Every finding on record at Willis Knighton Health System

Based on record reviews and interviews the provider failed to ensure an initial bereavement assessment was completed for 1 (Patient #8) out of 11 (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11) active patients records reviewed. --- Review of providers Core Services/Scope of Services policy (revision date 06/2024) revealed in part: Bereavement Counseling: Hospice bereavement services begin with the initial assessment and continue through the bereavement period to help the patient/caregiver cope with death related grief and loss issues. Bereavement services are based on an assessment initiated at the time of admission. The assessment includes: patient/caregiver grief and loss issues, the survivor(s) needs, social, religious, and cultural variables, risk factors, and potential for pathological grief reactions Review of Patient #8s record revealed start of care date of 08/10/2023 with a terminal diagnosis of malignant neoplasm of bladder. During an interview on 10/28/2024 at 2:10 p.m., S1 RN (Registered Nurse) Regulatory Coordinator and Education reported initial bereavement risk assessments should be completed by the nurse. Review of Patient #8s record with S1 RN Regulatory Coordinator and Education and S2 RN Manager/Patient Care Coordinator failed to reveal a bereavement risk assessment was completed on admit. During an interview on 10/29/2024 at 3:35 p.m., S1 RN Regulatory Coordinator and Education and S2 RN Manager/Patient Care Coordinator reviewed Patient #8s record and confirmed a bereavement risk assessment was not completed on admit.

Based on record review and interview, the agency failed to ensure it maintained a system of communication and coordination of care for 5 (#1, #5, #6 #7 and #9) of 13 sampled patients reviewed. The agency failed to notify patients physician of missed visits. --- Findings: Review of the agencys Clinical Records Policy (Reviewed 06/2022; Revised 04/2024) revealed in part: 6. Clinical Records a. ...When a scheduled visit is not made, the clinician will document a Missed Visit note and fax to the physician within 24 hours of the occurrence or the next working day, if on weekend or holiday. Patient #1 Review of Patient #1 record revealed a start of care date of 4/11/2024 with a terminal diagnosis of senile degeneration of the brain. Review of Patient #1s plan of care for the benefit period of 07/10/2024 to 10/07/2024 revealed patient #1 was to received hospice aide visits once a week for 12 weeks and chaplain/minister visits once a week for 13 weeks. Review of Patient #1s documented visits revealed patient #1 failed receive a hospice aide visit on 07/24/2024 and 07/31/2024 and a chaplain/minister visit on 08/28/2024. Further review failed to reveal documentation that Patient #1s physician was notified of these missed visits. Patient #5 Review of Patient #5 record revealed Patient #5s start of care date was 7/31/2024 with a terminal diagnoses of chronic systolic (congestive) heart failure. Review of Patient #5s orders for the benefit period 07/31/2024 to 10/28/2024 revealed an initial order for Social Services visit once within 5 days for 5 days. Further review revealed an order dated 08/07/2024 for Aide visits 2 every week for 12 weeks, and an order dated 08/12/2024 for Social Services, Medical Social Worker (MSW) one visit every other week for 10 weeks. Review of Patient #5s record revealed documented missed MSW visits on 08/15/2024 and 08/29/2024 and a missed Aide visit on 08/07/2024. Further review of Patient #5s record failed to reveal documentation that Patient #5s physician was notified of the missed MSW and Aide visits. Patient #6 Review of Patient #6 record revealed a start of care date of 09/13/2024 with a terminal diagnosis of chronic systolic congestive heart failure. Review of Patient #6s plan of care for the benefit period of 09/13/2024 to 12/11/2024 revealed patient #6 was to receive staff nurse visits once a week for 12 weeks. Review of Patient #6s documented visits revealed patient #6 failed receive a staff nurse visit on 10/17/2024. Further review failed to reveal documentation that Patient #6s physician was notified of missed visit. Patient #7 Review of Patient #7s record revealed a start of care date of 08/02/2024 with a terminal diagnoses of hypertensive heart and chronic kidney disease. Review of Patient #7s plan of care for the benefit period of 07/13/2024 to 10/10/2024 revealed Patient #7 was to receive hospice aide visits twice a week for 10 weeks. Review of Patient #7s documented visits revealed Patient #7 failed to receive hospice aide visits on 08/09/2024, 08/20/2024, 09/05/2024, 09/26/2024, 10/01/2024, 10/03/2024, 10/08/2024, and 10/10/2024. Further review failed to reveal documentation that Patient #7s physician was notified of the missed visits. Patient #9 Review of Patient #9 record revealed a start of care date of 9/27/2024 with a terminal diagnosis of senile degeneration of the brain. Review of Patient #9s plan of care for the benefit period of 09/27/2024 to 12/25/2024 revealed Patient #9 was to receive 2 hospice aide visits per week for 12 weeks and 1 every week for one week. Review of Patient #6s documented visits revealed patient #1 failed receive a hospice aide visit on 10/04/2024 and 10/14/2024. Further review failed to reveal documentation that Patient #9s physician was notified of these missed visits. During an interview on 10/29/2024 at 3:15 p.m. S1 Registered Nurse, Regulatory Coordinator/Educator reviewed Patient #1, #5, #6 #7 and #9s visit documentation and confirmed each patients physician should have been notified of the documented missed visits.

