Gentiva

“Based on interview and record review, the hospice agency failed to ensure the Interdisciplinary Group maintained an effective system of communication to maintain support and optimal coordination of services for 1 of 3 patients reviewed for wound care of a total sample of 11 patients, (#1). Review of the hospice agency’s policy and procedures for Interdisciplinary Group Plan of Care, revised 10/11/23 read, “The hospice interdisciplinary group will retain professional management responsibilities for the provision of services and will ensure that services are furnished in a safe and effective manner…the hospice will utilize a case management system to guide and an interdisciplinary group to provide comprehensive, coordinated health care to patients and families/caregivers….the level of care will be unique to each patient and family/caregiver unit and will change as the needs of the patient and family/caregiver evolve…It will be the responsibility of the Case Manager to facilitate communications about changes in the patient’s status between interdisciplinary group members and patient’s attending physician…the hospice personal will communicate changes in a timely manner…Documentations will include…information discussed…When the hospice requires services from the interdisciplinary group…Care will be provided by and interdisciplinary group made of physicians, nurses, social workers, hospice aids…Continuity of care will be maintained throughout the patients’ course with hospice. Exchange of information between hospice staff…will be documented in the clinical record…”Review of the medical record revealed patient #1, a 76-year-old female, was admitted to hospice agency on 8/1/24 while living at an Assisted Living Facility (ALF) with terminal diagnosis of Alzheimer’s Disease. Her secondary diagnoses included dementia, hypertension, and peripheral vascular disease (PVD). The patient was transferred to the hospital via 911 on 4/02/25. Per the family she was dehydrated and her wound smelled bad. The Hospice IDG (interdisciplinary group) Comprehensive Assessment and Plan of Care (POC) Updated Report indicated the IDG meeting was on 3/05/25. Case Manager RN #A documented, “ACCORDING TO THE CAREGIVER, PATIENT COMPLAINS OF PAIN IN THE LOWER EXTREMITIES…WOUND IN THE LEFT HEEL AND NOW ANOTHER NEW ONE IN THE SAME FOOT IN THE MEDIAL AREA…CEPHALEXIN 500 MG TABLET 1 TABLET, 3 TIMES DAILY X 7 DAYS FOR INFECTION IN WOUNDS…The Hospice Recertification Plan of Care dated 3/05/25 revealed orders, “SN TO ASSESS/PATIENT/CAREGIVER FOR BASELINE KNOWLEDGE AND BARRIER TO LEARING TO INCLUDE THE ABILITY AND WILLIGNESS TO PROVIDE CARE IN PERSON…SN TO PROVIDE WOUND CARE ACCORDING TO MEDICAL ORDER WOUND CARE TO LEFT LOWER POSTERIOR LEG THREE TIMES A WEEK AND AS NEEDED FOR SOILED OR LOOSE DRESSING CLEAN WITH WOUND CLEANSER; PAT DRY; APPLY HYDROGEL, COVER WITH NON-ADHERENT DRESSING AND WRAP WITH GAUZE BANDAGE; SECURE WITH TAPE. WOUND CARE TO BE PERFORMED BY HOSPICE RN/SN…. EDUCATE FOR PREVENTION INFECTION IN WOUNDS. SN TO INSTRUCT PATIENT/CAREGIVER ON MEASURES TO PREVENT INFECTION PROPER PERSONAL HYGIENE AND PRESSURE RELIEF…. Goals: PATIENT/CAREGIVER WILL DEMONSTRATE UNDERSTANDING OF INSTRUCTION…PATIENT’S POC WILL BE MANAGED EFFECTIVELY WITH INPUT FROM PHYSICIANS…. PATIENT WILL RECEIVE MAXIMAL WOUND HEALING AND COMFORT WITHIN DISEASE PROCESS. SN PROVIDED ACCORDING TO MEDICAL ORDER WOUND CARE TO LEFT FOOT WOUND MEASURING 6 LONG, 3.0 WIDE AND 0.5 DEEP, WOUND CARE EVERY OTHER DAY CLEAN WITH WOUND CLEANSER WITH GAUZE 4X4, PAT DRY WITH GAUZE 4X4, APPY XEROFORM AND COVERING WITH SECURE OPTIFORAM 6X6 WOUND CARE TO BE PERFORMED BY HOSPICE NURSE ACCORDING TO MD….FACILITY STAFF IS KNOWLEDGEABLE, AWARE AND INVOLVED IN THE HOSPICE PLAN OF CARE SET FORTH BY THE HOSPICE IDG FOR THE PATIENT.”Per the IDG Comprehensive Assessment and Plan of care Update Report dated 4/16/25 Registered Nurse (RN) A documented “PATIENT DISCHARGED APRIL 3, FOR AGGRESSIVE TREATMENT, AMPUTATION OF HER LEG (NECROTIC AREA), COMPLICATED LEG AFTER RECEIVING TREATMENT FOR AROUND 3 WEEKS…FROM …MANAGER OF ALF, PATIENT AFTER DISCHARGE WILL BE TRANFERRED TO A NEW FACILITY…FOR A BETTER QUALITY OF LIFE….” On 7/29/25 an interview was conducted with registered nurse (RN) A and the executive director (ED) of Orlando hospice location. The ED assisted with interpretation during interview as the nurse was more comfortable speaking Spanish than English. The nurse recalled during her visits at the assisted living facility (ALF) that patient #1 had a couple of care givers present at the ALF and one of the caregivers who she thought was the owner wanted to try to do the wound care her way and not follow the doctor’s orders. Initially her husband did not want the caregiver touching his wife but then agreed to allow her to do the wound care for 1-2 weeks because she promised she would get the wound healed in a short amount of time. However, the wound then worsened and became necrotic. The nurse then showed a picture on her cell phone of patient’s heel completely covered with black dried eschar. The nurse could not give a date as to when she took the pictures or even a time frame because she