Affinity Hospice Madison

“Based on review of medical records (MR), agency policy and procedure, observations, and interviews, it was determined the hospice agency failed to ensure medication profiles were updated and current for two of seven Home Visits (HV) conducted, including HV # 3 and HV # 4. This deficient practice had the potential to affect all patients served by the agency. Findings include: Agency Policy: Medication Profile Policy Number: 4-050.1 Date Revised: November 2018 Policy: Patients receiving medications administered by the organization will have a current, accurate medication profile in the clinical record. The medication profiles will be updated for each change to reflect current medications, and new and /or discontinued medications. Procedure: ...Upon admission to hospice, the admitting nurse will initiate a medication profile to document the current medication regimen... 2. A drug regimen review will be performed by a registered nurse at the time of initial and comprehensive assessment, when updates... are performed, ...and with the addition of a new medication... 1. HV # 3 was admitted to the agency on 4/3/24 with diagnoses including Chronic Kidney Disease, Stage 4 (four) (Severe), and Essential (Primary) Hypertension. A HV was conducted on 5/21/24 at 12:40 PM to observe care provided by Employee Identifier (EI) # 4, Registered Nurse (RN). During the HV, the surveyor compared the patient’s medications to the current medication profile provided by the agency. HV # 3’s routine medications were in bubble packs prepared by the patient’s pharmacy. The bubble pack contained 11 unidentified pills in one bubble marked AM, and 3 unidentified pills in the bubble marked PM. The surveyor was unable to determine the names of the medications in the home, and there was no list of medications. The surveyor requested the current list of medications from HV # 3’s pharmacy, from the agency. The medication list received was dated 5/22/24 and was compared to the agency’s medication profile for HV # 3. The following discrepancies were observed: a. Dicyclomine 10 mg (milligrams), one capsule three times daily, was on the pharmacy list and not on the agency’s list. b. Januvia 50 mg, one tablet by mouth daily, was on the pharmacy list and not on the agency’s list. c. Fluconazole 150 mg, one tablet daily, was on the pharmacy list and Fluconazole 150 mg, one half tablet daily was on the agency’s list. d. Lorazepam 0.5 mg, one tablet three times a day was on the pharmacy list, and a bottle of Lorazepam 0.5 mg, one tablet three times a day as needed, was in the home, dispensed date 4/8/24. Lorazepam 0.5 mg was not on the agency’s list. e. Simvastatin 20 mg, one tablet every PM, was on the agency’s list, and not on the pharmacy list. f. Santyl ointment, use as directed, apply to right heel once daily was on the pharmacy list and not on the agency’s list. g. Triple antibiotic ointment, apply one inch daily to right toe, was on the pharmacy list and not on the agency’s list, and a tube was in the home. An interview was conducted on 5/23/24 at 2:50 PM with EI # 3, Executive Director Cullman, who confirmed staff failed to maintain an accurate medication profile. 2. HV # 4 was admitted to the hospice agency on 8/28/23 with diagnoses including Hypertensive Chronic Kidney Disease, Stage 5, and Anemia in Chronic Kidney Disease. Review of the Hospice Recertification Plan of Care Update, dated 4/12/24, revealed an order for the SN (Skilled Nurse), effective 4/24/24, 1 WK 1 (one time per week times one week), 2 WK 8... A HV was conducted on 5/21/24 at 3:10 PM to observe support provided by EI # 5, Chaplain. During the HV, a medication reconciliation was conducted with HV # 4’s spouse, who is the primary caregiver (cg). Medications in the home were compared to the current medication list (med list) printed on 5/21/24. The following discrepancies were observed: a. Ativan 0.5 mg tablet (tab), one tab po (by mouth) every four hours PRN (as needed) for anxiety was on the med list, and not in the home. The cg confirmed the patient had not taken the medication in at least six months. b. Oxybutynin Chloride ER (Extended Release) 5 mg tab, one tablet at bedtime for overactive bladder relief was on the med list, and not in the home. The cg confirmed the patient had not taken the medication since last year. c. Restoril 15 mg capsule, take two capsules po at night for insomnia was on the med