Autumn View Hospice, LLC

“Based on record reviews, and staff interviews, it was determined that the interdisciplinary group (IDG) failed to ensure comprehensive assessments were updated and included evaluation and documentation of the patient’s response to wound care treatment and progress toward desired outcomes for two patients (P) (P5 and P12) of three patients reviewed for altered skin conditions. Findings include: 1. Review of the plan of care revealed P5 was admitted to hospice on 5/30/2024 with the diagnosis of stage I pressure ulcer to sacral area (wound to the buttock area). Review of the document titled “;Physician Order” dated 5/30/2024 for P5 reveals the following: wound care 3 times a week for skin care cleanse area with appropriate wound cleanser, apply appropriate Medi honey (wound and burn gel made from Manuka honey that has antibacterial and bacterial resistant properties), and cover with meplix (foam dressing for a wide range of acute and chronic wounds) dressing. Review of skilled nurse (SN) visit notes revealed the nurse visited the patient once a week. SN visit notes dated 5/31/2024, 6/4/2024, 6/9/2024, 6/10/2024, and 6/19/20204 failed to reveal wound care, wound measurements and progress or lack of progress of wound status. Review of the Interdisciplinary group (IDG) meetings dated 6/14/2024 failed to reveal documentation of the size of the sacral pressure ulcer wound and progress or lack of progress of the wound 2. Review of the plan of care revealed P12 was admitted to hospice on 6/18/2024 with the diagnosis of pressure ulcer (injuries to the skin and the tissue below the skin that are due to pressure on the skin for a long time) stage 4 to left hip, pressure ulcer stage 2 to right hip, pressure ulcer stage 4 to left ankle, and left lateral foot, and right plantar foot. Review of the document titled “;Physician Order” dated 6/18/2024 for P12 reveals the following: wound care once a week for skin care, cleanse wound with a wound cleanser, spray, apply Dakins (cleanser) wet to dry dressing and cover with foam dressing three times weekly. RN will do once a week and LPN will do once a week. Review of skilled nurse (SN) visit notes revealed the nurse visited the patient once a week. SN visit notes dated 6/18/2024, 6/19/2024 and 6/21/2024 failed to reveal wound care, wound measurements and progress or lack of progress of wound status. Review of the Interdisciplinary group (IDG) meetings dated 6/21/2024 failed to reveal documentation of the size, of the sacral pressure ulcer wound and progress or lack of progress of the wound. On 6/26/2024 at 10:15 am an office interview was conducted with the Executive Director (ED). ED revealed that the IDG and SN visit notes lack wound care/treatment, wound measurements and progress or lack of progress of multiple wounds. ED verbalized that the expectation of the SN is to measure the wound at every visit and the SN did not measure the wound as required. On 6/25 /2024 at 11:15 am, telephone interview was conducted with Registered Nurse (RN) RN AA revealed that P12 receives wound care once a week on (Monday) from a Certified wound Care nurse (CWCN). RN AA also revealed that on 6/19/2024 P12 received wound care from a prior Home Health Agency. RN AA revealed that wound care was performed on 6/21/2024 but did not document in the record. On 6/26/2024 at 1:25 pm, an office interview was conducted with the Executive Director (ED) revealed that the ED was not aware of CWCN was providing wound care on Mondays and was not aware that HHA agency provided wound care on 6/19/2024. ED was unable to provide contact information for CWCN and the HHA who provided wound care to the patient. ED verbalized that IDG and SN visit notes lack wound care coordination with team members, lacked wound care/ treatment, wound measurements and progress or lack of progress of multiple wounds. ED verbalized that IDG failed to ensure that physician orders were created and updated for each wound and orders for CWCN to continue providing wound care services for P12. ED revealed that the IDG and SN visit notes lack wound care/treatment, wound measurements and progress or lack of progress of the sacral wound for P5.”

