Columbus Hospice of Alabama

“Based on review of medical records (MR), hospice policy and procedure, and staff interview it was determined the hospice failed to ensure a suicide risk assessment was conducted to assess the patient’s emotional needs related to the terminal illness. This deficient practice did affect 19 of 19 MR’s reviewed, including MR # 1, MR # 2, MR # 3, MR # 4, MR # 5, MR # 6, MR # 7, MR # 8, MR # 9, MR # 10, MR # 11, MR # 12, MR # 13, MR # 14, MR # 15, Home Visit (HV) # 1, HV # 2, HV # 3, and HV # 4 and had the potential to negatively affect all patient served by the hospice. Findings Include: Hospice Policy: Suicidal Precautions Policy Number: 14.60 Revised Date: 1/20/23 Purpose: To provide a continuous integrated process of patient assessment for those patients who may be suicidal. Elements: 1. A suicide risk assessment will be completed on all hospice patients during the initial social worker assessment.... 2. All clinical information will be assessed to determine emotional, mental, or situational factors thought to be associated with suicidal behaviors... Procedure: 1. The hospice social worker will complete a suicide risk assessment... Review of the initial social worker assessment for 19 of 19 MR’s reviewed revealed no documentation a suicide risk assessment had been conducted as directed per policy. Review of MR # 1, MR # 5, MR # 9, and MR # 14 revealed documentation the patient had a history of depression. An interview was conducted on 5/16/24 at 2:13 PM with Employee Identifier # 1, Nurse Director, who confirmed there was no suicide risk assessment conducted as directed in hospice policy.”

“Based on review of Medical Records (MR), hospice policy and procedure, and staff interview it was determined the hospice staff failed to obtain physician orders for wound care and document the specific wound care provided. This deficient practice did affect two of ten MR’s review with a wound, including MR # 1 and MR # 14, and had the potential to affect all patient’s who required wound care. Findings include: Hospice Policy: Physician Orders Policy Number: 27.27 Revised Date; 3/13/23 Purpose: To have a consistent, uniform, and dependable method for obtaining physician orders in accordance with patient’s plan of care. ...Procedure: 1. All physician orders must be complete. Complete physician orders should include the following: ...b. Wound care order - the location of the wound, type of wound cleanser, medication if applicable, type of dressing, and frequency of dressing change. 2. MR # 14 was admitted to the hospice on 2/2/24 with diagnoses including Heart Disease with Heart Failure and Atrial Fibrillation. Review of the nursing notes dated 2/5/24 and 2/12/24 revealed the nurse performed wound care to a wound on the left lower leg. There was no documentation of the specific wound care provided. Review of the Team Care Plan and Physician Orders dated 2/2/24 revealed no physician order for wound care to the left lower leg. An interview was conducted on 5/16/24 at 3:17 PM with EI # 9, Quality Safety Coordinator, who confirmed the nurse failed to obtain a physician’s order for wound care and document the specific wound care provided. 1. MR # 1 was admitted to the hospice on 3/21/24 with diagnoses including Fracture of Ramus of Left Pubis, Sequela and Alzheimer Disease. Review of the nursing note dated 3/21/24 revealed the nurse performed wound care for wounds to the left elbow, right inner elbow, right top of wrist, right lower arm, and right lower leg. There was no documentation of the specific wound care provided. . Review of the nursing note dated 3/28/24 revealed the nurse performed a wound care for wounds to the right lower leg, left forearm, and left upper arm. There was no documentation of the specific wound care provided. Review of the Team Care Plan and Physician Orders dated 3/21/24 to 3/28/24 revealed no physician order for wound care to the left elbow, right inner elbow, right top of wrist, right lower arm, right lower leg, left forearm, and left upper arm. An interview was conducted on 5/16/24 at 3:05 PM with Employee Identifier (EI) # 1, Nurse Director, who confirmed the nurse failed to obtain a physician’s order for wound care and document the specific wound care provided.”

