Baptist Health Hospice Little Rock

“Based on a review of clinical records and staff interviews, it was determined that the agency failed to include all medications utilized by the patient on the medication list for two (#2,#11) of nineteen (#1-#19) clinical records reviewed. This failure had the potential to impact all patients currently on census and may result in inadequate medication management, potential drug interactions, and prevent a thorough medication regimen review to ensure patient safety and effective symptom management. Findings follow: A. A review of clinical record #2, with a start of care (SOC) date of 03/08/26, revealed a patient diagnosed with Acute Respiratory Failure with Hypoxia. A review of skilled nursing visit notes revealed that on 03/08/26 the nurse documented the patient was currently utilizing oxygen. Review of a form titled, “Outpatient Medications on the Plan of Care,” did not reflect oxygen as part of the patient’s active medications. There was no documentation in the chart to indicate that oxygen had been checked for actual or potential drug interactions.B. A review of clinical record #11, with a SOC date of 02/06/26, revealed a patient diagnosed with Atherosclerosis of Native Coronary Artery. A review of skilled nursing visit notes revealed that on 02/19/26 the nurse documented “Oxygen on at 4 L (liters)at this time.” Review of a form titled, “Outpatient Medications on the Plan of Care,” did not reflect oxygen as part of the patient’s active medications. There was no documentation in the chart to indicate that oxygen had been checked for actual or potential drug interactions.C. On 04/03/26 at 1:10 PM, Agency Personnel #2 confirmed that not all medications were included on the patient’s medication list and no documented evidence in the clinical record that medications had been reviewed for actual or potential drug side effects or interactions.”

“Based on a review of clinical records, observation of Interdisciplinary Group (IDG) meeting, agency policies, and staff interviews, it was determined that the agency failed to ensure that the IDG updated and coordinated individualized plans of care in response to changes in the condition or needs of the patient in six (#2, #3, #8, #11, #13, and #16) of nineteen (#1 - #19) clinical records reviewed. This failure of the IDG to comprehensively assess, coordinate, and revise the plan of care in a timely manner placed all patients currently on census at risk for receiving care that does not reflect their current clinical status and unmet clinical, emotional, and comfort care needs. Findings follow: A. A review of clinical record #2, with a start of care (SOC) date of 03/08/26, revealed a patient diagnosed with Acute Respiratory Failure with Hypoxia. Review of skilled nursing visit notes indicated that on 03/11/26, the nurse documented that the patient’s sister reported concerns of a possible urinary tract infection (UTI), including dark urine, decreased urinary output, and elevated temperature. The nurse documented that these findings were reported to the Advanced Practice Nurse (APN), and orders were received to encourage increased water intake and decrease soda consumption. The nurse also documented a plan to increase visits to daily for close monitoring. In a subsequent skilled nursing visit note dated 03/15/26, the nurse documented that the patient’s sister reported the patient was complaining of pain associated with the Foley catheter. The APN was notified and provided an order for over-the-counter Pyridium 100 mg every 8 hours for 3 days. The nurse also documented that the urinary catheter was leaking and was flushed with sterile water. Review of the “Hospice Plan of Care Update” dated 03/18/26 revealed that the plan of care did not include the above referenced changes in patient’s condition, reported symptoms, interventions, or new orders related to urinary concerns and catheter management. B. A review of clinical record #3 with a SOC date of 02/07/26, revealed a patient with a diagnosis of Malignant Neoplasm of breast with Metastasis. Review of skilled nursing visit notes dated 02/23/26, 03/05/26, 03/29/26, and 03/26/26 that the patient had constipation and needed to have a suppository to relieve this issue. Furthermore, on 03/05/26, a new order was noted to include Lactulose every day as an intervention. The initial Hospice Plan of Care and throughout the certification period to the Hospice Plan of Care update dated 03/18/26 did not include a constipation Plan of Care. C. A review of clinical record #8, with a SOC date of 02/19/26, revealed a patient diagnosed with Severe Protein Calorie Malnutrition. Review of skilled nursing visit notes indicated that on 02/24/26, the nurse documented the patient experienced a fall that morning resulting in a skin tear to the left arm. Review of the “Hospice Plan of Care Update” dated 03/04/26 revealed no documentation of this fall or related