Bristol Hospice Fresno

“It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as: hand hygiene. This standard was not met as evidenced by document review, interview and observation. In 1 of 6 (17%) home visit observations revealed the agency did not ensure the staff followed the hand hygiene policy. DOCUMENT 3: Agency policy, “Hand Hygiene Policy No. 7-009,” last revised 09.2024, stated in part, “Hand decontamination using an alcohol-based hand rub should be performed: before having direct contact with patients;…after contact with a patient’s intact skin (when taking a pulse, blood pressure or lifting a patient); after contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressings, if hands are not visibly contaminated; when moving from a contaminated body site to a clean body site during patient care; after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient; and after removing gloves.” HOME VISIT 2: During the home visit (Clinical Record 18) on 04/28/2026, the Hospice Aide (Personnel Record 14) (HA) was observed to don a pair of gloves, clean the right side of the patient’s body, and begin to change the sheets on the bed. The HA changed the gloves without disinfecting their hands. The HA washed the right side of the body and then emptied the water into the toilet. The HA removed the glove without disinfecting the hands, rinsed out the basin in the sink, used alcohol, and donned a new pair of gloves. The HA prepped the clean linens for the bed, removed the gloves without disinfecting the hands, and adjusted the towels that had been on the patient during the bath. The HA donned a new pair of gloves, completed peri care, and then changed the gloves without disinfecting the hands between the glove changes. The HA turned the patient and cleaned the back and buttocks. The HA removed the gloves without disinfecting their hands and grabbed the bottom sheets. The HA began to put the linens on the bed, stopped, used alcohol, and put on a new pair of gloves. The HA finished changing out the linens on one side, changed out the gloves without disinfecting the hands, cleaned the patient’s other side, removed all of the dirty linens, and changed the gloves without disinfecting the hands. During a joint document review and interview on 04/28/2026, the Executive Director (ADS) agreed that the staff did not follow the hand hygiene policy. During a joint document review and interview on 04/28/2026, the Director of Patient Care Services (Parent site) agreed that the aide did not follow the hand hygiene policy.”

“It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The hospice documents the cost savings achieved through volunteers. Documentation includes the identification of each position that is occupied by a volunteer, the work time spent by volunteers occupying those positions, estimates of the dollar costs that the hospice would have incurred if paid employees occupied the positions noted in Item 1, and for the durations noted in Item 2. This standard was not met as evidenced by document review and interview. Upon reviewing the volunteer program, the documentation lacked evidence that day-to-day administrative or direct patient care services accounted for at least five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The agency identified that the total percentage for 2024 was below 5% and initiated a Performance Improvement Plan (PIP) on 03/20/2025. The parent location’s total percentage from April 2025 through March 2026 was 1.85%, with the highest month of 3.68% in March 2025. The alternate delivery site’s (ADS) total percentage from April 2025 through March 2026 was 3.41%, with percentages increasing starting in January 2026 to 4.35%, February 2026 to 7.34%, and March 2026 to 5.66%. The combined total volunteer percentage for the parent and ADS was 2.28%. During a joint document review and interview on 04/28/2026, the Director of Patient Care Services (Parent site) confirmed that the volunteer hours did not meet the minimum of 5% of total patient care hours by all paid hospice employees and contract staff. The DPCS stated that there had been difficulty increasing the number of volunteers and the hours current volunteers worked. The DPCS stated that the agency had experienced growth in census and an increase in direct patient care hours. The DPCS discussed the measures taken as part of the Performance Improvement Project and the results observed. The DPCS reported an increase in volunteer hours, resulting in a higher ADS percentage over the past three months. During a joint document review and interview on 04/29/2026, the Volunteer Coordinator (Parent site) discussed efforts to increase the number of volunteers and volunteer hours at the parent site over the past year since the PIP began. During a joint document review and interview on 04/29/2026, the Volunteer Coordinator (ADS) discussed efforts to increase the number of volunteers and volunteer hours at the alternate delivery site over the past year since the PIP began. Upon reviewing the volunteer program, the documentation lacked evidence that day-to-day administrative or direct patient care services accounted for at least five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The agency identified that the total percentage for 2024 was below 5% and initiated a Performance Improvement Plan (PIP) on 03/20/2025. The parent location’s total percentage from April 2025 through March 2026 was 1.85%, with the highest month of 3.68% in March 2025. The alternate delivery site’s (ADS) total percentage from April 2025 through March 2026 was 3.41%, with percentages increasing starting in January 2026 to 4.35%, February 2026 to 7.34%, and March 2026 to 5.66%. The combined total volunteer percentage for the parent and ADS was 2.28%.”

