St Croix Hospice

“Based on clinical record review, hospice policy review, nursing home record review, nursing home staff interview and hospice staff interview, the hospice failed to: ensure the hospice nurse member of the interdisciplinary group updated the comprehensive assessment with changes to the patient condition and included wound assessment and measurements per hospice policy (see L0533). Findings include: The cumulative effects of these systemic practices resulted in the failure of the hospice to ensure the Interdisciplinary Group of personnel completed a comprehensive assessment of all patient care and treatment needs to their hospice patients.”

“Based on clinical record review, hospice policy review, and staff interview, the hospice failed to ensure nurse members of the Interdisciplinary Group (IDG) updated the comprehensive assessment with changes to the patient condition regarding wound description, measurements, and changes to treatment for 2 of 6 sampled patients with a wound (Patients #2 and #5). Failure by the hospice IDG registered nurses to update the comprehensive assessment with complete wound descriptions and measurements placed the patient at risk for ineffective staff collaboration and communication regarding patient’s wound status and effectiveness of treatments and interventions. Findings include: According to the undated hospice policy titled, Comprehensive Assessment, during the comprehensive patient assessment, all baseline data and other relevant information will be documented in the patient’s clinical record, including an assessment of severity of skin integrity. During an interview on 4/9/24 at 11:10 AM, Staff C, RN (Registered Nurse) stated Patient #5 developed a pressure sore that appeared out of nowhere. The patient also had necrotic toes and the hospice was treating the necrotic toes with betadine and gauze. During an interview with Staff L, Licensed Practical Nurse (LPN) on 4/10/24 at 9:34 AM she stated Patient #5 had wounds on the toes that were superficial. I did not measure the toe wounds because I did not feel the toe wounds were any type of wound that needed to be measured. During an interview on 4/10/24 9:47 AM, the Administrator stated she was unaware patient # 5 had any wounds. She further stated the expectation of staff was to assess wounds weekly and include measurements in the assessment. During an interview on 4/10/24 at 2:48 PM, Staff F, Hospice Aide (HA) stated she noticed an open are on Patient #5 bottom. She further stated she notified Staff C, RN of the open area. Staff F reported, Staff C stated he would look at the wound at his next visit. 1. Patient #5 had a hospice admission date of 1/5/24 and date of death of 2/27/24 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The hospice aide visit note, dated 2/12/24, Staff F , HA documented the patient had open area to both buttocks soiled through the pants, sheet and chuck. Registered Nurse Case Manager notified. b. Staff B, Clinical Manager, skilled nurse visit notes, dated 2/13, 2/15 and 2/16/24, lacked documentation of assessment of the patient’s buttocks. c. Staff L, LPN, skilled nurse visit notes, dated 2/17/24, included documentation the patient toes were necrotic with sores on the toes. New order included Vaseline gauze to provide wound care. The documentation lacked assessment of the sores on the toes. d. Staff M, RN, skilled nurse visit note, dated 2/18/24, included documentation the aide reported a reddened area on the patient’s coccyx during the visit. The documentation included the patient refused to allow the RN to assess the area. e. Staff C, RN skilled nurse visit note, dated 2/19/24, included documentation the patient had a stage 2 pressure area to the coccyx. Staff C contacted the physician and received new orders which included zinc oxide ointment, cover with optifoam pad. Change daily and as needed if soiled. The nurse to assess every visit. The document also included a Roho cushion ordered. The note failed to include documentation of an assessment of the pressure wound on the coccyx or necrotic toes including measurements. f. The physician’s order, dated 2/19/24, included orders for zinc oxide 20% ointment: apply thin layer to affected area 2 times a day and as needed for pressure wounds, cover with optifoam pad. Change daily and as needed if soiled for pressure wounds. Caregiver to complete. Hospice nurse to assess every visit. Wound care for necrotic left toes, paint with betadine, wrap with Vaseline gauze. Caregiver to complete daily and as needed. Hospice nurse to assess every visit. g. Staff C, RN skilled nurse visit notes, dated 2/21/24 and 2/26/24, included documentation the patient had wounds to the left dorsum foot and necrotic toes and a stage 2 pressure area to the coccyx. The document failed to include assessment including measurements. The hospice staff failed to complete timely assessment which caused a delay in receiving Physician orders. The skilled nurse failed to fully assess the patients’ wounds in order to provide a complete description of the patient’s current physical status with updates to the comprehensive assessment. 2. Patient #2 had a hospice admission date of 11/29/23 and received hospice services while residing in a nursing facility. Review of the clinical record revealed the following: a. The plan of care (POC) dated 2/27/24 to 5/26/24, included skilled nursing services 1 time per week. b. Comprehensive assessments completed by Staff O, RN, dated 3/25/24 included documentation of a skin tear to the left proximal dorsum (top foot/ankle) with an onset on 3/22/24 due to a fall. The facility provided wound care and dressing change this morning so no assessment of the wound was made. The assessment failed to include documentation of the Nursing facilities findings or any further description or measurements of the wound. c. A comprehensive assessment completed by Staff P, RN, dated 4/1/24, included documentation of skin tear to the left proximal dorsum and a new skin tear to the left mid pretibial area (shin). The assessments failed to include a description or measurements of the wounds. d. The skilled nurse visit note, dated 4/5/24, Staff O, RN included documentation of skin tear to the left proximal dorsum and a skin tear to the left mid pretibial area (shin). The assessments failed to include a description or measurements of the wounds. The hospice failed to complete assessments of wounds or identify the facilities assessments including wound measurements. The above findings were reviewed with the Administrator and Clinical Manager.”