injury. Further review of a telephone encounter note dated 03/07/26 indicated that the on-call nurse received a call from the patient’s spouse reporting that the patient was sitting on the floor and required assistance getting up. The Registered Nurse (RN) advised the spouse to call a non-emergency line for lift assistance. Prior to providing the contact number and informing the spouse that a nurse visit would be initiated for assessment, the call was disconnected. Attempts to return the call were unsuccessful. Subsequent skilled nursing visit notes dated 03/09/26 indicated that the patient’s spouse reported the patient had fallen while attempting to transfer from a recliner to a wheelchair. No injuries were reported from this fall. Review of the Hospice Plan of Care Update dated 03/18/26 revealed that none of the above fall events, interventions, or changes in patient condition were included.D. A review of clinical record #11, with a SOC date of 02/06/26, revealed a patient diagnosed with Atherosclerosis of Native Coronary Artery. Review of skilled nursing visit notes indicated that on 02/19/26, at 9:38 PM, the registered nurse (RN) received a call from the patient’s daughter reporting chest pain for 30 minutes unrelieved by two doses of nitroglycerin, shortness of breath, and increased extremity swelling. The RN instructed the daughter to administer morphine concentrate 5 mg and to call back in 10-15 minutes if symptoms persisted. The RN completed a home visit at 10:34 PM and found the patient sitting on the side of the bed, short of breath, and receiving oxygen at 4 liters. Assessment revealed periorbital edema, bilateral edema of the feet ankles, and calves and diminished lung sounds with crackles. The daughter reported the patient had a prescription for Lasix 20 mg daily as needed but had not taken it for two weeks. The Advanced Practice Registered Nurse (APRN) was notified and ordered Lasix 40 mg immediately and again the following morning, then to continue Lasix 20 mg daily. Morphine was also increased to 10 mg every 2 hours as needed for shortness of breath and pain. Review of the Hospice Plan of Care Update dated 03/04/26 revealed none of these events, interventions, or changes in patient condition were included. E. A review of clinical record #13, with a SOC date of 10/19/24, revealed a patient diagnosed with Cerebrovascular Accident. Review of skilled nursing visit notes indicated that on 02/26/26, the nurse documented the patient’s urine had a foul odor and an order was received to start Bactrim DS BID for 5 days for probable UTI. Review of the Hospice Plan of Care Update dated 03/04/26 revealed that the plan of care did not include the above reported symptoms or new orders related to urinary concerns.F. Review of Clinical Record #16 with a start of care date of 09/23/25 revealed a patient with a diagnosis of Malignant Neoplasm of the breast with metastasis to the liver, bile duct, and bone. The Skilled Nurse Hospice Visit note dated 10/02/25 documented that the patient was responsive to stimulation and unable to follow commands. The Actions/Narrative section documented the patient was “...moaning consistently...will intermittently lean forward and back...” The note documented that the liquid morphine (increased dose ordered 9/30/25) was not delivered on 10/01/25. The Skilled Nurse Hospice Visit note dated 10/03/25 documented the patient was unresponsive, unable to follow commands and was moaning loudly. On 04/08/26 at 10:31 a.m., during a phone interview, Personnel #5 was asked about the assessments, treatments and care provided in the last 2 visits of this patient’s life. She stated the patient began moaning in a rhythmic manner and it was continuous. She stated the patient’s mother administered the pain medication frequently and the increased dose of pain medications were picked up and administered by the patient’s family. These details of the nurse’s assessments and the plan of care were not documented in the medical record and therefore, the medical record was incomplete. G. A Policy and Procedure titled, “Interdisciplinary Conference/ Care Plan Update- Hospice” documented, “...The IDG...to review the care plan, identify patient, family, and caregiver problems, provide appropriate intervention, and ensure comprehensive and holistic care for patients and their families...The IDG will review and update care plans on each Hospice patient at intervals specified in the plan...” A Policy and Procedure titled, “Assessment and Reassessment” documented, “...a patient may be reassessed for a variety of reasons, including the following: 1. To evaluate response to care, treatment, and services 2. To gather information regarding onset of new symptoms or unsatisfactory symptom control...”H. On 04/03/26 at 1:10 PM, Agency Personnel #2 confirmed the agency failed to document updates to the plan of care in response to new or ongoing clinical needs.”