could not remember. The nurse explained she recently got a new phone and the pictures that transferred over from her old phone were not dated, however she was adamant that the pictures were of patient #1’s heel. The RN also showed a picture of a 10-ounce bottle of magnesium citrate and explained that the care giver was not following doctors’ order for wound care. The nurse said the ALF care giver told her she cleaned the patients’ wounds with the magnesium citrate and then wrapped the heel and back of the leg with gauze. The RN verbalized that at a follow-up visit she attempted to remove the dressing to look at the wound and the caregiver and family did not want her to remove the dressing because it was already changed by the caregiver, and this went on for about 2-3 weeks till she was able to then take pictures of the patient wounds. During the interview the RN stated that she did inform the IDG as well as the Doctor. There was no evidence noted in the IDG or mention in the nursing notes that care giver was using magnesium citrate for wound care. RN #1’s supervisor and the ED during interviews the following day both indicated no knowledge that the care giver was not following the doctor’s order by using magnesium citrate for the wound care. The nurse verbalized that the doctor told her that if that’s what the family wants to do, we cannot force them to follow the care plan. The RN also said doctor C called the family during their IDG meeting to encourage them to allow nurse to provide wound care. Record reviews showed no evidence that the IDG team ever discussed the unusual type of wound care provided by the caregiver at the ALF or a phone call made by the doctor. On 7/30/25, the doctor indicated he had no knowledge that the caregiver was using magnesium citrate for wound care. On 7/30/25 at 12:54 PM, Patient Care Manager (PCM) B said she is RN A’s supervisor and verified RN A was the case manage for patient #1. The PCM verbalized she was not aware the ALF owner was cleaning patient #1’s wounds with magnesium citrate and wrapping them with kerlix. The PCM said, if she had known this, it would have prompted her to make a joint visit to the home with RN A for a care conference with the ALF owner and the patients’ family where she would explain to care givers and family the importance of following physician orders with potential for negative outcomes if not followed. The PCM verbalized that she only heard at their IDG meeting the ALF owner preferred to do the wound care and did not want to follow the doctors’ orders. The PCM recalled that doctor C interjected and said that she needed to follow his orders. She added, she would have remembered if there was any discussion regarding someone doing wound care with magnesium citrate as this would have been unusual occurrence that would have prompted an immediate call to the doctor, re-education of the family and caregiver as well as documenting irregularity in the medical record. The PCM acknowledged there was no documentation in patient #1’s medical record regarding caregiver using magnesium citrate to do the wound care or potential negative outcomes regarding not following physician orders. On 7/30/25 at 1:47 PM, the ED acknowledged she was not aware of the caregiver for patient #1 using magnesium citrate for wound care until brought to their attention at the time of the survey. The ED said RN A should have informed the PCM exactly what the caregiver at ALF was using for wound care because they would have immediately intervened with the nurse, family and ALF caregiver/family to ensure they followed the physician orders. The ED verbalized that if the caregiver, then continued to refuse to follow the physician orders, then that would have prompted a report to Department of Children and Family Services (DCF) for neglect. On 7/30/25 at 12:08 PM, Doctor C said he attended the IDG meetings where they discussed patient #1’s care and could not recall any discussion regarding caregivers at ALF using magnesium citrate for the wound care. He would have instructed to follow the doctors’ orders, which most likely would have been Medi honey for a necrotic wound. Review of hospice policy for Wound Assessment, Documentation and Clinical Oversight revised 2/21/24 read, “Patient/Caregiver Refusal of Wound Assessment and/or Care…The nurse must ensure patient/caregiver is educated on the consequences of refused care…Educate patient and caregiver on importance of wound assessment and wound care and potential consequences to patient when assessment and wound care are not provided….Notify the attending physician…of refusal for wound assessment and/or care, include any orders that are not being followed due to the refusal and request assistance in facilitating care where possible….Report refusals to the hospice medical director and other members of the IDG. Report should include specifics regarding the refusals and any orders not followed as a result of the refusal. Collaborate with IDG members on plan to address repeated refusals and request assistance from other IDG members as appropriate…Document the report, the plan to address refusals, and collaboration in the IDG note….””

