Brightmoor Hospice, LLC

“Based on observation and staff interviews it was determined the facility failed to ensure that the walls and ceiling tiles had no penetration. This affects 1 of 2 smoke compartments or what areas are affected. During a tour of the facility with Staff M on 4-3-2025 between 1:30 and 2:30 pm. Observation revealed that there is penetration in the wall by room A660 and in room A670 there is penetration in the ceiling tile. These findings were confirmed by Staff M at the time of the observation. Reference: 2012 NFPA 101, Chapter 21, Section 21.3.7.1”

“Based on observation, review of facility records, and staff interviews it was determined the facility failed to have the patient room doors properly closing. Room 670This affects 1 of 2 smokes compartments or what areas are affected. The findings include:During a tour of the facility with Staff M on 4-3-2025 between 1:30 pm - 2:30 pm observation revealed facility failed to have the patient room doors properly closing. Room 670These findings were confirmed by Staff M at the time of discovery.Reference: 2012 NFPA 101, Chapter 19, Section 19.3.6.3.1 and CMS S&C-07-18”

“Based on observation and staff interviews it was determined the facility failed to label emergency receptacles in patient rooms.This affects 2 of 2 smoke compartments or what areas are affected. Based on observation and staff interviews it was determined the facility failed to label emergency receptacles in patient rooms.This affects 2 of 2 smoke compartments or what areas are affected.During a tour of the facility with Staff M on 4-3-2025 between 1:30 and 2:30 pm. Observation revealed that receptacles in patient rooms weren’t labeled.These findings were confirmed by Staff M at the time of the observation.Reference: 2012 NFPA 101, Chapter 19, Section 19.5.1.1, Chapter 9, Section 9.1.2 and 2011 NFPA 70 Article 408.4, 725.30”

“Based on review of records, staff interviews, observation, and review of policy titled “Interdisciplinary Group (IDG) Care Planning Process”, it was determined the hospice failed to ensure the requirements for the interdisciplinary group, care planning and coordination of services were met. Specifically, that the initial plan of care (POC) was developed for each patient and followed an individualized written POC established by the hospice interdisciplinary group (IDG); to ensure the plans of care reflect individualized goals and interventions identified at the initial patient assessment for two patients (P) (P#9 and #10) of 30 sampled patients. Findings include: Review of the undated policy titled “Interdisciplinary Group (IDG) Care Planning Process” revealed the following: 6. All care and services furnished to patient and families follows an individualized written plan of care established by the IDG in collaboration with the attending physician. 8. An individualized written plan of care is developed for each patient. Standing orders or routine orders will be individualized to address the specific patient’s needs and signed by the physician. 1. During an inpatient visit observation for P#9 on 6/4/2024 at approximately 10:00 a.m., observed P#9 lying in bed with a Foley catheter (a flexible tube that drains urine from the bladder) bag hanging on right side of bed. Yellow colored urine was observed in the catheter bag. Review of the clinical record revealed a generic physician’s order that reveals the following: Irrigate (flush) as needed and change monthly and as needed. May insert indwelling Foley catheter for urinary retention and/or comfort. Indicate size: 14fr, 16fr, 18fr, 20fr or Coude14, 16, 18 or 20 in shift assessment and care need. The hospice failed to specify the size of the Foley catheter based on the assessed need for P#9. 2. Review of the clinical record for P#10 revealed the Registered Nurse (RN) inserted a 16 french Foley catheter (a medical device inserted into the bladder to help drain urine from the bladder) via sterile technique with clear amber urine return. However, the plan of care dated 6/2/2024 to 8/30/2024 failed to indicate a specific catheter size for insertion. The hospice failed to specify the size of the Foley catheter based on the assessed need of the patient. On 6/5/2024 at approximately 1:00 pm, and interview was conducted with the Director of Nursing (DON) who acknowledged the plan of care was not specific and did not identify a specific catheter size to be used. The DON also stated they use standing orders for the patients as needed. On 6/5/2024 an interview was conducted with the Assistant Director of Nursing who confirmed that the plan of care lacked a specific catheter size to be used for catheter care and maintenance.”