“The hospice agency failed to ensure that the Condition of Participation 418.76 for hospice aide and homemaker services was met as evidenced by the following: 1.Hospice Aide (HA) 1 did not have the professional training and did not use appropriate technique in applying wound/stoma (ostomy-surgical opening on the surface of the body) adhesive (a paste that bonds the skin with the ostomy wafer [special adhesive sticker for skin around a stoma] together by adhering [attaching or causing something to stick] to the surfaces) and gauze to Patient 1’s skin. (Refer to L 626) The cumulative effect of this systematic practice resulted in the failure of the hospice agency to deliver care in compliance with the Condition of Participation for hospice aide and homemaker services.”

“Based on interview and record review, the facility failed to ensure hospice aide services were provided in accordance with state law and professional standards of practice for one of one sampled patients, Patient 1, when Hospice Aide (HA) 1 did not have the professional training and did not use appropriate technique in applying wound/stoma (ostomy-surgical opening on the surface of the body) adhesive (a paste that bonds the skin with the ostomy wafer [special adhesive sticker for skin around a stoma] together by adhering [attaching or causing something to stick] to the surfaces) and gauze to Patient 1’s skin. These failures resulted in HA 1 providing services out of the scope of practice, not adhering to professional standards of wound care and caused gauze to adhere to Patient 1’s wound and surrounding skin and caused avoidable pain and anxiety. Patient 1 was transferred to the Emergency Room (ER) for debridement (procedure to remove tissue or material from a wound) to remove the gauze from his wound which resulted in increased pain, requiring him to take pain medication which caused him anxiety, redness, bleeding around the wound and ongoing skin irritation to the surrounding tissue. Findings:During a review of Patient 1’s face sheet titled “Demographics,” undated, the face sheet indicated, “… Patient Note Home … Primary Diagnosis Hypertensive chronic kidney disease [high blood pressure caused by damage to the kidneys] …” During a concurrent interview and record review on 7/7/25 with the Executive Director (ED) and Clinical Supervisor (CS) 1, CS 1 stated Patient 1 was admitted to hospice services on 1/20/25 for hypertensive chronic kidney disease. CS 1 stated HA 1 made a visit to Patient 1’s home to provide personal care on 6/5/25. CS 1 stated when Patient 1’s bath was complete, the patient asked HA 1 to apply cream and a dressing to his wound. CS 1 stated HA 1 used stoma paste instead of calcium alginate (highly absorbent wound dressing) in and around the wound which caused the dressing to adhere to the wound bed and surrounding area. CS 1 stated Patient 1 complained of pain in the area and was sent to the Emergency Room (ER) for debridement to remove the dressing from the wound bed. The ED stated hospice agency management was notified about the incident the following day on 6/6/25. The ED stated hospice aides must follow the patient’s plan of care, and the Registered Nurse Case Manager (RNCM) was responsible to ensure the care plan is specific and within the hospice aide’s’ scope of practice. The ED stated when management discussed the incident with HA 1, HA 1 was aware he was not supposed to perform wound care. The ED stated wound care was outside of the HA’s scope of practice and he should not have applied any treatment or dressing to Patient 1’s wound. The ED stated the management team performed a root cause analysis which indicated HA 1 did not follow the agency’s policy and procedures (P&P) and performed work duties outside of his scope of practice. The ED stated the hospice agency held a QAPI (quality assurance and performance improvement-a data driven approach to improving quality of care and services) meeting and implemented a performance improvement plan including reeducating staff on expectations and policies and procedures for wound care, documentation and scopes of practice. The ED stated after the incident investigation was complete, HA 1, RNCM 1 and LVN 1 were terminated. During a telephone interview on 7/7/25 at 1:07 p.m. with CS 2, CS 2 stated she was RNCM 1’s supervisor and followed up on the incident with RNCM 1 and HA 1. CS 2 stated she discussed the incident with HA 1 and was told Patient 1 had asked the HA to put the cream on the wound and cover it with gauze. CS 2 stated HA 1 told her he was not paying attention to the cream before he applied it to the wound. During a telephone interview on 7/7/25 at 4:41 p.m. with HA 1, HA 1 stated on 6/5/25 he went to Patient 1’s house to provide a bath and personal care. HA 1 stated Patient 1’s usual HA was not available, and it was his first time seeing the patient. HA 1 stated Patient 1 had a large bedsore (pressure wound) on his bottom (sacrum) with new skin forming around it. HA 1 stated Patient 1 asked him if he would clean the wound, put cream on it and