Hospice of Presbyterian

“It is required that the hospice Interdisciplinary Group, in consultation with the individual’s attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed revealed that the agency did not ensure the interdisciplinary comprehensive assessment was completed within 5 days after the election of hospice. CLINICAL RECORD 12: The patient elected hospice on 07/03/2025 with a diagnosis of malignant neoplasm. The skilled nurse assessment was completed on 07/03/2025. The spiritual assessment was completed on 07/11/2025 (day 8). The clinical supervisor confirmed that there were no documented previous attempts to visit the patient from the chaplain.”

“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 an RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 4 of 19 (21%) clinical records reviewed revealed that the agency did not ensure that the registered nurse wrote the aide’s care plan in a manner that provided the aide with specific, individualized instructions. CLINICAL RECORD 1: The patient was admitted in June 2024 with Alzheimer’s disease and atherosclerotic heart disease. The plan of care for episode 05/21/25- 07/19/2025 included orders for an aide 2 times per week for eight weeks and oxygen 1-4 L as needed. The aide care plan did not indicate that the patient was on oxygen or provide the aide with any information related to the need for oxygen precautions. In an interview with the clinical manager on 07/14/2025, she reviewed the chart and confirmed that the aide’s care plan should have included information related to the patient’s oxygen, but it did not. CLINICAL RECORD 6: The patient was admitted on 07/12/2025 with a diagnosis of malignant neoplasm of the peritoneum. The plan of care dated 07/12/2025 included oxygen at 5L and care for a PleurX drain. The aide care plan did not provide the aide with any instruction or information related to the patient’s PleurX drain. CLINICAL RECORD 7: The patient was admitted on 06/18/2025 with a diagnosis of malignant neoplasm of the dome of the bladder. The initial skilled nurse assessment on 06/18/2025 revealed that the patient had a urostomy. Orders were received for aide visits 2 x a week. The aide care plan dated 06/18/2025 included a back rub, shower with assistance, and empty urinary bag. The aide care plan did not explain that the patient had a urostomy versus a penile catheter. CLINICAL RECORD 8: The patient was admitted on 07/10/2025 with a diagnosis of alcoholic cirrhosis of the liver. The SN assessment conducted on 07/10/2025 revealed that the patient had a PleurX drain, Foley catheter, coccyx wound with dressing, and oxygen. The aide’s plan of care dated on 07/10/2025 ordered a bed bath, oxygen awareness, and emptying the urinary bag. The aide’s plan of care did not provide direction related to the wound dressing or the PleurX drain. During an interview with clinical supervisor, she stated, “That makes sense, and confirmed finding.”

“It is required that each patient in the hospice inpatient facility always has an adequate supply of hot water and has plumbing fixtures with control valves that automatically regulate the temperature of the hot water used by patients. This standard was not met as evidenced by interview and observation. In 1 of 2 (50%) Inpatient units observed revealed that the agency did not ensure that the hot water temperature remained under 110 degrees. IPU 2: During the tour of IPU 2with facility maintenance staff, noted that Water temperature tested in the shared patient bathroom was noted at 116 degrees. During the tour of IPU 2, the facility maintenance employee confirmed finding and immediately turned down hot water heater.”

“It is required that patients in the hospice inpatient facility have the right to be free from restraint or seclusion, or corporal punishment; seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others, and must be discontinued at the earliest possible time. This standard was not met as evidenced by document review, interview and observation. In 1 of 2 (50%) inpatient unit patients observed revealed that the agency did not ensure that all patients were free from restraints. Clinical Record 20: Patient was admitted on 07/01/2025 to the hospice inpatient unit. The patient has a diagnosis of malignant neoplasm of the uterus and epilepsy, unspecified, without status epilepticus. The clinical record revealed that the patient was discharged from the hospital on 06/28/2025 after having bilateral nephostomy tubes placed. The patient returned to the hospital after experiencing a grand mal seizure and was discharged and transferred to the inpatient hospice unit on 07/01/2025. During a visit on 07/15/2025 at 9:15 am, the patient was observed lying in bed with four side rails raised and a 5-foot-long pad attached to the bed rails. RN stated, “Those are pads for seizures.” The nurse stated that the patient had not had a seizure since arriving at the facility. The supervisor noted that all four side rails should not be raised and will lower one immediately, which was completed. The RN removed one of the pads, which could not be positioned appropriately without the side rail being up, and replaced it with a pillow on the side of the bed in which the bottom side rail was lowered. The clinical record and plan of care did not identify seizure precautions. There were no orders for restraints or for all four bed rails to be raised. Safety precautions on the plan of care read, instruct on fall precautions, emergency disaster plan, standard precautions, trip hazards, remove throw rugs, instruct on smoke detectors, O2 safety precautions.” The clinical supervisor stated in an interview on 07/15/2025, “Oh, we should not have all four side rails up. We will take it down right now.””

