Legacy Hospice of North Arkansas

“Upon patient record review, 4 of 23 (Patient #3, 9, 10, 13) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient 03: The medication profile includes Diclofenac 1% topical gel, apply to both knees topically as needed, there is no indication for use. (Corrected on site.) Patient 09: The medication profile includes Permethrin 1% topical liquid, apply to affected area, the site of application is no specified. (Corrected on site.) Patient 10: The medication profile includes Nystatin-Triamcinolone 100,000u/g - 0.1% topical cream, apply to affected area twice daily PRN for redness or itching, it does not include an application site. The medication profile includes Mupirocin 2% topical ointment, apply to affected area twice a day, it does not include an application site. (Corrected on site.) Patient 13: The medication profile includes Hydrocortisone topical cream 2.5%, apply to affected area four times daily as needed for rash, it does not include an application site. (Corrected on site.)”

“Upon patient record review, 3 of 23 (Patient #2, 4, 16) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient’s family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient 02: The patient was admitted on 1/24/22, the record does not include a bereavement assessment completed to date. Patient 04: The patient was admitted on 3/12/22, the bereavement assessment was completed on 4/1/22. Patient 16: The patient was admitted on 2/7/23, the bereavement assessment was completed on 10/17/23.”

“Upon patient record review, 5 of 23 (Patient #3, 4, 5, 8, 18) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 03: The patient was admitted on 3/14/24 with a primary diagnosis of osteomyelitis, the patient record includes evidence that the patient has pain that is managed with acetaminophen, Dilaudid, Fentanyl, diclofenac, and lidocaine, the plan of care does not include a problem statement with interventions and goals for the pain management. The patient has Type II DM and moderate protein calorie malnutrition with poor appetite. The DM is being managed with Lantus, Novolin R and Glipizide, the plan of care does not include a problem statement with interventions and goals for the management of the DM and nutritional issues. The patient has a history of frequent anxiety and uses lorazepam 0.5mg every 4 hours as needed, the plan of care does not include a problem statement with interventions and goals for the management of the anxiety. (Updated at the time of survey.) Patient 04: The patient was admitted on 3/12/22 with a primary diagnosis of cerebral infarction due to thrombosis of basilar artery, the patient requires oxygen for respiratory support and has a tracheostomy, the plan of care does not include a problem statement with interventions and goals for managing the respiratory conditions. (Updated at the time of survey) Patient 05: The patient was admitted on 5/5/23 and takes Xarelto, a blood thinner. The plan of care does not include precautions for bleeding risks. (Updated at the time of survey) Patient 08: The patient was admitted on 2/15/24 and the patient record indicates that she has a colostomy in place, the plan of care includes a problem statement for the altered gastrointestinal issue, but it does not include interventions and goals for the management of the colostomy. (Updated at the time of survey.) Patient 18: The patient was admitted on 3/5/24 with a diagnosis of toxic liver disease with ascites, the initial plan of care does not include a problem statement with interventions and goals for the management of the ascites.”

“Upon patient record review, 4 of 23 (Patient #3, 9, 10, 13) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 03: Medication order on 3/14/24 for Diclofenac 1% topical gel, apply to both knees topically as needed, does not include an indication for use. (Order correction completed on site.) Patient 09: Medication order on 9/22/23 for Permethrin 1% topical liquid, apply to affected area, does not include an application site. (Order correction completed on site.) Patient 10: Medication orders on 2/1/24 for Mupirocin 2% topical ointment, apply to affected area twice a day, does not include an application site. Medication orders on 2/28/24 for nystatin-triamcinolone 100,000u/g - 0.1% topical cream, apply to affected area twice daily PRN for redness or itching, does not include an application site. (Order correction completed on site.) Patient 13: Medication orders on 1/19/24 for Hydrocortisone topical cream 2.5%, apply to affected area four times daily as needed for rash, does not include an application site. (Order correction completed on site.)”