“Based on record reviews and staff interview, it was determined the agency failed to ensure the Certified Nursing Assistant (CNA) and nursing services were provided as ordered in the plan of care (POC) for five patients (P) (P#12, P#15, P#16, P#17, P#20) of 30 sampled patients. 1. Findings include: 1. Review of the clinical record revealed that P#12 was admitted to hospice services on 9/12/2023. The hospice CNA was scheduled to visit the patient three times a week for one week and five times a week for 12 weeks. The clinical record failed to reveal CNA visits for the weeks of 9/17/23 through 9/23/2023, 9/24/2023 through 9/30/2023, and 10/1/2023 through 10/7/2023. The clinical record failed to reveal documented CNA missed visits for the weeks of 9/17/2023 through 9/23/2023, 9/24/2023 through 9/30/2023, and 10/1/2023 through 10/7/2023. 2. Review of the clinical record revealed that P#15 was admitted to hospice services on 3/4/2024. The hopice CNA was scheduled to visit P#15 two times a week for one week and three times a week for 12 weeks. The clinical record failed to reveal CNA visits after 4/1/2024. The clinical record failed to reveal a physicians order to discontinue services. On 6/6/2024, the Assistant Director of Nursing (ADON) presented a physicians order dated 6/5/2024 to discontinue services. 3. Review of the clinical record for P#16 revealed that the patient was admitted to hospice services on 4/10/2024. The hospice CNA was scheduled to visit the patient two times a week for one week and five times a week for 12 weeks. The clinical failed to reveal two CNA visits for the week of 4/21/2024 through 4/27/2024. The clinical record failed to reveal documented CNA missed visit for the week of 4/21/2024 through 4/27/2024. 4. Review of the clinical record revealed that the P#17 was admitted to hospice services on 5/6/2024 The hospice CNA was scheduled to visit the patient five times a week for three weeks. The clinical record failed to reveal CNA visits after 5/20/2024. The clinical record failed to reveal a physicians order to discontinue services. On 6/6/2024, the ADON presented a physicians order dated 6/5/24 to discontinue services. 5. Review of the clinical record P#20 was admitted to hospice services on 1/12/2024. The hospice CNA was scheduled to visit the patient three times a week for 12 weeks. The clinical record failed to reveal one CNA visit for the week of 1/21/2024 through 1/27/2024. The clinical record failed to reveal a CNA missed visit for the week of 1/21/2024 through 1/27/2024. On 6/4/24 at 10:00 a.m., during an office interview, the Director of Nursing (DON) confirmed the missing supervisory visits for P#12, P#15, P#16, P#17, and P#20.”

“Based on record reviews and staff interviews it was determined the agency failed to ensure the Certified Nursing Assistant (CNA) on-site supervisory visits were completed by the Registered Nurse (RN) for four patients (P) (P#16, P#17, P#24, and P#26) of 30 sampled patients. 1. Findings include: 1. Review of the clinical record revealed P#16 was admitted to hospice services on 4/10/2024 and the hospice aide visited the patient one time a week for the week of 4/10/2024 through 4/13/2024 and five times a week from 5/14/2024 through 7/8/2024. However, the clinical record failed to reveal CNA supervisory visits. The hospice Registered Nurse (RN) failed to perform CNA supervisory visits every two weeks. 2. Review of the clinical record revealed P#17 was admitted to hospice services on 5/6/2024 and the hospice aide visited the patient three times a week from 5/6/2024 through 5/20/24. However, the clinical record failed to reveal CNA supervisory visits from 5/6/2024 through 5/20/2024. The hospice RN failed to perform CNA supervisory visits every two weeks. 3. Review of the clinical record revealed P#24 was admitted to hospice services on 3/27/2024 and the hospice CNA visited the patient five times a week from 3/31/2024 through 4/20/2024. However, the clinical record failed to reveal CNA supervisory visits from 3/31/24 through 4/20/2024. The hospice RN failed to perform CNA supervisory visits every two weeks. 4. Review of the clinical record revealed that P#26 was admitted to hospice services on 2/7/2024 and the hospice CNA visited P#26 five times a week from 4/28/2024 -5/22/2024. However, the clinical record failed to reveal supervisory visits from 4/28/2024- 5/22/2024. The hospice RN failed to perform CNA supervisory visits every two weeks. On 6/6/2024 at 9:30 a.m., an interview was conducted with the Director of Nursing (DON) who was unable to provide evidence that the certified nursing assistant (CNA) supervisory visits were completed every two weeks for P#16 and P#24. On 6/6/2024 at approximately 10:00 a.m., an in office interview was conducted with the Assistant Director of Nursing (ADON) who was unable to provide evidence that aide supervisory visits were completed every two weeks for P#17 and P#26.”

