Every finding on record at True Care Hospicellc

Based on record review and interview, hospice nurse (RN A) failed to ensure the nursing needs for 1 of 3 discharged patients (#1) were met when she failed to update patient #1's comprehensive assessment to include that a right heel pressure ulcer had developed, and deteriorated to require treatment, and failed to complete any Skilled Nurse visit notes from 5/12/24 – 5/21/24, and failed notify the physician of the wound and obtain and implement wound care orders. These failures resulted in the pressure ulcer on Patient #1s right foot deteriorating and the patient being transferred to the hospital for treatment of the pressure ulcer. This failure placed Patient #1 at risk of poor health outcomes including a decline in health status. --- Findings Include: Review of complaint intake # 507480 revealed the complainant alleged that the Med Tech (ALF staff) was assisting Patient #1 up for breakfast and he noticed that Patient #1 had a change in condition of the right heel. The Med Tech reported Patient #1s wound dressing appeared to have extensive discharge with a strong odor. The complainant stated they (the ALF) informed the Hospice of their observations and RN A arrived on 05/10/24 at 10:00am to assess Patient #1s change in condition of the right heel. The ALF staff reported RN A cleaned the wound and no further orders were received during RN As SN visit. Review of RN As nursing visit note dated 05/07/24 revealed documentation of vital signs but no documentation that the Patient# 1s feet were assessed. Further review revealed the clinical record did not contain a nursing visit note for the 05/10/24 Skilled Nursing visit, no documentation that the RN notified the physician of the wound and the comprehensive assessment was not updated to include the heel wound or the wound care procedures used. A phone interview with RN A was attempted on 06/04/24 at 3:12 pm. A voicemail was left to return call. No return call was received. Review of Patient #1s IDG Plan of Care dated 05/07/24 read in part that Patient # 1 had bilateral 2 + pitting edema to lower legs. Additional Comprehensive Assessment Comments: SN to continue to monitor for patient decline. Record review revealed no skilled nursing visit assessments of Patient # 1s feet. Record review of the ECR revealed no documented evidence of collaboration with the interdisciplinary team regarding Patient #1's change in status (wound development) and no documentation that RN A collaborated with facility staff. Record review of the Hospice complaint investigation documentation titled, ";Patient Complaint Form" provided by Adm/DON on 06/03/24 included the following information that RN A did not document Patient #1s pressure ulcer to right heel, failed to document any wound assessments, wound care orders and/ or any clinical notes. The form also read in part that due to [RN As] failure to provide a minimum standard of care this patient was subsequently sent to the hospital due to the wound and found to be septic [septic shock is a severe complication of sepsis that can include very low blood pressure, an altered mental state, and organ dysfunction]. The Patient Complaint Form also included that RN A resigned when she was given the option as she was going to be termed and failed to document any completed visits that were outstanding. Her resignation was received on 05/21/24 at approximately 12 pm and was effective immediately. She was instructed to complete her documentation on her completed visits but failed to document any visits. Further review of the ";Patient Complaint Form" read in part... ";05/30/24 self-report completed by Trinity Hospice. [RN A] reported to the Texas State board of nursing due to significant safety concerns, possible neglect, and failure to document visits." Interview on 06/04/24 at 11:32 am with the ALF executive director, stated that the Med Tech (ALF staff) was assisting Patient # 1 and noticed that she had a change in condition of the right heel. The Med Tech reported Patient # 1s wound dressing appeared to have extensive discharge with a strong odor. The ALF executive director stated they (the ALF) informed the Hospice of their observations and RN A arrived on 05/10/24 at 10:00am to assess Patient # 1s change in condition of the right heel. The ALF staff reported RN A cleaned the wound and no further orders were received during the SN visit. The ALF executive director stated RN A did not leave any visit notes or MD orders for patient Patient # 1 during any visits. The ALF executive director stated RN A visited Patient # 1 once per week and as needed for skilled nurse visits while patient #1 lived at the ALF. During an interview and concurrent record review with the Adm/DON on 06/05/24 at 5:05 p.m., the above findings on Patient # 1 were presented. The Admin/DON stated, she had been hired last week. When asked what the responsibilities of the Adm / DON were, she replied the Adm/DON was responsible for overseeing field staff to ensure they were following agency policies regarding documentation, assessments, communicating with IDG members and updating the POCs in a timely manner. Review of the policy titled, "Implementing care and treatment" dated 04/04/23 read in part:"....VI. When the provision of care/treatment cannot be implemented as established on the care planning document(s), the patient's physician will be notified. The appropriate documentation will be completed and submitted by discipline or Clinical Care Manager......" Review of the policy titled; "Plan of Care Process" dated 01/26/24 read in part:".... VII. The Hospice IDG/IDT (in collaboration with the individuals attending physician, if any) will review, revise, and document the individualized plan as frequently as the patient's condition requires, but no less frequently than every 15 calendar days. A. A revised POC will include information from the patient's updated comprehensive assessment and will note the patient's progress toward outcomes and goals specified in the POC. Documentation will support that the patient receives the appropriate level of care and services as indicated by the disciplinary assessments......."