Notre Dame Hospice

“Based on interview and record reviews the agency failed to ensure staff reported an allegation of neglect to the agency administrator and nursing facility administrator for 1 (Patient #16) of 1 (Patient #16) sampled patients identified with an allegation of neglect. Findings: Review of the agencys Abuse, Neglect, Mistreatment and Exploitation policy and procedure, with review date of 08/02/2024, revealed neglect was defined as failure to provide goods and services necessary to avoid physical harm or mental anguish. Further review revealed alleged violations of neglect involving a hospice employee or contractor were brought to the attention of the administrator immediately. Further review revealed when care was provided in a facility, the hospice personnel were required to report all alleged violations of neglect to the facility administrator within 24 hours of becoming aware of the alleged violation. Review of the agencys contract with the nursing facility dated 10/12/2023 revealed, in part, the hospice will report all alleged violations involving neglect to the hospice administrator and the nursing home administrator within 24 hours of the hospice becoming aware of the alleged violation of neglect. Review of Patient #16s Medical Social Worker (MSW) Visit Note dated 01/30/2025 revealed, in part, Patient #16s caregiver notified S2MSW of concerns with the nursing facility and that Patient #16 had wounds which were due to neglect. Review of Patient #16s record revealed no documented evidence, and the agency presented no documented evidence, S2MSW had reported to the agency administrator and/or the nursing facility administrator an allegation of neglect. In an interview on 02/21/2025 at 3:29PM, S1Administrator/Director of Nursing (DON) indicated he was not notified of the allegation of neglect; therefore, he did not report the allegation of neglect to the nursing facility, or any other entity. S1Administrator/DON further indicated S2MSW should have reported the allegation of neglect to him immediately.”

“Based on observation, interview, and record review, the agency failed to ensure hospice staff performed hand hygiene after contact with the patients immediate environment and prior to touching the patient for 1 (Patient #4) of 4 (Patient #1, Patient #2, Patient #3, Patient #4) sampled patients observed for infection control requirements during home visits. Findings: Review of the agencys Infection Control Hand Hygiene policy and procedure, reviewed on 08/02/2024, revealed, in part, hospice staff must wash their hands before touching a patient, and after any activity involving physical contact with a patients immediate environment. Observation on 02/19/2025 at 9:17AM, revealed S3Hospice Aide (HA) performed hand hygiene, applied gloves, then opened a drawer on Patient #4s nightstand with her gloved hand, removed a drape and supplies from the drawer, closed the drawer with her gloved hand, applied the drape to over bed table, picked up two wash bins, and turned on the water with her gloved hands. S3HA then prepared wash bins with water, turned off the water with her gloved hands, and placed the wash bins on the over bed table. S3HA opened the drawer on the nightstand with the same gloved hands, removed additional supplies, closed the drawer with her gloved hands and placed supplies on the over bed table. Observation further revealed S3HA grabbed the privacy curtain with the same gloved hands, pulled it closed, grabbed the door knob with her gloved hand, and then pulled it closed. S3HA then removed Patient #4s clothes, positioned Patient #4 in bed, and draped Patient #4s chest and brief with a towel for privacy. Observation further revealed after washing Patient #4s face she used the towel used to cover Patient #4s chest to then dry Patient #4s clean face. In an interview on 02/20/2025 at 2:40PM, S1Administrator/Director of Nursing (DON) was informed of the above observations, and S1Administrator/DON indicated S3HA should have changed gloves and performed hand hygiene after touching the items in Patient #4s environment and performing Patient #4s bed bath. S1Administrator/DON further indicated S3HA should not have used the towel covering Patient #4s soiled body to dry Patient #4s cleaned face. In an interview on 02/21/2025 at 2:36PM, S3HA indicated she should have changed her gloves and performed hand hygiene after touching the items in Patient #4s environment and prior to performing Patient #4s bed bath.”