“Upon patient record review, 7 of 23 (Patient #2, 4, 5, 9, 10, 13, 15) did not have evidence that a revised plan of care includes information from the patient’s updated comprehensive assessment and must note the patient’s progress towards outcome/goals from the plan of care. Patient 02: The patients primary diagnosis was changed to Alzheimer’s disease with late onset (G30.1) on 11/3/22, the revised plan of care does not include a problem statement with interventions and goals for the management of the neurological condition. (Corrected and updated on site.) Patient 04: The patient record includes evidence that the patient has a tracheostomy and requires frequent suction and management of the airway. The patient was treated for a trach infection with Clindamycin 300 mg TID x 7 days on 1/25/24 and an upper respiratory infection on 3/12/24 with Doxycycline 100mg BID x 7 days, the plan of care does not include a problem statement with interventions and goals for the airway management. Patient 05: The patient receives monthly visits for Spiritual Care support, the plan of care does not include addressed needs with interventions and goals for care. (Corrected and updated on site.) Patient 09: The patient record includes new orders on 10/17/23 for “Thick it” to be added to patient liquids due to aspiration risks, the documentation reports the patient has cachexia/anorexia, the plan of care is not updated to include a problem statement with interventions and goals for the nutritional status. (Corrected and updated on site.) Patient 10: The patient record includes orders for medication treatment and management of skin issues (rash to penis, underarms, groin and feet) starting on 2/28/24 with additional medication orders on 3/6/24, the plan of care is not updated to include interventions and goals for the treatment of the skin integrity issues. (Corrected and updated on site.) Patient 13: The patient record includes new orders on 3/13/24 for treatment of a UTI with Cephalexin 500mg TID x 10 days, the plan of care is not updated to include interventions and goals for the management and treatment of the UTI. (Corrected and updated on site.) Patient 15: On 3/2/24, the patient was started on Levaquin 750mg PO daily x 7 days for the treatment of aspiration pneumonia, the POC was not updated to include interventions and goals for the management of the infection.”

“Upon patient record review, 2 of 23 (Patient #5, 8) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient 05: The hospice aide task assignment does not include safety precautions for oxygen or bleeding (patient takes Xarelto.) (Corrected on site.) Patient 08: The hospice aide task assignment does not include safety precautions for bleeding, the patient takes Xarelto. (Corrected on site.)”

“Based on clinical record review and caregiver and staff interview, the Skilled Nurse (SN) failed to include all medications on the patient’s “Medications” list (a section of the Agency’s Care Plan containing the medication profile) in 3 (#9, #12 and #18) of 23 (#1-#23) clinical records reviewed. This deficient practice presented a potential risk to patients by delaying pertinent information to the attending Physician regarding the patients individualized medication regimen. Findings follow: 1. Review of clinical record #9 with a start of care of 12/18/23 revealed a patient with a diagnosis of End Stage Heart Failure. a. During a home visit and review of a document titled, “;Medicine List” printed on 03/13/24 with the caregiver revealed “;...Diltiazem 60mg tablet-oral 1 tablet 2 times daily...Flomax 0.4mg capsule-oral 1 capsule daily... Potassium Chloride Er [Extended Release] 20 Meq [milliequivalent]-oral 1 tablet 2 times daily...” b. The bottle for Lasix 40mg (milligrams) documented 1 tablet twice daily. The Medicine list documented 1 tablet daily. A physicians order dated 02/12/24 documented decrease Lasix to once daily. c. The caregiver stated the Lasix has been decreased to once daily. The caregiver stated, “;The hospital told us to not give him the Diltiazem and hospice told us to not give him Flomax.” The caregiver further stated, “;I was wondering why the Potassium wasnt cut back too since the Lasix was cut back.” d. During the home visit, Employee #4 looked in the laptop physicians medicine list and stated, “;the Potassium is once a day.” She further stated, “;Ill call the physician and get all the medicines reconciled.” 2. Review of clinical record #12 with a start of care of 02/12/24 revealed a patient with a diagnosis of Morbid Obesity with Alveolar Hypoventilation. a. Review of a document titled “Client Coordination Note Report” and dated 03/06/24 revealed an increase in patients pain medication. Fentanyl increased from 75micrograms/hour (mcg/hr) transdermal patch every 72 hours to 100 mcg/hr transdermal patch every 72 hours. Added Oxycodone 10 milligrams every 8 hours as needed for breakthrough pain. b. Review of a document titled “Client Medication Report” failed to include Fentanyl and Oxycodone on patient’s list of current medication. 3. Review of clinical record #18 with a start of care of 03/01/24 revealed a patient with a diagnosis of Moderate Protein-Calorie malnutrition. a. Review of a document titled “;HOSPICE CERTIFICATION AND PLAN OF CARE” with a certification period of 03/01/24-05/29/24 revealed DME (Durable Medical Equipment) and supplies included oxygen supplies. b. Review of a document titled “Visit Note Report” and dated 03/01/24 revealed types of treatment for shortness of breath included utilization of oxygen. c. Review of a document titled “Client Medication Report” failed to include oxygen on the patient’s list of current medication. 4. On 03/14/24 at 10:40 am Agency administrative staff were asked to provide any further documentation regarding the failure to include all medications on the patient’s current list of medications. No additional information provided.”

