dated 09/01/2025 at 10:20 PM by Person 24, from Entity 13. The note indicated the patient had fallen and had a small red bump on the right side of their head. The note revealed RN 4 was notified of the fall and injury. The inactive clinical record for Patient #10 evidenced a RN visit note dated 09/02/2025 at 10:52 AM by RN 1. The clinical record failed to evidence Patient #10 was seen in a timely manner after the report of a fall with injury. During an interview with RN 1 on 11/14/2025 at 3:26 PM, they explained the on-call process. The caller would call the on-call line and would be in contact with someone from the triage line. If a fall or change in condition is reported, they will go out to assess the patient as soon as possible if there is an injury. A fall with no injury would result in RN 1 asking the caller if they want the RN to make a visit, most of the time they decline, and they will do a follow-up visit for the fall the start of the next day. They will complete a client occurrence for any falls, will include what happened, how it was addressed, and determine what interventions needed to be changed.  7. During an interview with the Physician Designee (Other Staff 3) on 11/12/2025 at 2:03 PM, they indicated they were the acting Medical Director of the agency, while the Medical Director was not working at the agency. They explained how the Interdisciplinary group discussed any issues with the patients and any needs needing to be addressed. Other Staff 3 declared they were updated frequently on falls and infections. For falls, the clinicians were to assess the situation and determine why the patient fell and reevaluate to determine if any changes to care were needed. They indicated the patients had access to care 24 hours a day, seven days a week. If there is an issue or concern after hours, someone was available to address any issues after hours. 8. During an interview with Admin 1 and the Vice President of Quality (Admin 7) on 11/14/2025 at 3:45 PM, Admin 1 explained the on-call service included a triage nurse answering service, to determine what the needs were and whether a clinician visit was needed. If there was a fall with injury or a symptom needed to be managed, they should go to assess the patient immediately. At times, the facility will ask the clinician not to come because the patient was resting, they are to note the facility asking the clinician not to make a visit. If there is a fall with no injury, the clinician has 24 hours to go and assess the patient. An occurrence report will be filed when a fall occurs.

Observed in Record Review. In 1 of 9 active patient records reviewed, During RR# 10's patient record review it was noted the organization had not ensured the it provided the Notice of Medicare Non-Coverage (NOMNC) two days prior to discharge due to no longer being terminally ill or ineligible for hospice. For example: review of RR# 10's patient record revealed a NOMNC signed one day prior to RR# 10's discharge. Further review of the NOMNC revealed a hand written note that discharge planning was discussed seven days prior to discharge. This was reviewed, discussed, and validated with the Administrator/Branch Director.

Observed in Record Review. In 1 of 6 active patient records reviewed with MSW, During RR# 4's patient record review it was noted the organization had not ensured the Medical Social Worker (MSW) completed the initial assessment within five days after the election of hospice. For example: review of RR# 4's patient record revealed documentation that the MSW was unable to reach RR# 4 or RR# 4's patient representative dated six days after the election of benefit. Further review of RR# 4's patient record revealed an IDG/update to plan of care dated 12 days after the election of benefit with MSW documentation regarding not being able to reach RR# 4 or RR# 4's patient representative. In addition, the MSW documented the same day as the IDG/update to plan of care indicating RR# 4 had passed away. Further review of RR# 4's patient record revealed additional documentation by the MSW, dated 13 days after the election of benefit, that RR# 4 had passed prior to being able to complete the evaluation. However, RR# 4 was alive at the time the surveyor reviewed the record. This was reviewed, discussed, and validated by the Administrator/Branch Director.