cover it with gauze. HA 1 stated he followed Patient 1’s directions, put the cream around the wound where the new skin was and covered it with a dressing. HA 1 stated he thought the cream was for bedsores, but later found out it was some type of adhesive. HA 1 stated he told Patient 1 the cream was really sticky when he was applying it. HA 1 stated he was out of his scope of practice by performing wound care. HA 1 stated he thought he could put the cream around the wound, but not in the wound. HA 1 stated he did not have cellular service where Patient 1 lived and could not call the RNCM or office for instruction. HA 1 stated he was unsure of what was considered wound care and was told after the fact if there was a break in the skin it was a wound. During a telephone interview on 7/7/25 at 4:58 p.m. with RNCM 1, RNCM 1 stated she was Patient 1’s case manager at the time of the incident on 6/5/25. RNCM 1 stated she was not familiar with wounds. RNCM 1stated Patient 1’s family did his wound care, and she had only seen the sacral wound around three to four times. RNCM 1 stated she was off duty on 6/5/25 when she found out about the incident with HA 1. RNCM 1 stated Patient 1 told her the HA had put stoma paste on his back side and his skin started burning about two hours later. RNCM 1 stated Patient 1’s son found a gauze pad stuck in the wound and when he tried to remove it the patient refused because it was painful. RNCM 1stated the family had contacted Licensed Vocational Nurse (LVN) 1 who was on call, but she could not go out to see him, so he was sent to the ER. RNCM 1 stated Patient 1 had reported to her he was in a lot of pain from the adhesive and had to take pain medication which upset him because he tries not to take it. RNCM 1 stated the tube HA 1 used was clearly marked as stoma paste. RNCM 1 stated LVN 1 had called her even though she was off and told her what had happened. RNCM 1 stated she notified the agency’s ED on 6/6/25 that Patient 1 had gone to ER because HA 1 applied stoma adhesive and a dressing to his wound. RNCM 1 stated she did a follow up visit with Patient 1 on Monday 6/9/25 and when she saw him, “his back had white stuff on it and the skin was red around the wound down to his butt cheeks.” During a telephone interview on 7/10/25 at 2:39 p.m. with LVN 1, LVN 1 stated she was on call 6/5/25 and Patient 1 called her. LVN 1 stated she was notified HA 1 had put some cream on Patient 1’s wound, which was causing pain and burning. LVN 1 stated she was an hour away and Patient 1 notified her he had already called the ambulance. LVN 1 stated the patient sent her a picture of the cream applied to the wound, and it was marked stoma adhesive. LVN 1 stated Patient 1’s son notified her a gauze was stuck in the wound. LVN 1 stated Patient 1 was upset on the phone, sounding panicked and anxious because his son could not remove the gauze. LVN 1 stated HA 1 should not have performed wound care because it was outside of his scope of practice. During a telephone interview on 7/10/25 at 3:06 p.m. with Patient 1, Patient 1 stated on 6/5/25, HA 1 came to his house to give him a bath. Patient 1 stated it was HA 1’s first visit and after the bath was finished, he told HA 1 to put a cream around his wound and cover with an ABD pad (highly absorbent wound dressing used to manage heavily draining wounds). Patient 1 stated HA 1 grabbed a tube of cream and asked if it was the right one, but he could not see the tube. Patient 1 stated HA 1 put the cream all around the wound and down to his buttocks then put a gauze in it. Patient 1 stated he then rolled over to his back. Patient 1 stated approximately two hours later he knew something was wrong because he bent his legs and the dressing was pulling on his back. Patient 1 stated his son tried to remove the dressing, but it was glued to him. Patient 1 stated his son tried to rip it off but it was painful, so they called the on-call nurse. Patient 1 stated he spoke with the on-call nurse who could not be there for over an hour, so he called an ambulance and went to ER. Patient 1 stated his son grabbed the tube HA 1 used and it was marked stoma adhesive on the label. Patient 1 stated the stoma adhesive paste had been applied to the wound, down his “crack” and was partly up his back. Patient 1 stated when he arrived at ER, he was told there was a gauze stuck inside the wound. Patient 1 stated he was in the ER for five hours because they had to use (name of lubricating jelly) to soak the gauze, peel off the softened portion and then reapply the jelly, let it sit until softened and peel it again. Patient 1 stated at the end that’s the procedure the nurse had to do was to take tweezers to remove the final pieces of gauze from the wound. Patient 1 stated some of his skin had come off around the wound during the procedure which was painful. Patient 1 stated he was still having pain and there was one area around the wound that bled. Patient 1 stated he was in severe pain, had to take a pain pill at home, but did not take any pain medications while in the