“Based on observation, Centers for Disease Control and Prevention (CDC) Guidelines for Prevention of Catheter Associated Urinary Tract Infections, 2009, and staff interview the hospice failed to ensure staff maintained clean technique when inserting an indwelling urethral catheter. This deficient practice did affect Home Visit (HV) # 4, one of one observations conducted for the insertion of a indwelling urethral catheter. Findings include: CDC Guidelines for Prevention of Catheter Associated Urinary Tract Infections, 2009 Update Date: June 6, 2019 ...II. Proper Techniques for Urinary Catheter Insertion. ...D. In the non-acute care setting, clean (i.e., non-sterile) technique for intermittent catheterization is an acceptable and more practical alternative to sterile technique for patients requiring chronic intermittent catheterization... III. Proper Techniques for Urinary Catheter Maintenance ...1. If breaks in aseptic technique...replace the catheter...using aseptic technique and sterile equipment... 1. HV # 4 was admitted to the hospice on 6/17/23 with a diagnosis of Liver Cirrhosis. Review of the POC dated 4/17/24 revealed a physician’s order to change an indwelling urethral catheter as needed. A home visit was conducted on 5/14/24 at 3: 28 PM with Employee Identifier (EI) # 5, Registered Nurse, to observe the change of a indwelling urethral catheter. EI # 5 inserted the new indwelling urethral catheter two thirds of the length of the catheter into the patients urethra, then fully removed the catheter, and reinserted the same catheter back into the urethra for a second time. An interview was conducted on 5/16/24 at 2:15 PM with EI # 1, Director, who confirmed failed to maintain clean technique when inserting the indwelling urethral catheter as directed by the CDC.”

“Based on review of medical records (MR), hospice policy and procedure, and interviews it was determined the agency failed to ensure the hospice nurse notified the physician for the pronounce of the death. This did affect, MR # 5, one of three death at home MR’s reviewed and had the potential to affect all patients admitted to this hospice. Findings include: Hospice Policy: Pronouncement of Death/Telecommunication for Pronouncement of Patient Death Policy Number: 10.00 Revised: 1/31/24 ...Purpose: To provide guidelines for pronouncement of death of hospice patients in both Georgia and Alabama. ...Procedures for patients at home: Upon arrival at the residence the nurse will observe the death scene and the position of the body in death. The nurse will also: a. Check for the cessation of cardiopulmonary function b. Check for pupil response. ...4. In Alabama, once satisfied that the death was the result of natural causes: a. Notify the physician via telephone and report the findings of death, to include the absence of the signs of life and the time the RN (Registered Nurse) observed those findings. The physician, via telecommunication, will issue the pronouncement of death... 1. MR # 5 was admitted on 9/13/23 with a diagnosis of Closed Fracture of Right Femur, Sequala. Review of the Skilled Nursing Clinical Notes dated 10/4/23 revealed Employee Identifier (EI) # 6, RN, documented MR # 5 was found lying in bed with no pulse, no respirations, no blood pressure, pupils fixed and dilated and the coroner was notified. There was no documentation EI # 6 notified the physician to report the findings of death and no documentation of the pronouncement of death by the physician. An interview was conducted on 5/16/24 at 3:15 PM with EI # 1, Director, who confirmed MR # 5 was at home in Alabama at the time of death.”