list, and not in the home. The cg confirmed the patient had not taken the medication since last year. d. Stool Softener 100 mg capsule, one capsule daily, was on the med list and not in the home. The cg confirmed the patient had not taken the medication since last year. e. Donepezil Hcl (Hydrochloride) 10 mg tab, one tablet daily was in the home, and not on the med list. Dispensed date on the bottle was 4/26/24 and confirmed by the cg as currently taking for approximately six months. f. Hydrocodone 5 mg, Acetaminophen 325 mg tab, take one tab by mouth three times daily, was on the med list, and not in the home. The cg confirmed the patient no longer used the medication. g. Latanoprost 0.005 % (percent) eye drops, one drop every PM, was on the med list, and not in the home. The cg confirmed the patient has not used the drops in over 6 months. h. Lexapro 10 mg tab, one tab daily for depression was on the med list, and not in the home. The cg confirmed the patient has been off the med since last year. An interview was conducted on 5/23/24 at 2:41 PM with EI # 3, who provided an order dated 5/3/24 to discontinue the Ativan, Hydrocodone, Lexapro, and Oxybutynin Chloride. However, six Skilled Nurse visits have been conducted since the order was written. EI # 3 confirmed staff failed to maintain an accurate and current medication profile.”

“Based on medical record (MR) review, agency policy and procedure, and interview, it was determined the hospice failed to ensure staff provided education to patients and/or caregivers (cg). This deficient practice affected 2 of 18 active MR’s reviewed, including MR # 11, Home Visit (HV) # 3, and had the potential to negatively affect all patients served by the agency. Findings include: Agency Policy: Contents of Clinical Record Policy Number: 4-078.1 Revision Date: November 2018 Policy: A clinical record will be maintained for each patient receiving care. The clinical record will...accurately document care provided and results in detail... Procedure: ...2. Documentation will include: H. Educational needs of patient and family/caregiver. I. Patient and family education provided. 2. HV # 3 was admitted to the hospice agency on 4/3/24 with diagnoses including Chronic Kidney Disease, Stage 4 (Severe), and Essential (Primary) Hypertension. Review of the Hospice Certification and Plan of Care (POC) dated 4/3/24 to 7/1/24, revealed an order for the Hospice Nurse to instruct in Diabetes Management... with a goal for patient/ caregiver, verbalizes/ demonstrates understanding of management of diabetes to prevent a diabetic event. Further review of the POC revealed the patient’s medications included Toujeo Max U-300 Solostar Insulin Pen, Ozempic Subcutaneous Pen Injector, and Glipizide 5 mg (milligrams) tablets. During a HV conducted on 5/21/24 at 12:40 PM with EI # 4, Registered Nurse, Januvia was also observed in the home, and not on the patient’s medication list. Review of the RN (Registered Nurse) Hospice Start of Care note dated 4/3/24 revealed the nurse documented, “...Patient lives at home alone... with no primary caregiver. Review of the MR revealed no documentation of education or return demonstration regarding the patient’s insulin pen or Ozempic pen, signs and symptoms of low blood sugar, or how to prevent a diabetic event. An interview was conducted on 5/23/24 at 2:50 PM with EI # 3, Executive Director Cullman, who confirmed staff failed to document education and return demonstration for diabetes management. 1. MR # 11 was admitted to hospice services 4/22/24 with diagnoses including Atherosclerotic Heart Disease of Native Coronary Artery with Unspecified Angina Pectoris and Chronic Systolic (Congestive) Heart Failure. Review of the Hospice Certification and Plan of Care dated 4/22/24 revealed orders for the skilled nurse (SN) to visit three times a week for one week, then two times a week for 12 weeks, with four additional as needed visits. Review of the SN visit note dated 5/6/24 revealed a new order was obtained from the physician for Lasix 20 milligrams (mg) daily due to increased lower extremity swelling. No education on Lasix was provided during the visit. Review of the next SN visit note dated 5/10/24 revealed no education was provided for the Lasix. In an interview conducted on 5/23/24 at 4:25 PM with Employee Identifier (EI) # 1, Executive Director Madison, EI # 1 confirmed the SN did not provide education for the new medication.”