Observed in Record Review. In 8 of 8 active patient records reviewed on service for five days, During HV# 1, HV# 2, RR# 1, RR# 2, RR# 3, RR# 4, RR# 5, and RR# 6’s patient records review it was noted the organization had not ensured the plan of care included measurable goals with time frames to meet the goals. For example: Review of HV# 2's plan of care and subsequent recertification plan of care revealed a chaplain frequency of two visits a month and the goal of patient/caregiver will feel relief from spiritual concerns with no time frame or how to measure relief of spiritual concerns; and the goal Funeral/final arrangement acknowledged and completed per patient/family's wishes with no time frame. Review of RR# 1's plan of care revealed a chaplain frequency of two visits a month and the goal patient/caregiver will feel relief from spiritual concerns with no time frame or how to measure relief of spiritual concerns. Further review of RR# 1's plan of care revealed a Medical Social Worker (MSW) frequency of one visit a month and the goal Problems concerning patient's personal affairs will be resolved with no time frame or how to measure concerns. Review of RR# 2's plan of care revealed a MSW frequency of one visit a month and the goals patient/caregiver will experience an increase sense of closure and peacefulness of life and Caregiver will experience a sense of accomplishment to having supported the dying person with no time frames or how to measure an increase sense of closure or sense of accomplishment. Further review of RR# 2's plan of care revealed a chaplain frequency of two visits a month and the goals were verbatim as the MSW's goals. Review of RR# 6’s plan of care revealed a MSW frequency of two visits a month and the goal RR# 6 and family member “will have decreased fear/anxiety regarding death and dying process” with no time frames or how to measure decreased fear/anxiety. Further review of RR# 6’s plan of care revealed a chaplain frequency of two visits a month and the goal “patient/caregiver will feel relief from spiritual concerns” with no time frame or how to measure spiritual relief concerns. Review of HV# 1's plan of care and subsequent recertification plans of care revealed a chaplain frequency of two visits a month and the goal of patient/caregiver will feel relief from spiritual concerns with no time frame or how to measure relief of spiritual concerns. Review of RR# 3’s plan of care revealed a chaplain frequency of four visits a month and the goal “patient/caregiver will feel relief from spiritual concerns” with no time frame or how to measure spiritual relief concerns. Review of RR# 4’s plan of care revealed a chaplain frequency of two visits a month and the goal “patient/caregiver will feel relief from spiritual concerns” with no time frame or how to measure spiritual relief concerns. Review of RR# 5’s plan of care revealed a chaplain frequency for two visits a month and the goal “patient/caregiver will feel relief from spiritual concerns” with no time frame or how to measure spiritual relief concerns. This was reviewed, discussed, and validated with the Administrator/Branch Director.

Observed in Record Review. In 1 of 8 active patient records reviewed on service for five days, During RR# 2 patient record review it was noted the organization had not ensured the plan of care included interventions to manage symptoms. For example: review of RR# 2's registered nurse start of care comprehensive assessment revealed RR# 2 with a history of aspiration and on a puree diet. Review of the plan of care revealed no documentation of aspiration precautions. This was reviewed, discussed, and validated with the Administrator/Branch Director.

Observed in Record Review. In 7 of 8 active patient records reviewed on service for five days, During HV# 1, HV# 2, RR# 1, and RR# 2, RR# 3, RR# 4, and RR# 5's patient records reviewed it was noted the organization had not ensured the necessary medical equipment was on the plan of care. For example: during HV# 1's home observation HV# 1 was observed in a hospital bed, with a bolster mattress, low air loss mattress, and a Broda chair in the room. Review of the plan of care revealed no documentation of the medical equipment. During HV# 2's home observation it was noted HV# 2 had an oxygen concentrator, shower chair, and a wheelchair. Review of HV# 2's plan of care revealed no documentation of the medical equipment. Review of RR# 1's registered nurse (RN) start of care comprehensive assessment revealed RR# 1 had a walker and used a walker and wheelchair. Review of RR# 1's plan of care revealed no documentation of the medical equipment. Review of RR# 2's RN start of care comprehensive assessment revealed RR# 2 had a hospital bed and a low air loss mattress and needed an oxygen concentrator. Review of the plan of care revealed no documentation of the medical equipment. Review of RR# 5's RN start of care comprehensive assessment revealed RR# 5 used a Geri-chair and hospital bed. Review of the plan of care revealed no documentation of medical equipment. Review of RR# 3's start of care comprehensive assessment revealed RR# 3 used a Hoyer lift for transfers and had a hospital bed and wheelchair. Review of RR# 3's plan of care revealed no documentation of medical equipment. Review of RR# 4's start of care comprehensive assessment revealed RR# 4 had a walker and wheelchair. Review of RR# 4's plan of care revealed no medical equipment. This was reviewed, discussed, and validated with the Administrator/Branch Director

