Cherokee Regional Hospice

“Based on clinical record review, hospice policy, and staff interview, the hospice failed to ensure hospice nurse members of the Interdisciplinary Group (IDG) updated the comprehensive assessment with changes to the patient assessment wound assessment for 3 of 5 patients reviewed with wounds (Patients #9, #13, and #14). Failure of the IDG to update the comprehensive assessment placed the patient at risk for ineffective staff collaboration and communication regarding patient’s wound status and effectiveness of treatments and interventions. Findings include: 3. Patient #14 had a hospice admission date of 10/15/23 and date of death on 11/16/23 and received hospice services while residing in a private residence. Clinical record review revealed the following: a. The skilled nurse visit note, dated 10/18/23, performed by Staff B, Registered Nurse (RN) included documentation of a new skin tear on the right forearm, which measured 0.5 cm length by 0.5 cm width by 0.1 cm depth. The documentation lacked assessment of the wound bed. b. The skilled nurse visit note, dated 10/23/23 performed by Staff D, RN included documentation of the skin tear with measurements of 0.5 cm length by 0.5 cm width by 0.1 cm depth. The documentation lacked assessment of the wound bed. The hospice failed to complete comprehensive weekly assessments of the patient’s wound. The above findings shared with the Administrator/Clinical Manager and Social Worker. According to agency policy, Wound Care Home Health/Hospice dated December 2023, revealed in pertinent part: If the patient has a wound the nursing assessment will include the characteristics of the wound (e.g. measurement in centimeters to include length, width and depth, location, odor, drainage, color and condition of surrounding tissue),the type of wound (e.g. pressure ulcer, venous stasis ulcer, malignant, diabetic foot ulcer, skin tear/friction, rash, or infected). The nurse will assess and evaluate the condition of the wound at least on a weekly basis with documentation of the assessment in the patient’s record. According to agency policy, Interdisciplinary Group dated December 2023, in pertinent part, the primary responsibility of the IDG is to provide and supervise care and services delivered in the patient’s place of residence or on an inpatient basis. These cares and services are necessary to meet the patient and family-specific needs identified in the comprehensive assessment that are related to the terminal illness and related conditions. In an interview on 7/10/24 at 8:40 AM, the Administrator reported that wounds are comprehensively assessed on a weekly basis. Patient #9 had a hospice admission date of 6/4/24 and received hospice services while residing in a private home. Clinical record review revealed the following: The IDG note on 6/11/24 included that the patient had a wound to his left great toe present at admission with daily wound care. The left great toe wound lacked a weekly comprehensive assessment. The Skilled Nurse Visit (SNV) note on 6/7/24 performed by Staff D, Registered Nurse (RN), identified that the patient had a new skin tear to his right elbow staged at 2 (wound stage is used only with pressure ulcer wounds). The SNV note on 7/1/24 performed by Staff D assessed the left great toe wound at a stage 2. The patients left great toe wound lacked a weekly comprehensive assessment. Both of the patients non-pressure ulcer wounds were assessed at a stage 2. 2. Patient #13 had a hospice admission date of 2/22/24 and received hospice services while residing in a nursing home until his death on 3/8/24. Clinical record review revealed the following: The SNV note on 2/22/24 performed by Staff D included documentation of a left groin surgical wound at a stage 2 and left 5th toe amputation surgical wound. Neither wound was comprehensively assessed at this admission visit. The SNV note on 2/26/24 performed by Staff D included assessment of the groin surgical site and left 5th toe amputation surgical site with each assessment charted as NA (not applicable) for the wound bed. The measurement of each was the same, 1 cm (centimeter) length x 0.1 cm width x 0.1 cm depth, which indicated that the surgical sites were open wounds and have a wound bed. The SNV note on 3/6/24 performed by Staff D assessed the left groin surgical incision has healed. The left 5th toe surgical amputation was not comprehensively assessed. The patients 2 surgical wound sites lacked comprehensive weekly assessments. The patients left groin surgical incision site was incorrectly staged as a pressure ulcer.”