“Based on medical record (MR) review, agency policies and procedures, and staff interview, it was determined the agency failed to individualize the plan of care to meet patients nutritional needs. This affected one of 18 active MR reviews including MR # 3 and had the potential to negatively affect all patients served by the hospice agency. Findings include: Agency Policy: The Plan of Care Policy Number: 4-027.1 Revised Date: November 2018 Policy: ...The plan of care will include all services necessary for the palliation and management of the terminal illness and related conditions. Procedure: ... 7. Each patient will be monitored for his/her responses to care, or services provided... ... 9. The plan of care will be reviewed and revised as frequently as deemed necessary... based on ongoing comprehensive assessments of the patient and family/caregiver. ...12. The written plan of care will contain... ...F. Reduction in risk factors G. Functional limitations ...J. Nutritional requirements ...O. Individualized interventions... MR # 3 was admitted on 2/14/24 with diagnosis of Unspecified Protein-Calorie Malnutrition. Review of the Hospice Recertification Plan of Care (POC) update for certification period 4/14/24 to 6/12/24 revealed orders for SN (Skilled Nurse) to assess nutrition and hydration status. Review of the MR revealed seven SN Visit Note Reports (VNR) dated 4/24/24 through 5/13/24. The SN documented on every visit the patient was unable to prepare meals. There was no documentation the patient was provided nutritional supplements and resources necessary to meet nutritional needs. Review of two Interdisciplinary Group (IDG) Comprehensive Assessment and Plan of Care Update Reports dated 4/24/24 and 5/8/24 revealed the SN documented “;patient continues to have limited mobility making it difficult for her to prepare food.” There was no documentation the patients plan of care was individualized to meet patients nutritional needs. An interview was conducted on 5/23/24 at 3:40 PM with Employee Identifier # 2, Branch Director, Florence, who confirmed the agency failed to ensure an individualized plan of care was developed to address the patients nutritional needs.”

“Based on review of medical records (MR), agency policy and procedure, agency Wound Care Protocol, Physician’s Office Notes, and interviews, it was determined the agency failed to ensure staff: 1. Assessed and documented all wounds on admission. 2. Provided and documented wound care as ordered by the physician. 3. Obtained physician orders for wound care provided. This affected one of six MR’s reviewed with wounds including Home Visit (HV) # 3, and had the potential to affect all patients with wounds served by the agency. Findings include: Agency Policy: Comprehensive Assessment Policy Number: 4-042.1 Date Revised: November 2018 Policy: A comprehensive patient assessment will be performed by the interdisciplinary group no later than 5 calendar days after the election of hospice care... Procedure: During the comprehensive patient assessment, all baseline data... will be documented... ...G. A physical assessment, including... skin... Agency Wound Care Protocol Policy Number: None listed Date Revised: None listed Procedure: Initial Assessment 1. A Registered Nurse will assess wounds as part of the comprehensive initial assessment and will document all clinical findings... ...3. The admitting clinician will document each wound status including location and etiology, measurement..., description... 4. Each wound will be numbered and documentation associated with each numbered wound will be completed on each visit. ...Continued/ Ongoing Treatment 1. Nursing staff will provide wound care per physician orders... Documentation of wound care provided will include... wound care provided... and how patient tolerated the procedure. 1. HV # 3 was admitted to the agency on 4/3/24 with diagnoses including Chronic Kidney Disease, Stage 4 (four)(Severe), and Essential (Primary) Hypertension. Review of the Hospice Certification and Plan of Care (POC) dated 4/3/24 to 7/1/24 revealed an order for the Hospice Nurse to perform wound care as needed to wounds. Review of the Physician Office Notes, dated 4/2/24, revealed the following, “...Muscle debridement of bilateral heel wounds and subcutaneous debridement of right shin wounds performed... Non-viable tissue removed from bilateral heel wounds and right anterior shin... Will have hospice follow up for further wound care. Mild drainage/ weeping of right shin wound... Review of the MR