“Based on clinical record review, agency policy, and personnel interview, it was determined the agency failed to ensure there was an individualized plan of care for one (#16) of nineteen (#1 - #19) clinical records reviewed. This failed practice had the potential to affect all clients on census in that the direct caregivers, families, and/or responsible parties would not be aware of how and when to perform specific care tasks needed to optimize the patient’s health and prevent pain or discomfort. Findings follow: A. A review of clinical record #3 with a SOC date of 02/07/26, revealed a patient with a diagnosis of Malignant Neoplasm of breast with Metastasis. The Hospice Plan of Care documented to empty and change the dressing for the PleurX drain (an indwelling tube to drain the fluids which accumulate around the lungs) PRN (as needed) but had no specific indications or symptoms listed. Therefore, there was not a clear understanding of when to empty and change the dressing for the drain. B. A Policy and Procedure titled, “Interdisciplinary Conference/ Care Plan Update- Hospice” documented, “...The IDG...to review the care plan, identify patient, family, and caregiver problems, provide appropriate intervention, and ensure comprehensive and holistic care for patients and their families...”C. On 04/03/26 at 1:10 PM, Agency Personnel #2 confirmed the agency failed to include specific care elements in the plan of care in clinical record #3.”

“Based on a review of clinical records and staff interviews, it was determined the agency failed to include essential urinary catheter orders in the individualized plan of care for one (#2) of one (#2) clinical record reviewed for a patient requiring a urinary catheter. Specifically, the plan of care did not specify the catheter type, size, balloon volume, irrigation solution, or catheter replacement frequency. This deficient practice failed to ensure safe and appropriate catheter management and has the potential to affect all patients on census requiring a urinary catheter. The lack of complete orders increases the risk of preventable complications, including trauma and infection. Findings follow: A. A review of Clinical Record #2, with a start of care (SOC) date of 03/08/26, revealed a patient diagnosed with Acute Respiratory Failure with Hypoxia. A review of skilled nursing visit notes revealed that on 03/08/26 the nurse documented “Foley cath placed 3/8/26.” In a subsequent note dated 03/17/26 the nurse documented “catheter flushed with 10 ml (milliliter)sterile water” and “Caregiver educated on PRN (as needed) catheter flushing.” There was no documented physician orders for a urinary catheter in the plan of care or elsewhere in the clinical record.B. On 04/03/26 at 1:10 PM, Agency Personnel #2 confirmed there were no physician orders for a urinary catheter documented in the plan of care or elsewhere in the clinical record.”

“Based on a review of clinical records and staff interviews, it was determined that the agency failed to follow the written plan of care in seven (#1, #2, #7, #8, #13, #14, and #18) of nineteen (#1-#19) clinical records reviewed. This failure had the potential to impact all patients currently on census and may result in missed or delayed symptom management, ineffective care delivery, and unmet physical, psychosocial, or emotional needs. Findings follow: A. A review of clinical record #1, with a start of care (SOC) date of 03/04/26, revealed a patient diagnosed with Chronic Obstructive Pulmonary Disease. Review of a form titled “Hospice Plan of Care” revealed orders for Chaplain visits “4 visits every month for 4 months” with effective dates 03/04/2026 to 06/01/2026. Chaplain visit documented 03/05/26. Three Chaplain visits were missed during the month of March 2026.B. A review of clinical record #2, with a SOC date of 03/08/26, revealed a patient diagnosed with Acute Respiratory Failure with Hypoxia. Review of a form titled “Hospice Plan of Care” revealed orders for Chaplain visits “4 visits every month for 4 months” with effective dates 03/13/2026 to 06/05/2026. Chaplain visits documented 03/12/26 and 03/25/26. Two Chaplain visits were missed during the month of March 2026.C. A review of clinical record #7 with a SOC date of 01/20/26 revealed a patient with a diagnosis of Hypertensive Heart and Renal Disease with Congestive Heart Failure. Review of a form titled “Hospice Plan of Care” revealed orders for Chaplain visits “4 visits every month for 4 months” with effective dates 01/20/26 - 04/19/26. Chaplain