Sutter Care at Home

“Based on interview and record review, the hospice agency (HA), failed to ensure, the necessary services were provided according to accepted standards of practice to one out of three patients, (Patient 1), when the agency’s triage nurse did not follow up the replacement of Patient 1’s medical equipment for breathing and not following the agency’s policy of ordering equipment. This failure had the potential to compromise the patient’s health condition and well-being. Findings:Review of Patient 1’s hospice agency information indicated, Patient 1 was admitted to the agency on 11/12/2025 for his first hospice benefit period from 11/12/2025 to 2/9/2026, with the primary diagnosis of Parkinson’s disease (progressive disorder of the nervous system that affects movement and gets worse over time), unspecified whether dyskinesia (involuntary, erratic, and uncontrollable muscle movements) present, unspecified whether manifestations fluctuate (change continually or vary irregularly). Patient 1 passed away on 11/27/2025.Review of Patient 1’s plan of care effective from 11/20/2025 to 11/27/2025 indicated, he had an order of oxygen therapy, administer 1 to 5 liters/minute (a volumetric flow rate that measures how many liters of gas pass through a system in one minute) via nasal cannula as needed for shortness of breath. Patient 1’s planned visits include hospice aide, chaplain, medical social worker and skilled nursing.Review of Patient 1’s registered nurse A (RN A) visit notes on 11/27/2025 at 9:07 a.m., RN A visited Patient 1 because he was transitioning and for symptom management. RN A instructed the patient/caregiver, not to change the oxygen flow rate of 2 to 5 liters/minute continuously via nasal cannula, unless prescribed otherwise.During the concurrent interviews with hospice administrator (HADM) and director of patient care services (DPCS) and review of Patient 1’s clinical records on 7/20/2026 at 2:05 p.m., HADM and DPCS, both confirmed that hospice aide during the aide’s visit and family member of Patient 1 called triage and spoke with the nurse on 11/27/2025 at 10:53 a.m., informing that Patient 1’s oxygen concentrator was beeping and not working well and needed replacement. Family member of Patient 1 called back on 11/27/2025 at 8:05 p.m., reporting that they were currently using the portable oxygen emergency tank but it’s almost running out of oxygen. Triage nurse called back and spoke again to the family member of Patient 1 on 11/27/2025 between 8:05 p.m., to 8:45 p.m., informing that Patient 1 already passed away.During the further concurrent interviews with HADM and DPCS and review of Patient 1’s clinical records on 7/20/2026 at 2:26 p.m., they both verified that the triage nurse did not follow up with the equipment company regarding their request for Patient 1’s oxygen concentrator replacement. They further verified that the triage nurse did not follow the protocol of calling the equipment company, if they had not responded with the email request. They then said that they inserviced their clinicians with regards to this concern to prevent it from happening again.Review of the hospice agency’s policy titled, “Durable Medical Equipment and Supplies,” effective 3/26/2025 indicated, “To ensure that equipment and supplies are provided for hospice patients based on assessed health care needs. Equipment and supplies will be obtained through designated vendors……….Those supplies required for optimal comfort, care, and management of the hospice patient will be obtained from the hospice stock supplies or approved company……….”The Standard Operations Manual (provides interpretive guidelines and survey protocols for Medicare-certified hospices): Appendix M: Guidance to Surveyors: Hospice, §418.100(c) Standard: Services, issued on 6/7/2024 indicated, “……….(1) A hospice must be primarily engaged in providing the following care and services and must do so……….Medical supplies (including drugs and biologicals) and medical appliances……….””

