The Care Team Hospice

“Upon patient record review, 8 of 19 (Patient #2,#6,#8,#9,#10,#12,#13,#14) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient#2: The medication profile contained acetaminophen PRN for fever. However, there was no evidence of parameters for the fever. The medication profile contained oxygen. However, there was no evidence of an indication or route for the oxygen. This was corrected on site by adding the missing information. Patient#3,#6,#9,#10,#14: The medication profile contained acetaminophen for fever. However, there was no evidence of parameters for the fever. This was corrected on site by adding parameters. Patient#8: The medication profile contained lidocaine 5% topical ointment per instructions. There is no evidence of a specified area of application. This was corrected on site as specific are for application was added. Patient#12: The medication profile contained polyethylene glycol 17 grams. However, there is no evidence of instructions for preparation with dilutant. This was corrected on site by adding dilutant instructions. Patient#13: The medication profile contained Sarna to be applied topically for itching. However, there was no evidence of a specified area of application. This was corrected on site by adding the area for application.”

“Upon patient record review, 2 of 19 (Patient #6,#7) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient’s family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient#6: The patient was admitted on 5/23/25. There is evidence that the initial bereavement assessment was not completed until 6/6/25. Patient#7: The patient was admitted on 5/2/25. There is evidence that the initial bereavement assessment was not completed until 6/17/25.”

“Upon patient record review, 4 of 19 (Patient #2,#3,#6,#7) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient#2: The record indicates the patient is a fall risk, and requires oxygen in home. There is no evidence of problems with goals and interventions related to fall precautions or oxygen safety. Corrected on site by updating plan of care to include education and precautions for fall and oxygen safety. Patient#3,#6: The record indicates the patient has fall precautions and aspiration precautions on aide plan of care. However, there are no problems with goals and interventions on the plan of care for these needs. The agency corrected the fall precaution by adding this to the plan of care. They state their EMR does not have any options for aspiration precautions and are unable to correct at this time. Patient#7:The record indicates the patient has fall precautions on aide plan of care. However, there are no problems with goals and interventions on the plan of care for these needs. The agency corrected the fall precaution by adding this to the plan of care. The record indicates patient admitted with terminal diagnosis of Alzheimer’s. There is no evidence of neurological problems with goals and interventions on the plan of care related to this patient’s needs. This was corrected on site by agency adding related neurological problems, goals and interventions.”

“Upon patient record review, 11 of 19 (Patient #1,#2,#3,#6,#8,#9,#10,#12,#13,#14) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient#1: The record indicates patient has a foley catheter. There is no evidence of an order to change or replace the foley. This was corrected on site as an order obtained. Patient#2: The medical record contained an order for acetaminophen PRN for fever. However, there was no evidence of parameters for the fever. The medical record contained an order for oxygen. However, there was no evidence of an indication or route for the oxygen. This was corrected on site by obtaining order. Patient#3,#6,#9,#10,#14: The medical record contained an order for acetaminophen for fever. However, there was no evidence of parameters for the fever. This was corrected on site by obtaining order that included parameters. Patient#6:The record indicates patient required nectar thick liquids. There is no evidence of an order for this need. This was corrected on site by obtaining the order. Patient#8: The medical record contained an order for lidocaine 5% topical ointment per instructions. There is no evidence of a specified area of application. This was corrected on site as a correct order was obtained. Patient#12: The medical record contained an order for polyethylene glycol 17 grams. However, there is no evidence of instructions for preparation with dilutent. This was corrected on site by obtaining a correct order. Patient#13: The medical record contained an order for Sarna to be applied topically for itching. However, there was no evidence of a specified area of application. This was corrected on site by obtaining a correct order.”

“Upon patient record review, 2 of 19 (Patient #1,#5) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient#1: The record indicates patient has a foley catheter. There is no evidence of catheter supplies on the plan of care. This was corrected on site and these supplies were added. Patient#5: The record indicates the patient requires and is using a Hoyer lift, hospital bed, mattress, oxygen equipment, and a walker. There is no evidence of these items on the plan of care. This was corrected on site as these items were added to the plan of care.”