visits documented 01/23/26 and 02/05/26. There were 3 missing visits in January and 3 missing visits in February. There have been no visits for the months of March. D. A review of clinical record #8, with a SOC date of 02/19/26, revealed a patient diagnosed with Severe Protein Calorie Malnutrition. Review of a form titled “Hospice Plan of Care” revealed orders for Chaplain visits “4 visits every month for 4 months” with effective dates 02/19/2026 to 05/19/2026. Chaplain visit documented 02/20/26. Two Chaplain visits were missed during the month of February 2026; Four Chaplain visits were missed during the month of March 2026.E. A review of clinical record #13, with a SOC date of 10/19/24, revealed a patient diagnosed with Cerebrovascular Accident. Review of a form titled “Hospice Plan of Care 02/18/26” revealed orders for Chaplain visits “3 visits every month for 3 months” with effective dates 02/11/2026 to 04/11/2026. No Chaplain visits documented 03/01/26-03/31/26. Three Chaplain visits were missed during the month of March 2026.F. A review of clinical record #14 with a SOC date of 02/13/26 revealed a patient with a diagnosis of Coronary Artery Disease, Congestive Heart Failure with Preserved Ejection Fraction. The Hospice Plan of Care 02/13/26 revealed orders for Chaplain visits “4 visits every month for 4 months” with effective dates 02/13/26 - 05/13/26. There was one chaplain visit on 02/17/26 and none since. This demonstrated 3 missed visits for February and 4 missed visits for March.G. A review of clinical record #18 with a SOC date of 04/08/25 and expired on 10/20/05 revealed a patient with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD). The Hospice Plan of Care Update 10/07/05 documented, “...Medications...Oxygen 2 L/min [Liters per minute] by nasal route continuous. Use oxygen first for dyspnea...” The Hospice Plan of Care Update 10/07/25 documented the goal for the Problem COPD was for the patient’s pulmonary care needs met without signs/symptoms of complications and to have “...comfort, ease of respiratory effort...” The use of oxygen was included in the list of interventions. The Skilled Nurse’s (SN) note for 10/18/25 documented an Oxygen saturation (O2 Sat) level at 78%, (>90 is normal), on 10/19/25 the SN note documented an O2 sat of 71%, and on 10/20/25 the SN note documented an O2 sat of 66%. There was no documentation that O2 was being utilized. A Policy and Procedure titled, “Death/ Terminal Care” documented, “... Care of the terminally ill patient will be directed toward providing pain management, prevention and treatment of secondary symptoms and offering support for the patient/family/caregivers in the dying and grief process until patient death...” H. On 04/03/26 at 9:05 a.m., Personnel # 2 was asked to provide any further information or documentation regarding patient #18’s Oxygen Saturation being low and any interventions to provide comfort. On 04/03/26 at 12:30 p.m., Personnel #2 stated she reviewed the patient’s records and did not have any further documentation to provide.I. On 04/03/26 at 1:10 PM Agency Personnel #2 confirmed that the Chaplain visits had been missed.”

“Based on clinical record review and personnel interview, it was determined the agency failed to ensure all the required elements were included in the discharge summary for 2 of 2 (#15 and #17) clinical records reviewed that were considered transferred or revoked closed records. This failed practice demonstrated a lack of continuity of care which could impede effective care coordination and had the potential to affect all patients that are discharged or revoke the election of hospice care and continued care is needed. Findings follow: A. Review of Clinical Record #15 with a start of care date of 01/13/26 and discharged on 01/29/26 revealed a patient with a diagnosis of Malignant Neoplasm of the breast and metastasis to both lungs and brain. The Transfer/Discharge summary provided by Personnel #2 did not include the summary of the patient’s stay. B. Review of Clinical Record #17 with a start of care date of 09/29/25 and discharged on 10/17/25 revealed a patient with a diagnosis of Metastatic Cholangiocarcinoma. The Transfer/Discharge summary provided by Personnel #2 did not include the summary of the patient’s stay. C. On 04/03/26 at 9:15 a.m., Personnel #2 was interviewed and stated there were no further details in the discharge summary to provide and agreed the receiving agency must receive the required information to facilitate continuity of care.”