“Based on record reviews, staff interview, and review of policy titled “;Physician Orders,” it was determined the hospice failed to develop a plan of care that included all services and orders necessary for the palliation and management of the terminal illness and related conditions for three patients (P) (P#14, P#23, and P#24) of 30 sampled patients. Findings include: Review of the undated policy titled “Physician’s Orders” revealed: 4. Care and services provided will be provided according to physician orders. Orders are current and updated. 5. Drugs and treatments are administered by staff only as ordered by physician. 1.Review of the clinical record for P#14 admitted 3/3/2024 revealed the hospice nurse visited the patient on 5/9/2024 and 5/23/2024 and administered a subcutaneous (SQ) infusion (technique whereby fluids are inserted under the skin for absorption) to P#14. Review of the plan of care (POC) for certification period 3/3/2024 to 5/31/2024 failed to reveal a physician order for the SQ infusion. On 6/5/2024, the Director of Nursing (DON) presented an order dated 6/5/2024 which reveals the following: May continue Hizentra (used to boost the body’s natural defense system against infection in persons with a weakened immune system) 15m/75ml SQ every two weeks effective 3/3/2024 via infusion pump. The hospice nurse failed to obtain an order for the infusion prior to administration. 2. Review of the clinical record for P#23 admitted 2/27/2024 revealed the Skilled Nurse (SN) visited the patient on 5/8/2024 and 5/21/2024 and documented P#23 has a condom catheter (a urine (pee) collection device that fits like a condom over your genitals, but also has a tube that goes to a collection bag). The (SN) additionally documented on 5/8/2024 that the patient has a Foley catheter with clear urine noted per the caregiver. Review of the plan of care (POC) for certification period of 4/27/2024 through 6/25/2024 failed to reveal Medical Doctor (MD) order for the care and maintenance of the condom catheter or Foley catheter. 3. Review of clinical record for P#24, admitted on 3/27/2024, revealed on 5/15/2024 the Skilled Nurse (SN) documented: “;Foley catheter changed. 18F Coudé (curved tip makes insertion easier) inserted without incidence w/10cc balloon.” Review of the plan of care (POC), for certification period of 3/27/2024 through 6/24/24, failed to reveal a Medical Doctor (MD) order for a urinary catheter insertion. Review of clinical record for P#24 additionally revealed on 5/1/2024 the Skilled Nurse (SN) documented: “;wound care done to left hip, cleansed with wound cleanser, patted dry, xeroform applied, and covered with mepilex (conformable and highly absorbent wound dressing for chronic and acute wounds).” Review of the plan of care (POC), for certification period of 3/27/24 through 6/24/24, failed to reveal a Medical Doctor (MD) order for wound care. On 6/5/2024 at approximately 3:00 pm an in office interview was conducted with the DON who confirmed that P#23’s clinical record lacked an order for a condom/Foley catheter, lacked an order for the SQ infusion at the time it was administered and lacked MD wound care orders for P#24.”