“Based on interview and record review, the hospice agency failed to ensure that care and services were provided in accordance with the Hospice Physician Order and Hospice IDG (interdisciplinary group) Comprehensive Assessment and Plan of Care (POC) for 1 of 3 patients reviewed for wound care of a total sample of 11 patients, (#1). Review of the medical record revealed patient #1, a 76-year-old female, was admitted to hospice agency on 8/1/24 while living at an Assisted Living Facility (ALF) with terminal diagnosis of Alzheimer’s Disease. Her secondary diagnoses included dementia, hypertension, and peripheral vascular disease. The patient was transferred to the hospital via 911 on 4/2/25, per the family she was dehydrated and her wound smelled bad. Review of the medical record revealed wound care orders dated 8/2/24 which read, “SN [skilled nurse] PROVIDED WOUND CARE ACCORDING TO MEDICAL ORDER WOUND CARE TO LEFT LOWER POSTERIOR LEG, THREE TIMES A WEEK AND AS NEEDED FOR SOILED OR LOOSE DRESSING. CLEAN WITH WOUND CLEANSER; PAT DRY APPLY HYDROGEL, COVER WITH NON-ADHERENT DRESSING AND WRAP WITH GAUZE BANAGE; SECURE WITH TAPE. WOUND CARE TO BE PREFORMED BY HOSPICE RN [Registered Nurse]/SN. CG [caregiver]…VERBALIZED UNDERSTANDING. SN PROVIDED ACCORDING TO MEDICAL ORDER WOUND CARE TO LEFT FOOT WOUND MEASUREING 6 LONG, 3.0 WIDE AND 0.5 DEEP. WOUND CARE EVERY OTHER DAY CLEAN WITH WOUND CLEANSER WITH GAUZE 4X4, PAT DRY WITH GAUZE 4X4, APPLY XEROFORM AND COVERING WITH SECURE OPTIFORM 6X6 WOUND CARE TO BE PERFORMED BY HOSPICE NURSE ACCORDING TO MD…” The Hospice Recertification Plan of Care dated 3/5/25 revealed orders, “SN TO ASSESS/PATIENT/CAREGIVER FOR BASELINE KNOWLEDGE AND BARRIER TO LEARING TO INCLUDE THE ABILITY AND WILLIGNESS TO PROVIDE CARE IN PERSON…SN TO PROVIDE WOUND CARE ACCORDING TO MEDICAL ORDER WOUND CARE TO LEFT LOWER POSTERIOR LEG THREE TIMES A WEEK AND AS NEEDED FOR SOILED OR LOOSE DRESSING CLEAN WITH WOUND CLEANSER; PAT DRY; APPLY HYDROGEL, COVER WITH NON-ADHERENT DRESSING AND WRAP WITH GAUZE BANDAGE; SECURE WITH TAPE. WOUND CARE TO BE PERFORMED BY HOSPICE RN/SN…. EDUCATE FOR PREVENTION INFECTION IN WOUNDS. SN TO INSTRUCT PATIENT/CAREGIVER ON MEASURES TO PREVENT INFECTION PROPER PERSONAL HYGIENE AND PRESSURE RELIEF…. Goals: PATIENT/CAREGIVER WILL DEMONSTRATE UNDERSTANDING OF INSTRUCTION…PATIENT’S POC WILL BE MANAGED EFFECTIVELY WITH INPUT FROM PHYSICIANS…. PATIENT WILL RECEIVE MAXIMAL WOUND HEALING AND COMFORT WITHIN DISEASE PROCESS. SN PROVIDED ACCORDING TO MEDICAL ORDER WOUND CARE TO LEFT FOOT WOUND MEASURING 6 LONG, 3.0 WIDE AND 0.5 DEEP, WOUND CARE EVERY OTHER DAY CLEAN WITH WOUND CLEANSER WITH GAUZE 4X4, PAT DRY WITH GAUZE 4X4, APPY XEROFORM AND COVERING WITH SECURE OPTIFORAM 6X6 WOUND CARE TO BE PERFORMED BY HOSPICE NURSE ACCORDING MD….FACILITY STAFF IS KNOWLEDGEABLE, AWARE AND INVOLVED IN THE HOSPICE PLAN OF CARE SET FORTH BY THE HOSPICE IDG FOR THE PATIENT.”Further review reveals Hospice Physician Order dated 3/10/25 for left posterior heel and leg wounds read, “WOUND CARE 1-TO POSTERIOR LT [left] LEG 3 TIMES PER WEEK CLEAN WITH WOUND CLEANSER, PAT DR WITH GAUZE 4X4 , APPLY OPTICELL WITH MEDIHONEY, COVER WITH OPTIFOAM AND ROLL BULKEE AND SERCURE MEDFIX TAPE. WOUND CARE TO BE PERFORMED BY SN 3 TIMES PER WEEK AND AS NEEDED FOR SOILED OR DISLODGED…” On 7/29/25 at 11:52 AM, in a telephone interview with RN A she explained she was the Case Manager for patient #1. She said the patient had left foot pressure wound and poor circulation which required wound care three times a week. The wound started to become necrotic, and the patient was transferred to the hospital for an amputation of her foot. On 7/29/25 an interview was conducted with RN A and the Executive Director (ED) of Orlando hospice location. The ED assisted with interpretation during interview as the nurse was more comfortable speaking Spanish than English. The nurse recalled during her visits to the ALF that patient #1 had a couple of caregivers present and one of the caregivers she thought was the owner. RN A said the owner wanted to try to do wound care her way and not follow the doctor’s orders. Initially patient #1’s husband did not want the ALF caregiver touching his wife but then agreed to allow her to do the wound care for 1-2 weeks because she promised to get