revealed the first physician order for wound care to the heels was dated 5/3/24, which was 30 days after admission. Review of the 4/3/24 Start of Care Visit Note revealed the Wound Assessment documentation as follows: Wound number (#) one was Dist (Distal) LT (Left) Post (Posterior) Heel PU (Pressure Ulcer) Stage III (Not two as listed in Narrative Note), 7 x 7 x 5 cm (length x width x depth in centimeters). Wound care provided, “Cleaned, dried oinment (ointment) and dressing applied.” There was no documentation regarding what was used to clean or dry the wound, what type of ointment was used, what type of dressing was applied, or how the patient tolerated the wound care. Wound # two was Dist Post RT (Right) Heel, RT PU Stage III (Not two as listed in Narrative Note), 6 x 6 x 6 cm. Wound care provided, “Cleaned, died (dried), oinment (ointment) applied and dressing applied. There was no documentation regarding what was used to clean or dry the wound, what type of ointment was used, what type of dressing was applied, or how the patient tolerated the wound care. There was no assessment and documentation of wound care of “ulcers on both shins” as documented in the Narrative Note and the Physician’s Office Note. Review of the MR revealed two SN (Skilled Nurse) Visit Note Reports (VNR) dated 4/4/24 and 4/6/24. The SN documented, “Client completed care” for Wound #’s one and two. There was no documentation the patient had been taught the wound care and no documentation of a return demonstration. Review of the SN VNR dated 4/10/24 revealed there was no documentation of the wound care provided. There was no documentation regarding the shin wounds. Review of the SN VNR dated 4/12/24 revealed the SN documented care for wound # one as, “...cleansed with normal saline/ wound cleanser” then listed instructions to “...apply Santyl ointment to the wound, apply ABD (Abdominal) pads and tape with skin tape then wrap with ferlix (kerlix) and secure with tape.” There was no order for the wound care. Further review of the VNR dated 4/12/24 revealed the SN documented care for wound # two as, “...cleansed with normal saline” then listed the same instructions listed for wound # one. There was no order for the wound care. Further review of the narrative note for SN VNR dated 4/12/24 revealed the SN documented, “a couple of vascular ulcers on her right leg and one small on her left leg...” There was no assessment and measurement of these wounds, and they were not added to the wound list. Review of the MR revealed the following physician’s order dated 4/15/24, “Wound care to right distal 1st toe as follows: Cleanse wound with wound cleanser, pat dry with gauze, apply antibiotic ointment to wound bed. Wrap right foot with roll gauze. Secure with tape. Wound care to be provided at a frequency of daily. SN to provide each visit. CG (caregiver) may perform in absence of SN.” The patient lives alone and has no caregiver. Review of the SN VNR dated 4/15/24 revealed the nurse documented, “ New wounds noted laceration to top of right toe venous stasis ulcer to rt shin measures 2 x 1. DTI to bottom of rt great toe.” There was no depth documented for the rt shin ulcer, and it was not assessed and added to the wound list. Further review of the 4/15/24 SN VNR revealed the nurse added wound # three: “Rt great toe, Rt Unstage DTI (Deep Tissue Injury),” then documented the measurement as 1 x 1 x 0.5. Wound care instructions listed in the wound care provided area was documented as “...Cleanse wound with wound cleanser or normal saline...” and not cleanse with wound cleanser as ordered. Care was documented as “Cleaned and ointment applied, wrapped.” There was no documentation what the wound was cleansed with, what type ointment was applied, and what was used to wrap the wound. Further review of the SN VNR dated 4/15/24 revealed the SN documented no specific wound care for wounds one and two. There was no physician’s order for the wound care. Review of the SN VNR dated 4/22/24 revealed, “...New ulcer to distal left foot 3rd toe.” The wound assessment listed wound # 4 as Dist Post (Posterior) - Third Toe Rt, Unstage, 2 x 2 x 0, and described as “Necrotic.” The wound care was documented as “Cleaned and ointment applied.” There was no documentation what the wound was cleaned with and what ointment was applied. There was no wound care order obtained. Further review of the SN VNR dated 4/22/24 revealed the bilateral heels wound care was documented as “Cleaned, dried, ointment applied, dressing applied.” There was no