Alabama Hospice Care of Mobile

“Based on review Medical Records (MR), agency policy and procedure, and staff interviews it was determined the agency failed to include all interventions and goals on the patient’s Plan of Care (POC) which were necessary for the palliation and management of the terminal illness and related conditions. This deficient practice did affect MR # 15, MR # 8, MR # 9, three of fifteen MRs reviewed, and had the potential to affect all patients served by the agency. Findings include: Agency Policy: POC Policy Number: 3.003 Reviewed Date: 11/1/21 Purpose: To ensure each patient has an individualized POC that includes the specific needs, goals, and desires of the patient. Policy: A written POC is developed for each patient/family by the attending physician...and the Interdisciplinary Group (IDG). Procedure: ...2. The POC must include all services necessary for the palliation and management of the terminal illness and related conditions, including the following: ...c. Measurable outcomes anticipated from implementing and coordinating the POC... 3. MR # 9 was admitted to the agency on 7/10/24 with diagnoses including Malignant Neoplasm of Body of Pancreas and Hypertensive Heart Disease without Heart Failure. Review of the POC dated 7/10/24 revealed the patient had a life port (implanted devices giving access to vein) to the right upper chest. Review of the Hospice Certification and POC dated 7/10/24 to 10/7/24 revealed no documentation of an intervention and goal for the life port. An interview was conducted with EI # 1, who confirmed there was no documentation of an intervention and goal for the life port. 1. MR # 15 was admitted to the agency on 6/24/24 with diagnoses including Metabolic Encephalopathy, Unspecified and Dementia, Unspecified Severity, with Other Behavioral Disturbances. Review of the POC dated 6/24/24 revealed no interventions or goals for the Home Hospice Aide (HHA). An interview was conducted on 8/1/24 at 1:52 PM with Employee Identifier (EI) # 1, Executive Director, who confirmed the agency failed to document an intervention or goal on the POC for the HHA. 2. MR # 8 was admitted to the agency on 6/25/24 with diagnoses including Hemiplegia Following Cerebral Infarction Affecting Unspecified Side and Encephalopathy Unspecified. Review of the POC dated 6/25/24 revealed no specific intervention for the amount of flush to be administered via peg tube before and after medication administration. An interview was conducted on 8/1/24 at 2:05 PM with EI # 1, who confirmed the agency failed to document a specific order for the peg tube flush to be administered before and after medication administration on the POC.”

“Based on review of Medical Records (MR), agency policy and procedure, and staff interviews, it was determined the agency failed to ensure: 1. Wounds were assessed and documented per agency policy. 2. IDG (Interdisciplinary Group) was notified of the presence of a new wound in order to determine the treatment necessary to the wound. 3. Wound care was provided per the physician order. This deficient practice did affect MR # 1 and MR # 6, two of four MRs reviewed with wounds and had the potential to affect all patients with wounds requiring treatment by the agency. Findings include: Agency Policy: Wound Care Policy Policy Number: 3.029 Effective Date: 3/1/21 Policy: Upon initial visit and subsequently as applicable, all wounds will be assessed with appropriate documentation within the medical record. Procedure: 1.Explain the procedure to the patient/representative. 2. Perform wound care according to physician orders specified in the patient’s plan of care. 3. Document the following in the medical record: a. Treatment and condition of the wound (each visit). b. Appearance of the wound bed (black, yellow, red). c. Wound measurements (weekly) including the length, depth, and width of the wound in centimeters. d. Depth and location of undermining in centimeters. e. Surrounding tissue. f. Color, odor, and estimated amount of drainage. g. Stage the wound weekly. h. Patient/representative/caregiver instructions on wound care and compliance with wound management: including ability to change dressings. Education and instruction should include return demonstration and documentation of patient/representative/caregiver level of understanding. i. Other pertinent findings: i. Wound ulcer classification. ii. Wound care and dressing change procedure. iii. Client symptoms and response to the procedure. 4. Redress the wound using appropriate wound care dressing procedure following physician orders. The dressing will be labeled with the date and time of application and the clinician’s initials 1. MR # 1 was admitted to the agency on 7/10/24 with diagnoses including Atherosclerosis Heart Disease of Native Coronary Artery without Angina Pectoris and Hypertensive Heart Disease without Heart Failure. Review of the Plan of Care (POC) dated 7/10/24 revealed no wounds, wound care orders and no wound measurements of left heel, Stage II Pressure Ulcer, and right heel, Stage I Pressure Ulcer. Review of the Skilled Nurse (SN) Visit Notes, dated 7/14/24 revealed the following wounds, left heel, Stage II Pressure Ulcer, and right heel, Stage I Pressure Ulcer, there were no measurements, assessments or wound care documented. Review of the SN Visit Note dated 7/21/24 revealed the following wound, right elbow, skin tear. There were no measurements documented. An interview was conducted on 8/1/24 at 3:23 PM with Employee Identifier (EI) # 1, Executive Director, who confirmed the agency failed to ensure wounds were assessed and documented per the agency policy and procedure. 2. MR # 6 was admitted to the Hospice Agency on 6/26/24 with diagnoses including Hypertensive Heart and Chronic Kidney Disease with Heart Failure and Stage 1-4 Unspecified Chronic Kidney Disease and Chronic Diastolic Congestive Heart Failure. Review of three SN Visit Notes, dated week of 6/30/24, 7/7/24, and 7/21/24 revealed no documentation of wound measurements of Stage I Pressure Ulcer to Coccyx. An interview was conducted on 8/1/24 at 3:19 PM with EI # 1 who confirmed the agency failed to perform weekly wound measurements per the agency policy and procedure.”

“Based on review of the Medical Record (MR) and staff interviews the agency failed to ensure a dietician consult was performed per the physician order. This deficient practice did affect MR # 11, one of one MRs reviewed with a dietician consult ordered and had the potential to affect all patients who require a dietician consult. MR # 11 was admitted to the agency on 5/22/24 with diagnoses including Senile Degeneration of Brain, Not elsewhere Classified and Anorexia. Review of the MR revealed no documentation a dietary consult had been performed. An interview was conducted on 8/1/24 at 3:01 PM with Employee Identifier # 1, Executive Director, who confirmed there was no documentation of a dietician consult.”