the wound healed in a short amount of time. RN A explained the ALF caregiver continued to do the dressing changes for the next 2-3 weeks she did not look at the patient’s wounds because the caregiver indicated the dressings were already changed. RN A said the wound worsened and became necrotic. RN A showed a picture on her cell phone of patient #1’s heel completely covered with black dried eschar. RN A could not give a date as to when she took the pictures or even a time frame because she could not remember. RN A could not show a time/date stamp on her phone and explained she recently got a new phone, although the pictures transferred over from her old phone they were not dated. RN A then showed a picture of a 10-ounce bottle of magnesium citrate and explained that the caregiver was not following doctors’ order for wound care. RN A said the care giver told her she was cleaning the wounds with magnesium citrate and wrapped the heel and leg with kerlix. RN A recalled that the patient ended up in the hospital due to wound infection and had an amputation. A 10 oz bottle of magnesium citrate saline laxative is primarily used to relieve occasional constipation. It works by attracting water into the intestines through osmosis, which softens the stool and increases its volume. This action stimulates the intestinal walls to contract, aiding in the movement of stool through the digestive tract. The laxative is typically used for short-term relief and is effective for bowel preparation before medical procedures, such as colonoscopies (retrieved form www.drugs.com on 8/01/25).On 2/11/25 the Advance Practice Registered Nurse (APRN) documented patient #1 has wound present left lower leg and heel. On 2/12/25 Wound Report Record showed addition of new order for wound care read, “NURSE HOSPICE MANAGEMENT WOUND CARE 3X WK. RN WILL PROVIDE WOUND CARE TO LEFT FOOT WOUND MESURING 6 LONG, 3.0 WIDE AND 0.5 DEEP, WOUND CARE EVERY OTHER DAY CLEAN WITH WOUND CLEANSER WITH GAUZE 4X4. PAT DRY WITH GAUZE 4X4, APPLY EXEROFORM AND COVERING WITH SECURE OPTIFOAM 6X6 WOUND CARE TO BE PERFORMED BY HOSPCE NURSE…” Review of the medical record revealed documentation by Master of Social Work D during her home visit on 3/13/25, the husband voiced he only wanted the hospice nurse going forward to do the wound care and not the facility caregiver. Review of the nursing notes revealed that although the husband had insisted on the hospice nurse doing the wound care on 3/13/25 and ordered by the doctor to be done 3 times per week the hospice nurse failed to provide wound care for 5 days between 3/14/25 to 3/19/25. The patient was seen by the hospice nurse on 3/21/25, 3/24/25, 3/26/25, 3/28/25 and 3/31/25 and wound care was not provided by nurse. The patient had not received wound care from the hospice nurse from 3/20/25 through her transfer to the hospital on 4/2/25, therefore the hospice nurse had not provided the dressing changes as ordered by the doctor for 2 weeks. The nurses continued to document that the caregiver refused to allow the nurse to do the care however did not document the husband’s refusal for care after he stated on 3/13/25, he only wanted hospice staff to do the wound care. RN A indicated the caregiver at ALF was using magnesium citrate for the wound care and this was not noted in any of nurses’ notes at all. On 7/30/25 at 12:08 PM, Hospice Doctor C said he attended the IDG meetings regarding patient #1 and could not recall any discussion regarding caregivers at ALF using magnesium citrate for the wound care and would have instructed to follow orders which most likely would have been Medi honey for a necrotic wound. On 7/30/25 at 12:54 PM, Patient Care Manager (PCM) B said she is RN A’s supervisor. The PCM verbalized she was not aware the ALF owner was cleaning patient #1’s wounds with magnesium citrate and wrapping them with kerlix. The PCM acknowledge there was no documentation in patient #1’s medical record regarding caregiver using magnesium citrate to do the wound care. On 7/30/25 at 1:47 PM, the hospice ED of the Orlando location acknowledged that she was not aware of the caregiver for patient #1 using magnesium citrate for the wound care until brought to their attention at the time of the survey. The ED said, RN A should have informed the PCM exactly what the