“Upon patient record review, 2 of 19 (Patient #1,#2) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient#1: The aide plan of care states all task to be completed every visit. The details of the assignment done by RN state “offer every visit”. Aide POC did not note patient was cognitively able to make decisions. Patient#2: The record indicates the 7/14/25 aide plan of care assigns aide to assist to toilet per patient request. This was corrected on site by removing the “per patient request” and designating to be completed every visit.”

“Upon patient record review 2 of 19 (Patient #2,#3) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient’s needs. Patient#2: There is no evidence of an aide supervisory visit being completed from 6/16/25 to present. Patient#3: There is no evidence of an aide supervisory visit being completed from 5/21/25 to present.”

“Based on record review and interview, the agency failed to notify the Indiana Department of Health of the neglect of a patient for 1 of 1 neglect incidents, with the potential to affect all patients. Findings include: 1. Review of the policy on Abuse, Neglect and Exploitation, last reviewed 10/01/2021, identified neglect as “;... failure to provide goods and/ or services necessary to avoid physical harm, mental anguish, or mental illness.” The policy evidenced instruction for the hospice to report verified violations to “;... the State Survey and Certification Agency ... within five working days of becoming aware of the verified violation ....” 2. Review of the addendum to the Abuse, Neglect, and Exploitation policy, specific to Indiana, last reviewed 11/27/2023, defined neglect as “;... fails to provide adequate food, clothing, shelter or medical care.” 3. Review of video clips of Former Employee 4 with Patient #3 on 1/9/2025, evidenced Former Employee (LPN) 4 assist Patient #3 out of the recliner, then sat in a chair while the patient used a rollator to ambulate to the bathroom, where Patient #3 fell. 4. Review of the occurrence report completed by Former Employee 4 on 1/13/2025, indicated “;Pt [patient] was standing halfway nud3 [sic] her bathroom after saying come in after writer knocked. Writer sat writer”s [sic] things and put on gloves. Pt asked writer to get [Patient #3s] baby wipes from shelf. Writer did so and whe [when] writer put down package sat down on floor on bath mat. Pt sat rather than sit down firml y [sic] against a flat surface. Pt denied dizziness or pain. No NV [nausea or vomiting]. Writer stood between Pt and wall to prevent Pt from hitting [Patient #3s] head. When staff nurse [nurse at Entity 1] arrived writer took Pts vitals which were WNL [within normal limits] for Pt...” 5. In an email exchange between Corporate Staff 6, the Human Resources Manager, and the Chief Compliance Officer, dated January 13 and 14, 2025, the Chief Compliance Officer indicated Patient #3 fell while alone in the bathroom. The email indicated the agency determined that neglect occurred by Former Employee 4. 6. The Administrator provided notes regarding the fall. The notes indicated Former Employee 4 said they escorted Patient #3 to the bathroom and remained with them. According to the notes, Former Employee 4 assisted the patient to the floor in a controlled fall. The notes indicated Former Employee 4 did not call the hospice RN, Clinical Manager, Administrator, or the Physician. The notes outlined a discussion with Person 3, from Entity 1. Person 3 indicated Former Employee 4 did not assess or provide post – fall care to Patient #3. The notes indicated the Administrator called Adult Protective Services to report neglect on 1/13/2025. During an interview beginning at 4:35 PM on 2/26/2025, the Administrator indicated they believed they reported the neglect to Adult Protective Services and the report would then go to all required agencies. The Administrator confirmed they did not report the neglect to the Indiana Department of Health.”