documentation what the wound was cleaned with and what ointment was applied. There were no wound care orders for the bilateral heel wounds. Review of three SN VNR’s dated 4/24/24, 4/26/24, and 4/29/24 revealed no specific wound care provided, and no wound care orders for wound #’s one, two, and four. Review of the MR revealed a physician’s order dated 5/3/34: “Bi- lateral heels- Cleanse with wound cleanser and gauze. Pat dry. Apply Santyl ointment to wound bed. Cover with abd pad, wrap with rolled gauze. Change daily. Patient may perform on days SN does not visit.” Review of two SN VNR’s dated 5/6/24 and 5/8/24 revealed specific wound care was not documented for all wounds. A HV was conducted on 5/21/24 at 12:40 PM to observe wound care provided by Employee Identifier (EI) # 4, Registered Nurse. Before entering the home, EI # 4 stated the patient’s Santyl ointment was on backorder at the pharmacy and the patient was currently out of the ointment. EI # 4 provided a physician’s order dated 5/21/24 at 11:55 AM that omitted the Santyl ointment until obtained from the pharmacy. Review of the SN documentation for the visit revealed the SN documented using Santyl ointment on the bilateral heels during wound care. The surveyor observed the wound care, and there was no Santyl ointment applied to the wounds. Additional wound care documentation for wound #’s three, four, and five, revealed no specific wound care provided. The SN documented “Tolerated well” for wound care provided. An interview was conducted on 5/23/24 at 2:50 PM with EI # 3, Executive Director Cullman, who confirmed orders were not obtained for wound care, all wounds were not identified and assessed on admission, and staff failed to document specific wound care provided, per policy.”

“Based on observation, policy and procedure, and interview, it was determined agency staff failed to perform hand hygiene per policy. This affected one of six Home Visits (HV) conducted, including HV # 3, and had the potential to negatively affect all patients served by the agency. Findings include: Agency Policy: Hand Hygiene Policy Number: 6-006.1 Revision Date: November 2018 Purpose: To prevent cross contamination and home care-acquired infections. Policy: Personnel providing care in the home setting will regularly wash their hands... Procedure: ...3. Hand decontamination using an alcohol-based hand rub should be performed: A. Before having direct contact with patients. ...C. After contact with a patient’s intact skin (when taking a pulse, blood pressure or lifting a patient). D. After contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressings... E. When moving from a contaminated body site to a clean body site during patient care. F. After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. G. After removing gloves. 1. HV # 3 was admitted to the hospice agency on 4/3/24 with diagnoses including Chronic Kidney Disease, Stage 4 (Severe), and Essential (Primary) Hypertension. A HV was conducted on 5/21/24 at 12:40 PM to observe wound care provided by Employee Identifier (EI) # 4, Registered Nurse (RN). EI # 4 performed hand hygiene, donned gloves, and prepared supplies for wound care. During preparation, EI # 4 dropped a wrapper on the floor, picked up the wrapper, waded it up, and placed it down into the bag prepared for waste. Wearing the same gloves, EI # 4 continued to obtain supplies for wound care. EI # 4 failed to remove gloves and perform hand hygiene after picking up trash off the floor. EI # 4, wearing gloves, reached in to her/his uniform pocket and retrieved and cleaned a pair of scissors. EI # 4 then removed gloves and failed to perform hand hygiene. EI # 4 cleaned the wound on the left heel, removed gloves, and failed to perform hand hygiene. EI # 4 then donned new gloves, opened packages for ABD (Abdominal) pad and gauze wrap, used them to dress the wound, taped the wrap, removed gloves, and failed to perform hand hygiene. The RN then performed wound care to the right heel and toes. After cleaning the heel wound, EI # 4 picked up 4 x 4 gauze, then dropped them on the floor. Wearing the same gloves, EI # 4 picked up the gauze off the floor, placed in garbage, and retrieved new 4 x 4’s with the same gloves, and proceeded to clean the right great toe, and third and fourth toes. Following wound care, EI # 4 removed gloves and failed to perform hand hygiene. An interview was conducted on 5/23/24 with EI # 3, Executive Director Cullman, who confirmed staff failed to perform hand hygiene according to agency policy.”

