Madrone Hospice, Inc.

“Based on interview, and record review, the agency failed to ensure the plan of care (a personalized, doctor approved roadmap outlining the specific medical services, goals, and treatments a patient receives at home) was followed for one of 19 sampled patients (Patient 4), when Patient 4 did not receive a skilled nursing (SN, services performed by or under the supervision of a licensed nurse, and included assessment of patient condition, monitoring for signs of infection, and addressing patient concerns) visit as ordered by the physician. This failure had the potential to cause a delay in needed services, which could lead to negative clinical outcomes and poor symptom management for end of life care. Findings: During a review, of the agency’s policy and procedure (P&P) titled “Implementing Care and Treatment,” dated 9/1/24, the P&P indicated, when the provision of care/treatment cannot be implemented as established on the Plan Of Care (POC), the patient’s physician will be notified. The appropriate documentation will be completed and submitted by the assigned discipline. The Clinical Manager (CM) will be notified as appropriate. Patient 4’s clinical record was reviewed. Patient 4 was admitted for hospice (end of life care) services on 10/2/25, for diagnoses that included chronic obstructive pulmonary disease (COPD, a progressive lung disease that makes it hard to breathe), sleep apnea (a common, serious disorder when breathing repeatedly stops and starts during sleep), mild cognitive impairment (a slight decline in memory, thinking process and decision making such as planning and judgement), acquired absence of cervix and uterus (surgical removal of female reproductive organs due to cancer or other complications), carpal tunnel syndrome of bilateral upper limbs (common, painful condition caused by compression of nerves in the hands or wrists that can include numbness, tingling, and weakness in the thumbs and fingers), and spinal stenosis (narrowing of the spinal region that puts pressure on the spinal cord and nerves, causing pain, numbness, tingling and muscle weakness). During a record review, a document titled, “Hospice Plan of Care,” dated, 10/2/25, indicated that the frequency ordered for Patient 4 was SN to complete two visits weekly through 12/20/25, and six as needed visits for complications or support. During a record review, of Patient 4’s clinical record, there was only one SN visit completed for week of 10/12/25, completed on 10/15/25, but no other SN visits completed, and no documentation of a SN visit attempted, or that the physician was updated of a missed visit per the POC. During an interview, on 5/5/26 at 4:42 pm, the Clinical Manager (CM) confirmed, that Patient 4 missed a SN visit the week of 10/12/25, and the POC was not followed, and the physician had not been updated of this change. CM stated, “Usually there is a note for communication, but I cannot find any documentation the visit was attempted, or the physician was notified of the change in frequency for Patient 4.””

“Based on observation, interview, and record review, the facility failed to ensure that all aspects of the Infection Control Program were carried out when five out of ten reviewed employee files did not contain documentation that staff had completed infection control orientation training, two of ten employee files did not contain documentation of up to date tuberculosis (a highly contagious respiratory disease) testing, and the medical supplies closet contained two catheters (tube inserted into the bladder to remove urine) that were expired. These failures had the potential to place patients at increased risk for infections, which could lead to negative clinical outcomes. The facility’s policy titled, “Equipment and Supply Maintenance,” dated 2/1/26, indicated that the hospice may choose to obtain and store a limited amount of supplies for staff and patient use on the facility site. Supplies will be checked for expiration date prior to use. If out of date, the supplies will be discarded. During a concurrent observation, and interview, with the Executive Director (ED) on 5/7/26 at 10:50 am, in the medical supply closet two items were confirmed expired. One Bardex Foley Catheter, expired 10/19/24, and one Magic3 coude catheter expired 3/28/26. The ED confirmed that both items were expired, and in supplies that staff would utilize for patient care. The ED stated that all employees are responsible for ensuring that expired supplies are not utilized. The facility’s policy titled, “Selection of Agency Staff,” dated 9/26/23, indicated that the initial health examination will include a tuberculosis screening. Tuberculosis screening will occur annually thereafter. During a concurrent interview, and record review, with Human Resources (HR) on 5/6/26 at 3 pm, employee files were reviewed. HR confirmed that Licensed Nurse (LN) K did not have documentation indicating she had completed the facility’s infection control orientation training. HR confirmed that, the Clinical Manager did not have documentation indicating she had completed the facility’s infection control orientation training. During a concurrent interview, and record review, with ED on 5/7/26 at 2:20 pm, employee files were reviewed. ED confirmed, that Speech Therapist (ST)’s employee file indicated her last TB test was 5/30/23, and Physical Therapist (PT)’s employee file indicated her last TB test was on 12/21/22. ED reviewed the employee file for for herself, and confirmed her employee file did not contain documentation that she had completed the facility’s infection control training. ED reviewed the employee file for ST’s and confirmed her employee file did not contain documentation that she had completed the facility’s infection control training. ED reviewed the employee file for PT and confirmed her employee file did not contain documentation that she had completed the facility’s infection control training. ED confirmed that the facility’s expectation is for all staff to complete the infection control orientation training, and to have a TB test upon hire, and then annually.”