“Based on record review and interview, the hospice failed to ensure care and services were provided according to the physical needs of the patient and failed to ensure all members of the IDG were notified of a fall for 1 of 1 records reviewed of a patient who sustained a fall with a hospice staff member present (Patient #3). Findings include: The review of Patient #3s clinical record indicated a hospice benefit election date of 4/26/24, terminal diagnosis of heart disease, and secondary diagnoses including dementia. Patient resided at Entity 1, an assisted living facility. The record included a recertification POC for the benefit period 12/22/24 – 2/19/25, which indicated Patient was to receive SN visits once a week. The POC indicated the SN was to “;evaluate Patient and develop a nursing plan of care ... coordinate plan of care with facility staff.” The POC also included an identified problem of “;Altered Home Safety” with a goal of “;Patient/Caregiver verbalizes/demonstrates understanding of proper safety measures related to fall prevention.” Skilled nurse interventions for this problem included the nurse would assess “;Patients functional status in relationship to potential safety hazards in Patients living area” and would instruct “;on safety measures.” The record included a NP Face-to-Face note, dated 12/10/24 by NP 1, which indicated Patient required a one-person physical assist to ambulate to the bathroom, along with a walker. NP 1 noted Patient had “;progressive weakness” to the lower extremities. At the time of the exam, Patient had 11 falls in 6 months, including two with injury. NP 1 noted Patient had a hand tremor in both hands with “;action,” and Patient “;chronically laughs at no particular stimuli.” The record included a SN visit note, dated 12/23/24 by Former Employee 4, an LPN. The nurse documented Patient was not having pain during the visit nor did Patient have any pain since the last visit. Patient was noted to be “;forgetful,” have “;abnormal insight and judgement,” and was “;impulsive.” The note failed to evidence a musculoskeletal assessment was completed. The record included a SN visit note, dated 1/02/25 by Former Employee 7, an RN. The nurse documented Patient was not having pain during the visit nor did Patient have any pain since the last visit. The RN noted Patient had decreased strength to his/her lower extremities and Patient required assistance with toileting. The record included a SN visit note, dated 1/09/25 by Former Employee 4. The nurse noted she began the visit by conducting aide tasks. Former Employee 4 documented she walked with Patient to the bathroom while Patient used their walker. After toileting, Patient ambulated with their walker to the sink. While performing personal care tasks, the nurse documented Patient “;took a half step back as if [he/she] were going to sit.” The nurse documented she “;stood behind [Patient] immediately as writer remains within arms reach of [Patient] at all times due to [history of] falls.” The LPN reportedly assisted Patient down to the bathroom floor and called for assistance. Former Employee 4 documented Patient had pain to the “;mid and lower back,” which was rated as a “;6” on a 0-10 verbal pain scale and was exacerbated with movement. Patient also had “;pain/stiffness” and decreased strength to all extremities and their back. The LPN documented interventions performed during the visit included instructing Patient on home safety measures, and Patients goal for verbalizing/demonstrating understanding of proper safety measures related to fall prevention was marked as “;met.” The record failed to evidence the nurse notified Patients physician of the fall. The review of home camera footage from 1/09/25 evidenced Former Employee 4 assisted Patient up from a chair. Patient ambulated him/herself to the bathroom with a walker while the nurse sat down in the living room. Once in the bathroom, Patient stood at the sink with the walker between him/herself and the bathroom door. The LPN later stood outside of the bathroom door, with the walker between the nurse and Patient. Patient could then be seen taking a step back and beginning to lose their balance, before the video ended. Footage from later in the visit evidenced Patient and Former Employee 4 sitting on the bathroom floor. Person 5, an employee of Entity 