Abode Hospice of Colorado

“Based on interview and record review the hospice failed to ensure the patients served were free from neglect for 1 of 4 patient records reviewed (Patient #2). Agency Policy Any difference of opinion, dispute, or controversy between a patient or family/caregiver or patient representative and the hospice concerning any aspect of services or the application of policies or procedures will be considered a grievance. The Executive Director/Administrator will serve as patient care advocate and liaison between the patient and the agency. He/she will be informed of situations that may become detrimental to good patient relations and will be committed to maintaining a consistently high level of patient relations. At admission, each patient will be given a copy of the Patient Bill of Rights that includes this grievance procedure as well as information on how to contact the Director/Administrator, and numbers for the State and CHAP hotlines. Patients will be informed of the complaint process in a manner that he or she can understand, including the provision of interpretation or translation services, as applicable. The organization will investigate complaints regarding treatment or care, mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and/or misappropriation of patient property by anyone furnishing services on behalf of the organization. The organization shall be responsible for asking the necessary questions to determine cause of injuries. The organization does not discriminate or retaliate against a patient for expressing a complaint or multiple complaints. Patients are encouraged to speak out and present grievances without fear of retribution. Findings include: 1. The clinical record for Patient #2 was reviewed on 4/20/26. The patient was admitted to hospice care and services on 9/6/23, with a terminal diagnosis of senile degeneration of the brain. The plan of care for the certification period dated 2/22/26 to 4/22/26, included orders for skilled nursing twice per week for pain control and symptom management, certified nursing assistant (hospice aide) twice per week for assistance with personal care/hygiene needs, chaplain twice per month for spiritual support, and social worker twice per month for psychosocial support. Review of the patients record on 4/20/26 showed that a visit note on 2/23/26 from Social Worker #2 indicated that the granddaughter of Patient #2 expressed concern about lack of care from the assisted living residence (ALR). The social worker advised the granddaughter at the end of the conversation that the ALR’s administrator was in their office. On 4/20/26 the agency’s complaint log was reviewed. There was no complaint entered by the social worker about the lack of care from the ALR for Patient #2. Further review into the patients record indicated that there had not been an investigation or communication into the lack of care by the ALR. On 4/20/26 at 2:35 p.m, the Director or Nursing/Alternate Administrator stated that the concern of lack of care from the ALR by the family of Patient #2 should have been put into the complaint log. They also stated that there should have been an investigation into the complaint and that it violated their policy.”

“Based on record review and interview, the hospice failed to ensure care and services were provided in accordance with the plan of care. Specifically, for 1 of 4 sample hospice patients, the hospice did not ensure physician orders were followed (Patient #2). Findings include:The clinical record for Patient #2 was reviewed on 4/20/26. The patient was admitted to hospice care and services on 9/6/23, with a terminal diagnosis of senile degeneration of the brain. The plan of care for the certification period dated 2/22/26 to 4/22/26, included orders for skilled nursing twice per week for pain control and symptom management, certified nursing assistant (hospice aide) twice per week for assistance with personal care/hygiene needs, chaplain twice per month for spiritual support, and social worker twice per month for psychosocial support.a) The hospice failed to ensure patient repositioning was completed every two hours as ordered by the physician.Review of the clinical record revealed Patient #2 resided in an assisted living residence (ALR). Further review of the clinical record revealed a physician order, dated 2/11/26, to turn and reposition Patient #2 every two hours to maintain skin integrity. Repositioning was documented in visit notes for hospice nurse visits twice per week and in hospice aide visit notes twice per week. No additional documentation of repositioning every two hours was found in the clinical record. No documentation of hospice staff instructions to the ALR staff to reposition Patient #2 every two hours was found in the clinical record.During an interview on 4/20/26 at 2:50 p.m., the hospice director of nursing (DON) stated the hospice had sent the repositioning order to the ALR. The DON stated the ALR should know the ALR staff were responsible for repositioning Patient #2 when the hospice staff were not with Patient #2. The DON stated she had not been able to find documentation Patient #2 was repositioned every two hours by the ALR staff.”

“Based on record review and interview, the hospice failed to ensure the ongoing sharing of information regarding services provided by staff at an assisted living residence (ALR). Specifically, for 1 of 4 sample hospice patients who received care at an ALR, the hospice did not ensure physician orders were followed by ALR staff (Patient #2). Findings include:The clinical record for Patient #2 was reviewed on 4/20/26. The patient was admitted to hospice care and services on 9/6/23, with a terminal diagnosis of senile degeneration of the brain. The plan of care for the certification period dated 2/22/26 to 4/22/26, included orders for skilled nursing twice per week for pain control and symptom management, certified nursing assistant (hospice aide) twice per week for assistance with personal care/hygiene needs, chaplain twice per month for spiritual support, and social worker twice per month for psychosocial support.a) The hospice failed to ensure the ongoing sharing of information between hospice staff and staff at the ALR where the patient resided.Review of the clinical record revealed Patient #2 resided in an assisted living residence (ALR) with a written agreement between the hospice and ALR for the ALR to provide services under the direction and supervision of the hospice.Further review of the clinical record revealed a physician order, dated 2/11/26, to turn and reposition Patient #2 every two hours to maintain skin integrity. Repositioning was documented in visit notes for hospice skilled nursing visits twice per week and in hospice aide visit notes twice per week. No additional documentation of repositioning every two hours was found in the clinical record. No documentation of hospice staff instructions to the ALR staff to reposition Patient #2 every two hours was found in the clinical record.During an interview on 4/20/26 at 2:50 p.m., the hospice director of nursing (DON) stated the hospice had sent the repositioning order to the ALR, but the ALR had not confirmed their staff had repositioned the patient as ordered. She stated although care conferences between the hospice and ALR had been documented, the ongoing sharing of information regarding repositioning the patient was not not documented in the care conference notes. The DON further stated she had believed the ALR had been responsible for ensuring the patient was repositioned. The DON stated she had not known the hospice was required to maintain oversight of all the care provided.”

“It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed in which the patient was a live discharge, the hospice did not ensure that the discharge summary was forwarded to the patient’s attending physician. Clinical Record 19: The patient elected hospice care on 08/09/2022 and was discharged as no longer terminally ill (NLTI) on 05/21/2024. There was no documented evidence that the discharge summary was sent to the patient’s attending physician. Clinical Record 20: The patient elected hospice care on 02/28/2024 and was discharged (revocation) on 04/28/2024. There was no documented evidence that the discharge summary was sent to the patient’s attending physician. During a joint review of the record and interview on 07/11/2024, the Executive Director agreed there was no documented evidence that the discharge summary was sent to the patient’s attending physician.”