Saint John Hospice

“Based on interviews and record review, the Hospice Agency (HA, healthcare agency providing specialized care to terminally ill patients who have six months or less to live) failed to ensure the Condition of Participation (CoP, requirements that healthcare organizations must meet to participate in federal healthcare programs) for Initial & Comprehensive Assessment (thorough evaluation of the patient’s needs that must be addressed to promote comfort and dignity throughout the dying process) of Patient was met as follows: The HA failed to ensure that an accurate and ongoing assessment of the patient’s right heel diabetic ulcer (open wound caused by nerve damage, high blood sugar level and poor circulation) was completed for one of fourteen sampled patients (Patient 11). This failure had the potential to result in the progression of the wound, delayed healing, and increased risk of wound infection causing pain and discomfort to the terminally ill patient. (Refer to L533). The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily (written law) mandated compliance with federal regulation for Initial and Comprehensive Assessment of Patients to ensure the highest quality of care was being provided to patients certified to receive the hospice benefits.”

“Based on observation, interview, and record review, the Hospice Agency (HA, agency that provides specialized care and support for people with a terminal illness and nearing the end of life) failed to ensure the Condition of Participation (refer to the requirements that healthcare organizations must meet to participate in federal healthcare programs) for Interdisciplinary Group (IDG, a collaborative team of healthcare professionals responsible for providing holistic care [care for the patient as a whole person] to hospice patients and their families), Care Planning, Coordination of Services was met as follows: The HA failed to ensure a wound dressing treatment order was obtained for one of fourteen sampled patients (Patient 11).Patient 11 developed a right heel diabetic ulcer and was initially identified on 6/8/2026. There was no physician’s order for wound dressing treatment from 6/8/2026 to 6/17/2026.This failure placed Patient 11 at increased risk for deterioration of the right heel wound and delayed healing causing pain and discomfort to the terminally ill patient. (Refer to L549). The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily (written law) mandated compliance with the IDG, Care Planning, and Coordination of Services to ensure provision of quality care and services to patients certified to receive the hospice benefits.”

“Based on interviews and record review, the Hospice Agency (HA, healthcare agency providing specialized care to terminally ill patients who have six months or less to live) failed to ensure that an accurate and an ongoing assessment of the patient’s right heel diabetic ulcer (open wound caused by nerve damage, high blood sugar level and poor circulation) was completed for one of fourteen sampled patients (Patient 11). This failure had the potential to result in the progression of the wound, delayed healing, and increased risk of wound infection causing pain and discomfort to the terminally ill patient. During a review of Patient 11’s clinical record titled “Personal Information” (summary of patient’s basic information), the “Personal Information” indicated that Patient 11 was admitted on 10/25/2026 with terminal diagnosis of Alzheimer’s disease (a disease characterized by a progressive decline in mental abilities). During a joint home visit on 6/24/2026 at 11:59 AM, with Licensed Vocational Nurse 1 (LVN 1), an interview was conducted regarding Patient 11’s current wound care assessment. LVN 1 stated that the wound care provider completes the assessment and measurements of Patient 11’s right‑heel wound. LVN 1 stated that she would conduct home visits twice a week to provide wound‑care treatment for Patient 11. During a concurrent interview and record review on 6/25/2026 at 1:28 AM, with the Registered Nurse/Chief Operating Officer (RN/COO), Patient 11’s clinical record titled “Visit Note – On call Triage”, dated 6/8/2026 was reviewed. The “Visit Note – On call Triage” indicated that Registered Nurse Case Manager 1 received a call from Patient 11’s primary caregiver (PG 1) reporting an open wound on the patient’s right heel, accompanied by a foul odor and yellow drainage. The RN/COO stated that the right‑heel wound was first identified on 6/8/2026. The registered nurse should have visited Patient 11 to perform and complete the initial assessment of the identified wound to the right heel. During a concurrent interview and record review on 6/25/2026 at 1:30 PM, with the RN/COO, Patient 11’s clinical record titled “Visit Note”, dated 6/9/2026, 6/10/2026, 6/12/2026, 6/15/2026, 6/17/2026 and 6/20/2026 was reviewed. The “Visit Note” indicated a nickel-sized wound on Patient 11’s right heel. The RN/COO stated the licensed nurse should assess Patient 11’s right heel wound at least weekly and include the wound type, measurements (length, width and depth), location, appearance, odor, inflammation, drainage, surrounding skin condition, and treatment provided. The RN/COO stated the “Visit Notes” did not contain any wound assessment of Patient 11’s right heel. The RN/COO stated that thorough and accurate assessment of Patient 11’s right heel wound would determine whether the wound was improved or worse, and whether the current treatment remained appropriate. The RN/COO stated that failing to complete regular and comprehensive wound assessments may cause the wound to worsen, delay healing, and increase the risk of infection. During a review of HA’s policies and procedures (P&P), titled “Wound Assessment”, updated on November 2024, the P&P indicated:a. Upon identification of a new wound the registered nurse will complete a wound assessment that includes wound type, suspected cause, location, stage or classification, length, width, depth, wound bed description, drainage amount, color, consistency and odor, peri-wound (skin surrounding the wound) condition, pain, signs and symptoms of infection, current dressing or treatment.b. Wounds shall be assessed for focused monitoring at every skilled nursing visit when wound care is provided, at least weekly for active wounds, with any reported change in wound condition and when there is increased drainage, odor, bleeding, fever, redness, swelling, warmth or caregiver concern.c. The wound assessment shall compare current findings with prior documentation to determine improvement, stabilization, deterioration, or comfort-focused maintenance.”