caregiver at ALF was using for wound care because they would have immediately intervened with the nurse, family and ALF caregiver to ensure they followed the physician orders. On 7/30/25 from 12 PM to 12:47 PM, repeated attempts were made to talk to staff or owner of the ALF where patient #1 resided. The hospice ED provided phone numbers and was informed before exit on 7/30/25 at 3:15 PM, that surveyor was unable to reach anyone at the ALF. To date 8/03/25 no call back was ever received from the owner or staff at ALF. Review of hospice policy for Wound Assessment, Documentation and Clinical Oversight revised 2/21/24 read, “Patient/Caregiver Refusal of Wound Assessment and/or Care…The nurse must ensure patient/caregiver is educated on the consequences of refused care…Educate patient and caregiver on importance of wound assessment and wound care and potential consequences to patient when assessment and wound care are not provided…””

“Based on interview and record review, the hospice agency failed to provide appropriate nursing services, according to professional standards, for 1 of 3 patients reviewed for wound care of a total sample of 11 patients, (#1). Florida Board of Nursing, Nurse Practice Act, 464.003 (19) (20) (a) (b) reads, “Practice of practical nursing means the performance of selected acts, including the administration of treatments and medications, in the care of the ill, injured, or infirm; the promotion of wellness, maintenance of health, and prevention of illness of others under the direction of a registered nurse, a licensed physician . A practical nurse is responsible and accountable for making decisions that are based upon the individual’s educational preparation and experience in nursing. 20) Practice of professional nursing means the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not be limited to: (a) The observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care; health teaching and counseling of the ill, injured, or infirm; and the promotion of wellness, maintenance of health, and prevention of illness of others. (b) The administration of medications and treatments as prescribed or authorized by a duly licensed practitioner authorized by the laws of this state to prescribe such medications and treatments.”Review of the medical record revealed a note by the Master of Social Work (MSW) D written during her home visit on 3/13/25.Resident #1’s husband voiced, going forward he only wanted the hospice nurse to do the wound care and not the facility care giver. Review of the nursing notes revealed that although the husband had insisted on the hospice nurse doing the wound care on 3/13/25, and it was ordered by the doctor to be done 3 times per week and the hospice nurse failed to provide the wound care dressing changes for 5 days between 3/14/25 to 3/19/25. The patient was seen by the hospice nurse on 3/21/25, 3/24/25, 3/26/25, 3/28/25 and 3/31/25. The wound care was not provided by the nurses on these visits. The patient did not receive wound care from 3/20/25 through her transfer to the hospital on 4/02/25, therefore the hospice nurse did not provide the dressing changes as ordered by the doctor for 2 weeks. The nurses continued to document that the caregiver refused to allow the nurse to do the care, however did not document the husband’s refusal for care after he stated on 3/13/25 he only wanted hospice staff to do the wound care. The Hospice Case Manager (CM) had indicated that the caregiver at Assisted Living Facility (ALF) was using magnesium citrate for wound care, and this was not noted in any of Registered Nurse (RN) A’ s notes either. Review of the medical record revealed patient #1 had a stage 2 pressure ulcer on her left Achilles with and onset date of 11/30/24 and left distal calf pressure ulcer stage 2 with onset dated of 2/12/25. According to National Pressure Ulcer Advisory Panel (NPUAP) staging system, pressure injuries (formerly pressure ulcers) are categorized into several stages: “Stage 2: Partial-thickness skin loss involving the epidermis and/or dermis, appearing as an abrasion, blister, or shallow crater…. Unstageable Pressure Injury: Full-thickness loss where the base is covered by dead tissue (slough or eschar) of various colors, making the depth and stage unclear. Deep Tissue Pressure