St. Joseph Hospice of Acadiana, LLC

“Based on record reviews and interviews, the hospice agency failed to ensure the Interdisciplinary Group (IDG) developed and maintained a system of communication, coordination, and integration of services for 1 (#2) of 3 (#1, #2, and #3) patients reviewed in the sample. The agency failed to inform and involve Patient #2s prescribing physician and other members of the IDG when: 1. Nursing staff were unable to perform wound care as ordered; and 2. Nursing staff were unable to perform wound measurements as required. Review of the Louisiana State Board of Nursing Declaratory Statement Scope of Practice for Registered Nurses - Wound Care Management adapted 02/1999 revealed the following in part: Registered nurses render care that is directed towards the prevention and treatment of wounds. Wounds are a common health care challenge that often occur with or result from chronic disorders such as impaired circulation and malnutrition. Nursing care of skin/wound conditionsinvolves the identification, assessment, management, and ongoing evaluation of patients with alterations in skin/tissue integrity that includes but is not limited to draining wounds, pressure ulcers, and vascular ulcers, and conditions resulting from incontinence, surgical procedures, and/or trauma. Scope of Practice - The Louisiana State Board of Nursing recognizes that assessment, planning,intervention, teaching, evaluation, and supervision are the major responsibilities of the registered nurse in the practice setting. The registered nurse is responsible for performing a nursing assessment and physical examination for preventative and restorative nursing and for providing patient/family teaching. Recognizing that the physician must always prescribe wound care, the following roles are defined to delineate the scope of practice for each member of the nursing team members. The registered nurse initiates appropriate wound preventative measures, stages wounds and collaborates with the wound care team in the implementation and evaluation of nursing interventions as prescribed by an authorized prescriber. Review of the agencys policy, “;Wound Care Protocol”, created 10/19/2020, revealed, in part, the following: Purpose: To provide clinical guidance on wound care with the goal to prevent further wound deterioration while maintaining the patients dignity and respect. Process: The Registered Nurse (RN) will assess the wound bed of the patient and collaborate with the Hospice Medical Director to establish the most appropriate plan of care (POC) to meet the palliative goals in coordination with the patient/family and all contracted care providers. Wound care treatment and interventions will be individualized. Licensed Practical Nurse/Licensed Vocational Nurse: c. Performs wound treatments per orders in the individualized patients treatment plan. e. Observes patients response and wound status, reporting any changes to the RN or Supervising Clinician. Review of Patient #2s Clinical Record revealed a Start of Care Date of 01/17/2025 with a current Certification Period of 01/17/2025 through 04/16/2025. Further review revealed admitting diagnoses, which included, in part, Hairy Cell Leukemia, Dementia, and the presence of a Deep Tissue Injury (DTI) to the Right Hip. Review of the facilitys current Inpatient Unit (IPU) Roster, as of 01/27/2025, revealed Patient #2 was currently admitted to the agencys IPU and had been since 01/17/2025. Review of the facilitys current Wound List for IPU Residents, as of 01/27/2025, revealed Patient #2 was listed as receiving treatment for a Stage II Pressure Ulcer to the Right Hip. 1. Review of Patient #2s Plan of Care (POC) and Physician Orders, dated 01/17/2025 through 01/29/2025, revealed, in part, the following: 01/17/2025 – Hospice nurse to perform wound care to Stage II on Right Hip daily. Utilizing clean technique, cleanse with wound cleanser, apply barrier cream, cover with bordered foam. Discontinued 01/23/2025. 01/23/2025 – Right Hip wound. Cleanse with wound cleanser daily. Pat dry. Apply foam dressing. Review of Patient #2s Wound Record Report for the Stage II Pressure Ulcer to the Right Hip, dated 01/17/2025 through 01/29/2025, revealed no documented evidence wound care was performed during any shift on the following dates: 01/19/2025, 01/20/2025, 01/21/2025, 01/25/2025, 01/27/2025, or 01/28/2025. Further review revealed no documented evidence of Patient #2s prescribing physician or any other members of the IDG being notified the wound care was not performed as ordered on any of the aforementioned dates. Review of Patient #2s SOAP Notes, Visit Notes and Coordination Notes, dated 01/17/2025 through 01/28/2025, revealed no documented evidence wound care was performed for Patient #2s Stage II Pressure Ulcer to the Right Hip during any shift on the following dates: 01/19/2025; 01/20/2025; 01/21/2025; 01/25/2025; 01/27/2025; and 01/28/2025. Further review revealed no documented evidence of Patient #2s prescribing physician or any other members of the IDG being notified the wound care was not performed as ordered on any of the aforementioned dates. Review of Patient #2s IDG Comprehensive Assessment and Plan of Care Update Report, dated 01/24/2025, revealed no documented evidence of discussion regarding Patient #2 not receiving his wound care as ordered since his admission on 01/17/2025. 