Hospice Family Care

“Based on review of medical records (MR), agency policy and procedure, and interview it was determined the agency failed to ensure an Initial Bereavement Risk Assessment was completed for each patient and family. This affected eight of 26 MRs reviewed, including Home Visit (HV) # 5, MR # 5, MR # 6 MR # 8, MR # 11, MR # 19, HV # 1, HV # 6, and had the potential to negatively affect all patients and families served by the hospice agency.Findings include:Agency Policy: Initial Bereavement AssessmentPolicy Number: 9012Date Revised: 10/31/21Purpose:To provide guidelines for the assessment and reassessment of the bereavement needs of families or caregivers.Policy:...Information obtained from the initial bereavement assessment shall be incorporated into the plan of care and in the bereavement plan of care.Procedure:On admission, the hospice social worker or spiritual counselor shall complete a Bereavement Risk Assessment. Review of the initial assessments completed by the social worker and the chaplain revealed no documentation of an initial bereavement risk assessments for HV # 5, MR # 5, MR # 6 MR # 8, MR # 11, MR # 19, HV # 1, HV # 6, per the agency’s policy.An interview was conducted on 10/9/25 at 5:30 PM with Employee Identifier # 1, Director of Operations, who confirmed there was no documentation the initial bereavement risk assessment was obtained and incorporated into the bereavement plan of care for patients and families per the agency’s policy.”

“Based on review of medical records (MR), agency policy and procedure, and staff interviews, it was determined the agency failed to ensure staff obtained a return demonstration from the patient/caregiver (pt/cg) for wound care and blood glucose monitoring, per the physician’s order.This affected MR # 16 in one of one MRs reviewed with orders for pt/cg education and return demonstration for wound care and obtaining the blood glucose level.Findings include: Agency Policy: Patient Education ProcessPolicy Number:9201Date Revised: 10/31/21Policy:The assessed needs of pt, family, cg will determine the scope of teaching and the medical plan of care.Procedure:...Unless specifically ordered by a physician, the pt, family, or cg shall receive verbal, and when appropriate written instructions, when indicated in:...Prescribed treatments, ...Safe and effective use of equipment and supplies......Documentation of pt, family, cg education shall consist of:Describing patient teaching...describing patient’s response to teaching...The hospice shall assess the pt, family, cg’s knowledge, skills, and behaviors during the home visit....provide re-education as needed. 1. MR # 16 was admitted to the agency on 6/26/25 with a primary diagnosis of Sarcopenia.Review of the Physician’s Orders/Plan of Care dated 6/26/25 to 9/23/25 revealed the following orders:Skilled Nurse (SN) to teach pathophysiology, care, and treatment of stage two sacral pressure ulcer dated 6/26/25. Wound care to be provided to stage two sacral pressure ulcer as follows: cleanse site with wound cleanser, gently pat dry with gauze. Cover wound with adhesive bordered foam dressing. Dressing to be changed every seven days or as needed if soiled/dislodged. SN to perform wound care during visits, family to provide at all other times after adequate education and return demonstration.SN order dated 6/26/25-Fingerstick blood sugar (FSBS) checks as needed for signs/symptoms of hyperglycemia or hypoglycemia. To be performed by SN or pt/cg after adequate return demonstration.Review of the SN Initial Visit Note dated 6/26/25 and SN Routine Visit Note dated 7/2/25 revealed no documentation of a return demonstration from the pt/cg for wound care or FSBS monitoring.An interview was conducted on 10/9/25 at 4:36 PM with EI # 1, Director of Operations, who confirmed staff failed to ensure a return demonstration was obtained for wound care and blood glucose monitoring, per the physician’s order.”