“Based on hospice staff interview, clinical record review, and agency policy, the agency failed to include the patients progress towards outcomes and goals specified in the plan of care (POC) for aide services at Interdisciplinary Group (IDG) meetings for 7 of 7 patients reviewed with aide services (Patients #4, #5, #6, #7, #8, #10, and #14). Failure of the hospice to ensure that the IDG include progress towards patients goals and outcomes placed patients at risk to not receive care and services based on their current assessed needs. Findings include: 4. Patient #5 had a hospice admission date of 6/16/23 and received hospice services while residing in a nursing home. Clinical record review revealed the following: a. The POC, dated 6/10/24 to 8/8/24, included orders for skilled nursing and hospice aide services. b. The IDG meeting notes, dated 5/21/24, 6/4, 6/18/24 and 7/2/24, lacked documentation of the patients progress towards outcomes and goals specified in the POC for hospice aide services. The hospice failed to note the patients progress towards outcomes and goals specified in the POC for hospice aide services. 5. Patient #7 had a hospice admission date of 3/20/24 and received hospice services while residing in a private home setting. Clinical record review revealed the following: a. The POC’s, dated 3/20/24 to 5/18/24, 5/18/24 to 7/4/24 and 7/5/24 and 7/17/24, included orders for skilled nursing and hospice aide services. b. The IDG meeting notes, dated 5/21/24, 6/4, 6/18/24 and 7/2/24, lacked documentation of the patients progress towards outcomes and goals specified in the POC for hospice aide services. The hospice failed to note the patients progress towards outcomes and goals specified in the POC for hospice aide services. 6. Patient #10 had a hospice admission date of 6/27/24 and received hospice services while residing in a nursing home. Clinical record review revealed the following: a. The POC, dated 6/27/24 to 9/24/24, included orders for skilled nursing and hospice aide services. b. The IDG meeting notes, dated 7/9/24, lacked documentation of the patients progress towards outcomes and goals specified in the POC for hospice aide services. The hospice failed to note the patients progress towards outcomes and goals specified in the POC for hospice aide services. 7. Patient #14 had a hospice admission date of 10/15/23 and date of death of 11/16/23 and received hospice services while residing in a private home residence. Clinical record review revealed the following: a. The POC, dated 10/15/23 to 12/23/23, included orders for skilled nursing and hospice aide services. b. The IDG meeting notes, dated 10/25/24 and 11/8/24, lacked documentation of the patients progress towards outcomes and goals specified in the POC for hospice aide services. The hospice failed to note the patients progress towards outcomes and goals specified in the POC for hospice aide services. The above findings shared with the Administrator/Clinical Manager. According to agency policy, Interdisciplinary Group dated December 2023, in pertinent part, The IDG will be composed of other periodic members of the IDG are those individuals providing care to the patient, which may include but are not limited to Hospice Aide. The IDG members provide the care and services offered by hospice. The IDG in its entirety must supervise the care and services provided. The IDG will be active in the Quality Assessment and Performance Improvement (QAPI) program by implementing and reporting on QAPI activities. A committee formed from the IDG will make an annual program evaluation of the hospice’s total operation. This assessment shall address services provided directly or under contract, on indicators related to palliative outcomes, end-of-life support systems, adverse patient events, problem prone and safety areas, and the hospice’s processes of care and operations. Providing input into eliminating problems, which become apparent as a result of QAPI studies. Supervising care provided utilizing conferences, evaluations, and discussions, as well as direct observations, and access to inservices and continuing education. In an interview on 7/10/24 at 8:20 AM, when asked which member of the IDG is responsible for coordination and supervision of hospice aide services, the Administrator reported that she is responsible for this. 1. Patient #4 had a hospice admission date of 6/19/24 and received hospice services while residing in a nursing home. Clinical record review revealed the following: The POC dated 6/19/24 to 9/16/24 included orders for nursing and aide services. The IDG meeting note on 7/2/24 did not include the patients progress towards outcomes and goals specified in the POC. The hospice failed to note the patients progress towards outcomes and goals specified in the POC for hospice aide services. 2. Patient #6 had a hospice admission date of 5/1/24 and received hospice services while residing in a private residence. Clinical record review revealed the following: The POC dated 5/1/24 to 7/29/24 included orders for nursing and aide services. The IDG meeting notes on 5/7/24, 5/21/24, 6/4/24, 6/18/24, and 7/2/24 did not include the patients progress towards outcomes and goals specified in the POC. The hospice failed to note the patients progress towards outcomes and goals specified in the POC for hospice aide services. 3. Patient #8 had a hospice admission date of 5/9/24 and received hospice services while residing in a nursing home. Clinical record review revealed the following: The POC dated 5/9/24 to 8/6/24 included orders for nursing and aide services. The IDG meeting note on 5/21/24, 6/4/24, 6/18/24, and 7/2/24 did not include the patients progress towards outcomes and goals specified in the POC. The hospice failed to note the patients progress towards outcomes and goals specified in the POC for hospice aide services.”