“Based on clinical record review and personnel interview, it was determined the Agency did not ensure all orders were complete and accurate in 2 (#1 and #5) of 3 (#1, #2 and #5) records reviewed with pressure ulcers, 1(#18) of 8 (#2, #3, #4, #9, #12, #14, #16, and #18) records reviewed with oxygen orders and 3 (#4, #5, #12 and #18) of 6 (#1, #4, #5, #6, #12, #18) records reviewed with urinary catheter orders. 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 #1 with a start of care of 01/25/24 revealed a patient with a diagnosis of Malignant Neoplasm of Vertebral Column. a. Review of a document titled “;Hospice Certification and Plan of Care” revealed, “;... Orders of Discipline and Treatments: ... Facility Nurse to perform wound care to all wounds per wound care orders. Instruct Caregiver in wound care...DME and Supplies [no wound supplies listed] ...” b. Review of a document titled “;Hospice IDG [Interdisciplinary Group] Comprehensive Assessment and Plan of Care update Report” dated 03/01/24 revealed, “;...Hospice Physician...He has wounds requiring daily dressing changes...Registered Nurse [no pressure ulcer notation] ...Medication List [no wound orders] ...” 2. Review of clinical record #4 with a start of care of 01/27/24 revealed a patient with a diagnosis of Hepatic Failure without coma. a. Review of a document titled “;Hospice Certification and Plan of Care” revealed, “;...Orders of Discipline and Treatments: ... Hospice nurse to insert/Maintain indwelling catheter -FR -CC balloon, may irrigate with sterile water. Change catheter every month or as needed...” b. There was no evidence of an order that specifies type and size of catheter, how much sterile water to use as a flush and when. 3. Review of clinical record #5 with a start of care of 03/08/24 revealed a patient with a diagnosis of Moderate Protein-Calorie Malnutrition. a. Review of a document titled “;Visit Note Report” dated 03/08/24 revealed, “;...RN Hospice Start of Care...Integumentary [Skin]...Number of Pressure ulcers- stage 3 ONE...” The wound assessment section of the Visit Note Report dated 03/08/24 documented, “;...Mid-UP [upper] buttock, LT [left] PR [pressure ulcer] stage III...cleanse with wound cleanser patted dry apply Mesalt cover with a foam border dressing...” In addition, it was noted, “;.... Genitourinary...patient requires a urinary catheter...inserted 03/04/24...catheter size 16 Fr...” b. Review of a document titled “;Hospice Certification and Plan of Care” revealed, “;...Skilled nursing to provide wound care per orders...” There was no evidence of an order for Mesalt dressing change and how frequently. Additionally, there was no evidence of an order for the catheter including the type, size, or frequency of catheter changes. 4. Review of clinical record #12 with a start of care of 02/12/24 revealed a patient with a diagnosis of Morbid Obesity with Alveolar Hypoventilation. a. Review of a document titled “Client Coordination Note Report” and dated 02/22/24 revealed patient had “;INDWELLING CATHETER IN PLACE” and patients husband reported catheter was due to be changed. Registered Nurse (RN) attempted to “;PLACE 16F WITH 30ML BULB” but was unable to replace and left catheter out. b. Review of a document titled “Client Coordination Note Report” and dated 02/23/24 revealed RN replaced catheter with “;20F 30ML foley” and taught catheter care and irrigation prn (as needed). c. Review of a document titled “Client Coordination Note Report” and dated 02/26/24 revealed RN removed previous foley catheter placed and “;ONE UNSUCCESSFUL ATTEMPT TO PLACE 24F 30-50ML”, then “;SUCCESSFULLY PLACED 20F 30ML FOLEY”. There was no evidence of orders to specify the type, size, irrigation, or frequency of change for catheter 02/12/24-03/07/24. d. Review of a document titled “;Order Number: 162273” and an “;Order Type: HOSPICE RECERTIFICATION PLAN OF CARE UPDATE” with a certification period of 03/08/24 to 05/06/24 included orders to “;INSERT/CHANGE INDWELLING 20 FR/30 CC BALLON FOLEY CATHETER PER AGENCY PROTOCOL”. e. Review of a document titled “Client Coordination Note Report” and dated -3/08/24 “;FOLEY CATHETER WAS FLUSHED DUE TO AN INCREASE IN SEDIMENT”. No evidence of orders to irrigate foley catheter. 5. Review of clinical record #18 with a start of care of 03/01/24 revealed a patient with a diagnosis of Moderate Protein-Calorie malnutrition. a. Review of a document titled “;HOSPICE CERTIFICATION AND PLAN OF CARE” with a certification period of 03/01/24-05/29/24 revealed DME (Durable Medical Equipment) and supplies included oxygen and catheter supplies. b. Review of a document titled “Visit Note Report” and dated 03/01/24 revealed types of treatment for shortness of breath included utilization of oxygen and the patient requires a urinary catheter. There was no evidence of orders to specify the dose, route of delivery or frequency for use of oxygen, or type, size, or frequency of change for catheter. 6. On 03/14/24 at 10:40 am Agency administrative staff were asked to provide any further documentation regarding the failure to ensure all orders were complete and individualized and specific for each patient. No additional information provided.”