“Based on medical record (MR) review, agency policy and procedure, and interview, it was determined the agency failed to ensure the nursing staff received the pronouncement of death via telecommunication with the physician as required by the Alabama Board of Nursing. This affected one of three records reviewed for death, including MR # 14, and had the potential to negatively affect all patients admitted to the hospice. Findings include: Agency Policy: Death At Home Policy Number: 4-069.1 Revision Date: November 2018 Purpose: To establish the process to follow when a patient dies. Policy: It is anticipated that hospice patients will die at home... ...Note: Hospice should check specific state law regarding death at home and adapt policy to meet state law/statute. Procedure: ...4. The nurse will notify the attending physician of the patient’s death. It will be the attending physician’s responsibility to pronounce death (dependent on state regulations)... MR # 14 was admitted to the hospice agency on 3/4/24 with diagnoses including Malignant Neoplasm of Lower Lobe, Right Bronchus or Lung, and Secondary Malignant Neoplasm of Left Lung. Review of the MR revealed a RN (Registered Nurse) Hospice Death at Home visit note dated 3/28/24. The RN documented the following in the Narrative Note, “...Patient lying in bed upon arrival. No respiratory effort and no pulse present after 2 (two) minutes of auscultation. TOD (Time of Death): 3/28/24 @ (at) 1306 (1:06 PM).” There was no documentation the RN received the pronouncement of death from the physician. An interview was conducted on 5/23/24 at 2:30 PM with Employee Identifier # 3, Executive Director Cullman, who confirmed there was no documentation the physician made the death pronouncement.”

“Based on medical record (MR) review, agency policy and procedure, and interview, it was determined the hospice failed to ensure staff documented accurately and completely in the clinical record. This deficient practice affected 4 of 23 MR’s reviewed, including MR # 8, MR # 7, MR # 5, and Home Visit (HV) # 3, and had the potential to negatively affect all patients served by the agency. Findings include: Agency Policy: Contents of Clinical Record Policy Number: 4-078.1 Revision Date: November 2018 Policy: A clinical record will be maintained for each patient receiving care. The clinical record will...accurately document care provided and results in detail... Procedure: 1. The following information will be available in the clinical record as applicable to care and services provided: K. Legible, complete, and individualized diagnostic and therapeutic orders... 2. Documentation will include: H. Educational needs of patient and family/caregiver. I. Patient and family education provided... M. Signed and dated clinical notes. 4. HV # 3 was admitted to the hospice agency on 4/3/24 with diagnoses including Chronic Kidney Disease, Stage 4 (Severe), and Essential (Primary) Hypertension. Review of the Hospice Certification and Plan of Care dated 4/3/24 to 7/1/24 revealed an order for the hospice nurse to perform wound care as needed to wounds. Review of the MR revealed 10 VNR’s dated 4/4/24 to 5/8/24 with inaccurate numbers and locations of wounds, inaccurate assessment of wounds, and incomplete documentation of wound care provided. The 10 VNR’s reviewed also included inaccurate frequency of finger stick blood sugars, which the SN documented “125” as the frequency of finger sticks. An inaccurate Covid screening documented the patient had been out of the country, was suffering