Tapestry Hospice of Northwest Georgia, LLC

“Based on record review and staff interview, it was determined the hospice failed to ensure that the interdisciplinary group included physician attendance for eight of 15 sampled Interdisciplinary Group (IDG) meetings. Findings include: Review of documents in the binder titled, “;IDG Meetings”, revealed IDG minutes with attached attendance sign-in sheets. A review of documents titled “;IDG MEETING AGENDA/ ATTENDANCE” for dates of September 6, 2023, through March 20, 2024, revealed sign-in sheets failed to reveal physician signatures for IDG meetings dated 9/6/2023, 10/18/2023, 11/1/2023, 11/29/2023, 12/13/2023, 2/7/2024, 3/6/2024, and 3/20/2024. On 5/22/2024 at 10:00 a.m., an interview with the Director of Clinical Services (DCS) revealed all IDG meeting attendees are to sign the attendance sheet during the meeting. The DCS agreed the records lacked physician signatures but stated a physician is always present for IDG meetings.”

“Based on record reviews, staff interview, and review of policy titled “;Physician Orders,” it was determined the agency failed to develop a plan of care that included all services necessary for the palliation and management of the terminal illness and related conditions for one patient (P) (P#8) of 19 sampled patients. The findings include: Review of policy titled, “;Physician Orders”, Policy #704, dated October 2012 reveals the following: Policy “;Only a physician or nurse practitioner in accordance with the plan of care and State law, may provide orders for the patient.” Procedure 5. “;A copy of the physicians order is kept in the clinical record.” Record review reveals P#8 was admitted to hospice on 9/7/23. Review of the plan of care dated 3/5/24 – 5/3/24 revealed pressure ulcers to the right and left buttocks (unstaged) and unspecified part of spine, stage 3 wound (full thickness tissue loss but bone and tendons not visible). Review of the clinical record for P#8 reveals home visits by a Registered Nurse (RN) on dates of 4/8/24 and 4/17/24. RN noted performing the following wound care to pressure ulcer upper spine: cleansed with wound cleanser, applied Medi honey (wound and burn gel made from 100% Leptospermum (Manuka) honey that has antibacterial and bacterial resistant properties) to areas of eschar (piece of dead tissue that is cast off from the surface of the skin) and applied calcium alginate (biodegradable dressing made from seaweed that absorbs exudate and forms a gel) to wound bed and covered with optifoam (foam dressing with a silicone border, waterproof backing and high absorbency). Review of Skilled Visit dated 4/18/2024 revealed RN documentation of the following: “;I performed wound care as ordered.” Review of Skilled Visit dated 4/23/2024 revealed RN documentation of the following: “;Wound care performed as ordered.” The RN failed to document supplies used or steps used to complete wound care during the visits on 4/18/2024 and 4/23/2024. Review of a physician’s order for wound care is dated 5/21/24 (one month after wound care was provided). A review of the clinical record failed to reveal physician orders regarding wound care interventions or goals prior to the start the certification period dated 3/5/24 – 5/3/24. Additional review of plan of care dated 3/5/24 – 5/3/24 revealed P#8 has an indwelling suprapubic catheter (a thin flexible rubber tube used to help drain urine from your bladder through a small incision in your abdomen). Further review of the clinical record failed to reveal a physician order for suprapubic catheter insertion or care, maintenance of the catheter, and failure to reveal insertion date for the catheter. Interview with the Regional Director of Clinical Services on 5/22/2024 at 10:00 a.m. confirmed P#8 lacked a physician order for management of the pressure wounds before 5/21/2024 or any documentation of discussions with the physician regarding wound care. Regional Director of Clinical Services acknowledged that the plan of care lacked physicians orders for the Foley catheter care and maintenance.”

“Based on record reviews and staff interviews, it was determined the hospice governing body failed to ensure the Interdisciplinary Group (IDG) developed a plan of care to include all services necessary for the palliation and management of the terminal illness for one patient (P) (P#8) of 19 sampled patients and to ensure physician attendance at IDG meetings for eight of 15 sampled IDG meetings. Findings include: Record review reveals P#8 was admitted to hospice on 9/7/23. The plan of care dated 3/5/24 – 5/3/24 revealed pressure ulcers to the right and left buttocks (unstaged) and unspecified part of spine, stage 3 wound (full thickness tissue loss but bone and tendons not visible). Review of the clinical record for P#8 reveals visits by a Registered Nurse (RN) on dates of 4/8/24 and 4/17/24, noting the pressure ulcer to the upper spine and wound care consisting of cleansed with wound cleanser, applied Medi honey to areas of eschar and applied calcium alginate to wound bed and covered with optifoam. The RN visited P#8 on 4/18/24 and 4/23/24 and documented wound care was provided as ordered. The RN failed to document supplies used or steps used to complete wound care. Review of a physician’s order for wound care is dated 5/21/24 (one month after wound care was provided). A review of the clinical record reveals no physician orders regarding wound care interventions or goals prior to the start the certification period dated 3/5/24 – 5/3/24. Additional review of plan of care dated 3/5/24 – 5/3/24 revealed P#8 has an indwelling suprapubic catheter (a thin flexible rubber tube used to help drain urine from your bladder through a small incision in your abdomen). Further review of the clinical record failed to reveal a physician order for suprapubic catheter insertion or care and maintenance of the catheter. Review of documents in a binder titled, “;IDG Meetings”, revealed IDG meeting minutes with attached attendance sign-in sheets. A review of documents titled “;IDG MEETING AGENDA/ ATTENDANCE” for dates of September 6, 2023, through March 20, 2024, revealed sign-in sheets lacked physician signatures for IDG meetings dated 9/6/2023, 10/18/2023, 11/1/2023, 11/29/2023, 12/13/2023, 2/7/2024, 3/6/2024, and 3/20/2024. On 5/22/2024 at 10:00 a.m., an interview with the Director of Clinical Services (DCS) revealed all IDG meeting attendees are to sign the attendance sheet during the meeting. The DCS agreed the records lacked physician signatures but stated a physician is always present for IDG meetings. Interview with the Regional Director of Clinical Services on 5/22/2024 at 10:00 a.m. confirmed P#8 lacked a physician order for management of the pressure wounds before 5/21/2024 or any documentation of discussions with the physician regarding wound care. Regional Director of Clinical Services acknowledged that the plan of care lacked physicians orders for catheter care and maintenance.”