Lightways Hospice and Serious Illness Care

“Based on clinical record review, document review and staff interview, it was determined the Hospice failed to ensure the patient and/or patient’s representative was informed and involved in updating the plan of care. This was found in 1 of 27 (Pt. #25) records reviewed. 1. Patient #25 was admitted to hospice services on 02/04/23 with a terminal diagnosis of Cerebral Ischemia. The clinical record was reviewed on 10/31/23. The record included a hospice nursing visit note dated 07/23/23 at 10:52 AM. The visit note included, “...Wound has white looking bugs or worms in head (possible maggots).” The nursing visit note lacked documentation of the patient’s representative being informed of the condition of the wound. 2. During an interview with the Clinical Supervisor on 11/09/23 at 10:05 AM, the above findings were confirmed. The Clinical Supervisor confirmed the patient’s representative was not notified of the change in patient’s wound status and updated plan of care.”

“Based on the clinical record review, policy review and staff interview, it was determined the Hospice Staff did not provide the care and services in accordance with the plan of care. This was found in 6 of 27 (Pts. #25, 14, 16, 1, 11 and13) records reviewed. 4. Patient #1 was admitted to hospice on 09/14/23 with the primary diagnosis of Demyelinating disease of central nervous system. The Plan of Care for the certification period of 09/14/23 to 12/12/23 required, “other orders: Decubitus/Pressure Ulcer stage 1/ Left lower buttock gluteal fold, cleanse left hip with soap and water or non-rinse foam soap, pat dry and apply remedy “Phtoplex” silicone cream twice a day and as needed...start date 09/14/23.” Patient #1s clinical record was reviewed and included the following documentation on a Hospice follow up visit dated 10/16/23: “;Left lower buttock gluteal fold/decubitus...onset 09/14/23...cleansed with wound cleanser, application/packing: calcium alginate...” The clinical record did not have updated wound orders on 10/16/23. The RN did not follow ordered wound treatment on the Plan of Care. 5. Patient #11 was admitted to hospice on 09/19/23 with the primary diagnosis of Hypertensive chronic kidney disease with stage 5 chronic kidney disease or End Stage Renal Disease. The Plan of Care for the certification period of 9/19/23 to 12/17/23 included, “additional services: Several tiny stage 2 open areas on coccyx, moisture associated...follow hospice protocols for pain and symptom management as needed.” Patient #11s clinical record was reviewed and included documentation on the Hospice Initial Assessment dated 9/19/23 and on a Hospice follow up visit dated 10/11/23: “;Medial buttocks coccyx scattered tiny openings/other stage II onset date 9/19/23...” The record also indicated on a Hospice follow up document dated 11/01/23 that the status of the wound on the same location – healed. The record lacked documentation of a weekly wound assessment as required by the Hospice policy. 6. Patient #13 was admitted to hospice on 09/25/23 with the primary diagnosis of Dysphagia following cerebral infarction. The Plan of Care for the certification period of 09/25/23 to 12/23/23 did not include an order for Physical Therapy. As of review of 11/02/23, the clinical record included documentation of Physical Therapy services that were provided to the patient on 10/04/23, 10/12/23, 10/13/23 and 10/20/23. The Hospice provided services that were not indicated in the Plan of Care. 7. The policy “;Wound Assessment and Documentation” with a review date of 2/23, was reviewed and required: “;Policy Purpose: 2. To document an accurate, ongoing assessment of wound in the medical record. The (Hospice) recognizes that a systemic, ongoing wound assessment is necessary to determine the response to nursing care and treatment modalities. A complete wound assessment will be done by a nurse for all wounds, ulcers, and other impairments in the skin integrity. The wound assessment will be documented during the initial assessment and weekly thereafter on the (electronic record) wound flowsheet. The weekly wound assessment will include - date and time of assessment, wound classification, wound location, staging (for pressure ulcers), degree (burn), description of the wound bed, color of the wound bed, drainage, wound edges, color of the wound, surrounding skin and odor, wound measurements and wound related pain.” 8. The above findings were confirmed during the interview with the Director of Clinical Services on 11/02/23 between 2:00 PM and 3:20 PM and with the Chief Executive Officer, Director of Clinical Services, Senior Director of Operations and Chief Operating Officer on 11/03/23 at 1:45 PM. Findings include: 1. Patient #25 was admitted to hospice 02/04/23 with a terminal diagnosis of Cerebral Ischemia. The clinical record includes a plan of care dated 05/05/23 for Aide services two times a week. The Aide did not provide care two times a week for the weeks of 06/25/23 and 07/02/23. 2. Patient #14 was admitted to hospice 09/12/23 with a terminal diagnosis of Hypertensive Heart and Chronic Kidney Disease with heart failure. The record included an initial plan of care dated 09/12/23 for Aide services two times a week. The Aide did not provide care two times a week for the weeks of 09/10/23, 09/17/23,10/01/23 and 10/22/23. 3. Patient #16, was admitted to hospice 08/07/23 with a terminal diagnosis of Hypertensive Heart and Chronic Kidney Disease with heart failure. The record included an initial plan of care dated 08/07/23 for Aide services two times a week. The Aide did not provide care two times a week for weeks of 10/22/23 and 10/29/23.”

