Traditions Health

“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 3 (33%) home visits observed, the agency did not ensure that clinical staff followed the agency’s policy on hand hygiene. The agency’s “Hand Hygiene” policy (Policy No. 7-009, Revised 07/2023) stated in part, “3. Hand decontamination using an alcohol-based hand rub should be performed: D. After contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressings... G. After removing gloves.” HOME VISIT 1/CLINICAL RECORD 1: During a home visit observation with the Registered Nurse (RN) (Personnel Record 3) on 05/19/2026. The RN was observed performing wound care for a stage 2 pressure ulcer located on the patient’s coccyx. The RN put on gloves and removed the dirty dressing, cleansed the wound with a wound cleanser, and applied a new dressing, without removing gloves after contact with the soiled dressing. The RN then removed the gloves and did not sanitize hands as per agency’s policy. The Administrator/Director of Patient Care Services (DPCS) (Personnel Record 1) was interviewed on 05/19/2026 and stated, “The nurse should disinfect her hands after removing the dirty dressing and after removing gloves.””

“It is required that Nursing care and services are provided by or under the supervision of a registered nurse and per the patient plan of care; 1. Nursing services ensure that the nursing needs of the patient are met as identified in the patient’s initial assessment, comprehensive assessment, and any updated assessments. This standard was not met as evidenced by clinical record review and interview. In 3 of 14 (21%) clinical records reviewed, the agency did not ensure Nursing care and services were provided by or under the supervision of a registered nurse and per the patient plan of care. CLINICAL RECORD 1: The patient elected the hospice benefit on 01/13/2026 with a diagnosis of cerebrovascular disease and congested heart failure. A review of the clinical record revealed that a comprehensive assessment was completed on 01/13/2026. The Plan of Care (POC) dated 04/13/2026-07/11/2026 included an order for Skilled Nursing (SN) visits twice weekly. A verbal order dated 04/22/2026 was documented that stated in part, “Wound Care to stage 2 pressure ulcer coccyx area. Hospice RN to perform wound care during visits to stage 2 pressure ulcer to coccyx area using clean technique. Cleanse with wound cleanser, pat dry with 4x4 gauze, apply hydrocolloid dressing 3 times per week and as needed for torn, tattered, soiled, or dislodged dressing until wound is healed. The [ALF] staff in memory care is to perform wound care on non-SN visit days after a successful return demonstration PRN. Buddy code SN93 added for weekly measurements.” The clinical record included skilled nursing (SN) visits provided twice weekly, 04/22/2026 through 05/21/2026, as ordered on the POC. The SN visit documentation did not provide evidence of weekly wound measurements as ordered on the POC. CLINICAL RECORD 4: The patient elected the hospice benefit on 03/20/2026 with a diagnosis of Parkinson’s disease and protein-calorie malnutrition. A review of the clinical record revealed that a comprehensive assessment was completed on 03/20/2026. The Plan of Care (POC) dated 03/20/2026-05/18/2026 included orders for Skilled Nursing (SN) visits with a frequency of 2 visits each week. The clinical record included a skilled nursing note dated 04/24/2026, that stated in part, “PT scratches herself and caused a scrape on right inner arm to bleed.” The clinical record included a verbal order dated 04/24/2026, that stated in part, “Hospice SN to perform wound care during visits to right inner arm area. Using clean technique, cleanse with wound with wound cleanser, pat dry with 4x4 gauze, apply dressing 3 times per week. Perform same wound care PRN for torn, tattered, soiled or dislodged dressing until wound is healed. [ALF] staff in memory care to perform wound care on non-SN visit days after successful return demonstration PRN. SN to measure wound weekly.” The clinical record included skilled nursing (SN) visits provided twice weekly, 04/24/2026 through 05/18/2026, as ordered on the POC. The SN visit documentation did not provide evidence of weekly wound measurements as ordered on the POC. CLINICAL RECORD 7: The patient elected the hospice benefit on 12/02/2025 and recertified for the service dates of 03/02/2026-05/30/2026 with a diagnosis of heart failure. The Plan of Care (POC) dated 03/02/2026-05/30/2026 included an order for Skilled Nursing (SN) with a visit frequency of 1 visit weekly. The clinical record included a skilled nursing note dated 04/25/2026, that documented that the patient’s right big toenail had fallen off. The clinical record included an order dated 04/25/2026 that stated in part, “Hospice RN to perform wound care during visits to wound to right big toe (toenail has fallen off). Using clean technique, cleanse the wound with wound cleanser, pat dry with 4x4 gauze, apply dressing 3 times per week and as needed for torn, tattered, soiled, or dislodged dressing until wound is healed. [ALF] staff in memory care to perform wound care on non-SN days after successful return demonstration. SN to measure wound every 7 days...”. The clinical record included documentation of weekly skilled nursing visits provided 04/25/2026 through 05/15/2026. The SN visit notes documented that the “wound has healed”, and an order was obtained to discontinue wound care on 05/15/2026. The SN visit documentation did not provide evidence of weekly wound measurements as ordered on the POC. The Administrator/Director of Patient Care Services (DPCS) (Personnel Record 1) reviewed the clinical records and verified that wound measurements were not documented as ordered. The Administrator/DPCS (Personnel Record 1) was interviewed on 05/20/2026 and stated, “We talked to the nurse. She has the measurements in her notebook, but she forgot to put them in the chart.””