“Based on observation and staff interviews it was determined the Brightmoor Hospice Care Macon 115 Arkwright Landing failed to ensure that Hazardous areas were protected as required. This could place 10 residents at risk in the event of laundry room fire. The findings include: During a tour of the facility with Staff M on 05/08/24 between 08:00 am and 11:00 pm observation revealed that the self closing device for the laundry room door has been disabled. These findings were confirmed by Staff M at the time of discovery. Reference:2012 NFPA 101, Chapter 19, Section, 19.3.2.1.2,Chapter 8, Section 8.4.3.2,Chapter 7 Section 7.2.1.8.1, and 7.2.1.8.2”

“Based on observation and staff interviews it was determined the Brightmoor Hospice Care Macon 115 Arkwright Landing, failed to ensure that the instillation requirements of NFPA 72. This could place 10 residents at risk in the event of a fire. The findings include: During a tour of the facility with Staff M on 05/08/00 between 08:00 am and 11:00 am observation revealed that the facility failed to ensure a lock on device was installed on the Fire Alarm Circuit breaker. These findings were confirmed by Staff M at the time of discovery. Reference:2012 NFPA 101, 19.3.4.1, 9.6.1.3, 2010 NFPA 72, 10.5.5.2.1 thru 10.5.5.2.4”

“Based on observation, review of facility records, and staff interviews it was determined the Brightmoor Hospice Care Macon 115 Arkwright Landing, failed to ensure required fire drills were documented properly. This could place 10 residents at risk in the event of a fire or smoke event. The findings include: During a tour of the facility with Staff M on 05/08/24 between 08:00 am and 11:00 pm observation revealed that there was not a lock on device provided for the circuit breaker that controls the power for the fire alarm system. These findings were confirmed by Staff M at the time of discovery. Reference:”

“Based on review of Brightmoor Hospice Care Conyers 1374 Manchester Dr. NE Emergency Preparedness Program and interviews with staff it was determined that the facilities plan was not in substantial compliance set forth in 42 CFR 418.113 The findings include: During a review of the facilities Emergency Preparedness Program on 05/07/2024 between 10:00AM and 12:00PM it was noted that the plan provided to the surveyor was the plan for the Griffin Ga. Facility. The plan is required to be specific to this location with the Rockdale County Emergency contacts and other items specific to this facility. Plan must also be adopted with an effective date. These findings were confirmed by Staff at the time of discovery.”

“Based on observation and staff interviews it was determined the Brightmoor Hospice Care Conyers 1374 Manchester Dr. NE failed to ensure that all instillation requirements of NFPA 72 were met. This could place 10 patients at risk in the event of fire or smoke event. During a tour of the facility with Staff N on 05/07/24 between 10:00 am and 1:00 pm observation revealed that the circuit breaker for the Fire Alarm was not identified by red markings and provided with a lock on device as required. These findings were confirmed by Staff N at the time of discovery. Reference: 2012 NFPA 101, 19.3.4.1, 9.6.1.3, 2010 NFPA 72, 10.5.5.2.1 thru 10.5.5.2.4”

“Based on review of facility records and staff interviews it was determined Brightmoor Hospice Care Conyers 1374 Manchester Dr. NE, failed to ensure Fire Drill documentation was maintained as required. This could place 10 patients at risk in the event of a fire or smoke event. The findings include: During a review of the facility records with Staff N on 05/07/24 between 10:00 am and 1:00 pm records review revealed that only two fire drills documentation records could be provided when requested. the requirement is one drill per shift per quarter. These findings were confirmed by Staff N at the time of discovery. Reference: 2012 NFPA 101, Chapter 19, Sections 19.7.1.4 through 19.7.1.7”

“Based on observation and staff interviews it was determined the Brightmoor Hospice Care Conyers 1374 Manchester Dr. NE, failed to ensure proper signage was posted for the oxygen storage room. This could place 10 patients at risk in the event of O2 leak. The findings include: During a tour of the facility with Staff N on 05/07/24 between 10:00 am and 1:00 pm observation revealed that there was no sign indicating location of Oxygen storage nor warning of the hazards. These findings were confirmed by Staff M at the time of discovery. Reference: 2012 NFPA 101, Chapter 19, Section 19.3.2.4, Chapter 8, Section 8.7 and 2012 NFPA 99 Chapter 11, Sections 11.3.4.1 and 11.3.4.2”