“It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review, interview, and observation. In 11 of 14 (79%) clinical records reviewed of patients who received Hospice Aide services, the organization did not ensure that all written instructions were included in the aide care plan. Clinical Record 3: The patient elected hospice care on 02/24/2024. The plan of care dated 02/24/2024 ordered a continuous hydromorphone infusion via CADD Prizm Pump and continuous oxygen at 2-5 liters (L)/minute (min) per nasal cannula, titrated to the patient’s comfort. The aide care plan dated 10/16/2024 did not provide the aide with instructions or precautions for the patient’s continuous oxygen or the CADD Prizm Pump during patient care. The findings were confirmed during a joint record review and interview with the Administrator, Director of Patient Care Services (DPCS), and Clinical Managers on 12/05/2024. Clinical Record 4: The patient elected hospice care on 12/05/2023. The plan of care dated 12/05/2023 ordered oxygen 2-4L per nasal cannula for the patient’s comfort. The aide care plan dated 12/08/2023 did not provide the aide with instructions or precautions for the patient’s oxygen. The findings were confirmed during a joint record review and interview with the Administrator, Director of Patient Care Services (DPCS), and Clinical Managers on 12/05/2024. Clinical Record 6: The patient elected hospice care on 07/19/2024. The plan of care dated 07/22/2024 ordered oxygen 2-5L per nasal cannula for the patient’s comfort. The aide care plan dated 07/22/2024 did not provide the aide with instructions or precautions for the patient’s oxygen. The findings were confirmed during a joint record review and interview with the Administrator, Director of Patient Care Services (DPCS), and Clinical Managers on 12/05/2024. Clinical Record 10: The patient elected hospice care on 05/02/2023. The plan of care dated 10/23/2024 documented a right hip unstageable pressure ulcer requiring wound care dressing changes twice weekly. The aide care plan dated 12/20/2023 had not been updated to include instructions for the patient’s right hip wound dressing should the dressings become wet or dislodged during bathing. The findings were confirmed during a joint record review and interview with the Administrator, Director of Patient Care Services (DPCS), and Clinical Managers on 12/05/2024. Clinical Record 15: The patient elected hospice care on 08/28/2024. The plan of care dated 11/26/2024 documented a laceration to the left arm with wound care (effective 11/19/2024). The aide care plan dated 08/30/2024 had not been updated to include instructions for the patient’s left arm wound dressing should they become wet or dislodged during bathing. The findings were confirmed during a joint record review and interview with the Administrator, Director of Patient Care Services (DPCS), and Clinical Managers on 12/05/2024. Clinical Record 16: The patient elected hospice care on 08/13/2024. The plan of care dated 11/11/2024 ordered oxygen 2-5L/min per nasal cannula for the patient’s comfort. The aide care plan dated 09/30/2024 did not provide the aide with instructions or precautions for the patient’s oxygen. Additionally, the aide care plan did not include instructions for the patient’s weeping and edematous lower extremities during personal care and bathing, which had been written in a physician’s interim order, with instruction provided to facility staff on 12/04/2024. The findings were confirmed during a joint record review and interview with the Administrator, Director of Patient Care Services (DPCS), and Clinical Managers on 12/05/2024. Clinical Record 17: The patient elected hospice care on 11/02/2024. The plan of care dated 11/02/2024 ordered oxygen at 2L/min per nasal cannula to be used as needed for comfort. The aide care plan dated 11/05/2024 did not provide the aide with instructions or precautions for the patient’s oxygen. The findings were confirmed during a joint record review and interview with the Administrator, Director of Patient Care Services (DPCS), and Clinical Managers on 12/05/2024. Clinical Record 18/Home Visit 1: The patient was admitted to hospice services on 01/11/2024. During the home visit with the Registered Nurse (RN) [Personnel Record 5] on 12/03/2024, the patient was observed to be dependent on supplemental oxygen. The plan of care effective 11/06/2024 ordered 2-4L per nasal cannula for the patient’s comfort. The aide care plan, last updated 01/12/2024, did not provide the aide with instructions or precautions for the patient’s continuous oxygen. The findings were confirmed during a joint record review and interview with the Administrator, Director of Patient Care Services (DPCS), and Clinical Managers on 12/05/2024. Clinical Record 20/Home Visit 3: The patient was admitted to hospice services on 10/04/2024. During the home visit with the Hospice Aide (HHA) [Personnel Record 7] on 12/04/2024, a wound on the patient’s left arm, which was discovered by the HHA [Personnel Record 7] on 11/29/2024, was covered with dry gauze as ordered by the physician. The aide care plan, last updated 10/15/2024, had not been updated to include instructions for the patient’s left arm wound dressing should the dressing become wet or dislodged during bathing. The findings were confirmed during a joint record review and interview with the Administrator, Director of Patient Care Services (DPCS), and Clinical Managers on 12/05/2024. Clinical Record 21/Home Visit 4: The patient was admitted to hospice services on 03/14/2023. During the home visit with the Hospice Aide (HHA) [Personnel Record 8] on 12/04/2024, the patient was observed to be dependent on supplemental oxygen. The plan of care effective 11/03/2024 ordered 2-4L per nasal cannula for the patient’s comfort. The aide care plan, last updated 07/15/2024, did not provide the aide with instructions or precautions for the patient’s continuous oxygen. The findings were confirmed during a joint record review and interview with the Administrator, Director of Patient Care Services (DPCS), and Clinical Managers on 12/05/2024. Clinical Record 22/Home Visit 5: The patient was admitted to hospice services on 01/29/2024. During the home visit with the Chaplain (CH) [Personnel Record 9] on 12/04/2024, the patient was observed to be dependent on supplemental oxygen. The plan of care dated 11/03/2024 ordered 2-4L per nasal cannula for the patient’s comfort. The aide care plan dated 10/16/2024 did not provide the aide with instructions or precautions for the patient’s continuous oxygen. The findings were confirmed during a joint record review and interview with the Administrator, Director of Patient Care Services (DPCS), and Clinical Managers on 12/05/2024.”