Arkansas Hospice Inc.

“Based on clinical record review and staff interview, it was determined the agency failed to include all medications utilized by the patient on the medication list in 1 (#15) of 27 (#1-#27) clinical records reviewed. This failed practice by the agency resulted in an inaccurate and incomplete clinical record and presented a risk to all patients on current census as the failure to include all medications could potentially inhibit the patient’s attending physician from making an informed decision regarding the patient’s medication regimen related to potential adverse effects, drug reactions, significant side effects or significant drug interactions. Findings follow: Review of clinical record #15 with a start of care of 10/14/24 revealed a patient with a diagnosis of Malignant Neoplasm of the Prostate. On a form titled “;Visit Note Report” and dated 10/22/24 the skilled nurse documented orders received for “;Guaifenesin 600 mg Q6H (every 6 hours) as needed for cough”. Review of a form titled “Client Medication Report” failed to include the medication Guaifenesin. There was no documentation in the chart to indicate that Guaifenesin had been checked for actual or potential drug interactions that Guaifenesin had been checked for actual or potential drug interactions. An interview on 11/08/24 at 4:00 PM with personnel #1 confirmed that Guaifenesin was not included on the medication profile and no evidence the new medication was checked for actual or potential drug interactions.”

“Based on clinical record review and staff interview, it was determined the agency failed to ensure that the hospice interdisciplinary group (IDG) and attending physician had skilled nurse (SN) comprehensive assessment updates in 2 (#15 and #20) of 27 (#1-#27) clinical records reviewed. This failed practice by the agency resulted in an inaccurate clinical record and presented a risk to all patients on current census as the failure to include information on the patients changes in treatment plan or response to treatment had the potential to prevent the IDG and physician from implementing changes to the patients plan of care based on current and complete assessment updates. Findings follow: Review of clinical record #15 with a start of care of 10/14/24 revealed a patient with a diagnosis of Malignant Neoplasm of the Prostate. A document titled “;HOSPICE CERTIFICATION AND PLAN OF CARE” with certification period of 10/14/24 to 01/11/25 revealed orders “;TO INSERT/MAINTAIN INDWELLING CATHETER”. Review of a document titled “;Client Coordination Note Report” and dated 10/22/24 revealed “;PATIENT PULLED FOLEY OUT WITH BULB INTACT” and “;DTR (daughter) WOULD LIKE TO KEEP OUT”. Review of a form titled “IDG SUMMARY REPORT” dated 10/29/2024 failed to include change in urinary continence status. No evidence the attending physician or IDG aware of change in patients treatment plan. Review of clinical record #20 with a start of care of 10/08/24 revealed a patient with a diagnosis of Malignant Neoplasm of Endometrium. Review of a document titled “;Patient Information Report” revealed coordination note dated 10/16/24 “;PT HAD PLEURX DRAIN PLACED ON 10/14/24 AND PROCEDURE WENT WELL. DRESSING WAS STILL INTACT”. Review of forms titled “;IDG SUMMARY REPORT” and dated 10/18/24 failed to include change in patients condition. No evidence the attending physician or IDG aware of change in patients treatment plan. An interview on 11/08/24 at 10:00 AM with personnel #1 confirmed the patients plan of care failed to include the SN comprehensive assessment updates.”

“Based on clinical record review and staff interview, it was determined the agency failed to follow the attending physicians orders contained in the Plan of Care (POC) for 3 (#1, #3, and #11) of 27 (#1 - #27) clinical records reviewed. This failed practice had the potential to place all patients on current census at risk for adverse outcomes related to lack of interventions being performed as the physician ordered. Findings follow: Review of clinical record #1 with a start of care (SOC) of 10/16/24 revealed a patient with a diagnosis of Parkinson’s. A document titled “Aide Care Plan Report” showed orders for a home health aide (HHA) effective 10/20/24 “;5X’S A WEEK AND PRN (Five times a week and as needed)”. 1 aide visit missed the week of 10/20/24-10/26/24 and 1 aide visit missed the week of 10/27/24-11/02/24. No evidence the attending physician was notified of the missed visits. Review of clinical record #3 with a SOC of 08/13/24 revealed a patient with a diagnosis of Hemiplegia following Cerebral Infarction. A document titled “;Hospice IDG Comprehensive Assessment and Plan of Care Update Report” with a benefit period of 10/20/2024 to 12/18/2024 revealed an order for “;SN (skilled nurse) 1X WEEKLY & PRN (as needed)”. No SN visit made the week of 10/27/24-11/02/24. No evidence the attending physician was notified of the missed visit. Review of clinical record #11 with a SOC of 09/24/24 revealed a patient with a diagnosis of Candidal Endocarditis. A document titled “;Order Number: 364272” and dated 10/3/2024 revealed an order to INCREASE CNA (certified nurse aide) VISITS TO 5X WEEKLY (Five times a week)”. 1 aide visit missed the week of 11/06/24-11/12/24. No evidence the attending physician was notified of the missed visit. An interview on 11/08/24 at 10:00 AM with personnel #1 confirmed the agency failed to complete the SN and HHA visits as ordered by the physician.”