“Based on clinical record review, home visit observation, family interview and hospice policy review, the hospice failed to ensure the hospice plan of care included all necessary treatments to meet the needs of the patient for 2 of 6 sampled patients (Patient #2 and #4). Failure to ensure the plan of care included complete and accurate physician orders for all necessary medications and treatments placed patients at risk to receive inappropriate treatment of symptoms. Findings include: Review of the hospice’s policy, titled Plan of Care (POC), dated 2/1/23, identified the Interdisciplinary Group (IDG) gathers the information from the initial and comprehensive assessment to develop the POC. Review of the hospice’s policy, titled Interdisciplinary Team Meetings, dated 7/28/21, identified the IDG reviews and updates each patient’s Plan of Care (POC) at least every 15 days, or more frequently, if needed. 1. Patient #2 had a hospice admission date of 11/20/23 and received routine home care services from the hospice while residing in an assisted living facility. Review of the clinical record revealed the following: a. The plan of care (POC), dated 3/19/24 through 5/17/24, identified the patient had orders for skilled nursing services and medications. b. The assisted living physician’s ordered, dated 4/9/24, included orders for lorazepam 0.5 mg every 6 hours as needed for agitation/anxiety effective 9/5/23. c. The Interdisciplinary Group (IDG) meeting, dated 3/21/24, did not include any information about the patient’s order for Lorazepam. d. The hospice medication report, dated 4/9/24, did not include the order for Lorazepam. The hospice failed to include the patient’s order for Lorazepam on the plan of care. 2. Patient #4 had a hospice admission date of 2/7/24 and received routine home care services from the hospice while residing in a private residence. a. The POC, dated 2/7/24 to 5/6/24, included orders for skilled nursing services and the medication cranberry supplements. b. The hospital discharge orders, dated 2/7/24, included orders for cranberry supplement 500 mg 3 times a day. c. The IDG note, dated 2/15/24, 2/29/24 and 3/1424, included orders for cranberry supplement 500 mg daily. The hospice failed to include IDG orders for correct, current medication of cranberry supplement of cranberry supplement 500 mg 3 times a day or clarify the discrepancy with the physician. The above findings were reviewed with the Administrator and Clinical Manager.”