Tru Community Care - Lafayette

“Observed in Patient Home. In 3 of 7 home visits conducted, the surveyor observed that the medication profile had not been accurate. In HOSHV#3 the SNF patient had narcan on profile of SNF, but narcan had not been listed on hospice profile. HOSHV#5 the surveyor observed that the patient’s dose of metformin had been decreased 3 weeks prior from 1000 to 500, but this had not been reflected on patients hospice medication profile, HOSHV#6 the patient had both senna and senna plus in home medication, but only senna had been listed on hospice medication profile. The surveyor discussed and confirmed issue with the SN on each case, the administrator and the director of regulatory & quality.”

“Observed in Individual Tracer. In 3 of 3 patient records reviewed, in the IPU the goals were observed to be vague and not individualized. An example in review of 3 of 3 IPU patient records revealed the same goal Patient symptoms will be consistent with stage of disease process and problems managed as well as disease process will allow. This has been validated by Administrator and the Director of Quality. Observed in Record Review. In 9 of 15 resident records reviewed, the surveyor observed that the goals for chaplain and MSW were vague, generic, repetitive and not measurable . In addition the surveyor observed that multiple nursing goals also had been vague and not measurable. Examples are: patient/caregiver will feel needs are being met as they have defined was receptive MSW goal. Repetitive chaplain goals observed had been patient /caregiver will cope with change in lifestyle, patient /caregiver will feel needs are being met as they have defined . . Examples of nursing goals that had been vague repetitive : patient’s symptoms will be consistent with stage of disease process and problems managed as well as disease process will allow. In discussion with administrator and director of regulatory and quality it was confirmed that not only was goals an issue, but one they had recently identified also. Observed in Record Review. In 3 of 3 patient records reviewed, the surveyor observed the goals to be vague and non-measurable. For example, SN: Patient/caregiver will demonstrate necessary behaviors to maintain good safety awareness andminimize the risk of falls and/or injury; Target Date: 4/10/2025.MSW: Continuity of care will be maintained as appropriate to patient/caregiver needs; Target Date: 1/14/26SN: Anxiety/agitation controlled through course of care; Target Date: 12/7/20251/14/2026. These goals are not individualized and do not clearly state the behaviors or actions to measure in order to determine success. This was reviewed and validated with the administrator of TRU Hospice.”

“Observed in Building Tour. The surveyor observed in supply room multiple expired items to include : Medihoney expired 1/2026, Xeroform expired1/2026,Iodine expired 10/2025, lemon glycerin swabs expired 2023. This issue was observed, discussed and confirmed with hospice unit manager and other hospice leadership. Observed in Patient Home. In 2 of 6 home visits conducted, the surveyor observed SN failed to perform hand hygiene consistent with policy. During HOSHV#2 the surveyor observed SN not complete hand hygiene between glove changes on 6 occasions while providing wound care to healing stage 4 coccyx wound and bilateral heel wounds. The surveyor also observed SN not change gloves or complete hand hygiene between moving from wounds on right foot to wounds on left foot. The patient had a foley and colostomy in place that the SN emptied. During HOSHV5 the surveyor observed the SN providing wound care to a recent mastectomy patient on oral chemo fail to perform hand hygiene consistent with policy. The surveyor observed the SN change gloves on 3 occasions without cleaning hands as required by organization policy. The issue was discussed and confirmed with organization leadership.”