“Based on review of medical records (MR) and staff interviews, it was determined the agency failed to ensure staff provided wound care per the physician’s orders.This affected three of eight MRs reviewed with wound care ordered, including MR # 20, MR # 16, and Home Visit (HV) # 6, and had the potential to negatively affect all patients served by the agency. Findings include: 3. HV # 6 was admitted to hospice services on 7/8/25 with a primary diagnosis of Senile Degeneration of Brain, Not Elsewhere Classified.Review of Supplemental Orders dated 7/29/25 revealed care and treatment orders for a third degree burn to the left lateral ankle as follows:Cleanse site with wound cleanser, gently pat dry with gauze. Apply Hydrofiber Ag (Aguacel Ag) to wound bed to decrease microbial load, assist with debridement, promote healing and assist with excessive draining. Cover with bordered foam dressing. Dressing to be changed every other day or prn (as needed) if soiled/dislodged. SN to perform wound care during visits, family to provide at all other times after adequate education and return demonstration.Review of 14 routine SN visit notes from 7/31/25 to 9/18 25 revealed the SN documented the following:Dressing Changed this Visit: “Yes, per orders, see Care Plan.” There was no documentation of the treatment performed. An interview was conducted on 10/9/25 at 5:00 PM with EI # 1 who confirmed the SN failed to document the wound care provided per hospice policy and procedure. 2. MR # 16 was admitted to the agency on 6/26/25 with a primary diagnosis of Sarcopenia.Review of the Physician’s Orders/Plan of Care from 6/26/25 to 9/23/25 revealed orders for Wound Care to be provided by the Skilled Nurse (SN) to Stage 2 sacral pressure ulcer as follows:Cleanse site with wound cleanser, gently pat dry with gauze. Cover wound with adhesive bordered foam dressing. Dressing to be changed every seven days or as needed if soiled or dislodged. SN to perform wound care during visits, family to provide at all other times after adequate education and return demonstration.Review of the SN Visit Note (VN) dated 6/26/25 revealed the SN failed to document the wound care provided.Review of the SN VN dated 6/27/25 revealed the SN documented the dressing was not changed.An interview was conducted on 10/9/25 at 4:36 PM with EI # 1, who confirmed staff failed to perform wound care per the physician’s order. 1. MR # 20 was admitted to the hospice on 9/24/25 with a primary diagnosis of Sarcopenia.Review of the physician’s wound care orders dated 9/24/25 revealed for the Skilled Nurse (SN) to provide wound care as follows to the Stage II Pressure Ulcer to right hip, Skin Tear to right shin, Trauma wound to right leg, Skin Tear to right lower leg:Remove old dressing. Cleanse site with soap and water, pat dry with gauze, apply bordered gauze, or adhesive dressing. Dressing to be changed every five days and when soiled or dislodged.Review of the On call/ Unscheduled visit notes dated 9/29/25 and 9/30/25 revealed no documentation the SN provided wound care every five days per the physician’s orders.An interview was conducted on 10/9/25 at 5:31 PM with Employee Identifier (EI) # 1, Director of Operations, who confirmed the SN failed to provide wound care per the physician’s orders.”

