Suncrest Hospice

“Based on interviews and record reviews, the agency’s licensed nursing staff did not ensure there was effective symptom relief for one of three sampled patients (Patient 1) when Patient 1 had exhibited an increase in agitation and nursing staff did not re-evaluate the effectiveness of the plan of care. This resulted in unnecessary distress for Patient 1. During record review of Patient 1’s clinical document titled, “Hospice Certification and Plan of Care”, the document showed Patient 1’s Start of Care was 8/16/2025 with the current certification period 8/16/2025 to 10/14/2025. Patient 1 resided in an assisted living facility with multiple medical diagnoses including “Senile Degeneration of Brain.” Orders/Treatment section included skilled nursing visits for “Assessment and symptom management.” The section “Psychosocial/Cognitive Status” showed “According to facility staff nurse, patient has been reported to have more events of agitation and restlessness.” Medication included “Valproic Acid 250mg/5 ml oral liquid; Take 3 milliliter(s) orally once a day (in the evening) for mood stabilizer.”Record review of Patient 1’s clinical document “Skilled Nursing Visit Note” (SNVN) dated 8/18/2025 showed Registered Nurse 1 (RN 1) documented Patient 1’s emotion/behavioral status as “Aggressive, Agitated, Uncooperative.”Record review of Patient 1’s clinical document “Aide Visit Note” dated 8/19/2025 showed Patient 1 had “Refused all care.”Record review of Patient 1’s clinical document SNVN dated 8/22/2025 showed RN 1 documented Patient 1 had become agitated and “Struck out 2 times.”Record review of Patient 1’s SNVN dated 8/28/2025 showed, Patient 1 had attempted to bite RN 1, pulled her hair and then struck her in the face.There was no documentation in the clinical record which showed staff re-evaluated the plan of care.During an interview on 10/1/2025 at 9:21 a.m., with RN 1, RN 1 confirmed she had not notified the doctor to re-evaluate the plan of care. RN 1 stated doing so would have been beneficial as it would have helped to “Ensure the patient was comfortable and safe.” During an interview on 9/30/2025 at 11:30 a.m., with the agency’s Administrator/Registered Nurse (ADM/RN), ADM/RN confirmed staff had not addressed the increased agitation.The Agency’s Director of Nursing visited Patient 1 on 8/29/2025. Record review of the SNVN dated 8/29/2025 showed the doctor had been notified that day and Patient 1’s mood stabilization medication was increased.During a record review of Patient 1’s document titled “Patient Care Order” dated 8/29/2025, the document showed the Valproic Acid was increased to 5 milliliters once per day.During a record review of the document “Identification, Prevention, and Treatment of Secondary Symptoms” dated November 2023, showed “Care will be directed to optimize the patient’s comfort and dignity through appropriate treatment of secondary symptoms as well as aggressively managing these symptoms.”Record review of the undated document “Job Description Summary. Job Title/Position: Registered Nurse” showed essential job functions/responsibilities included providing and maintaining a “Safe environment for the patient.””