“Based on observation, interviews and record review, the Hospice Agency (HA, healthcare agency providing specialized care to terminally ill patients who have six months or less to live) failed to ensure the HA obtained a physician’s order for wound dressing treatment for one of fourteen sampled patients (Patient 11).Patient 11 developed a right heel diabetic ulcer and was initially identified on 6/8/2026. There was no physician’s order for wound dressing treatment from 6/8/2026 to 6/17/2026. This failure placed Patient 11 at increased risk for deterioration of the right heel wound and delayed healing causing pain and discomfort to the terminally ill patient. During a review of Patient 11’s clinical record titled “Personal Information” (summary of patient’s basic information), the “Personal Information” indicated that Patient 11 was admitted on 10/25/2025 with terminal diagnosis of Alzheimer’s disease (a disease characterized by a progressive decline in mental abilities). During a concurrent observation and interview on 6/24/2026 at 11:59 AM with Licensed Vocational Nurse 1 (LVN 1), conducted in a joint home visit at Patient 11’s residence, LVN 1 was observed removing the dressing on Patient 11’s right heel wound, cleansed with wound cleanser, applied a layer of Medi-honey (medical grade honey used to promote wound healing), Calcium Alginate sheet (wound treatment to promote moist wound environment), applied a barrier cream on surrounding skin, covered with bordered dressing. LVN 1 stated the current order for Patient 11’s right heal wound was Santyl ointment (used to remove dead tissue on wounds to promote growth of healthy skin tissue). LVN 1 stated the Santyl ointment was a new wound treatment order and currently not available. LVN 1 stated Medi-honey was alternative wound treatment order for Patient 11’s right heel wound while waiting for the Santyl ointment and was the previous wound treatment order for Patient 11’s right heel wound. During a review of Patient 11’s clinical record titled “Plan of Care (POC)/ Interdisciplinary Group” (IDG, a collaborative team of healthcare professionals responsible for providing holistic care [care for the patient as a whole person] to hospice patients and their families), dated 6/10/2026 was reviewed. The POC/IDG indicated Patient 11’s right heel wound infection started on 6/8/2026 and identified the goal for Patient 11 to be free from discomfort related to the infection. The POC/IDG indicated to give Patient 11 cephalexin (antibiotic medication used to treat skin or wound infection) 500 milligrams (mg, unit of measurement) four times a day for seven days. The POC/IDG did not indicate any information regarding wound care dressing to provide on Patient 11’s right heel wound. During a concurrent interview and record review on 6/25/2026 at 11:28 AM with the Registered Nurse Chief Operating Officer (RN/COO), Patient 11’s clinical record titled “Visit Note – On call Triage”, dated 6/8/2026 was reviewed. The “Visit Note – On call Triage” indicated that Registered Nurse Case Manager 1 received a call from Patient 11’s primary caregiver (PG 1) reporting an open wound on the patient’s right heel, accompanied by a foul odor and yellow drainage and received an order from the physician for cephalexin 500 mg four times a day for seven days. The RN/COO stated that the right‑heel wound was first identified on 6/8/2026. The RN/COO stated that upon identifying Patient 11’s right heel wound the nurse should notify the IDG and the physician to obtain a wound treatment order and update the plan of care. The RN/COO stated that the antibiotic treatment alone was not sufficient to treat Patient 11’s right heel wound and would still require a wound-dressing treatment order. The RN/COO stated that without a wound treatment order Patient 11’s right heel wound may worsen or delay the healing process and may become infected once the antibiotic treatment is complete while the wound remains open. During a concurrent interview and record review on 6/25/2026 at 11:35 AM with the RN/COO, Patient 11’s clinical record titled “Wound Care Progress Note” (wound care provider note), dated 6/18/2026 was reviewed. The “Wound Care Progress Note” indicated that Patient 11’s right heel wound was a diabetic ulcer (open wound caused by nerve damage, high blood sugar level and poor circulation) to be treated with Santyl ointment and calcium alginate every one to two days and as needed. The RN/COO was unable to provide documented evidence that the treatment order for Santyl ointment and Calcium Alginate was carried out to Patient 11 and the POC was updated to reflect the wound treatment order from the wound care provider. During a concurrent interview and record review on 6/25/2026 at 11:37 AM with the RN/COO, Patient 11’s clinical record titled “Physicians Orders”, dated 6/23/2026 was reviewed. The “Physician Orders” indicated Patient 11’s right heel wound would be treated with Santyl ointment or equivalent topical (applied directly to the surface of the skin or wound bed) debridement (to remove or dissolve dead or damaged skill tissue) agent, followed by calcium alginate on wound bed, and cover with bordered dressing. The RN/COO was unable to provide documented evidence that a wound treatment order was received and provided on Patient 11’s right heel wound from 6/8/2026 to 6/17/2026. During a review of HA’s policies and procedures (P&P), titled “Wound Assessment”, updated on November 2024, the P&P indicated:a. The registered nurse shall notify the physician and IDG when new wound occurred. The POC changes shall be reviewed and updated by the IDG consistent with hospice care planning requirements.b. Wound care shall be performed according to the physician’s orders and the hospice plan of care. No staff member shall initiate a new wound treatment outside their scope of practice or without an appropriate order, except for immediate protective first aid or infection-control measures until the physician is notified.During a review of HA’s P&P titled “The Plan of Care”, revised on November 2024, the P&P indicated the care provided to the patient must be in accordance with the plan of care and will focus on identified problems, goals and interventions, any changes in the patient’s condition must result in change in the plan of care, prior to implementation of the new service.”