Injury (DTPI): Discolored intact skin or a blood-filled blister from damage to underlying tissue due to pressure or shear. The area might be painful or feel different from surrounding tissue. It can look like a deep bruise and may progress to a higher stage (retrieved on 8/02/2025 from https://npiap.com/). Patient #1’s Case Manager (CM) was RN A who did visits on 12/30/24, 1/6/25 and documented on the wound assessment 0-25 % slough and 0-25 % eschar tissue in the left Achilles pressure ulcer and continued to assess patient to have a stage 2 pressure ulcer. The patient had onset of stage 2 calf pressure ulcer on 2/12/25 and RN A continued to document wound as a stage 2 with presence of 0-25% slough and 0-25 % eschar on 3/10/25, 3/12/25, 3/14/25, 3/17/25 and 3/19/25. The nurse documented left Achilles pressure ulcer with increased slough/eschar 26-50 % on 1/6/25, 3/10/25, 3/12/25, 3/14/25, and 3/17/25. Then on 3/19/25 the RN assessed the left Achilles pressure ulcer as having greater than 50% necrotic tissue and continue to assess wound to be a stage 2 pressure ulcer.Per the IDG Comprehensive Assessment and Plan of care Update Report dated 4/16/25 Registered Nurse (RN) A documented “PATIENT DISCHARGED APRIL 3, FOR AGGRESSIVE TREATMENT, AMPUTATION OF HER LEG (NECROTIC AREA), COMPLICATED LEG AFTER RECEIVING TREATMENT FOR AROUND 3 WEEKS…FROM …MANAGER OF ALF, PATIENT AFTER DISCHARGE WIL BE TRANFERRED TO A NEW FACILITY…FOR A BETTER QUALITY OF LIFE….” On 7/29/25 at 11:52 AM, in a telephone interview with RN A she explained she was the Case CM for patient #1. She said the patient had left foot pressure wound and poor circulation which required wound care three times a week. The wound started to become necrotic, and the patient was transferred to the hospital for an amputation of her foot. The nurse was having difficulty answering the questions and indicated that she would come into the hospice office for an in-person.On 7/29/25 an interview was conducted with RN A and the Executive Director (ED) of Orlando hospice location. The ED assisted with interpretation during interview as the nurse was more comfortable speaking Spanish than English. The nurse recalled during her visits at the ALF that patient #1 had a couple of care givers present at the ALF and one of the caregivers who she thought was the owner wanted to try to do the wound care her way and not follow the doctor’s orders. Initially her husband did not want the caregiver touching his wife but then agreed to allow her to do the wound care for 1-2 weeks because she promised she would get the wound healed in a short amount of time. However, the wound then worsened and became necrotic. On 7/30/25 at 1:47 PM, the hospice ED of Orlando location and Patient Care Manager (PCM) B acknowledged that RN A should not have been documenting stage 2 for a pressure ulcer as well that was obviously an unstageable wound with black eschar/slough (dead tissue) present. Review of hospice policy for Wound Assessment, Documentation and Clinical Oversight revised 2/21/24, read, “Stage 1-4 for pressure injuries only. When eschar/slough is present the wound cannot be staged until it is removed…””

“Upon observation, there was no evidence the agency has conducted exercises to test the emergency plan every two years. There was no evidence that the facility had enacted their EPP in August 2023 (Communications observed regarding a possible weather emergency) and documented their compliance and ensured that this information is available for review at any time for a period of no less than three (3) years. There was no documentation of the lessons learned following their real-life emergency with demonstration that they have incorporated any necessary improvements in their emergency preparedness program.”

“Upon patient record review 3 of 23 (Patient #2,#10,#12) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual’s attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient#2: The patient was admitted on 8/1/23. The record indicated the spiritual assessment was completed on 8/7/23. Patient#10: The patient was admitted on 4/7/23. The record indicated the spiritual assessment was completed on 4/14/23. Patient#12: The patient was admitted on 5/3/23. The record indicated the spiritual assessment was completed on 5/17/23.”

