Passion Hospice

“Based on observation, interview, record review, and agency policy review, the hospice agency failed to ensure the facility interdisciplinary group (IDG) updated the comprehensive assessment to reflect the accurate code status for one of 14 current patients (Patient (P) 2) reviewed from a total sample of 14 patients. This had the potential to affect the planning of appropriate/anticipated care needs for the 24 patients who were currently receiving hospice services and all future hospice patients/patient family units. Findings include: Review of the electronic medical record (EMR) revealed P2 was admitted to the hospice agency on 01/09/24 with a diagnosis of Alzheimer’s disease. Review of P2’s EMR revealed P2 was admitted with a “Full Code” status, which meant in the event of cardiac arrest P2 would have cardiopulmonary resuscitation (CPR), ventilator support and other life saving measures done. The hospice agency “Face Sheet,” as of 11/21/24, reflected that P2 had a “Full Code” status. Continued review of P2s EMR revealed the IDG meeting dated 06/26/24 indicated Social Worker (SW) 2 was “. . . attempting to collect power of attorney (POA) paperwork . . .” Additional review of P2s EMR revealed two documents, POA paperwork and a completed Do Not Resuscitate (DNR) form were obtained, scanned, and uploaded to P2s EMR by the hospice agency on 06/13/24. The POA paperwork and DNR were signed by P2s family member on 06/13/24 and indicated a “DNR” status had been chosen for P2. P2s POC, dated 11/11/24, reflected that P2 had a “Full Code” status, and no POA paperwork had been received by the hospice agency as SW2 was “. . . attempting to collect POA paperwork. . .” Observation during a home visit on 11/22/24 at 9:00 AM revealed P2s hospice binder did not contain the DNR form. Review of the group home documentation for P2 revealed they identified P2 as a DNR. During an interview on 11/22/24 at 9:00 AM, RN1 stated P2 was a “Full Code.” RN1 was unaware that P2s family member had signed a DNR on 06/13/24. RN1 was unable to state which nurses signature was on the DNR form. During an interview on 11/22/24 at 9:15 AM, the owner of the group home confirmed P2 had a DNR order in place and provided the original DNR form to this surveyor. It was noted the DNR form had been scanned and uploaded to P2s EMR in June 2024. During an interview on 11/22/24 at 11:30 AM, SW1 stated the IDG reviewed uploaded documents in all patients’ EMRs at each meeting and made changes or adjustment, to a patients plan of care as needed. SW1 stated he/she was unaware that SW2 had not identified that P2s POA paperwork and DNR form had been uploaded to P2s EMR and stated, “This was an oversight by the IDG as a whole.” Review of the agency policy titled, “Do Not Resuscitate/Do Not Intubate Orders,” dated 02/05/24, revealed “. . . Upon receipt of a DNR/DNI order, the following documentation will occur in the clinical record: A) A summary of the medical situation, including the Case Managers discussion with the attending physician and a statement of the therapeutic plan for comfort care. B) An account of the discussion with the patient and/or legal representative, preferably by the attending physician. C) The DNR/DNI order will be clearly identified in the clinical record. D) A copy of the DNR/DNI will be kept in the patients home . . . and DNR/DNI status will be communicated as follows: the Case Manager will notify other personnel involved in the case within 24 hours . . . All communication between the organization personnel and the patient and family/caregiver regarding resuscitation of the patient will be documented in the clinical record . . .””

“Based on observations, interviews, record review, and facility policy review, the hospice agency failed to provide assistance with activities of daily living (ADLs) in a manner to prevent cross-contamination for one of 14 patients (Patient (P) 2) in the sample. Specifically, the facility failed to ensure proper hand hygiene and glove usage was implemented during assistance with ADLs. Findings include: Review of P2’s undated “Start of Care” document, provided by the facility, indicated he/she was admitted to hospice services on 01/09/24 with a primary diagnosis of Alzheimer’s disease and comorbidities including encephalopathy and depression. He/She resided in an adult care home where staff provided ongoing assistance with ADLs, and hospice aides visited three times per week for showering and other ADL assistance. Review of P2’s “Plan of Care,” located in the EMR under the “Certification/Care Plans” tab and effective 04/18/24, included assistance with showering, skin care, clothing assistance, oral care, and bathroom assistance. Review of Licensed Nurse Aide (LNA) 1’s personnel record review confirmed that he/she was hired on 03/05/24. LNA1’s “Team Member Education Record,” dated 03/28/24 and provided by the agency, included an infection control course. During an observation on 11/22/24 at 9:15 AM, P2 was assisted from his/her bed to the shower chair by LNA1 and an adult care home staff member. LNA1 applied hand sanitizer, allowed it to dry, and then donned gloves. LN1 rolled P2 to the shower room and proceeded to remove P2’s pants and soiled brief. The brief was soaked with urine and feces. LNA1 used wipes to clean feces from P2. LNA1 then removed P2’s shirt and rolled her into the shower. LNA1 did not perform hand hygiene or remove soiled gloves. LNA1 then proceeded to wash P2’s face with a clean soapy washcloth and then washed the rest of her body. LNA1 towel dried P2 and asked the adult care home staff member to prepare P2’s dentures by applying adhesive paste. The dentures were then handed to LNA1 at which time she inserted the dentures into P2’s mouth. P2 was dressed and assisted to the main living area for breakfast. LNA1 kept the same pair of gloves on from the time she assisted her out of bed, during incontinence care, showering, dressing, denture insertion, and ambulation to the living area. During an interview on 11/22/24 at 9:30 AM, the Director of Nurses (DON) confirmed that aides were to perform hand hygiene after providing incontinent care and then immediately after showering and before inserting dentures. The DON stated that after an aide removed their gloves, they should perform hand hygiene prior to donning clean gloves. During an interview on 11/22/24 at 9:40 AM, LNA1 confirmed that he/she had not changed his/her gloves or performed hand hygiene during ADL assistance for P2. He/She stated that when he/she showered P2, his/her gloves were rinsed off and that he/she was not trained to perform hand hygiene or change his/her gloves after providing incontinent care. During an interview on 11/22/24 at 3:30 PM, the Administrator confirmed that it was his/her expectation that aides perform hand hygiene prior to donning gloves and after doffing gloves. The Administrator confirmed gloves should be changed after providing incontinent care, after showering, and before inserting dentures. Review of the facility’s policy titled, “Infection Control and Prevention,” dated 2016, revealed, “. . . Proper hand hygiene is one component of standard precautions . . . Specific times in which hand hygiene with either hand washing or the use of an alcohol-based hand rub is required includes . . . After contact with any blood, body fluid, mucous membrane, non-intact skin, or intact skin . . . Another component to standard precautions used to break the chain of infection is wearing personal protective equipment or PPE to provide an additional barrier between you and potentially infectious material. PPE use is not a substitute for proper hand hygiene however. Remember, you must always perform hand hygiene before applying and after removing PPE. Be sure to change your PPE between tasks and procedures involving the same individual. For example, if you help . . . use the toilet then move to assisting him with brushing his teeth, you should remove your gloves, perform hand hygiene, and apply new gloves . . . Immediately change PPE if it becomes soiled or torn . . . Never wash and reuse PPE . . .””