Treasure Coast Hospice of St Lucie

“Observed in Record Review. In 2 of 20 patient records reviewed, The organization failed to ensure that the plan of care included measurable goals related to the patient’s identified problems. For example, in HHRRHV#5, the patient was assessed as having mild dysphagia and was placed on aspiration precautions; however, the hospice plan of care did not include patient-specific, measurable goals addressing dysphagia management and prevention of aspiration. HOSRRNHV#10, despite ongoing skilled wound care interventions, the hospice plan of care did not contain patient-specific, measurable wound care goals. This finding was discussed with the Compliance Director.”

“Observed in Record Review. In 1 of 20 patient records reviewed, the organization failed to ensure that the Interdisciplinary Group (IDG) updated the Plan of care to reflect the patient’s current wound care needs. During record review of HOSRRNHV#10, the hospice nurse documented that the patient’s bilateral heels became red, and order for Optifoam heel protectors was obtained. However, during the April IDG review, the goals were not revised to address the newly identified risk for skin breakdown., prevention measures, or expected outcomes. This finding was discussed and validated by the Compliance Director.”

“Observed in Record Review. In 10 of 23 patient records reviewed, the organization failed to ensure that the hospice plan of care includes all services needed for the palliation and management of the terminal illness and related conditions, including treatment necessary to meet the patient’s needs. For example, HOSInpatient#1, the wound care order to cleanse tumor site with normal saline, apply ABD pad daily included a PRN (as needed) intervention; however, the order did not specify the clinical indication or circumstances under which the PRN wound care should be performed. HOSInpatient#2, HOSRRHV#6, HOSRRHV#7, HOSRRHV#8, and HOSRRHV#9 the physician ordered oxygen at 2–5 liters per minute (LPM). However, the order did not include clinical parameters or indications to guide staff in determining the appropriate flow rate within the prescribed range. As a result, the order did not provide sufficient direction for consistent implementation of oxygen therapy and left the determination of the flow rate to the clinical judgment of staff without physician-defined parameters. HOSInpatient#3, the Foley catheter order did not specify the catheter size, resulting in incomplete instructions for catheter insertion and management. In record of HOSRRHV#1, an order for oxygen at 2-5 LPM PRN did not include clinical parameters indicating when oxygen should be administered or how the flow rate should be adjusted based on the severity of symptoms. HOSRRHV#4; HHRRHV#5; the physician’s order for oxygen at 2 LPM via nasal cannula PRN did not specify the indication for use e.g., shortness of breath, dyspnea, decreased oxygen saturation, or hypoxia; HOSRRHV#6: the wound care order directed application of triple antibiotic ointment; however, the order did not identify the specific medication or product to be used. This finding was discussed and validated by the Hospice Director.”

“Observed in Record Review. In 1 of 23 patient records reviewed, the organization failed to ensure that the care and services are provided in accordance with the plan of care. For example, HOSInpatient#3, the physician ordered skilled nursing to flush the gastrostomy tube (G-tube) every six (6) hours. However, clinical record review failed to demonstrate evidence that the G-tube flushes were performed as ordered. Documentation did not reflect the date, time, amount of flush administered, or confirmation that the intervention was completed. This finding was discussed and validated by the Hospice IPU Director.”

“Observed in Record Review. In 2 of 14 patient records with hospice aide services, the organization failed to ensure that the hospice aide care plan included patient-specific written instructions for observation, reporting, and safety measures. For example in record of HOSRRNHV#19 and HOSRRNHV#20, the patient was prescribed Aspirin, which may increase the risk of bleeding; however, the hospice aide care plan did not include instructions to observe and report signs and symptoms of bleeding gums, nosebleeds, blood in urine or stool, other abnormal bleeding. This finding was discussed and validated by the Compliance Director and Nurse Educator.”

“Observed in Patient Home. In 1 of 4 home visits with home oxygen conducted, the organization failed to provide patient with Information on the storage, handling, and access to medical gases. For example during a home visit of HOSRRHV#1, the hospice nurse observed an oxygen tank being stored in the garage. However, there was no evidence that the nurse provided re-education on proper oxygen storage and safety precautions in whick the patient was placed at risk for injury and a compromised safe home environment. This finding was discussed and validated by the Nurse Manager, who was present during the visit.”

“Observed in Document Review. The NFPA references with year edition were not on the 2026 and 2026 fire sprinkler inspection reports or the 2025 and 2025 fire alarm inspection reports as well as the 2025 annual fire extinguisher report. The observation was verified by the facilities director. Observed in Building Tour. In the inpatient hospice building there as trash can stored in front of the medical gas shut off near the nurse station and by the Fire Alarm Control Panel. The observation was verified by the facilities director. In the inpatient hospice building there as trash can stored in front of the medical gas shut off near the nurse station and by the Fire Alarm Control Panel. The observation was verified by the facilities director.”