Observed in Patient Home. In 2 of 3 home visits conducted, During HV# 1 and HV# 3's home observations it was noted the organization had not ensured staff followed the organization's Hand Hygiene policy-IC15, that included performing hand hygiene after removing gloves. For example: during HV# 1's home observation the Licensed Practical Nurse (LPN) was observed cleaning the vital sign equipment and then removed gloves and put them in the trash and put on new gloves without performing hand hygiene. During HV# 3's home observation the Registered Nurse (RN) was observed with gloves on and applied cream then removed gloves and had the patient squeeze the RN's fingers without performing hand hygiene after removing the gloves. This was discussed with the Administrator/Branch Director and validated.

Observed in Record Review. In 4 of 9 active patient records reviewed with home health aide, During HV# 1, RR# 3, RR# 4, and RR# 6’s patient records review it was noted the organization had not ensured the registered nurse responsible for hospice aide supervision prepared complete written patient instructions for the aide. For example: review of HV# 1's patient record revealed HV# 1 had a new wound to the coccyx with a foam dressing. Review of the aide care plan revealed no documentation HV# 1 had a wound dressing or what to do if the dressing fell off or got wet during the bed bath. Further review of HV# 1's patient record revealed the home health aide provided a bed bath during three visits when the wound dressing was present. Review of RR# 3’s patient record revealed RR# 3 had a wound with a foam dressing to the left heel. Review of the aide care plan revealed no documentation RR# 3 had a wound dressing or what to do if the dressing fell off or got wet during the bed bath. Review of RR# 4’s patient record revealed RR# 4 had a wound with a foam dressing to the left forearm. Review of RR# 4’s aide care plan revealed no documentation regarding a wound dressing or what to do if the dressing fell off or got wet during the shower. Review of RR# 6’s patient record revealed RR# 6 required a Hoyer lift with the assist of two to transfer. However, review of the aide care plan revealed no documentation of a transfer with a Hoyer lift. This was reviewed, discussed, and validated with the Administrator/Branch Director.

Observed in Record Review. In 1 of 7 active patient records reviewed on service greater than 14 days with a home health aide, During HV# 1's patient record review it was noted the organization had not ensured the home health aide was supervised by the registered nurse (RN) no less frequently than every 14 days. For example: review of HV# 1's patient record revealed the last RN supervisory visit completed was approximately 49 days prior to the surveyor review of the record. This was reviewed, discussed, and validated with the Administrator/Branch Director.

Observed in Patient Home. In 1 of 1 home visits conducted with medication reconciliation, During HV# 1's home observation it was noted the organization had not ensured the patient record reflected the patients care, treatment, or services. For example: during HV# 1's home observation the Licensed Practical Nurse (LPN) was observed completing a medication reconciliation. During the medication reconciliation it was noted the Skilled Nursing Facility (SNF) medication administration record (MAR) revealed no documentation of the scheduled 5mg Hydrocodone/325mg Tylenol every six hours that was initiated on HV# 1's medication profile approximately one year earlier. In addition, the SNF MAR revealed polyethylene glycol 17 grams by mouth every morning for constipation; Mylanta Suspension 15ml as needed for mild indigestion up to four doses daily; Mylanta Suspension 30 ml as needed for moderate indigestion up to four doses a day; and ferrous sulfate 325mg daily that were initiated on the SNF MAR approximately 18 months earlier. However, these medications were missing from HV# 1's medication profile. This was reviewed and discussed with the LPN during the home observation and validated and discussed and validated with the Administrator/Branch Director.