Based on record reviews and interview the facility failed to ensure care and services were provided in accordance with the plan of care for 1 (Patient #5) of 13 patient records reviewed. Findings: Review of Patient #5s record revealed Patient #5s start of care date was 07/31/2024 with a terminal diagnoses of chronic systolic (congestive) heart failure. Review of Patient #5s orders for benefit period 07/31/2024 to 10/28/2024 revealed an initial order for Social Services visit 1 within 5 days for 5 days. Further review of Patient #5s orders revealed an order dated 08/12/2024 for Social Services, Medical Social Worker (MSW) one visit every other week for 10 weeks. Review of Patient #5s documented MSW visits revealed a documented MSW visit on 08/01/2024 and two documented missed MSW visits on 08/15/2024 and 08/29/2024 with no further MSW visits/missed visits documented. During an interview on 10/29/2024 at 1:30 p.m. S1 Registered Nurse, Regulatory Coordinator/Educator and S2 Patient Care Coordinator reviewed Patient #5s record and confirmed there was no documentation of MSW visits/missed visits once every other week as ordered every other week for 10 weeks as ordered on 08/12/2024 after 08/29/2024.

Based on record reviews and interview provider failed to ensure bereavement services were made available to surviving family members/caregivers following the death of 2 (Patient #12, Patient #13) of 2 deceased patients records reviewed. Findings: Review of the facilitys Bereavement Counseling Policy dated 10/2024 revealed in part: Policy: ________ bereavement counselor offers bereavement services to caregivers and the hospice staff under the supervision of qualified professionals with experience or education in grief or loss counseling. These services help the family cope with death related grief, loss and adjustment issues....Bereavement services will be available for up to thirteen (13) months following the patients death. This includes phone calls, packet mail outs, letter and card mail outs, as well as offering support in a group or individual setting. Review of Patient #12s record revealed a start of care date of 09/09/2023 with a terminal diagnosis of End-Stage Heart Failure and a death date of 09/11/2023. Further review of Patient #12s record failed to reveal documentation that post death bereavement services were made available to Patient #12s family members/caregivers. Review of Patient #13s record revealed a start of care date of 09/05/2024 with a terminal diagnosis of Alcoholic Cirrhosis of the liver without ascites and a death date of 09/30/2024. Further review of resident #13s record failed to reveal documentation that post death bereavement services were made available to Patient #13s family members/caregivers. During an interview on 10/29/2024 at 3:15 p.m. S1 Registered Regulatory Coordinator/Educator reviewed Patient #12 and Patient #13s records and acknowledged there was not documentation that post death bereavement services were made available to Patient #12 or Patient #13s family members/caregivers.