Every finding on record at Wiregrass Hospice, LLC

Based on medical record review and interview, the agency failed to obtain physician orders for wound care for 1 patient (#7) of 13 patients reviewed. The findings included: Patient #7 was admitted to the agency on 3/8/2024 with diagnoses including Anoxic Brain Damage and Unspecified Convulsions. Medical record review of the Hospice Certification and Plan of Care dated 3/8/2024 to 6/5/2024 revealed skilled nursing (SN) visits at 3 times a week. SN was ordered to measure the wound weekly. SN was to document characteristic, integrity and signs/symptoms of infection of the wound weekly. Continued review revealed wound care was not ordered on admission. Medical record review of the SN visit note dated 3/8/2024 revealed a Pressure Ulcer, Stage 2 on the coccyx (wound #1). The wound was measured and assessed. Wound care was not provided secondary to the caregiver provided the wound care. Continued review revealed a Unstaged Pressure Ulcer on the anterior edge of right foot (wound #2). The area was measured and assessed. Wound care was not provided secondary to the caregiver provided the wound care. Further review revealed wound care orders had not been obtained from the physician. Medical record review of a physician's order dated 3/11/2024 revealed an order for wound care for wound #1 was obtained. Continued review revealed an order for wound #2 had not been obtained from the physician. Medical record review of SN note dated 3/11/2024 revealed the wound care was not provided to wound #1 due to ordered supplies were not delivered to the home. Further review revealed the area was "left open to air". Continued review revealed wound care was not provided to wound #2 due to the patient's caregiver provided the wound care. Further review revealed order for wound care to wound #2 was not obtained from the physician. Medical record review of SN visit note dated 3/13/2024 revealed wound care was provided to wound #1 as ordered by the physician. Continued review revealed wound care was provided to wound #2. Further review revealed no documentation the physician ordered the wound care for wound #2. The wound care provided to the area was "...cleaned with soap and water. Patted dry with gauze. Applied Iodine. Covered with Optifoam (foam wound dressing)." Medical record review of the SN visit note dated 3/14/2024 revealed the caregiver provided wound care to both wounds #1 and #2. Medical record review of the SN visit note dated 3/18/2024 revealed wound #1 was healed. Continued review revealed wound care not provided to wound #2 due to "not ordered this visit." Interview with the Area Director of Clinical Operation on 3/20/2024 at 12:45 PM, in the social worker's office, revealed wound care orders were received on 3/8/2024 for wounds #1 and #2. Continued interview confirmed the plan of care was not updated with the wound care orders on 3/8/2024. Further interview revealed the plan of care was updated with wound care orders for wound #1 on 3/11/2024, but was not updated with wound care orders for wound #2 at the time of the survey.

Upon patient record review, 2 of 19 (Patient #3, #13) did not have evidence that a Registered Nurse ensured continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). Patient #3- On 09/09/23 Triage received a call that the family had a concern that the patient's Foley bag was full. Triage documented the family member was unable to understand instructions given over the phone and the on call nurse would be contacted as the family requested a visit. There is no documentation from the on call nurse regarding the patient's concern. (late entry documentation correction on site) Patient #13-On 08/20/23 Triage received a call that the patient had pain from coughing. The caller was requesting something for the patient's cough that was not sedating. Triage notified the nurse on call for follow up. There is no documentation on record of the follow up (late entry documentation correction on site)

Upon patient record review, 1 of 19 (Patient # 3) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #3- Between 09/14/23 and 09/26/23 the nursing documentation indicates the patient was having issues with constipation. The plan of care does not include goals for constipation. (corrected on site)

Upon patient record review, 2 of 18 (Patient #9, #14) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including specific/accurate orders for all treatments. Patient #9-The 08/14/23 plan of care includes orders to teach the patient suctioning. The orders are not applicable to the patient's plan of care as the patient does not require suction (corrected on site) Patient #14 The record includes orders dated 07/25/23 to place a urinary catheter for difficulty urinating. The order does not address the catheter size, balloon size and ongoing maintenance/changes. (corrected on site)

Upon patient record review, 2 of 19 (Patient #3, #14) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #3-On 09/14/23 the nurse documents performing a disimpaction. The record does not include orders for disimpaction. (late entry orders corrected on site) Patient #14- On 08/07/23 and 08/25/23 the nurse documents performing a disimpaction. The record does not include orders for disimpaction. (late entry orders corrected on site)

Upon patient record review, 1 of 19 (Patient #19) did not have evidence the hospice offers bereavement counseling that includes: • Ensuring that bereavement services reflect the needs of the bereaved. Patient #19-The patient was admitted 05/19/23 and died 05/25/23. The bereaved was to receive a phone call within 2-4 weeks. The record does not document a phone call within 2-4 weeks. The record documents late entries on 07/24/23 noting the bereavement coordinator attempted to contact the bereaved on 01/03/23 and on 07/26/23 the bereavement coordinator attempted to contact the bereaved on 02/03. (The dates are erroneous as the patient was alive and not on service in January and February).

Upon patient record review, 2 of 19 (Patient #3. #6) did not have evidence in the patient record that hospice aide assignments and duties are: • Complete written patient care instructions for a hospice aide with all identified safety measures. Patient #3-The Aide care plan does not include aspiration precautions which is an identified issue documented in the 09/26/23 IDG. (corrected on site) Patient #6- The Aide care plan does not include bleeding precautions and oxygen precautions which are applicable to the care plan as the patient is on Eliquis , Aspirin, and Oxygen. (corrected on site)

Upon patient record review. 2 of 19 (Patient #2, #11) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group and included in the plan of care Patient #2-The Aide was assigned to change the patients linens every Monday and Friday. On Monday 09/11/23 and 09/18/23 the Aide documented linen changes were not needed. The Aide was assigned to perform a shower each visit. On 09/25/23 the Aide documented performing a bed bath. Patient #11-The Aide visit note on 08/10/23 documented all assigned tasks except for recording last BM as "not needed".

Upon patient record review, 1 of 19 (Patient # 16) did not have evidence that the discharge summary includes all required information. Patient #16-The patient revoked the Hospice election to receive aggressive treatment on 05/23/23. The discharge summary does not include a summary of the patient's stay, including treatments, symptoms and pain management.