“Based on clinical record reviews, and staff interviews it was determined the agency failed to ensure patient’s medication profile was updated to reflect current medications for two patients (P) (P#1, P#4) of four patients receiving hospice services. Findings include: 1. Review of the plan of care for P#1 revealed that P#1 was admitted to hospice on 2/1/2024, with diagnosis of lung cancer. Review of Licensed Practical nurse (LPN), visit note dated 2/3/2024, revealed that LPN AA administered 0.9 normal saline (0.9 NaCL) at 100 milliliters per hour as per physician verbal order. Review of patients medication profile dated 4/3/2024, failed to reveal (0.9 NaCL) at100 milliliters per hour. 2. Review of the plan of care for P#4 revealed that P#4 was admitted to hospice on 1/24/2024, with diagnosis of pancreas cancer. Review of the skilled nurse visit note dated 2/25/2024 revealed that Registered Nurse (RN) RN BB received a verbal order from physician to administer a onetime dose of Lasix 40 milligram (mg) by mouth (medication used to reduce extra fluid in the body). Review of the patients medication profile failed to include a onetime order of Lasix 40 mg. On 4/3/2024, at 10:30 a.m., a telephone interview was conducted with RN BB, who verbalized that RN BB was not aware to update the medication profile to reflect the one-time order of Lasix 40 mg. On 4/2/2024, at 2:30 p.m., a telephone interview was conducted with LPN AA. LPN AA verbalized that the medication profile was not updated to reflect the current medication 0.9 NaCL at100 milliliters per hour. On 4/3/2024 at 12:00 p.m., an interview was conducted with the Director of Nursing (DON) at the office. The DON revealed that the medication profile was not updated to reflect the current medications for P#1 and P#4. The DON additionally verbalized that medication profile has to be reviewed and updated to reflect current medications.”

“Based on record reviews and staff interviews, it was determined the hospice failed to develop and maintain a system of communication and integration in order to ensure that care and services provided are based on all assessments of the patient and family needs by failing to ensure a patient received medications in a timely manner for one patient (P) (P#1) of four sampled patients. Findings include: Record review reveals P#1 admitted to hospice on 1/10/2024 with a diagnosis of lung cancer. Service Note by the visiting Registered Nurse (RN) dated 1/24/2024 reveals, “;Pt out of albuterol, will put in for refill of med.” A packing slip from a pharmacy delivery, signed by a family member of P#1 reveals albuterol (a medication used to prevent and treat difficulty breathing and wheezing) was delivered to P#1 on 2/6/2024. On 4/2/2024 at 2:00 p.m., a phone interview was conducted with the pharmacy representative CC, who confirmed that the only request from the hospice for albuterol for P#1 was received on 2/5/2024 and was delivered on 2/6/2024. On 4/3/2024 at 12:00 p.m., an interview was conducted with the Director of Nursing (DON) at the office. The DON confirmed the medication was not ordered until 2/5/2024.”