ER. Patient 1 stated his family usually provided wound care because they never knew what time hospice was coming to visit him. During a review of Patient 1’s “Emergency Room Note,” dated 6/5/25, the ER note indicated, “… presents to the Emergency Department with complaint of glue accident on the buttocks sacral wound… today the home health nurse [HA] was supposed to put an ointment and instead she [he] placed stoma adhesive… Skin: Large chronic sacral wound that is 28 cm [cm is centimeters which is a unit of measurement, 28 cm is approximately 11 inches] in diameter with dry adhesive scattered 360 degrees [complete circle] around the wound … Procedures … Removed glue … presents to the emergency department with a focal complaint of adhesives that were applied to his chronic wound. Using [name of lubricating jelly] all of the scissors [sic- (in error)] were removed …” During a review of Patient 1’s “Narrative Note,” dated 6/6/25, the note indicated, “… Patient had ER visit to [name of hospital] on 6/5/25… Per patient wounds to backside were debrided at hospital for a period of a minimum of 5 hrs [hours] … Wound areas to lowerback/coccyx [tailbone area]/buttocks/holds [folds] under buttocks areas are pink/mild redness with some mild active bleeding to recently opened areas … site is sensitive to touch, areas are very raw,patient reports feeling increased pain during treatment, pain medication Morphine [morphine sulfate-narcotic pain medication] 0.25 ml [milliliters-unit of measurement] taken as ordered for mild-moderate pain … Patient appears mildly emotional regarding new injuries AEB [as evidenced by] verbalizing anger and sadness …” During a review of Patient 1’s “Narrative Note,” dated 6/9/25, the note indicated, “… pain level he said is eight out of 10 [on 1 to 10 pain scale- [1 to 3-mild pain, 4-7- moderate pain, 8 to 10-severe pain] … Patient has a wound to his coccyx area, pink around … edge of the wound small sores are starting to open up that weren’t there before … There are white spots around the wound where they scrap [scraped] the paste off. Patient is irritated due to having to take MS [morphine sulfate] …” During a review of the hospice agency’s “QAPI Program Performance Improvement Plan,” dated 6/10/25, the plan indicated, “… It is the expectation that [name of hospice agency] provide patient care in accordance with Condition of Participation … which states, in part…. All hospice aide services must be provided by individuals who meet the personnel requirements … Hospice aides are assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group [IDG-team of professionals who work together to create and implement a comprehensive care plan for patients]. 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… It is required that a hospice aide provides services ordered by the Interdisciplinary Group and included in the plan of care … During root cause analysis following a specific patient incident, in depth chart reviews were completed… it was noted that the location has had decreased level of compliance with meeting this standard… this is a high priority for an improvement plan to be implemented and increase compliance … Goal… Hospice Aide staff will provide services to the patient in accordance with the patient’s plan of care … RN will document HHA [hospice aide] supervision appropriately, ensure care being provided is appropriate, within scope of practice and follows the care plan provided … Hospice Aides will receive education … on the following on 6/13/25 … Policy … “Hospice Aide Services” … Reviewed “Coaching Content for Proper HCA [home care aide (hospice aide)] Documentation” which includes instructions … If there is anything on the care plan outside of your scope of practice that requires assessment, you must notify your RNCM/Clinical Supervisor/DPCS [Director Patient Care Services] and not perform the task … Always follow the task assigned on the care plan … Registered Nurses will receive education … on the following on 6/13/25 … Supervision of Hospice Aide Services … RESPONSIBILITIES.SUPERVISION OF CLINCIAL SERVICES … After education, 100% of HHA [hospice aide] care plans will be reviewed and updated …” During a review of the hospice agency’s “QAPI Program Performance Improvement Plan,” dated 6/10/25, the plan indicated, “… Wound Care … During root cause analysis following a specific patient incident … it was identified that this standard is not met … Actions … An audit will be conducted for all current patients with wounds on census to ensure all of the required documentation and orders are present and up-to-date in the chart by 6/20/25 … All nursing staff will be instructed to … Ensure that all wounds have care plans and interventions initiated … Wound care orders will be updated as appropriate … All nursing staff will be instructed … on the following on 6/13/25 … Wound Care Policy … Pressure Injury Explanation … Wounds and wound care should be on the care plan … All wounds will be discussed as part of the IDT [IDG] meeting …” During a review of the Hospice agency’s