“Upon patient record review, 9 of 23 (Patient #1,#2,#6,#7,#10,#12,#13, #14,#17) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #1: Medication profile indicated duplicated orders; Oxycodone-Acetaminophen 5mg/325mg 1 tablet PO every 6 hours PRN. Corrected on site. Patient #2: Medication profile indicated duplicated orders. Meloxicam 15mg PO 1 tablet daily, Meloxicam 7.5mg PO 2 tablets daily, and Meloxicam 7.5mg PO 1 tablet daily. Corrected on site. Patient#6: Medication profile indicated duplicated orders. Arthritis Pain Relief Acetaminophen 650mg ER PO 1 tablet every 6 hours PRN, and Acetaminophen 650mg 1 tablet PO every 6 hours PRN. Corrected on site. Patient#7: Narrative nurse documentation from IDG 11/15/23 indicated that oxygen was requested for 2L as needed use due to shortness of breath when sleeping and history of apnea. Narrative nurse documentation from 11/29/23 indicated patient was on oxygen 2L as needed. There was not evidence of oxygen being on the medication profile. Corrected on site Patient#10: Record indicated patient had a burn on his left anterior forearm which was being treated with Silver Sulfadiazine 1% topical cream. The wound and wound care was deactivated on 5/8/23. Silver Sulfadiazine remained on the medication profile. Corrected on site. Patient#12: Medication profile indicated Lidocaine 4% Topical Patch one patch on skin daily to affected area. There was not evidence of a specific location. Corrected on site. In addition, the medication profile indicated duplicate orders; Docusate Sodium 100mg PO 1 tablet 2 times daily as needed for constipation and Dulcolax 100mg PO 1 tablet 2 times daily as needed for constipation. Corrected on site. Also, medication profile included polyethylene glycol 17gm 1 daily PRN constipation. There was not evidence of which laxative to use first and under what conditions to use the second laxative. Corrected on site. Patient#13: Medication profile indicated duplicated orders; Stool softener 100mg PO 1 caplet daily for constipation and stool softener 100mg PO 1 caplet daily for constipation. Corrected on site. Patient#14: Medication profile indicated duplicated orders. Diclofenac 1% topical gel apply a dime size amount to right shoulder q6 hours PRN pain and Voltaren arthritis pain 1% topical gel apply dime size amount over painful joints q6 hours PRN pain. Corrected on site. In addition, Laxative stool softener with Senna 8.6mg-50mg PO 2 tablets daily, Lactulose 10gm/15ml 30ml PO twice daily, and Biscodyl 10mg rectal suppository 1 suppository daily PRN if no BM in 3 days. There was not evidence of which laxative to use first and under what conditions to use the second laxative. Corrected on site. Patient#17: The record indicated Lactulose 10gm/15ml, 15ml PO for constipation and Laxative stool softener with Senna 8.6mg-50mg PO 2 tablets daily for constipation. There was not evidence of which laxative to use first and under what conditions to use the second laxative. Corrected on site.”

“Upon patient record review, 2 of 23 (Patient #7,#10) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient#7: The record indicated patient diagnosis cerebral vascular disease. Also documentation indicated right hemiparesis, condition complicated by Alzheimer’s, dependent in 5 of 6 ADL’s, incontinent, worsening confusion, and increase combativeness. There was not evidence of a neurological care plan. Corrected on site. Patient#10: The record indicated patient diagnosis of Parkinson’s. Documentation included increased contractures, slurred speech, tremors, speaks minimally, maximum assist 6 out of 6 ADL’s, intermittent periods of confusion and anxiety, slow swallowing, long periods of time to finish meals, shuffles and drags feet, and sleeping 14 hours a day. There was not evidence of a neurological care plan. Corrected on site.”

“Upon patient record review, 5 of 23 (Patient #1,#7,#12,#14,#17) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient#1: Nursing documentation dated 10/17/23 indicated that zinc oxide was applied to the wound. Documentation from 10/18/23 indicated wound care was tolerated well. There was no evidence of wound care orders. Patient#7: Narrative nurse documentation from IDG 11/15/23 indicated that oxygen was requested for 2L as needed use due to shortness of breath when sleeping and history of apnea. Narrative nurse documentation from 11/29/23 indicated patient was on oxygen 2L as needed. There was not evidence of oxygen being in the record. Corrected on site. Patient#12: The record indicated Lidocaine 4% Topical Patch one patch on skin daily to affected area. There was not evidence of a specific location. Corrected on site. In addition, record included polyethylene glycol 17gm 1 daily PRN constipation. There was not evidence of which laxative to use first and under what conditions to use the second laxative. Corrected on site. Patient#14: The record indicated Voltaren arthritis pain 1% topical gel apply dime size amount over painful joints q6 hours PRN pain. There was not evidence of specific joints. Corrected on site. In addition, Laxative stool softener with Senna 8.6mg-50mg PO 2 tablets daily, Lactulose 10gm/15ml 30ml PO twice daily, and Bisacodyl 10mg rectal suppository 1 suppository daily PRN if no BM in 3 days. There was not evidence of which laxative to use first, second, or under what conditions to use the third laxative. Corrected on site. Also, narrative nurse documentation on 11/26/23 indicated patient was incontinent. On 11/29/23, nurse narrative documentation indicated patient had a foley catheter. There was not evidence of a foley catheter order. Corrected on site. Patient#17: The record indicated Lactulose 10gm/15ml, 15ml for constipation and Laxative stool softener with Senna 8.6mg-50mg 2 daily for constipation. There was not evidence of which laxative to use first and under what conditions to use the second laxative. Corrected on site.”