“Based on clinical record review and staff interview, it was determined the Agency failed to maintain coordination between all disciplines providing care to the patient in 1 (#16) of 23 (#1-#23) clinical records reviewed. This failed practice had the potential to leave patient and family needs unidentified and unmet. Findings follow: 1. Review of clinical record #16 with a start of care of 01/22/24 revealed a patient with a diagnosis of Congestive Heart Failure. Review of a document titled “;IDG (Interdisciplinary) Summary Report” and dated 02/08/24 revealed the PASTOR/COUNSELOR (Chaplain)documented “;THE PATIENT HAS NOT BEEN SEEN DURING THIS IDG PERIOD. THE NURSE DOES NOT REPORT ANY NEW SPIRITUAL ISSUES AT THIS TIME.” No documentation by Chaplain of identified spiritual problems, planned interventions, patient goals or visit frequencies. Review of a document titled “;Visit Note Report” and dated 01/24/24 revealed “;CHAPLAIN HOSPICE ADD-ON EVALUATION” visit completed by Chaplain. Review of a document titled “;IDG Summary Report” and dated 02/22/24 revealed Chaplain documented “;THE PATIENT HAS NOT BEEN SEEN DURING THIS IDG PERIOD. THE NURSE DOES NOT REPORT ANY NEW SPIRITUAL ISSUES AT THIS TIME.” Visit frequencies documented 1time per month and PRN (as needed) No documentation by Chaplain of identified spiritual problems, planned interventions, or patient goals. Review of a document titled “;Visit Note Report” and dated 02/13/24 revealed “;CHAPLAIN HOSPICE SUBSEQUENT VISIT” completed by Chaplain. Review of a document titled “;Hospice IDG Comprehensive Assessment and Plan of Care Update Report” and dated 03/07/24 revealed Chaplain documented “;THE PATIENT HAS NOT BEEN SEEN DURING THIS IDG PERIOD. THE NURSE DOES NOT REPORT ANY NEW SPIRITUAL ISSUES AT THIS TIME.” Visit frequencies documented 1time per month and PRN. No documentation by Chaplain of identified spiritual problems, planned interventions, or patient goals. Review of a document titled “;Visit Note Report” and dated 03/13/24 revealed “;CHAPLAIN HOSPICE SUBSEQUENT VISIT” completed by Chaplain. 2. On 03/14/24 at 10:40 am Agency administrative staff were asked to provide any further documentation of Chaplains involvement with updating patients plan of care or sharing information with all disciplines. No additional information provided.”

“Based on observation and interview, it was determined the agency failed to ensure optimal infection control practices were followed during a pressure ulcer dressing change for 1 of 1 (Patient #5) patients observed with a pressure ulcer. The failed practice had the potential to affect all patients on the census who have a pressure ulcer. Findings follow: On 03/13/24 at 10:50 a.m., during a home visit, Employee #3 failed to change gloves and sanitize hands after cleaning the pressure ulcer for Patient #5 and before applying a clean dressing. Employee #3 also changed the pressure ulcer dressing first and then changed the foley catheter causing urine to potentially soil the pressure ulcer dressing. On 3/14/23 at 10:30 a.m., the Interim and Regional Administrator were informed of the observation and made no comment. There was no additional information provided.”