“Based on clinical record review and staff interview, it was determined the agency failed to develop an individualized plan of care in 1 (#20) of 27 (#1-#27) clinical records reviewed. This failed practice could result in potential harm for all patients on census in that, the agency did not obtain individual and specific orders to address the patient’s specific needs. Findings follow: 1. Review of clinical record #20 with a start of care of 10/08/24 revealed a patient with a diagnosis of Malignant Neoplasm of Endometrium. A. Review of a document titled “;Patient Information Report” revealed coordination notes dated: a. 10/16/24 “;PT HAD PLEURX DRAIN PLACED ON 10/14/24 AND PROCEDURE WENT WELL. DRESSING WAS STILL INTACT” b. 10/24/24 “;REMOVED DRESSING AND SITE WAS WNL (within normal limits). DRAINED 1600ML (milliliter) THIN BLOODY DRAINAGE. PATIENT COMPLAINED OF FEELING WEAK, “;ODD” AT END OF DRAINING.” c. 10/26/24 “;PT (patient) WAS DRAINED ON MONDAY AND ALMOST 2L(liter) WAS TAKEN. PT DID NOT TOLERATE THE FLUID SHIFT WELL. AT THIS TIME, APPROXIMATELY 1L WAS DRAINED AND PT TOLERATED WELL.” AND “;DRESSING WAS ALSO CHANGED.” d. 10/28/24 “;DRESSING WAS STILL INTACT AT THIS TIME. 400ML OF DRAINAGE WAS REMOVED VIA PLEURX DRAIN.” e. 11/04/24 “;DRESSING WAS STILL INTACT. AT THIS TIME 700ML OF DRAINAGE WAS REMOVED VIA PLEURX DRAIN.” B. Review of a document titled “;IDG SUMMARY REPORT” and dated 11/01/24 revealed the Registered Nurse documented “;CHANGES TO PLAN OF CARE SINCE LAST IDG: FOCUSED VISIT ADDED D/T (due to) MAINTENANCE OF PLEURX DRAIN.” C. No evidence of specific or individualized orders drainage of, site care, dressing change or maintenance of pleurx drain 2. An interview on 11/08/24 at 10:00 AM with personnel #1 confirmed the agency failed to individualize the patients plan of care.”

“Based on clinical record review and staff interview, it was determined the agency failed to conduct a spiritual needs assessment of the patients/families in 2 (#11 and #21) of 27 (#1 - #27) clinical records reviewed. This failed practice prevented the agency from having a clear understanding of the patients/familys religious beliefs and/or spiritual needs and had the potential to place all patients/families on current census at risk of failure to provide relief from spiritual and/or emotional needs or conflicts. Findings follow: Review of clinical record #21 with a SOC of 06/14/24 revealed a patient with a diagnosis of Liver Cell Carcinoma. No evidence to indicate the agencys Chaplain assessed the patients or familys spiritual needs. Review of clinical record #11 with a SOC of 09/24/24 revealed a patient with a diagnosis of Candidal Endocarditis. No evidence to indicate the agencys Chaplain assessed the patients or familys spiritual needs. An interview on 11/08/24 at 4:00 PM with personnel #1 confirmed the agency failed to assess the patients or familys spiritual needs.”

“Based on clinical record review and staff interview, it was determined the Registered Nurse (RN) failed to supervise and assess the quality of care and services through supervisory aide visits (SAV) every 14 days in 2 (#11 and #19) of 21 (#1,#3, #4, #5,#7, #8, #9, #11, #12, #13, #14, #15, #16, #18, #19, #22, #23, #24, #25, #26, and #27) current patients records reviewed with Hospice Aide (HA) services. This lack of supervision by the RN had the potential to place all patients receiving HA services at risk for adverse outcomes due to possible delays in the discovery of noncompliance with the Plan of Care by the HA or possible changes in the needs of the patient and family. Findings follow: Review of clinical record #11 with a start of care (SOC) of 09/24/24 and a diagnosis of Candidal Endocarditis showed an order for HA services dated 10/01/24. The RN documented on a form titled “;Visit Note Report” SAVs conducted on 10/07/24 and 10/24/24 (3 days past the 14-day time frame). Review of clinical record #19 with a SOC of 09/12/24 and a diagnosis of Neoplasm of Unspecified Behavior of Brain showed orders for HA services 3 times per week. The RN documented on a form titled “;Visit Note Report” SAVs conducted on 09/13/24 and 10/02/24 (5 days past the 14-day time frame). An interview on 11/08/24 at 4:00 PM with personnel #1 confirmed the agency failed to conduct an aide supervisory visit every 14 days as required.”