Ouachita County Medical Center Hospice

“Based on clinical record review and staff interviews, it was determined that the Registered Nurse (RN) failed to complete a comprehensive wound reassessment for 2 (#3 and #8) of 3 (#3, #8, and #13) clinical records reviewed with documented wounds whose location of care was a skilled nursing facility. The hospice nurse instead obtained wound measurements and assessment information from the skilled nursing facility’s wound care nurse. The absence of a documented, comprehensive wound reassessment had the potential to impact all patients requiring wound care, as the RN was unable to independently evaluate and monitor the patients’ wound healing progress. Findings follow: A review of clinical record #3, with a SOC date of 12/22/25, revealed a patient diagnosed with Malignant Neoplasm of Prostate. A review of skilled nursing visit notes revealed that on 02/03/2026, the RN documented, “wound not assessed this visit” and “wound care nurse was not available to obtain readings from.” In a subsequent note dated 02/17/2026, the RN documented, “wound care nurse reports slight overall improvement and will fax updated measurements.” There was no additional documented evidence of wound assessments or measurements for the review period of 12/22/2025 through 03/21/2026.A review of clinical record #8, with a SOC date of 02/26/26, revealed a patient diagnosed with Unspecified Severe Protein Calorie Malnutrition. A review of skilled nursing visit notes revealed that on 02/26/2026, the RN documented, “wound details are documented separately per facility wound care nurse.” In a subsequent note dated 03/16/2026, the RN documented, “Information documented obtained from wound care nurse” There was no additional documented evidence of wound assessments or measurements for the review period of 02/26/2026 through 03/21/2026.During an interview conducted on 03/19/26 at 4:00 PM, Agency Personnel #2 reported that wound care, assessments, and measurements were completed by the facility’s wound care nurse and subsequently communicated to the hospice nurse.On 03/20/26 at 12:30 PM, Agency Personnel #1 and #2 confirmed the Hospice RN did not perform a comprehensive wound reassessment every fifteen days as required.”

“Based on clinical record review and staff interviews, it was determined that there was no documented evidence of attendance by the chaplain or spiritual counselor at Interdisciplinary Group (IDG) meetings, as evidenced by the absence of a signature on both the paper and electronic attendance records for 7 (#1, #2, #3, #6, #7, #9, #10) of 14 (#1-14) clinical records reviewed. The failure to participate in interdisciplinary care planning process had the potential to impact all patients on census and may result in incomplete care coordination, unmet patient and family spiritual needs, and could place patient and/or family at risk of inadequate coping mechanisms with end-of-life issues, lack of resources and ineffective family support. Findings follow: A review of clinical record #1, with a start of care (SOC) date of 08/12/25, revealed a patient diagnosed with Chronic Obstructive Pulmonary Disease. Review of a document titled “Interdisciplinary Team Meeting,” dated 02/25/2026 revealed no evidence of attendance by the chaplain or spiritual counselor at the IDG meeting for the purpose of care planning and coordination.A review of clinical record #2, with a SOC date of 02/22/26, revealed a patient diagnosed with Congestive Heart Failure. Review of a document titled “Interdisciplinary Team Meeting,” dated 02/25/2026 revealed no evidence of attendance by the chaplain or spiritual counselor at the IDG meeting for the purpose of care planning and coordination.A review of clinical record #3, with a SOC date of 12/22/25, revealed a patient diagnosed with Malignant Neoplasm of Prostate. Review of a document titled “Interdisciplinary Team Meeting,” dated 12/31/2025 revealed no evidence of attendance by the chaplain or spiritual counselor at the IDG meeting for the purpose of care planning and coordination.A review of clinical record #6, with a SOC date of 02/19/26, revealed a patient diagnosed with Malignant Neoplasm of Unspecified Ovary. Review of a document titled “Interdisciplinary Team Meeting,” dated 02/25/2026 revealed no evidence of attendance by the chaplain or spiritual counselor at the IDG meeting for the purpose of care planning and coordination.A review of clinical record # 7, with a SOC date of 02/16/26, revealed a patient diagnosed with End Stage Heart Failure. Review of a document titled “Interdisciplinary Team Meeting,” dated 02/25/2026 revealed no evidence of attendance by the chaplain or spiritual counselor at the IDG meeting for the purpose of care planning and coordination.A review of clinical record #9, with a SOC date of 10/25/24, revealed a patient diagnosed with Neurocognitive Disorder with Lewy Bodies. Review of a document titled “Interdisciplinary Team Meeting,” dated 02/25/2026 revealed no evidence of attendance by the chaplain or spiritual counselor at the IDG meeting for the purpose of care planning and coordination.A review of clinical record #10, with a SOC date of 02/20/26, revealed a patient diagnosed with Malignant Neoplasm of Right Kidney. Review of a document titled “Interdisciplinary Team Meeting,” dated 02/25/2026 revealed no evidence of attendance by the chaplain or spiritual counselor at the IDG meeting for the purpose of care planning and coordination.During an interview conducted on 03/19/26 at 4:00 PM, Agency Personnel #2 reported that electronic signatures are frequently not captured in the medical records system due to technical issues. As a result, a paper attendance record is also completed. Copies were submitted for review at this time. On 03/20/26 at 12:30 PM, Agency Personnel #1 and #2 confirmed there was no documented evidence of attendance by the chaplain or spiritual counselor at the IDG meeting for the dates referenced above.”

“Based on clinical record review and staff interviews, it was determined that the Interdisciplinary Group (IDG) failed to ensure inclusion of spiritual care services in the plan of care and did not demonstrate involvement of a chaplain or spiritual counselor in 2 (#2 and #10)) of 14 (#1-14) clinical records reviewed. This failure to address the patient’s spiritual needs has the potential to impact all patients on census and may result in unmet patient and family spiritual needs. Additionally, this deficiency may place patients and/or families at risk for inadequate coping with end-of-life issues and insufficient emotional and supportive care. Findings follow: A review of clinical record #2, with a start of care (SOC) date of 02/22/26, revealed a patient diagnosed with Congestive Heart Failure. Review of a document titled “Interdisciplinary Team Meeting,” dated 03/10/2026 showed no evidence of chaplain or spiritual counselor involvement in the development of the patient’s plan of care.A review of clinical record #10, with a SOC date of 02/20/26, revealed a patient diagnosed with Malignant Neoplasm of Right Kidney. Review of a document titled “Interdisciplinary Team Meeting,” dated 03/10/2026 showed no evidence of chaplain or spiritual counselor involvement in the development of the patient’s plan of care.On 03/20/26 at 12:30 PM, Agency Personnel #1 and #2 confirmed there was no documented evidence of chaplain or spiritual counselor involvement in the development of the patient’s plan of care.”