1, entered and Former Employee 4 reported Patient was standing at the sink and “;just sat down on the floor ... just hit [his/her] butt.” The review of an agency Client Occurrence Report, documented on 1/13/25 by Former Employee 4, indicated when the nurse arrived for her visit, Patient was “;standing halfway [nude]” in their bathroom. The nurse documented she entered the bathroom and was obtaining supplies for Patient, then Patient “;sat down on floor on bath mat. [Patient] sat rather than sit down firmly against a flat surface.” The nurse documented Patient “;moved all extremities per baseline.” The incident report failed to evidence the nurse notified Patients physician of the fall. The review of Entity 1s clinical record for Patient included a service plan, dated 11/21/24, which indicated Patient required standby assistance during bathroom use and bathing. A nurse note, documented on 1/09/25 at 1:07 PM by Person 5, indicated Patient was found “;sitting up on buttock in bathroom with hospice nurse.” Former Employee 4 documented Patient was standing up at the sink, began to complain of feeling dizzy, then Patient “;sat on [his/her] buttock.” Entity 1s documentation after the fall evidenced the following nurse notes- a. On 1/10/25 at 6:22 AM, Person 8 documented Patient was unable to stand and bear weight to walk to the bathroom. b. On 1/10/25 at 2:19 PM, Person 5 documented Patient complained of pain to the right buttock and was unable to bear weight to his/her lower extremities. c. On 1/10/25 at 7:08 PM, Person 9 documented Patient complained of pain to the right buttock and was unable to bear weight to his/her lower extremities. d. On 1/11/25 at 6:12 AM, Person 10 documented Patient complained of pain to the “;butt” and was unable to bear weight to his/her lower extremities. e. On 1/11/25 at 2:31 PM, Person 11 documented Patient complained of pain and was unable to bear weight to his/her lower extremities. Patient remained in bed during Person 9s shift. f. On 1/11/25 at 9:51 PM, Person 11 documented Patient complained of pain to the hip and was unable to bear weight to his/her lower extremities. g. On 1/12/25 at 3:52 AM, Person 10 documented Patient was unable to bear weight to his/her lower extremities. h. On 1/12/25 at 2:02 PM, Person 11 documented Patient complained of pain to the hip. The entitys records also indicated Patient received doses of Tramadol (a pain medication), ordered to be given as needed for pain, on the following days and times for the month of January 2025: a. 1/10/25 at 8:09 AM b. 1/10/25 at 3:15 PM c. 1/14/25 at 3:46 PM d. 1/16/25 at 3:07 PM e. 1/21/25 at 7:47 AM f. 1/22/25 at 3:18 PM g. 1/23/25 at 9:39 AM During an interview with Person 3 and Person 13, employees of Entity 1, on 2/25/25 beginning at 12:25 PM, the facility staff reported prior to the 1/09/25 fall, Patient was a known high fall risk due to their history of falls. Due to Patients history of dementia, Patient would “;laugh at everything,” which would cause him/her to lose their balance. The facility staff reported Patient was to have someone walk with him/her at all times due to the risk of falls. The hospice record evidenced Patient was discharged on 1/13/25 to Entity 6, a hospice agency, per Patients caregiver request. The review of Entity 6s clinical record evidenced a hospice admission assessment completed on 1/13/25. The entitys hospice nurse noted Patient had acute, daily pain to the “;bottom/hip” which was worse with movement. The assessment noted “;prior to this admission Patient participated in activities. Patient sustained a fall 4 days ago and has been bedbound since. Patient is no longer able to stand and bear weight. Patient was able to ambulate short distances with a walker and used a wheelchair for long distances. Patient was able to assist with cares [sic] and now is a total care ....” During an interview with Administrator on 2/26/25 at 10:47 AM, she reported she was notified of Patients fall by Person 3 on 1/13/25. Administrator reported Patient was at risk for falls, however the POC failed to evidence interventions to address the fall risk. Administrator reported Former Employee 4 should have assisted Patient with ambulation due to his/her fall risk. Administrator also stated Former Employee 4 failed to communicate the fall to Patients RN case manager or physician.”