“The type of technique of restraint or seclusion used is the least restrictive intervention that is effective to protect the patient, staff, or others from harm. This standard was not met as evidenced by interview and observation. In 1 of 2 (50%) Observations of IPU patients revealed that the agency did not ensure that the least restrictive intervention was used for seizure precautions. Policy and Procedures: Agency policy E.87200.604, last revised on 07/03/2023, titled “Restraints, Non-Violent/Non-Self-Destructive and Violent Self Destructive” stated in part, “Restraints may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time. Clinical Record 20: Observation visit of IPU patient on 07/15/2025 observed patient alert and oriented, lying in bed with a foam-like pad that was approximately 5 feet long by 1 foot wide, lining the entire sides of the bed attached to the four side rails that were each raised, barricading the patient in the bed. Immediately upon identification of the 4 side rails up, the clinical supervisor and RN removed one of the 5 foot pads and lowered one of the bottom side rails, and placed a pillow net to the top side rail for protection, revealing a less restrictive intervention. Clinical Supervisor stated we will take that side rail down right now. We should not have all side rails up.””

“It is required that the use of restraint or seclusion in the hospice inpatient facility is in accordance with the order of a physician authorized to order restraint and seclusion per hospice policy and state law and regulation. This standard was not met as evidenced by document review, interview and observation. In 1 of 1 (100%) patients observed in the inpatient unit with physical restraint of 4 side rails did not have a physician order for restraint. Policy and Procedures: Agency policy E.87200.604, last revised on 07/03/2023, titled “Restraints, Non-Violent/Non-Self-Destructive and Violent Self-Destructive,” stated in part, The policy requires that a physician responsible for the care of the patient order the restraint before the application of restraint. Clinical Record 20: During observation of the patient in the inpatient unit noted that the patient was lying in the bed with all four side rails raised, with 5-foot pad attached to the side rails. Review of the clinical record revealed that the patient had a grand mal seizure prior to hospice election and admission to the inpatient unit. The plan of care dated 07/01/2025 did not include seizure precautions or any interventions related to restraints or padding side rails. There were no orders in the record related to restraints. The clinical supervisor stated in an interview on 07/15/2025, “I looked at the chart, and there was no order or seizure precautions identified on the chart. This will be a good learning lesson for the staff.’”

“It is required that the medical director or physician designee is consulted as soon as possible if the attending physician did not order the restraint or seclusion. This standard was not met as evidenced by clinical record review, interview and observation. In 1 of 1 (100%) clinical record in which a restraint system was utilized on the patient revealed that the agency did not ensure that the physician was notified. Clinical Record 20: The clinical record contained no evidence that the medical director was notified that the staff were raising all four bed rails and using a five-foot pad to line each side of the bed causing a physical restraint. The Clinical Supervisor stated in an interview on 07/15/2025, “I looked at the chart and there is nothing documented about the seizure precautions or notifying the doctor.”

“It is required that when restraint or seclusion is used, documentation in the patient’s clinical record includes alternatives or other less restrictive interventions attempted, the patient’s condition or symptom(s) that warranted its use; the patient’s response to the intervention(s), including the rationale for continued use of the restraint or seclusion. This standard was not met as evidenced by clinical record review, document review, interview and observation. In 1 of 1 (100%) clinical records reviewed in which a restraint system was used revealed that the agency did not ensure that the clinical record included documentation related to other interventions attempted, rationale for initiation and continuation of restraint in the form of all four side rails raised with padding barriers. Policy and Procedures: Agency policy E.87200.604, last revised on 07/03/2023, titled “Restraints, Non-Violent/Non-Self-Destructive and Violent Self Destructive” stated in part, “K. Ongoing monitoring and assessment of a patient in restraint. 1. Determining the necessary frequency of assessment and monitoring should be individualized to the patient. L. Depending on the patient’s needs and situational factors, the use of restraint may require every 15 minutes or every 2 hours of monitoring and assessment. The minimum frequency of ongoing assessment of a restrained patient is at least every 2 hours. Clinical Record 20: The clinical record did not include documented evidence that the patient was observed regularly and at least every two hours. The clinical record contained no documentation related to all four side rails being raised. The clinical record contained no evidence of documentation related to the rationale for the use of restraints. The RN stated on 07/15/2025 that the patient had not had a seizure since being admitted to the hospice house.”