“Based on interviews and record reviews, the agency failed to ensure the registered nurse measured wounds weekly to determine wound healing for 2 (Patient #11, Patient #13) of 3 (Patient #3, Patient #11, Patient #13) sampled patients reviewed for weekly wound care measurements. Findings: Review of the Wound Ostomy and Continence Nurses Society’s Guidelines revealed the assessment and documentation of wound status included comprehensive clinical data demonstrating evidence of progress in healing or failure to heal. Comprehensive wound assessment included: dimensions and depth, presence, location and depth of any sinus tracts or undermining areas, status and characteristics of the wound bed, volume, color, and odor of exudates, and evidence of infection in surrounding tissues. Further review revealed when recorded over time, this information can be used to track the progress of wound healing. Patient #11 Review of Patient #11s plan of care for the certification period of 01/10/2025 through 03/10/2025 revealed Patient #11 was to receive skilled nursing services twice a week for eight weeks. Review of Patient #11s Registered Nurse (RN) Skilled Nursing Visit note dated 01/17/2025 revealed, in part, Patient #11 had a stage one pressure ulcer (area of redness on the skin which does not turn blanch (turn white) when pressed, caused by prolonged pressure) on his left heel, with a wound status of open, and measurements of the wound was recorded as not applicable. Review of Patient #11s RN Skilled Nursing Visit note dated 01/20/2025 revealed, in part, Patient #11 had a stage one pressure ulcer to the left heel, with a wound status of open, and measurements of the wound was recorded as not applicable. Further review revealed the wound to Patient #11s left heel wound was worse with purple noted to base of wound. Review of Patient #11s RN Skilled Nursing Visit notes dated 01/20/2025, 01/24/2025, 01/27/2025, and 01/29/2025 revealed, in part, Patient #11 had a stage one pressure ulcer to the left heel, with a wound status of open, and measurements of the wound was recorded as not applicable. Review of Patient #11s RN Skilled Nursing Visit note dated 01/31/2025, revealed Patient #11 had a left heel deep tissue injury (DTI) (wound in which the depth cannot be accurately measured due to tissue type or evidence of deeper trauma), with a wound status of open, and measurements of the wound was recorded as not applicable. Review of Patient #11s RN Skilled Nursing Visit notes dated 02/03/2025 and 02/10/2025, revealed, in part, Patient #11 had a stage one pressure ulcer to the left heel, with a wound status of open, and measurements of the wound was recorded as not applicable. Review of Patient #11s RN Skilled Nursing Visit note dated 02/14/2025 revealed, in part, Patient #11 had a stage two (open area of the skin caused by prolonged pressure) pressure ulcer to the left heel, with a wound status of open, and measurements of the wound was recorded as not applicable. Further review revealed Patient #11 had an open wound to the mid back with no measurements of the wound recorded. Review of Patient #11s RN Recertification Visit note dated 02/17/2025 revealed, in part, open wounds to wound 2, wound 3, and wound 4 with no description of the wounds. Review of Patient #11s RN Skilled Nursing Visit note dated 02/19/2025 revealed, in part, Patient #11 had a stage two pressure ulcer to the left heel with status of the wound as open, and measurements of the wound was recorded as not applicable. In an interview on 02/21/2025 at 3:18PM, S1Administrator/Director of Nursing (DON) indicated the registered nurses for Patient #11 did not obtain wound care measurements as required for Patient #11s above mentioned wounds. Patient #13 Review of Patient #13s record revealed Patient #13 was to receive skilled nursing services once a week. Review of Patient #13s RN Skilled Nursing Visit note dated 01/20/2025 revealed, in part, Patient #13 had a chronic stage one pressure ulcer to the sacral area. There was no documented evidence, and the agency presented no documented evidence, the skilled nurse had measured Patient #13s stage one sacral wound. In an interview on 02/21/2025 at 3:22PM, S1Administrator/DON indicated the agency had no documented evidence Patient #13s sacral wound was measured by a registered nurse the week of 01/19/2025 through 01/25/2025.”

“Based on interviews and record reviews, the agency failed to ensure the registered nurse supervised the hospice aide no less frequently than every 14 days to assess the quality of care and services for 2 (Patient #5, Patient #12) of 18 (Patient #1, Patient #2, Patient #3, Patient #4, Patient #5, Patient #6, Patient #7, Patient #8, Patient #9, Patient #10, Patient #11, Patient #12, Patient #13, Patient #15, Patient #16, Patient #17, Patient #18, Patient #19) sampled patients reviewed for hospice aide supervisory visits. Findings: Review of the agencys Hospice Aide Supervision policy and procedure, with a review date of 08/02/2024, revealed, in part, a registered nurse was to make an on-site supervisory visit to the patients home no less frequently than every 14 days to ensure the services ordered by the interdisciplinary group and provided by the hospice aide met the patients needs. Patient #5 Review of Patient #5s plan of care for the certification period of 11/27/2024 through 02/24/2025 revealed Patient #5 was to receive hospice aide services twice a week for twelve weeks. Review of Patient #5s record revealed Patient #5 received a hospice aide supervisory visit by the registered nurse on 01/13/2025; however, Patient #5 did not receive a hospice aide supervisory visit again until 01/28/2025, which was 15 days after the last supervisory visit. Review of Patient #5s record revealed Patient #5 received a hospice aide supervisory visit by the registered nurse on 01/28/2025; however, Patient #5 did not receive a hospice aide supervisory visit again until 02/13/2025, which was 16 days after the last supervisory visit. There was no documented evidence, and the agency presented no documented evidence, a registered nurse completed a hospice aide supervisory visits every 14 days as required for Patient #5. In an interview on 02/21/2025 at 3:14PM, S1Administrator/Director of Nursing (DON) could offer no explanation as to why a registered nurse did not complete an on-site hospice aide supervisory visit every 14 days as required. Patient #12 Review of Patient #12s plan of care for the certification period of 01/09/2025 through 03/09/2025 revealed Patient #12 was to receive hospice aide services once a week for one week, then three times a week for eight weeks. Review of Patient #12s record revealed Patient #12 received a hospice aide supervisory visit by the registered nurse on 01/15/2025; however Patient #12 did not receive a hospice aide supervisory visit again until 01/31/2025, which was 16 days after the last supervisory visit. There was no documented evidence, and the agency presented no documented evidence, the registered nurse completed Patient #12s hospice aide supervisory visit every 14 days as required. In an interview on 02/21/2025 at 3:20PM, S1Administrator/DON indicated Patient #12s hospice aide supervisory visit was late as noted above.”