“Based on record review, staff interviews, and review of the policy titled, “;Medication Orders”, it was determined that the Administrator failed to provide adequate oversight, monitoring and ensuring staff continued education regarding policy on verbal orders (verbal orders were created, documented and signed and dated by the individual receiving the order and verified and signed and dated by the prescribing physician, integrated into the Electronic Medical Record), and ensuring patient’s medication profile were updated to reflect current medications for two patients (P) (P#1, P#4) of four patients receiving hospice services. Findings include: Review of the policy titled, “;Medication Orders”, Policy Numbered 8.2.1, dated 2009 reveals the following: Procedure 2. If the drug order is verbal or given by or through electronic transmission: The individual receiving the order must record and sign it immediately and have the prescribing person sign it in accordance with State and Federal regulations. 11. Verbal or telephone orders will be written down, read back for verification and confirmation received. 1. Review of the plan of care for P#1 revealed that P#1 was admitted to hospice on 2/1/2024, with diagnosis of lung cancer. Review of Licensed Practical nurse (LPN), visit note dated 2/3/2024, revealed that LPN AA administered 0.9 normal saline (0.9 NaCL) at 100 milliliters per hour as per physician verbal order. Review of the clinical record for P#1 failed to reveal verbal order for the IV fluid administration. Furthermore, review of P#1’s medication profile failed to include (0.9 NaCL) at 100 milliliters per hour. 2. Review of the plan of care for P#4 revealed that P#4 was admitted to hospice on 1/24/2024, with diagnosis of pancreas cancer. Review of the skilled nurse visit note dated 2/25/2024 revealed that Registered Nurse (RN) RN BB received a verbal order from physician to administer a onetime dose of Lasix 40 milligram (mg) by mouth (medication used to reduce extra fluid in the body). Review of the clinical record for P#4 failed to reveal verbal order for Lasix 40 mg. Furthermore, review of the patients medication profile did not include onetime order of Lasix 40 mg. On 4/2/2024, at 2:30 p.m., a telephone interview with LPN AA revealed that LPN AA did not receive the order from the doctor but was told by the on-call nurse about an order for IV start and administration of fluids. She states she did not confirm the physician’s order in the electronic medical record. LPN AA also verbalized that the medication profile was not updated to reflect the current medications. On 4/3/2024, at 10:30 a.m., a telephone interview with RN BB revealed that RN BB received a verbal order from the doctor to administer Lasix 40 milligrams by mouth to P#4. RNBB verbalized that RN was not aware that a verbal order has to be created and documented in the Electronic Medical Record (EMR) and the verbal order has to be signed by the RN BB and the doctor. RN BB also verbalized that RN BB was not aware that the medication profile has to be updated to reflect the one-time order of Lasix 40 mg. On 4/3/2024 at 12:00 p.m., an interview was conducted with the Director of Nursing (DON) at the office. The DON revealed that the clinical record lacked verbal orders for P#1 and P#4 and the medication profile was not updated to reflect the current medication for P#1 and P#4. The DON verbalized that all verbal orders has to be reread and verified and signed by the individual taking the order and signed and dated by the doctor and must be entered into the EMR. The medication profile has to be updated to reflect current medications.”

“Based on record review, staff interviews, and review of policy titled, “;Medication Orders”, it was determined that the hospice agency failed to ensure the verbal orders were created, documented, signed and dated by the individual receiving the order and verified, signed and dated by the prescribing physician for two patients (P) (P#1, P#4) of four patients receiving hospice services. Findings include: Review of the policy titled, “;Medication Orders”, Policy Numbered 8.2.1, dated 2009 reveals the following: Procedure 2. If the drug order is verbal or given by or through electronic transmission: The individual receiving the order must record and sign it immediately and have the prescribing person sign it in accordance with State and Federal regulations. 11. Verbal or telephone orders will be written down, read back for verification and confirmation received. 1. Review of the plan of care for P#1 revealed that P#1 was admitted to hospice on 2/1/2024, with diagnosis of lung cancer. Review of Licensed Practical nurse (LPN), visit note dated 2/3/2024, revealed that LPN AA administered 0.9 normal saline (0.9 NaCL) at 100 milliliters per hour as per physician verbal order. Further review of the clinical record for P#1 failed to reveal verbal order for the IV fluid administration was created, documented and signed by the individual receiving the order and signed and dated by the physician. 2. Review of the plan of care for P#4 revealed that P#4 was admitted to hospice on 1/24/2024, with the diagnosis of pancreas cancer. Review of the skilled nurse visit note dated 2/25/2024 revealed that Registered Nurse (RN) BB received a verbal order from physician to administer a onetime dose of Lasix 40 milligram (mg) by mouth (medication used to reduce extra fluid in the body). Review of the clinical record for P#4 failed to reveal verbal order for Lasix 40 mg PO. Clinical records failed to reveal verbal order for Lasix 40 mg was created, documented and signed by the individual receiving the order and signed and dated by the physician. On 4/2/2024, at 2:30 p.m., a telephone interview with LPN AA revealed that LPN AA did not receive the order from the doctor but was told by the on-call nurse about an order for IV start and administration of fluids. She states she did not confirm the physician’s order in the electronic medical record. On 4/3/2024, at 10:30 a.m., a telephone interview with RN BB revealed that RN BB received a verbal order from the doctor to administer Lasix 40 milligrams by mouth to P#4. RN BB verbalized that RN was not aware that a verbal order has to be created and documented in the Electronic Medical Record (EMR) and the verbal order has to be signed and dated by the doctor. RNBB also verbalized that RNBB was not aware that the medication profile has to be updated to reflect the one-time order of Lasix 40 mg.”