respiratory symptoms such as fever, cough and sore throat, and documented “Yes” to the question ‘Have you or anyone in your household had contact with someone under investigation for Covid?” The SN inaccurately documented “No” to the question, “Is patient taking Insulin?” A HV was conducted on 5/21/24 at 12:40 PM to observe wound care performed by EI # 4, RN (Registered Nurse). Review of the SN VNR dated 5/21/24 revealed the nurse documented using Santyl ointment on both heel wounds. There was no Santyl ointment in the home, as observed by the surveyor and confirmed by the SN during the visit. An interview was conducted on 5/23/24 with EI # 3, Executive Director Cullman, who confirmed staff failed to document accurately in the medical record. 3. MR # 5 was admitted to hospice services 6/16/23 with diagnoses including Malignant Melanoma of Skin Unspecified and Neoplasm Related Pain (Acute) (Chronic). Review of the Hospice Physician Order dated 4/16/24 revealed wound care twice weekly and as needed. Review of the RN VNR dated 5/2/24, revealed RN documented dressing changed today without difficulty. RN documented under Wound Assessment, wound care not provided: not ordered this visit. An interview was conducted on 5/23/24 at 3:35 PM with EI # 2, Executive Director of Florence, who confirmed the hospice staff failed to accurately document wound care was provided. 1. MR # 8 was admitted to hospice services 4/27/24 with diagnoses including Interstitial Pulmonary Disease, Unspecified and Unspecified Severe Protein Calorie Malnutrition. Review of the Hospice Certification and Plan of Care dated 4/27/24 revealed the following: Orders of Discipline and Treatment; ...Hospice nurse to insert/maintain (an) indwelling catheter (foley) 16 French (size)/10 CC (cubic centimeter) balloon. May irrigate with NS (normal saline). Change catheter every four weeks or as needed. Goals: ...Indwelling urinary catheter will remain patent. Review of the skilled nurse (SN) visit note dated 4/28/24 revealed the SN placed a new indwelling 16 french indwelling urinary catheter. Review of SN visit notes dated 4/29/24, 5/1/24, 5/3/24, 5/8/24 and 5/20/24 revealed the SN failed to assess the indwelling urinary catheter. Review of SN visit notes dated 5/6/24, 5/10/24, 5/13/24 and 5/15/24 revealed the SN documented the indwelling urinary catheter was placed on dates 5/4/24, 4/27/24, 4/30/24 and 5/1/24 respectively. Review of the SN visit note dated 5/10/24 revealed the SN documented the indwelling urinary catheter was a size 18 french. The SN failed to assess and accurately document the indwelling urinary catheter. In an interview conducted on 5/23/24 at 4:30 PM with Employee Identifier (EI) # 1, Executive Director Madison, EI # 1 confirmed the SN documentation was not complete and accurate. 2. MR # 7 was admitted to hospice services 4/18/24 with diagnoses including Unspecified Combined Systolic and Diastolic (Congestive) Heart Failure and Chronic Obstructive Pulmonary Disease, Unspecified. Review of the Hospice Certification and Plan of Care dated 4/18/24 revealed an order for oxygen humified at 2 - 10 liters for SOB (shorten of breath) as needed, and oxygen with supplies ordered through the DME (durable medical equipment). Review of the SN Visit Note Reports (VNR) dated 4/24/24, 5/9/24 and 5/20/24 revealed no oxygen equipment in the home. An interview was conducted on 5/23/24 at 3:37 PM with EI # 2, Executive Director of Florence, who confirmed the hospice staff failed to accurately document oxygen equipment and supplies were in the home.”