“Observed in Record Review. In 1 of 10 patient records reviewed, it was noted that the organization did not ensure its policy related to pain assessment was implemented. For example, during a review of the medical record for RRHV#1, it was noted that during week 5 of services, the LVN member of the health care team documented the presence of generalized pain. This was the first documentation of pain since the start of hospice services. A subsequent visit 2 days after the LVN visit, completed by the RN member of the health care team, identified the presence of pain in the patient’s abdomen and back. The pain assessment completed by the RN member of the team did not include the following information related to the patient’s pain: Intensity, Frequency, Duration, and Relief Measures. This observation was reviewed with the agency leadership team.”

“Observed in Record Review. In 1 of 10 patient records reviewed, it was noted that the plan of care was not revised when the patient’s condition changed. For example, a review of the medical record for RRNHV#1 revealed that during the 11th benefit period the interdisciplinary team documented that the patient had experienced multiple falls. The plan of care was not updated with a goal statement to evaluate the response to care, treatment, and services related to fall prevention activities. This observation was reviewed with agency leadership. Observed in Record Review. In 4 of 10 patient records reviewed, it was noted that the organization did not ensure that the plan of care included outcome measures for specific care activities. For example, the comprehensive assessment for RRHV#1, identified a problem with the patient’s skin integrity. The clinician documented the presence of two stage 1 pressure ulcers at the patient’s sacral area. The plan of care did not include a goal statement to evaluate the response to care, treatment, and services related to the patient’s altered skin integrity. Example #2: A review of the plan of care for RRHV#2, and RRNHV#6, revealed the following goal statement: Prevent/manage cardiac/circulation episodes. The goal statement did not include a method to measure the effectiveness of problem interventions. Example #3: During a review of the medical record for RRNHV#7, the comprehensive assessment included the description of an unstageable pressure ulcer at the left heel, an unstageable pressure ulcer at the right heel, and a stage 4 pressure ulcer at the sacrum. The plan of care did not include a goal statement to evaluate the response to care, treatment, and services related to wound care interventions. This observation was reviewed with the agency leadership team.”

“Observed in Record Review. In 2 of 10 patient’s records, it was noted that the plan of care did not include interventions based on the problems identified in the comprehensive assessment. For example, the comprehensive assessment for RRHV#1, identified a problem with the patient’s skin integrity. The clinician documented the presence of two stage 1 pressure ulcers at the patient’s sacral area. In addition, the clinician documented that the pressure areas were treated with Calmoseptine ointment. The plan of care did not describe interventions to provide care, treatment, and services to address the skin impairment, and measures to protect the patient’s skin integrity. Example #2: During a review of the medical record for RRNHV#7, the comprehensive assessment included the description of an unstageable pressure ulcer at the left heel, an unstageable pressure ulcer at the right heel, and a stage 4 pressure ulcer at the sacrum. The plan of care did not include interventions related to wound care. This observation was reviewed with the agency leadership team. Observed in Record Review. In 1 of 10 patient records reviewed, it was noted that the plan of care was not revised when the patient’s condition changed. For example, a review of the medical record for RRNHV#1 revealed that during the 11th benefit period the interdisciplinary team documented that the patient had experienced multiple falls. The plan of care was not updated with interventions to maintain patient safety, and strategies to prevent injury. This observation was reviewed with the agency leadership team.”