“Based on record review and family and staff interviews, it was determined that the agency failed to notify the family that the patient had been assessed by the Medical Doctor (MD) to be stable for discharge/transfer from the inpatient care unit (IPU) to routine home care (RHC) for one patient (P) (P#1) of one record reviewed. Findings include: Review of records revealed the medical doctor (MD) assessed P#1 on 10/13/2023 at 2:25 p.m. The MD assessment revealed, “;We will continue oxygen and change her to routine home care today”. On 1/9/2024 at 3:41 p.m., family member of P#1 revealed no notification of the decision to discharge/transfer from the IPU until spouse received a phone call on 12/11/2023 and again on 12/18/2023 from the social worker (SW). Family member of P#1 revealed “;my (spouse) was told (P#1) could not stay here in the IPU, and that (P#1) had been here too long already”. Family member of P#1 additionally revealed the SW, and the Registered Nurse (RN) AA was the only people the family communicated with from the facility and family member and spouse were never invited to a team meeting or any discussion about the decision to discharge/transfer P#1 out of the IPU to the home setting. During an interview with the SW on 1/10/2024 at 10:40 a.m., the SW confirmed she and the nursing staff at the IPU were aware of the MDs orders to discharge P#1 from impatient care to RHC and transfer P#1 home. SW states “;I advocated for the patient to stay in the IPU. Within 10 days of the patient (P#1) arriving to the IPU, I talked with MD, and he told me the patients pneumonia had improved and the patient needed to be transferred out of the facility”. She admitted discussion of the patients transfer out of the IPU was discussed in the biweekly interdisciplinary Team (IDT) meeting on 10/25/2024 about the MD determination that P#1 was no longer eligible to remain in the IPU. She also admitted the family was not notified that P#1 was no longer eligible for inpatient care and was determined by the medical doctor (MD) to be stable for transfer to a home setting, or routine home care (RHC), until she called (another family member) on 12/11/2023. SW stated “;Looking back I know what I did was wrong by not following the MDs orders to have the patient transferred out of the facility. I know I should have started the conversation about transfer earlier with the family, and I know it was wrong to allow the family to believe the patient was still eligible to stay in the IPU”. On 1/10/2023 at 10:00 a.m., during an interview with RN AA, he stated he talked to P#1s family about discharge/transfer from IPU to the home setting the week of 12/17/2023 through 12/23/2023 but he could not recall the exact day. Additional record review revealed no documentation of conversation between RN AA and family member.”

“Based on record reviews and staff interview, it was determined the agency interdisciplinary team (IDT) failed to follow the individualized plan of care (POC) for one patient (P) (P#1) of one patient record reviewed. Findings include: Review of records revealed the Medical Doctor (MD) assessed P#1 on 10/13/2023 at 2:25 p.m. The MD assessment reveals, “;We will continue oxygen and change her to routine home care today”. An interview with the social worker (SW) was conducted on 1/10/2024 at 10:40 a.m. SW revealed it was her responsibility to initiate the conversation, between patients/families and the agency, about discharge/transfer decisions made by the interdisciplinary team (IDT). SW confirmed she knew the MD had ordered RHC and she knew that changing P#1 to RHC, in this case, meant the patient was to be transferred out of the IPU. SW additionally confirmed she did not follow through with the MD order on 10/13/2023 and did not talk to the family on or after 10/13/2023 about the order to transfer P#1 to RHC. Furthermore, she admitted she did not talk to the family about alternative facilities or home care until 12/11/2023. SW stated, “;looking back now I know what I did was wrong”.”