“Based on record reviews, staff interview, and review of policy titled “;IDG Care Planning/Plan of Care Processes”, it was determined the hospice 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 two patients (P) (P12, P13) of 14 sampled patients. Failure to coordinate patient care and update plan of care could lead to delay in interventions and outcomes for all patients receiving care. 1. Review of the plan of care revealed P12 was admitted to hospice on 6/18/2024, with the diagnosis of pressure ulcer stage 4 to left hip, pressure ulcer stage 2 to right hip, pressure ulcer stage 4 to left ankle, pressure ulcer to left lateral foot, and right plantar foot. Review of the document titled “;Physician Order” dated 6/18/2024 for P12 reveals the following: wound care once a week for skin care, cleanse wound with a wound cleanser, spray, apply Dakins wet to dry dressing and cover with foam dressing. RN will do once a week and LPN will do once a week. The plan of care lacked wound care orders for multiple wounds for P12. On 6/25/2024 at 10:15 am an office interview was conducted with the Executive Director (ED). ED verbalized that plan of care lacked wound care orders for multiple wounds for P12. On 6/25 /2024 at 11:15 am, telephone interview was conducted with Registered Nurse (RN) RN AA revealed that P12 receives wound care once a week on (Monday) from a Certified wound Care nurse (CWCN). RN AA also revealed that on 6/19/2024 P12 received wound care from a prior Home Health Agency. RNAA revealed that wound care was performed on 6/21/2024 but did not document in the record. On 6/25/2024 at 1:25 pm, an office interview was conducted with the Executive Director (ED) revealed that the ED was not aware of CWCN was providing wound care on Mondays and was not aware that HHA agency provided wound care on 6/19/2024. ED was unable to provide contact information for CWCN and the HHA who provided wound care to the patient. ED verbalized that IDG and SN visit notes lack wound care coordination with team members, lacked wound care/ treatment ,wound measurements and progress or lack of progress of multiple wounds. ED verbalized that IDG failed to ensure that physician orders were created and updated for each wound and orders for CWCN to continue providing wound care services for P12. 1. Record review reveals P12 was admitted to hospice on 6/18/2024 with a diagnosis of Unspecified severe protein-calorie malnutrition (lacking enough protein in diet to sustain energy). P12 resides in a personal care home (PCH). Review of medications from the PCH revealed patient was taking the following medications: Megestrol (20 mg/1 tablet) by mouth once a day for appetite stimulation, and Zofran (4mg/1tablet) by mouth every 8 hours as needed for nausea, although the hospice plan of care (POC) did not contain a written physicians order for the medications. 2. Record review reveals P13, admitted to hospice on 8/16/2023, with a diagnosis of Senile degeneration of brain (a type of dementia that affects memory, thinking, and behavior), and hypertension (high blood pressure). P13 resides in a personal care home (PCH). Review of medications from the PCH revealed patient was taking the following medications: Amlodipine/Lipitor (10/20 milligram (mg) tablets by mouth once a day for HTN/Lipid lowering, Buspar (10 mg/1 tablet) by mouth twice a day for mood disorder, and Hydrochlorothiazide (25 mg/1 tab) by mouth once a day for HTN, although, the hospice plan of care (POC) did not contain a written physicians order for the medications. On 6/26/2024 at 10:00 am, during an office interview, the Administrator did acknowledge P12 did not have a current physicians order for the following medications: Megestrol (20 mg/1 tablet) by mouth once a day for appetite stimulation, and Zofran (4mg/1tablet) by mouth every 8 hours as needed for nausea. The administrator provided a physicians order for Megestrol (20 mg/1 tablet) by mouth once a day for appetite stimulation, and Zofran (4mg/1tablet) by mouth every 8 hours as needed for nausea dated 6/26/2024. On 6/26/2024 at 10:00 am, during an office interview, the Administrator did acknowledge P13 did not have a current physician order for the following medications: Amlodipine/Lipitor (10/20 milligram (mg) tablets by mouth once a day for HTN/Lipid lowering, Buspar (10 mg/1 tablet) by mouth twice a day for mood disorder, Hydrochlorothiazide (25 mg/1 tab) by mouth once a day for HTN. The administrator provided a physicians order for Amlodipine/Lipitor (10/20 milligram (mg) tablets by mouth once a day for HTN/Lipid lowering, Buspar (10 mg/1 tablet) by mouth twice a day for mood disorder, and Hydrochlorothiazide (25 mg/1 tab) by mouth once a day for HTN dated 6/26/2024. Review of the document titled “;Physician Order” dated 6/18/2024 for P12 reveals the following: wound care once a week for skin care, cleanse wound with a wound cleanser, spray, apply Dakins wet to dry dressing and cover with foam dressing. RN will do once a week and LPN will do once a week. The plan of care lacked wound care orders for multiple wounds for P12. Review of policy titled “;IDG Care Planning/Plan of Care Processes”, (not dated) revealed: Procedure 1. The plan of care specifies the care and services necessary to meet the patient and family specific needs identified in the comprehensive assessment as such needs related to the terminal illness and related conditions. 2. Standing orders or routine orders will be individualized to address the specific patients needs and signed by the patients physician. a. Drugs and treatments necessary to meet the needs of the patient. The IDG (in collaboration with the patients attending physician, if any) reviews, revises and documents the individualized plan as frequently as the patient’s condition requires, but no less frequently than every 15 calendar days. The revised plan of care includes information from the patients updated comprehensive assessment and notes the patients progress toward outcomes and goals specific in the plan of care.”