“Based on review of medical records (MR), hospice policy, and staff interviews it was determined the agency failed to ensure the hospice aide (HA) notified the Registered Nurse (RN) with changes in the patient’s condition or need for changes in the Plan of Care (POC). This deficiency was identified on the prior recertification survey dated 2/2/23.This affected three of 21 MRs reviewed with aide services ordered, including MR # 8, MR # 12, and MR # 14, and had the potential to negatively affect all patients served by the agency.Findings include:Hospice Policy: Hospice Aide ServicesPolicy Number: 9107Revised: 10/31/21Purpose: To specify the role of the Hospice Aide. Policy: Hospice Aide services shall include personal care and non-skilled services provided by the trained Hospice Aides. …The core skills include: Monitoring pain and symptom management and reporting to the RN…Routine care shall include Hospice Aide services for personal care as needed. Hospice Aide shall provide services such as giving a bath… 3. MR # 14 was admitted to the in patient hospice on 10/3/25 with primary diagnosis of Second Malignant Neoplasm of Unspecified site. Review of the Hospice POC with start of care date 10/3/25 revealed orders for Aide frequency visits for one visit times one week.Review of the Change Aide Care Plan Order dated 10/7/25 revealed orders for Aide to perform a bed bath every other day and prn (as needed).Review of six Aide Regular Visits dated 10/3/25 to 10/8/25 revealed no bed bath was performed and no documentation the RN was notified. An interview was conducted on 10/9/25 at 4:40 PM with EI # 1, who confirmed the HA failed to notify the RN the interventions were not completed which required a change to the patient’s POC. 1. MR # 8 was admitted to the agency on 9/5/25 with a primary diagnosis of Cerebrovascular Disease.Review of the Hospice POC for Certification Period 8/31/25 to 10/29/25 revealed orders for HA visits once weekly for one week, then twice weekly for four weeks.Review of the Team Care Plans dated 9/3/25, 9/16/25, and 9/30/25 revealed HA Interventions as follows:Incontinence/diapers, Complete bed bath, hair care, notify RN if no bowel movement (BM) in 3 days or hasn’t voided in 12 hours, oral hygiene/mouth swab every visit and shave patient and change bedding per caregiver request.Review of the Visit Record (VR) dated 9/3/25 revealed the HA documented the complete bed bath, shaving, bedding change, and oral hygiene were not completed.Review of the VR dated 9/8/25 revealed the HA documented the complete bed bath, shaving, assist with dressing, and bedding change were not completed.Review of the VR dated 9/10/25 revealed the HA documented the complete bed bath, shaving, and bedding change were not completed.Review of the VR dated 9/15/25 revealed the HA documented the complete bed bath, notify RN if no BM in 3 days or hasn’t voided in 12 hours, and bedding change were not completed.Review of the VR dated 9/17/25 revealed the HA documented the complete bed bath, shaving, and bedding change were not completed.Review of the VR dated 9/24/25 revealed the HA documented the incontinence/diapers and shaving were not complete.Review of the VR dated 9/29/25 revealed the HA documented the complete bed bath, shaving, assist with dressing, and bedding change were not completed.There was no documentation the HA notified the RN the interventions were not completed, which required a change to the POC.An interview was conducted on 10/9/25 at 4:34 PM with Employee Identifier (EI) # 1, Director of Operations, who confirmed the HA failed to notify the RN the interventions were not completed, which required a change in the patient’s POC.2. MR # 12 was admitted to the agency on 9/7/25 with a primary diagnosis of Malignant Neoplasm of Unspecified Ovary.Review of the Hospice POC for Certification Period 9/7/25 to 12/5/25 revealed orders for HA visits once weekly for one week, then twice weekly for nine weeks.Review of the Team Care Plans dated 9/16/25, 9/30/25, and 10/7/25 revealed the following HA Interventions were added to the Care Plan on 9/2/25:Shower, Assist with dressing, Notify RN if no BM for 3 days or hasn’t voided in 12 hours, Incontinent/Diapers, Change bedding,Review of the Aide Care Plan dated 10/1/25 to Current revealed HA tasks as follows:Apply deodorant, Apply lotion to all extremities, Assist with dressing, Brush teeth with toothbrush and toothpaste, change linens, clean finger nails, Comb or brush hair, Document last BM, Perineal Care, Shower, all to be done every visit, and Wash hair weekly and as needed at patient or caregiver request.Review of the VRs dated 9/7/25, 9/11/25, and 9/16/25 revealed the HA documented the bedding change was not completed.Review of the VRs dated 9/18/25, 9/23/25, 9/25/25, and 9/30/25 revealed the HA documented the shower and bedding change were not completed.Review of the Aide Regular Visit on 10/2/25 revealed the HA documented the patient refused the bedding change.There was no documentation the HA notified the RN of interventions that were not completed, which required a change in the POC.An interview was conducted on 10/9/25 at 4:35 PM with EI # 1, who confirmed the HA failed to notify the RN of interventions that were not completed, which required a change in the patient’s POC.”

“Based on review of medical records (MR), hospice policies and procedures, and staff interview, it was determined the hospice nurse failed to document the disposal of all medications per the hospice policies and procedures. This affected one of three death records, including MR # 17, and had the potential to negatively impact all patients.Findings include:Hospice Policy: Death at HomePolicy Number: 9118Revised: 10/31/21Purpose:To establish the process to follow when a patient dies at home while receiving care from hospice...Procedure:…The hospice skilled nurse (SN) shall instruct the family how to dispose of all medications, including controlled substances, per local and state regulations. The SN documents the medications disposed in the clinical record.Hospice Policy: Controlled Drug Disposal In The HomePolicy Number: 7012Revised: 10/31/21Policy:… The staff member that oversees the disposal of the controlled drugs will document the following in the clinical record:1. Name of drug2. Amount disposed3. Method of disposal4. Name of the person destroying the medication(s)5. Name of the staff witness6. … Date and time MR # 17 was admitted to the hospice on 9/1/24 with primary diagnosis of Malignant Neoplasm of Vulva Unspecified.Review of the On-call/Unscheduled (Death) visit dated 10/16/24 revealed no documentation of the method of disposal, name of the person destroying the medication(s), name of witness, and date and time the controlled drugs were disposed. An interview was conducted on 10/9/25 at 4:43 PM with Employee Identifier # 1, Director of Operations, who confirmed the nurse failed to document the disposal of medications per the agency policy.”