“Based on record review and interview, the hospice agency failed to develop and follow an individualized written plan of care in accordance with the patients needs for 6 of 8 records reviewed of a patient with a fall (Patients #3, 6, 7, 8, 9, 10). Findings include: 1. The agency policy “;The Individualized Plan of Care,” last reviewed 11/06/24, indicated “;Hospice care and services provided to patients and their families need to stick to a personalized written Plan of Care. This plan should capture the goals of the patient and their family, along with the actions to take based on the issues found in the initial and ongoing reassessments.” 2. The review of Patient #3s clinical record indicated a hospice benefit election date of 4/26/24, terminal diagnosis of heart disease, and secondary diagnoses including dementia. Patient resided at Entity 1, an assisted living facility. The record included a recertification POC for the benefit period 12/22/24 – 2/19/25, which indicated Patient was to receive SN visits once a week. The POC indicated the SN was to “;evaluate Patient and develop a nursing plan of care ... coordinate plan of care with facility staff.” The POC also included an identified problem of “;Altered Home Safety” with a goal of “;Patient/Caregiver verbalizes/demonstrates understanding of proper safety measures related to fall prevention.” The POC failed to evidence patient-specific interventions to address Patients fall risk. The record included a NP Face-to-Face note, dated 12/10/24 by NP 1, which indicated Patient required a one-person physical assist to ambulate to the bathroom, along with a walker. NP 1 noted Patient had “;progressive weakness” to the lower extremities. At the time of the exam, Patient had 11 falls in 6 months, including two with injury. NP 1 noted Patient had a hand tremor in both hands with “;action,” and Patient “;chronically laughs at no particular stimuli.” The record included a SN visit note, dated 1/09/25 by Former Employee 4. The nurse noted Patient needed a staff member to remain within arms-reach while ambulating due to a history of falls. Former Employee 4 documented Patient had an assisted fall while in the bathroom during the visit. The review of Entity 1s clinical record for Patient included a service plan, dated 11/21/24, which indicated Patient required standby assistance during bathroom use and bathing. During an interview with Person 3 and Person 13, employees of Entity 1, on 2/25/25 beginning at 12:25 PM, the facility staff reported prior to the 1/09/25 fall, Patient was a known high fall risk due to their history of falls. Due to Patients history of dementia, Patient would “;laugh at everything,” which would cause him/her to lose their balance. The facility staff reported Patient was to have someone walk with him/her at all times due to the risk of falls. During an interview with Administrator on 2/26/25 beginning at 10:47 AM, she reported Patients POC should have included individualized interventions to address Patients fall risk. 3. The review of Patient #6s clinical record indicated a hospice benefit election date of 9/24/24 and terminal diagnosis of lung cancer. The record included a recertification POC for the benefit period of 12/23/24 – 3/22/25. The POC included an identified problem of “;Altered Home Safety” with a goal of “;Patient/Caregiver verbalizes/demonstrates understanding of proper safety measures related to fall prevention.” The POC failed to evidence patient-specific interventions to address Patients fall risk. The review of an agency “;Client Occurrence Report” evidenced Patient sustained a fall on 2/16/25 with a skin tear above the right eye. During an interview on 2/26/25 beginning at 1:32 PM, CM reported the POC did not include individualized safety measures to address Patients fall risk. 4. The review of Patient #7s clinical record indicated a hospice benefit election date of 10/16/23, a terminal diagnosis of heart disease, and secondary diagnoses including dementia. The record included a recertification POC for the benefit period of 2/01/25 – 4/01/25. The POC included an identified problem of “;Altered Home Safety” with a goal of “;Patient/Caregiver verbalizes/demonstrates understanding of proper safety measures related to fall prevention.” The POC failed to evidence patient-specific interventions to address Patients fall risk. The review of two agency “;Client Occurrence Report” evidenced Patient sustained a fall on 2/05/25 and 2/21/25. During an interview on 2/26/25 beginning at 1:41 PM, CM reported the POC did not include individualized safety measures to address Patients fall risk. 5. The review of Patient #8s clinical record indicated a hospice benefit election date of 1/03/23, a terminal diagnosis of Alzheimers disease, and secondary diagnoses including “;history of falling.” The record included a recertification POC for the benefit period of 12/23/24 – 1/22/25. The POC included an identified problem of “;Altered Home Safety” with a goal of “;Patient/Caregiver verbalizes/demonstrates understanding of proper safety measures related to fall prevention.” The POC failed to evidence patient-specific interventions to address Patients fall risk. The review of two agency “;Client Occurrence Report” evidenced Patient sustained a fall on 2/14/25. During an interview on 2/26/25 beginning at 1:48 PM, CM reported the POC did not include individualized safety measures to address Patients fall risk. 6. The review of Patient #9s clinical record indicated a hospice benefit election date of 8/28/24, a terminal diagnosis of Parkinsons Disease, and secondary diagnoses including dementia and a history of falling. The record included a recertification POC for the benefit period of 12/26/24 – 2/23/25. The POC failed to evidence goals or patient-specific interventions which would be enacted to address Patients fall risk. The review of an agency “;Client Occurrence Report” evidenced Patient sustained a fall on 1/15/25. During an interview on 2/26/25 beginning at 1:55 PM, CM reported the POC did not include individualized safety measures to address Patients fall risk. 7. The review of Patient #10s clinical record indicated a hospice benefit election date of 8/19/21, a terminal diagnosis of heart failure, and secondary diagnoses including dementia. The record included a recertification POC for the benefit period of 12/01/24 – 1/29/25. The POC failed to evidence goals or patient-specific interventions which would be enacted to address Patients fall risk. The review of two agency “;Client Occurrence Report” evidenced Patient sustained a fall on 1/02/25 and 1/06/25. During an interview on 2/26/25 beginning at 1:55 PM, CM reported the POC did not include individualized safety measures to address Patients fall risk”