“Based on clinical record review and caregiver and personnel interviews, it was determined that the agency failed to ensure a need of financial assistance was identified and addressed to ensure medications were available for 1 (#5) of 23 (#1-#23) records reviewed. The failed practice had the potential to affect all patients on census in that the agency did not address the issue of lack of financial means to ensure medications were purchased. Findings follow: Review of clinical record #5 with a start of care date of 3/8/24 revealed a patient with a diagnosis of Moderate Protein-Calorie Malnutrition. a. On 3/13/24 during a home visit, the primary caregiver stated, “Eliquis is going to be $280! I haven’t gotten that. I was going to give her aspirin instead.” b. A document titled, “Visit Note Report” revealed, “...MSW [Medical Social Worker] Hospice Add-On Evaluation...Medications... No problems with cost or accessing medications...” c. On 3/14/24 at 10:45 a.m., the Interim Administrator and Regional Administrator were asked for any additional information regarding this finding and none was provided.”

“Based on record review and interview, it was determined that the agency failed to offer bereavement counseling services for the family of 1 (#23) of 3 (#21, #22, and #23) expired patients’ records reviewed. This failed practice had the potential to delay the appropriate and healthy grieving process to occur for those families who have lost loved ones while under the care of the hospice agency. Findings follow: Review of clinical record #23 revealed a start of care 02/04/24 and a diagnosis of Chronic Hepatic Failure with coma. All disciplines made their initial visit on 02/05/24. The patient expired at home on 02/05/24. There were no bereavement notes or documentation in the clinical record, nor the bereavement file after 02/05/24. The policy provided by the Interim Administrator on 03/12/24 documented, “Bereavement Services...8.Within one (1) week after the death of a patient, a sympathy card will be sent to the bereaved. 9. A bereavement letter will be sent to the bereaved giving support and outlining the hospice bereavement services within one (1) month. 10. Within three (3) weeks after the patient’s death, a bereavement assessment... will be completed by the bereavement counselor following the family/caregiver. This assessment will note and observe the bereaved for symptoms related to grief...” On 03/14/23 at 10:30 a.m., the Interim Administrator and Regional Administrator were asked to provide any additional information regarding this lack of documentation. No additional information was provided.”

“Based on clinical record review and staff interview, it was determined the Agency failed to facilitate or coordinate with the patients identified local clergy to provide support of the patient and/or family spiritual needs in 2 (#2 and #9) of 23 (#1 - #23) clinical records reviewed. This lack of facilitation and coordination had the potential to affect the patients and families in obtaining relief from spiritual and/or emotional conflict to improve the quality of life for the patient and/or family. Findings follow: Review of clinical record #2 revealed start of care date of 01/05/24 and a diagnosis of Frontal lobe and Executive Function deficiency following Cerebral Infarction. The Chaplain admission narrative dated 01/08/24 revealed Patient #2 was an active member of their local church. There was no evidence of coordination from the chaplain with the local clergy to provide support of the patient and family’s spiritual needs. Review of clinical record #9 revealed start of care date of 12/18/23 and a diagnosis of End Stage Heart Failure. The Interdisciplinary Group (IDG) meeting notes on 12/22/23 revealed Patient #9 was an active member of their local church. There was no evidence of coordination from the chaplain with the local clergy to provide support of the patient and family’s spiritual needs. On 3/14/24 at 10:30 a.m., the Interim Administrator and Regional Administrator were asked to provide any additional information to demonstrate a collaboration between the Agency’s chaplain and the local clergy for these two patients. There was no additional information provided.”

“Based on record review and interview, it was determined the agency failed to obtain a required Arkansas Department of Health (ADH) letter which determines the clearance for an employee to work for 1 (Employee # 2) and did not have a required 5-year re-check for a state criminal check for 1 (Employee # 5) of 6 (Employee #1- #6) non-licensed employee records reviewed. This failed practice had the potential to affect all patients on the census list. Findings follow: The employee file of Employee #2 with a hire date of 11/06/23 noted to not have an ADH determination letter included. On 03/14/24 the Interim Administrator, via the Human Resources (HR) Department, when asked, was not able to provide the document and asked, “Chaplains have to have a determination letter?” The employee file of Employee #4 with a hire date of 02/18/08 noted to not have a state background check with an ADH determination letter in the last 5 years. On 03/14/24 the Interim Administrator, via the HR department, when asked was not able to provide the document.”