“Based on interview and record review, the agency failed to ensure that care was provided in a manner free from abuse for one of three sampled patients (Patient 1) when Licensed Registered Nurse 1 (RN 1) struck Patient 1 across the face, resulting in visible bruising. This failure placed Patient 1 at high risk for experiencing unnecessary emotional and physical distress. During a record review of Patient 1’s clinical document titled, “Hospice Certification and Plan of Care” showed Patient 1’s Start of Care was 8/16/2025 with the current certification period 8/16/2025 to 10/14/2025. Patient 1 resided in an assisted living facility. Diagnoses included “Senile Degeneration of Brain.” Goals included “Isolation/loneliness will be decreased per staff; Patient 1 will feel adequately supported by hospice team.” The section “Psychosocial/Cognitive Status” showed “According to facility staff nurse, patient has been reported to have more events of agitation and restlessness.”Record review of Patient 1’s clinical document “Skilled Nursing Visit Note” (SNVN) dated 8/18/2025 showed, RN 1 documented Patient 1’s emotional/behavioral status as “Aggressive, Agitated, Uncooperative.”Record review of Patient 1’s clinical document “Aide Visit Note” dated 8/19/2025 showed, Patient 1 had “Refused all care.”Record review of Patient 1’s clinical document SNVN dated 8/22/2025 showed, RN 1 documented Patient 1 had become agitated and “Struck out 2 times.”Record review of Patient 1’s SNVN dated 8/28/2025 showed Patient 1 had attempted to bite RN 1, pulled her hair and then struck her in the face.Record review of Patient 1’s SNVN dated 8/29/2025 showed Patient 1 was noted to have “Left temple bruising” which was reported to the doctor.During an interview on 9/30/2025 at 10 a.m., with the agency’s Administrator/Registered Nurse (ADM/RN), ADM/RN stated, during the visit on 8/28/2025 and following Patient 1’s aggressive behavior, RN 1 had hit Patient 1 on the left side of her head which caused bruising.During an interview on 10/1/2025 at 9:21 a.m. with RN 1, RN 1confirmed on 8/28/2025 during the visit and following Patient 1’s display of aggressive behavior, she then hit Patient 1 on her left temple which caused bruising.Record review of facility’s undated document “Job Description Summary. Job Title/Position: Registered Nurse” showed essential job functions/responsibilities included providing and maintaining a “Safe environment for the patient.””

“Based on interview and record review licensed Agency staff did not notify the doctor for a change in condition for one of three sampled patients (Patient 1). Nursing staff did not notify the physician when Patient 1’s agitation had escalated.This resulted in unnecessary distress for Patient 1. Record review of the document “Hospice Certification and Plan of Care” showed Patient 1’s Start of Care was 8/16/2025 with the current certification period 8/16/2025 to 10/14/2025. Patient 1 resided in an assisted living facility. Diagnoses included “Senile Degeneration of Brain.” Goals included “… Patient 1 will feel adequately supported by hospice team.” The section “Psychosocial/Cognitive Status” showed “According to facility staff nurse, patient has been reported to have more events of agitation and restlessness.”Record review of the document “Skilled Nursing Visit Note” (SNVN) dated 8/18/2025 showed Registered Nurse 1 (RN 1) documented Patient 1’s emotion/behavioral status as “Aggressive, Agitated, Uncooperative.”Record review of the document “Aide Visit Note” dated 8/19/2025 showed Patient 1 had “Refused all care.”Record review of the SNVN dated 8/22/2025 showed RN 1 documented Patient 1 had become agitated and “Struck out 2 times.”Record review of the SNVN dated 8/28/2025 showed Patient 1 had attempted to bite RN 1, pulled her hair and then struck her in the face. There was no documentation in the clinical record which showed the doctor had been notified regarding the increased agitation.During an interview on 10/1/2025 at 9:21 a.m. RN 1 confirmed she had not notified the doctor. RN 1 stated it would have been beneficial to call the doctor as it would have helped to “Ensure the patient was comfortable and safe.” During an interview on 9/30/2025 at 11:30 a.m. the agency’s Administrator/Registered Nurse (ADM/RN) confirmed staff had not notified the doctor regarding the increased agitation and the Director of Nursing visited Patient 1 on 8/29/2025. Record review of the SNVN dated 8/29/2025 showed the doctor had been notified and Patient 1’s mood stabilizing medication was increased.Record review of the document “Monitoring Patient’s Response/Reporting to Physician” dated November 2024, showed “Clinicians will monitor, document, and report the patient’s response to care and treatment provided on each hospice visit. Progress of goals will be measured at regular intervals.”Record review of the undated document “Job Description Summary Job Title/Position: Registered Nurse” showed responsibilities included “Communicates with the physician regarding the patient’s needs and reports changes in the patient’s condition; obtains/receives physician’s orders as required.””