“Based on record review and interview, the licensed professional failed to document events of a skilled nurse visit according to professional standards for 1 of 1 record reviewed of a patient who sustained a fall with a hospice staff member present (Patient #3). Findings include: 1. The agency policy “;Medical Record Content,” last reviewed 11/30/22, indicated an “;accurate” medical record would be maintained for all patients. Clinical notes were to include “;functional and activity limitations, all actions, interventions, and procedures provided by the hospice ....” 2. The review of Patient #3s clinical record indicated Patients medical history included dementia. Patient resided at Entity 1, an assisted living facility. The record included a SN visit note, dated 1/09/25 by Former Employee 4. The nurse noted she began the visit by conducting aide tasks. Former Employee 4 documented she walked with Patient to the bathroom while Patient used their walker. After toileting, Patient ambulated with their walker to the sink. While performing personal care tasks, the nurse documented Patient “;took a half step back as if [he/she] were going to sit.” The nurse documented she “;stood behind [Patient] immediately as writer remains within arms reach of [Patient] at all times due to [history of] falls.” The LPN reportedly assisted Patient down to the bathroom floor and the nurse then called for assistance. The review of home camera footage from the 1/09/25 visit evidenced Former Employee 4 assisted Patient up from a chair in the living room. Patient ambulated him/herself to the bathroom with a walker while the nurse sat down in the living room. Once in the bathroom, Patient stood at the sink with the walker between him/herself and the bathroom door. The nurse was observed looking at her tablet, vaping, then looking at her phone while Patient ambulated then stood at the bathroom sink. The nurse then walked and stood outside of the bathroom door, with the walker between the nurse and Patient. Patient could be seen taking a step back and beginning to lose their balance, before the video ended. Footage from later in the visit evidenced Patient and Former Employee 4 sitting on the bathroom floor. Person 5, an employee of Entity 1, entered and Former Employee 4 reported Patient was standing at the sink and “;just sat down on the floor ... just hit [his/her] butt.” The review of an agency Client Occurrence Report, documented on 1/13/25 by Former Employee 4, indicated when the nurse arrived for her visit, Patient was “;standing halfway [nude]” in their bathroom. The nurse documented she entered the bathroom and was obtaining supplies for Patient, then Patient “;sat down on floor on bath mat. [Patient] sat rather than sit down firmly against a flat surface.” The review of Entity 1s clinical record for Patient included a nurse note, documented on 1/09/25 at 1:07 PM by Person 5, indicated Patient was found “;sitting up on buttock in bathroom with hospice nurse.” Former Employee 4 documented Patient was standing up at the sink, began to complain of feeling dizzy, then Patient “;sat on [his/her] buttock.” The review of an internal email exchange sent by HR Manager 2 on 1/14/25 indicated after speaking with Administrator, Former Employee 4 reported she had stayed with Patient while Patient walked to and was in the bathroom, but the “;video footage says otherwise.” During an interview with Administrator on 2/26/25 at 10:47 AM, she reported she discussed the 1/09/25 visit with Former Employee 4 after it was reported to the agency. The LPN was reportedly adamant she remained with Patient at all times during the visit. Administrator stated Entity 1s staff report of the events and review of the home camera footage conflicted with the nurses report and documentation. Administrator reported she had not reviewed the occurrence report the nurse documented regarding Patients fall.”