“Based on record reviews, and staff interview, it was determined that hospice agency failed to ensure that wound care was provided in accordance with the plan of care for one patient (P) (P5) of three patients reviewed for altered skin conditions. Findings include: Review of the plan of care revealed P5 was admitted to hospice on 5/30/2024, with the diagnosis of stage I pressure ulcer to sacral area (skin loss at the buttock area). Review of the document titled “;Physician Order” dated 5/30/2024 for P5 reveals the following: wound care 3 times a week for skin care, cleanse area with appropriate wound cleanser, apply appropriate medihoney (wound and burn gel made from Manuka honey that has antibacterial and bacterial resistant properties) and cover with meplix (foam dressing for a wide range of acute and chronic wounds) dressing. Review of skilled nurse (SN) visit notes revealed the nurse visited the patient once a week. SN visit notes dated 5/31/2024, 6/4/2024, 6/9/2024, 6/10/2024, and 6/19/20204 failed to reveal wound care, wound measurements and progress or lack of progress of wound status. Review of the Interdisciplinary group (IDG) meetings dated 6/14/2024 failed to reveal documentation of the size, of the sacral pressure ulcer wound and progress or lack of progress of the wound. SN failed to provide wound care as per physician orders. On 6/26/2024 at 11:15 am, an office interview was conducted with the Executive Director (ED). ED revealed that the IDG and SN visit notes lack wound care/treatment, wound measurements and progress or lack of progress of the sacral wound. ED verbalized that the SN did not provide wound care as per physician orders.”

“Based on record reviews, staff interview and review of policy titled “;IDG Care Planning/Plan of Care Processes”, it was determined that the interdisciplinary group (IDG) failed to ensure and provide an ongoing sharing of information between all disciplines providing care and services in all settings, whether the care and services are provided directly or under arrangement for one patient (P) (P12) of three patients reviewed for altered skin conditions. Findings include: Review of undated policy titled “;IDG Care Planning/Plan of Care Processes,” revealed the following: Procedure 1. The plan of care specifies the care and services necessary to meet the patient and family specific needs identified in the comprehensive assessment as such needs related to the terminal illness and related conditions. 2. The IDG (in collaboration with the patients attending physician, if any) reviews, revises and documents the individualized plan as frequently as the patient’s condition requires, but no less frequently than every 15 calendar days. The revised plan of care includes information from the patients updated comprehensive assessment and notes the patients progress toward outcomes and goals specific in the plan of care. 3. IDG works together to meet the physical, psychosocial emotional spiritual needs of the patient and families facing terminal illness. IDG supervise the care and services. Review of the plan of care revealed P12 was admitted to hospice on 6/18/2024, with the diagnosis of pressure ulcer (ulcers which occur on the skin surface due to prolonged pressure) stage 4 to left hip, pressure ulcer stage 2 to right hip, pressure ulcer stage 4 to left ankle, pressure ulcer to left lateral foot, and pressure ulcer right plantar foot. Review of the document titled “;Physician Order” dated 6/18/2024 for P12 reveals the following: wound care once a week for skin care, cleanse wound with a wound cleanser, spray, apply Dakins (cleanser) wet to dry dressing and cover with foam dressing three times weekly. RN will do once a week and LPN will do once a week. Review of skilled nurse (SN) visit notes revealed the nurse visited the patient once a week. SN visit notes dated 6/18/2024, 6/19/2024 and 6/21/2024 revealed lack of wound care, wound measurements and progress or lack of progress of wound status. Review of the Interdisciplinary group (IDG) meetings dated 6/21/2024 failed to reveal documentation of the size, of the sacral pressure ulcer wound and progress or lack of progress of the wound. On 6/25/2024 at 10:15 am an office interview was conducted with the Executive Director (ED). ED revealed that the IDG and SN visit notes lack wound care/treatment, wound measurements and progress or lack of progress of multiple wounds. ED verbalized that the expectation of the SN is to change wound dressing and measure the wound at every visit and the SN did not change the dressing nor measure the wound as required. On 6/25/2024 at 11:15 am, telephone interview was conducted with Registered Nurse (RN) RN AA revealed that P12 receives wound care once a week on (Monday) from a Certified Wound Care Nurse (CWCN). RN AA also revealed that on 6/19/2024 P12 received wound care from a prior Home Health Agency. RN AA revealed that wound care was performed on 6/21/2024 but did not document in the record. On 6/25/2024 at 1:25 pm, an office interview was conducted with the Executive Director (ED) revealed that the ED was not aware of CWCN was providing wound care on Mondays and was not aware that HHA agency provided wound care on 6/19/2024. ED was unable to provide name and contact information for CWCN and the HHA who provided wound care to the patient. ED verbalized that IDG and SN visit notes lack wound care coordination and communication with team members and members providing services who are not part of hospice team, lacked wound care/ treatment, wound measurements and progress or lack of progress of multiple wounds. ED verbalized that IDG failed to ensure that physician orders were created and updated for each wound and orders for CWCN to continue providing wound care services for P12. ED verbalized that the IDG failed to communicate and coordinate wound care treatment plan with team members and physician for P12.”