“Upon client record review, 6 of 23 (Patient #1,#2,#8, #14,#15,#17) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient#1: The visit frequency for social work was an evaluation for 1 every 2M2, 1M1. The record indicated that an evaluation was conducted on 10/18/23 and a routine visit on 11/14/23. Patient#2: The visit frequency for spiritual care dated for 11/28/23 was 2M1, 1M2 effective 11/01/23. There was no evidence in record of visits in November. Patient#8: The visit frequency for spiritual care for the benefit period beginning 9/26/23 was 1M3. The record indicated that during the month of October, 2 SC visits were conducted on 10/2/23 and 10/26/23. In addition, the SN frequency for the benefit period beginning 11/25/23 was 3 every 2WK2, 3WK7. The record indicated SN visits were conducted on 11/27/23, 11/29/23, 12/1/23, 12/4/23, 12/6/23, and 12/8/23. Patient#14: The visit frequency for spiritual care was 1x/week and increased to 2x/week effective 12/1/23. The record indicated 2 visits by the spiritual care counselor for the month of November and 3 spiritual care visits were conducted the week of 12/3/23-12/9/23, on 12/4/23, 12/5/23, and 12/6/23. In addition, the SN frequency was 2x/week 4PRN effective 10/23/23, with additional 4 PRN effective 11/30/23. The record indicated SN conducted 10 PRN visits. Also, SN frequency daily visits x2 weeks effective 12/5/23. The record indicated 3 SN visits were conducted 12/5/23, 12/7/23, and 12/10/23. Patient #15: The visit frequency for social work was 1x month. For the month of November record indicated two visits on 11/01/23 and 11/14/23. Patient#17: The record indicated an order for PT evaluation dated 10/31/23. There was not evidence of a visit that evaluation was completed. In addition, the visit frequency for the spiritual care counselor was for an evaluation and then 1x per week for 3 weeks, followed by 2 times per month. The evaluation was performed on 10/30/23. Visits were conducted on 11/09/23 and 12/04/23, and a missed visit documented on 11/30/23. Also, a nurse note dated 12/05/23 at 8:30pm indicated wound cleaned per order. There was not evidence of the wound location or the wound care that was provided.”

“Upon patient record review, 2 of 23 (Patient #1,#14) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient#1: Nursing documentation indicated no wound since 10/27/23. The aide plan of care continued to indicate under alerts that dressings are to be left in place. There was not evidence that the aide care plan was revised to reflect these changes. Corrected on site Patient#14: The aide plan of care dated 8/13/23 indicated nail care weekly or as needed and shampoo weekly or as needed as patient prefers. Corrected on site.”

“Upon patient record review 2 of 23 (Patient #15,#17) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient#15: The aide visit frequency was 3x per week. For the week of 11/26/23-12/01/23, the record indicated only 2 visits. Patient#17: The aide plan of care dated 10/27/23, indicated shave three times per week (visit frequency was 5 times per week). The record indicated a shave was done on all visits.”

“Upon patient client record review, 1 of 23 (Patient #3) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient#3: The benefit election was signed by the patient/caregiver on 7/13/23. The patient/caregiver elected to receive the notification of non-covered drugs/items on this date. The record indicated that this documented was furnished and signed on 7/31/23. Another request was made on 09/7/23. There was not evidence of a date that the document furnished was signed on 9/12/23.”

“Upon patient client record review, 3 of 23 (Patient #3,#6,#17) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient#3: The record indicated a nurse visit note (on paper), dated 10/16/23. There was not evidence of credentials. Patient#6: The initial certification of terminal illness narrative written by the medical director indicated left hip pressure ulcer, initiated wound care. There was not evidence of a wound or wound care orders. Patient#17: The record indicated that the DNR was signed on 12/05/23. There was not evidence that the advance directive was in the record. Leadership confirmed that the notation made on 12/5/23 was incorrect. Patient remained a full code without Advance Directives.”