“Based on interviews and record reviews the agency failed to protect patient rights specifically; be free from mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property for 2 of 2 patients (Patients #1 and #8). Findings include: AGENCY POLICY According to the policy titled, “Rights/Responsibility,” dated, 10/5/2023 (in part): “The right to be free from mental, physical, sexual, and/or verbal abuse, neglect, or exploitation.” According to the policy titled, “Scope of Services,” dated, 10/5/2023 (in part): “TRU Community Care provides hospice services that are intended to meet the physical, psychosocial, practical, and spiritual needs of hospice patients and family/caregivers. The core hospice team members (registered nurse, medical social worker, physician, and Chaplain) are available to patients and family/caregivers seven (7) days a week, 24 hours a day.” 1. The clinical record for Patient #1 was reviewed on 1/7/25. The patient was admitted to hospice care and services on 9/8/24, with a terminal diagnosis of Senile degeneration. The plan of care for the certification period dated 9/8/24 to 11/6/24, included orders for a skilled nurse twice a week for wound care, nurse aide twice a week for activities of daily living, medical social worker once to twice a month for psychosocial needs, and chaplain once a month for spiritual needs. He resided in an assisted living facility that was contracted with the hospice agency. a. The agency failed to protect Patient #1 from neglect. Record review showed Patient #1 had three (3) wounds; one on the right foot, left heel and on the coccyx/buttocks area. On 10/22/24 the coccyx wound was described and documented by hospice skilled nurses to be yellow-green in color and to have a foul odor, which were signs and symptoms of an infection. Further record review failed to show evidence that wound care was provided by the agency’s skilled nurse twice a week as ordered by the physician. The weeks of 11/4/24 through 11/30/24 and 12/4/24 through 12/16/24, no wound care was provided to the patient by the hospice staff. There were five (5) missed wound care and dressing changes the patient did not receive from the hospice agency’s skilled nurse as ordered by a physician. Review of a missed visit note created by RN (Employee #4) on 11/14/24, showed RN #4 had concerns shared with her by the patient’s family about wound care frequency and the patient’s repositioning frequency at which the nurse advised the family member to speak to the facility. She further documented the facility staff would do the dressing change that day. There was no evidence Employee #4 did anything about the family members’ concerns. Review of a missed visit note created by RN #4 on 11/28/24 revealed RN #4 wrote, “No visit made due to Thanksgiving holiday.” RN #4 documented on 12/5/24, dressing change completed by facility staff and that no visit was needed until next week. A review of the contract between Patient #1’s hospice agency and the assisted living facility showed no evidence that skilled nurse wound care services were to be provided by the assisted living facility. On 12/17/24, RN #4 created a discharge summary for Patient #1, this summary failed to communicate the patient’s wound characteristics, number of wounds, location of wounds and any wound care treatments that were given to the patient while under the hospice agency’s care. Further review showed the agency failed to send the discharge summary to the home health agency that the patient was transferred to after discharge. On 12/21/24, Patient #1 was admitted to the hospital with the acute medical problem of septic shock suspect bacteremia due to necrotic grade 4 pressure ulcer/buttock with suspicion of sacral osteomyelitis. In non medical terms, this is a bacterial infection in the blood from the coccyx/buttock wound with a suspicion that the patient’s sacral bone is also infected by bacteria. At the entrance interview with the hospice leadership team which included, Employees #1, #3, and #8 on 1/7/25 at 10:42 a.m., they were asked the definition of patient neglect. They collectively stated the following; failure to follow the plan of care, failure to provide the patient with treatment or services, missing visits, and not responding to the patient’s needs. An interview with the hospice leadership team which included, Employees #1, #2, #3, and #8 occurred on 1/13/25 at 4:00 p.m. They acknowledged the agency failed to provide Patient #1 with ethical care that was in the best interest of the patient which constituted patient neglect. They also acknowledged that the contract with Patient #1’s assisted living facility failed to include wound care as a contracted service, and therefore wound care should have only been provided by the hospice skilled nursing staff. They further acknowledged that the discharge summary was sent to the hospice agency physicians and that they had failed to send the patient’s discharge summary to the patient’s new home health agency. Additionally, the discharge summary failed to mention the patient’s current state or wounds that the patient had at the time of discharge while under their care. Lastly, they acknowledged that skilled nurse, Employee #4 failed to provide Patient #1 with quality nursing care or documentation and they had plans to educate and re-train her immediately. 2. An active clinical record for Patient #8 was reviewed on 1/7/25. The patient was admitted to hospice care and services on 9/10/24, with a terminal diagnosis of Senial degeneration. The plan of care for the certification period dated 9/10/24 to 12/8/24, included orders for a skilled nurse once a week for 13 weeks, nurse aide once a week for activities of daily living, medical social worker once to twice a month for psychosocial needs, and chaplain once to twice a month for spiritual needs. He resided in an assisted living facility that was contracted with the hospice agency. a. The agency failed to provide treatment or services to Patient #8 as ordered by a physician. On 1/8/25 at 12:30 p.m., an observation of Patient #8 in their assisted living residence took place, RN #9 was there to assess the patient and to provide wound care to the right hip. Upon arrival, RN #9 stated the facility had already provided the patient’s wound and dressing changes prior to her arrival and that Patient #8 was on a facility outing and would return shortly. She was asked how the assisted living facility was approved to provide wound care that was ordered for the hospice staff to perform. She proceeded to show an intervention in the patient’s record that stated, “Facility to manage daily care needs.” She also stated that she received wound updates from the facility nurse with each visit. She went on to say, with any hospice patient concerns she was called immediately by the assisted living staff or they called an afterhours hotline to get a hospice nurse. During this same discussion, RN #9 had given an introduction to the assisted living facility director of nursing (DON). The assisted living DON acknowledged that her staff had provided wound care for Patient # 8 and other hospice patients when it was needed and that the hospice agency had supplied wound care supplies. When asked about billing procedures and the facility contract with the agency she said, she was unsure how billing worked when her staff provided wound care instead of the hospice agency’s skilled nurses. She did not know if the contract between the hospice agency and the assisted living facility covered wound care services. A review of the contract between Patient #8’s hospice agency and the assisted living facility showed no evidence that skilled nurse wound care services were to be provided by the assisted living facility. Record review for Patient #8 revealed a fall on 12/29/24, resulting in a hip wound. Documentation showed the hospice agency was aware of the fall on 12/31/24 but there was no evidence of a wound assessment for infection or provision of wound care until 1/6/25. Further review showed on 1/8/25, the patient’s nurse practitioner reclassified the wound as an unstageable wound with the presence of slough. At the entrance interview with the hospice leadership team which included, Employees #1, #3, and #8 on 1/7/25 at 10:42 a.m., they were asked the definition of patient neglect. They collectively stated the following; failure to follow the plan of care, failure to provide the patient with treatment or services, missing visits, and not responding to the patient’s needs. An interview with the hospice leadership team which included, Employees #3 and #8 occurred on 1/14/25 at 12:00 p.m. They acknowledged that the agency delayed Patient #8 from treatment and services and that the agency should have made a visit to the patient after he had fallen to assess the patient’s needs, therefore constitutes neglect. They also acknowledged that the contract with Patient #8’s assisted living facility failed to include wound care as a contracted service, and therefore wound care should have only been provided by the hospice skilled nursing staff.”