“Based on review of medical records (MR), hospice policy and procedure, and interviews, it was determined the hospice failed to ensure the Certified Nursing Assistant (CNA, Hospice Aide) followed plan of care, visit frequency, and documented the specific care provided to the patient. This affected five of 12 MR’s reviewed of patients receiving HA services including Home Visit (HV) # 3, MR # 6, MR # 7, HV # 4, and MR # 9 and had the potential to affect all patient requiring aide services. Findings include: Hospice Policy: CNA Plan of Care Policy Number: 8.00 Revised: 2/16/24 Purpose: To provide a plan for the CNA to follow for each patient assigned to their care... Procedure... 8. The CNA must follow the plan of care as written... 9. The CNA will document completion of assigned tasks from the plan of care in the EMR (Electronic Medical Record) during the visit. If a task cannot be completed, the reason why must be indicated in the record. 5. MR # 9 was admitted to the hospice on 4/4/24 with a diagnosis of Cardiovascular Disease with Hypertension. Review of the POC dated 4/4/24 revealed orders for CNA services three times a week for one week beginning 4/4/24 then two times a week for one week beginning 4/17/24 then three times a week for ten weeks beginning 4/22/24. Review of the CNA visit notes revealed no documentation a visit was completed during week one which was 4/8/24 to 4/14/24. A review of the CNA visit notes dated 4/19/24 to 5/3/24 revealed 10 out of 11 visits the CNA failed to document the specific care provided during the visit. An interview was conducted on 5/16/24 at 1:41 PM with EI # 1 who confirmed there were no documentation a CNA visit was performed for the week of 4/4/24 and the CNA failed to document the specific care provided during the visits. 4. HV # 4 was admitted to the hospice on 6/17/23 with a diagnosis of Liver Cirrhosis. Review of the POC dated 4/15/24 revealed orders for CNA two times a week for eight weeks and a CNA POC with the following interventions: Take BP (blood pressure) every visit. Notify RN for systolic over 180 or under 90, diastolic over 100 or under 50. Take pulse every visit. Notify RN if pulse over 104 or under 50. Take respirations every visit. Notify RN of respirations less than 16 or over 30. Take temperature every visit. Notify RN of temperature over 100. Record BM each visit if no BM x 3 days notify RN. Review of the CNA visit notes dated 4/12/24 to 6/10/24 revealed the CNA failed to document the patient’s BP, pulse, respirations, and temperature on 21 of the 21 CNA visit notes reviewed. Further review of the CNA visit notes dated 4/12/24 to 6/10/24 revealed the CNA failed to document the date of the last BM on 18 of the 21 CNA visit notes reviewed. An interview was conducted on 5/16/24 at 3:00 PM with EI # 1 who confirmed the staff failed to follow the POC and document the patient’s vital signs and date of the last BM. 1. HV # 3 was admitted to the hospice on 11/7/23 and recertified from 2/5/24 to 5/2/24 with a diagnosis of Heart Disease. Review of the Plan of Care (POC) dated 2/5/24 revealed orders of CNA three times a week for 13 weeks. Review of the Team Care Plan dated 2/5/24 revealed CNA POC Interventions including for the CNA to record the bowel movement (BM) each visit and if no BM for three days to notify the Registered Nurse (RN). Review of the CNA visit notes from 2/5/24 to 5/13/24 revealed the CNA failed to document the date of the last BM on 39 of 43 visit notes reviewed. An interview was conducted on 5/16/24 at 1:52 PM with Employee Identifier (EI) # 1, Director, who confirmed the staff failed to follow the POC and document the date of the last BM. 2. MR # 6 was admitted to the hospice on 12/11/23 and recertified from 3/10/24 to 6/7/24 with a diagnosis of Alzheimer Disease. Review of the CNA POC dated 3/10/24 revealed orders for CNA seven times a week for 12 weeks beginning 3/11/24, record BM each visit, and notify RN if no BM for three days. Review of the CNA visit notes from 3/11/24 to 5/6/24 revealed the CNA failed to document the date of the last BM on 47 of the 56 CNA visit notes reviewed. An interview was conducted on 5/16/24 at 3:00 PM with EI # 8, Compliance Officer, who confirmed the staff failed to follow the POC and document the date of the last BM each visit. 3. MR # 7 was admitted to the hospice on 4/19/24 with a diagnosis of Heart Disease. Review of the POC dated 4/19/24 revealed orders for CNA two times a week for 11 weeks beginning 4/19/24. Review of the CNA visit notes revealed no documentation a visit was completed during week one which was 4/19/24 to 4/21/24. Review of the physician’s orders and Interdisciplinary Team (IDT) Meeting notes revealed no documentation of the reason for missed visits. An interview was conducted on 5/16/24 at 2:38 PM with EI # 8 who confirmed there were no CNA visits completed during week one and there was no documentation the physician was notified of the missed visit.”

“Based on review of the Medical Record (MR), hospice policies and procedures, and staff interview it was determined the hospice nurse failed to document the medications administered to flush an implanted port. This did affect MR # 13, one of one MR’s reviewed with an implanted port, and had the potential to negatively affect all patients with an implanted port. Findings include: Hospice Policy: Intravenous (IV) Line Management Policy Number: 27.35 Revised Date: 1/30/23 Purpose: To establish clinical guidelines for the management of IV lines in hospice patients. Elements: ...2. Care of IV lines will include.. flushes to maintain patency. Procedure: ...Implanted Ports: ...b. An implanted device should be accessed and flushed every thirty days when not in use. Flush with 10 ml (milliliters) of 0.9 % Sodium Chloride (Normal Saline) or with 5 ml of 10 Units/ml Heparin solution... assess the patient’s pain tolerance and discuss the preference for using a local anesthetic before accessing the port. ...Document the procedure... Hospice Policy: Medication Administration and Management Policy Number: 27.24 Revised Date: 12/3/21 Purpose: To ensure that medications are provided and administered correctly according to physician orders... and patients’ plans of care... Procedure: ...2. When a hospice employee is administering any medication to the patient, the medication name, strength, dose, route, date, and time will be documented in the record. MR # 13 was admitted to the hospice on 5/1/24 with diagnoses including Lung Cancer Metastatic to Brain and History of Left Breast Cancer. Review of the Plan of Care dated 5/7/24 revealed an order to flush the venous access device with Normal Saline (NS) and Heparin and the patient was to apply Lidocaine-Prilocaine Cream 2.5-2.5% prior to the flush. Review of the nurse note dated 5/7/24 revealed “Implanted port flushed per policy...” There was no documentation of the medication name, strength, and dose used to flush the implanted port. Further review revealed no documentation if the patient had applied the Lidocaine-Prilocaine cream to the site. An interview was conducted on 5/16/24 at 2:50 PM with Employee Identifier # 8, Compliance Officer, who confirmed the nurse failed to document the medications administered to flush an implanted port.”