Policy and Procedure (P&P) titled “Hospice Aide Services,” dated 9/2024, the P&P indicated, “… specify the role of the hospice aide … Services provided by an aide could include assistance with activities of daily living as defined on the plan of care, directed by the RN, within the appropriate scope of practice of the aide … These activities in accordance with the plan of care and physician’s (or other authorized independent practitioner’s) orders will be assigned and supervised by a hospice registered nurse. These activities are permitted to be performed under state law and regulations and is consistent with hospice aide training …” During a review of the hospice’s P&P titled “Wound Care,” dated 9/2024 indicated, “… provide guidelines for wound assessment and treatment … admitting registered nurse will assess wound(s) as part of the comprehensive initial assessment and will document all clinical findings … admitting registered nurse will document each wound status including, location and etiology, measurement of length, width, and depth, undermining and tunneling, if present, description of the wound bed, drainage, signs and symptoms of infection, healing and peri wound skin condition … Documentation associated with each identified wound will be completed on each visit … hospice nurse will provide wound care per physician orders and continue to implement and evaluate the plan of care based on the effectiveness of the treatment regimen, response to treatment … At each dressing change the wound will be assessed and documentation will include a description of the wound bed, drainage, signs and symptoms of infection, healing and peri wound skin condition … At least every week, the wound assessment and documentation will include measurement of length, width, depth and undermining and tunneling if present … Monthly audits of clinical record documentation will be conducted to identify staff education needs …” During a review of the RNCM 1’s job description titled “Job Title: Registered Nurse Case Manager,” dated 8/9/2022, the job description indicated, “… The Registered nurse case manager (RNCM) plans, organizes and directs patient care and is experienced in nursing... Must demonstrate nursing skills per competency checklist... Complete, maintain and submit accurate and relevant clinical notes regarding patient’s condition and care given... Responsible for supervising Hospice aides... [signed by RNCM 1 on 1/14/25]” During a review of RNCM 1’s “Annual Competency Assessment Skills Checklist-Registered Nurse,” Dated 1/14/25, the form indicated, “… Knowledge of nursing assessment [yes]… Clinical notes...[yes] ...” The competency list did not include competency regarding wound care, wound measurements or assessment. During a review of HA 1’s job description titled “Home Health Aide,” dated 8/26/22, the job description indicated, “... The home health aide is a paraprofessional member of the interdisciplinary group who works under the supervision of a registered nurse and performs various services for a patient as necessary to meet the patient’s personal needs and to promote comfort... Essential job functions... Perform personal care needs after given a patient’s assignment and attending to patient requests promptly... Report immediately to Case Manager if unable to perform a certain task... Give personal care including baths, back rubs, oral hygiene, shampoos and changing bed linen as often as assigned... Provide proper care and observation of patient’s skin to prevent breakdown of tissue over Bony prominence... Assess and report on patient’s condition and significant changes to the Case Manager... [signed by HA 1 on 9/10/24]” During a review of the HA’s “Initial Orientation Checklist-Direct-Care Staff,” dated 12/10/24, the checklist indicated, “… Hire Date 9/10/24… orientation to job description and responsibilities... [signed by the HA and the supervisor on 9/10/24] …” During a review of the agency’s policy and procedure titled “Serious Adverse Events,” dated 9/2024, the P&P indicated, “… Incidents that conform to hospice’s definition of serious adverse events will be immediately reported to the Executive Director/Administrator of designee … the Executive Director/Administrator, the Director of Patient Care Services/Clinical Supervisor, and/or designee will conduct a root cause analysis of the serious adverse event … Immediately after the event, or hearing about the event (the first 48 hours) … Inform the Executive Director/Administrator of designee … Make sure the organization is doing everything possible to provide follow-up care/services to ensure the best possible outcomes for injured parties … Gather detailed information about the event … Within 45 days of the event …. Determine the root cause(s) of the event, including an analysis of all processes and systems related to its occurrence… Determine potential improvements in processes or systems that would tend to decrease the likelihood of such events occurring in the future… Establish a plan to address identified opportunities for improvement …””