“Based on hospice staff interview, clinical record review, and agency policy, the hospice failed to document all required components of hospice aide supervision including demonstrating competency with assigned tasks for 7 of 7 patients reviewed with aide services (Patients #4, #5, #6, #7, #8, #10, and #14). Failure to ensure the supervision of hospice aides by registered nurses (RN) to maintain documentation of all required components of aide supervision increased the risk of agency staff not meeting the patients personal care needs. Findings include: 4. Patient #5 had a hospice admission date of 6/16/23 and received hospice services while residing in a private home setting. Clinical record review revealed: a. The IDG meeting notes, dated 5/21/24, 6/4, 6/18/24 and 7/2/24, included orders for hospice aide and skilled nursing services. b. The skilled nurse visit notes, dated 5/13/24, 6/3, 6/17, 6/24 and 7/7/24, included documentation the nurse supervised the hospice aide and the aide followed the care plan. The visit notes lacked documentation the required components of demonstrating competency with assigned tasks were completed. The hospice failed to complete all required components of hospice aide supervision. 5. Patient #7 had a hospice admission date of 3/20/23 and received hospice services while residing in a private home setting. Clinical record review revealed: a. The IDG meeting notes, dated 5/21/24, 6/4, 6/18/24 and 7/2/24, included orders for hospice aide and skilled nursing services. b. The skilled nurse visit notes, dated 5/13, 5/23, 5/31/24, 6/17, 6/24 and 7/3/24, included documentation the nurse supervised the hospice aide and the aide followed the care plan. The visit notes lacked documentation the required components of demonstrating competency with assigned tasks were completed. The hospice failed to complete all required components of hospice aide supervision. 6. Patient #10 had a hospice admission date of 6/27/27 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The Interdisciplinary Group meeting notes, dated 7/9/24, included orders for hospice aide and skilled nursing services. b. The skilled nurse visit notes, dated 7/1/24, included documentation the nurse supervised the hospice aide and the aide followed the care plan. The visit notes lacked documentation the required components of demonstrating competency with assigned tasks were completed. The hospice failed to complete all required components of hospice aide supervision. 7. Patient #14 had a hospice admission date of 10/15/23 and date of death of 11/16/23 received hospice services while residing in a private home setting. Clinical record review revealed: a. The Interdisciplinary Group meeting notes, dated 10/25/23 and 11/8/23, included orders for hospice aide and skilled nursing services. b. The skilled nurse visit notes, dated 10/30/23, 11/1 and 11/15/23, included documentation the nurse supervised the hospice aide and the aide followed the care plan. The visit notes lacked documentation the required components of demonstrating competency with assigned tasks were completed. The hospice failed to complete all required components of hospice aide supervision. According to agency policy, Hospice Aide and Homemaker Service dated December 2023, in pertinent part, the IDG RN will make supervisory visits at the patient’s place of residency at least every 14 days while hospice aide services are being provided. The supervisory visit will allow the nurse to evaluate the hospice aide’s ability to provide assigned duties. In an interview on 7/15/24 at 8:57 AM, Staff B, RN, reported that Aide supervision is done every 14 days and it is documented in our regular visit note. It can be done in a follow up note as well. Patient #4 had a hospice admission date of 6/19/24 and received hospice services while residing in a nursing home. Clinical record review revealed the following: The POC dated 6/19/24 to 9/16/24 included orders for nursing and aide services. The Skilled Nurse Visit (SNV) on 7/1/24 included supervision of the hospice aide and was missing the required supervision of competency of the aide in completing assigned tasks. The supervision documentation failed to include demonstrating competency with assigned tasks. 2. Patient #6 had a hospice admission date of 5/1/24 and received hospice services while residing in a private residence. Clinical record review revealed the following: The POC dated 5/1/24 to 7/29/24 included orders for nursing and aide services. The SNV with hospice aide supervision performed by Staff D, Registered Nurse (RN) on 5/13/24, 5/20/24, 6/3/24, 6/9/24, 6/24/24, and 7/2/24 were missing the required supervision of competency of the aide in completing assigned tasks. The supervision documentation failed to include demonstrating competency with assigned tasks. 3. Patient #8 had a hospice admission date of 5/9/24 and received hospice services while residing in a nursing home. Clinical record review revealed the following: The POC dated 5/9/24 to 8/6/24 included orders for nursing and aide services. The SNV with hospice aide supervision performed by Staff C, RN on 5/28/24, 6/11/24, 6/26/24, and 7/1/24 were missing the required supervision of competency of the aide in completing assigned tasks. The supervision documentation failed to include demonstrating competency with assigned tasks.”