“Based on clinical record review and staff interview, it was determined the Hospice did not ensure the Interdisciplinary Group was notified of changes in wound symptoms in order to maintain responsibility for directing, coordinating and supervising patient care. This was found in 1 of 27 (Pts. # 25) records reviewed. Findings include: 1.Patient #25 was admitted to hospice 02/04/23 with a terminal diagnosis of Cerebral Ischemia. The clinical record was reviewed on 10/31/2023. The record included a plan of care dated 05/05/23 that included, “;Hospice MD to symptom manage.” 2. The clinical record also included a nursing visit note dated 07/23/23 at 10:52 AM. The visit note documented, “;Beefy Red Pink Wound Edges Dehiscence Detached Drainage Amount Moderate Color Other: Red blood Odor None... Patient has open raise mass cancerous wound to posterior head. Blood dry in tingles hair... Blood dry and dark. Continue to assess. Wound has white looking bugs or worms in head (possible maggots).” The record lacked documentation of coordination with the Medical Director on new onset of symptoms associated with the wound. 3. During staff interviews with the Director of Clinical Services on 11/02/23 from 3:00 PM to 3:20 PM, it was stated that the Hospice MD was not notified because it did not require a change in the level of care and the RN handled the concerns. 4.The above findings were confirmed during the interview with the Director of Clinical Services on 11/02/23 between 2:00 PM and 3:20 PM.”

“Based on clinical record review and staff interview, it was determined the Hospice did not ensure the patients needs were met. This was found in 1 of 27 (Pts. # 25) records reviewed. Findings include: 1.Patient #25 was admitted to Hospice on 02/04/23, with a terminal diagnosis of Cerebral Ischemia. The clinical record was reviewed on 10/31/23. The record included Employee #6s nursing visit note, dated 07/23/23 at 10:52 AM. The visit note documented, “;Beefy Red Pink Wound Edges Dehiscence Detached Drainage Amount Moderate Color Other: Red blood Odor None Dressing/Wound Vac: Wound Cleansing/Dressing Change Per Care Plan Care Performed: With assistance.... Patient has open raise mass cancerous wound to posterior head. Blood dry in tingles hair... Blood dry and dark. Continue to assess. Wound has white looking bugs or worms in head (possible maggots).” The record lacked documentation of the patients new onset of symptoms being met by the nurse. 2. The clinical record also included a communication note form Employee # 6 dated 07/23/23 at 5:25 PM, that documented, “;...made phone call to...” Director of Facility, “;...reports patient was sent out to... hospital, due to persistence of family.” The same communication note also documented phone call to POA, “;...POA has questions on maggots in patient wound and why no further action taken...Education given on maggots and role of maggots with wound healing... POA reports patient is in severe pain... education given on morphine, POA verbalized understanding... followed up if patient is going to the hospital, POA confirmed.” 3. During staff interview with the Director of Clinical Services on 11/02/23 from 3:00 PM to 3:20 PM, it was stated that the Hospice MD was not notified because it did not require a change in the level of care and that the RN handled the concerns. 4. The above findings were confirmed during the interview with the Director of Clinical Services on 11/02/23 between 2:00 PM and 3:20 PM.”

“Based on the clinical record review and Staff interview, it was determined the Hospice Staff did not complete the discharge summaries. This was found in 2 of 3 (Pts. #25 and 26) live-discharge records reviewed. Findings include: 1. Patient #25 was admitted to hospice on 08/24/23 with a diagnosis of Cerebral Ischemia. The clinical record was reviewed on 10/31/23. The discharge summary lacked a summary of the patient’s stay including treatments, symptoms and pain management, the patient’s current plan of care, and the patient’s latest physician orders. 2. Patient #26 was admitted to hospice on 10/28/23, with a diagnoses of “Hyp Chr Kidney Disease w stage5 chr Kidney Disease or ESRD.” The clinical record was reviewed on 10/31/23. The discharge summary lacked a summary of the patient’s stay including treatments, symptoms and pain management, the patient’s current plan of care, and the patient’s latest physician orders. 3. The above findings were confirmed during the interview with the Director of Clinical Services on 11/02/23 between 2:00 PM and 3:20 PM.”