2. Review of Patient #2s Wound Record Report for his Stage II Pressure Ulcer to the Right Hip, dated 01/17/2025 through 01/28/2025, revealed no documented evidence wound measurements were performed during any shift on the following dates: 01/17/2025, 01/18/2025, 01/19/2025, 01/20/2025, 01/21/2025, 01/22/2025, 01/23/2025, 01/24/2025, 01/25/2025, 01/26/2025, 01/27/2025 and 01/28/2025. Further review revealed no documented evidence of Patient #2s prescribing physician or any other members of the IDG being notified the wound measurements were not performed as required on any of the aforementioned dates. Review of Patient #2s SOAP Notes, Visit Notes and Coordination Notes, dated 01/17/2025 through 01/28/2025, revealed no documented evidence wound measurements were performed for Patient #2s Stage II Pressure Ulcer to the Right Hip during any shift on the following dates: 01/17/2025, 01/18/2025, 01/19/2025, 01/20/2025, 01/21/2025, 01/22/2025, 01/23/2025, 01/24/2025, 01/25/2025, 01/26/2025, 01/27/2025 and 01/28/2025. Further review revealed no documented evidence of Patient #2s prescribing physician or any other members of the IDG being notified the wound measurements were not performed as required on any of the aforementioned dates. Review of Patient #2s IDG Comprehensive Assessment and Plan of Care Update Report, dated 01/24/2025, revealed no documented evidence of discussion regarding Patient #2 not having wound measurements performed since his admission on 01/17/2025 through 01/28/2025. An interview was conducted on 01/28/2025 at 2:40 p.m. with S2ADON. She confirmed wounds should be measured and documented by an RN every 7 days. She confirmed she would expect the policy for wound measurements to be followed for pressure ulcers and DTIs, whether they were stageable or not. An interview was conducted on 01/30/2025 at 9:45 a.m. with S4RN. S4RN confirmed she worked as an RN for the agencys IPU. S4RN confirmed Patient #2 was admitted to the IPU on 01/17/2025 with a DTI wound to his Right Hip which progressed and presented as a Stage II Pressure Ulcer a few days later. S4RN confirmed Patient #2 refused to allow his wound care or wound measurements to be performed at times. S4RN confirmed if a nurse were unable to perform wound care or wound measurements, the prescribing physician and IDG should be made aware so it could be addressed appropriately and they were not for Patient #2. An interview was conducted on 01/30/2025 at 10:30 a.m. with S3DCS. S3DCS confirmed he oversaw the clinical operations of the agencys IPU. S23DCS confirmed Patient #2 was admitted to the IPU with a wound to his Right Hip. S3DCS confirmed if an IPU nurse were unable to perform wound care and/or wound measurements, for any reason, including refusal, he would expect them to notify the prescribing physician and IDG so they could appropriately address the reason why the care and/or measurements were not able to be performed. An interview was conducted on 01/30/2025 at 11:00 a.m. with S1ED. S1ED confirmed he would expect his staff to follow all regulations and protocol for wounds at all times, including notifying the appropriate persons if unable to provide or perform care while in the IPU.”

“Based on interviews and record reviews, the agency failed to follow an individualized written Plan of Care for 1 (#2) of 3 (#1, #2 and 3) patients reviewed in the sample. The agency failed to provide wound care while in the Inpatient Unit (IPU) as ordered by the prescribing physician for Patient #2. Review of the Louisiana State Board of Nursing Declaratory Statement Scope of Practice for Registered Nurses - Wound Care Management adapted 02/1999 revealed the following in part: Registered nurses render care that is directed towards the prevention and treatment of wounds. Wounds are a common health care challenge that often occur with or result from chronic disorders such as impaired circulation and malnutrition. Nursing care of skin/wound conditions involves the identification, assessment, management, and ongoing evaluation of patients with alterations in skin/tissue integrity that includes but is not limited to draining wounds, pressure ulcers, and vascular ulcers, and conditions resulting from incontinence, surgical procedures, and/or trauma. Scope of Practice - The Louisiana State Board of Nursing recognizes that assessment, planning, intervention, teaching, evaluation, and supervision are the major responsibilities of the registered nurse in the practice setting. The registered nurse is responsible for performing a nursing assessment and physical examination for preventative and restorative nursing and for providing patient/family teaching. Recognizing that the physician must always prescribe wound care, the following roles are defined to delineate the scope of practice for each member of the nursing team members. The registered nurse initiates appropriate wound preventative measures, stages wounds and collaborates with the wound care team in the implementation and evaluation of nursing interventions as prescribed by an authorized prescriber. Review of the agencys policy, “;Wound Care Protocol”, created 10/19/2020, revealed, in part, the following: Purpose: To provide clinical guidance on wound care with the goal to prevent further wound deterioration while maintaining the patients dignity and respect. Process: The Registered Nurse (RN) will assess the wound bed of the patient and collaborate with the Hospice Medical Director to establish the most appropriate plan of care (POC) to meet the palliative goals in coordination with the patient/family and all contracted care providers. Wound care treatment and interventions will be individualized. Licensed Practical Nurse/Licensed Vocational Nurse: c. Performs wound treatments per orders in the individualized patients treatment plan. e. Observes patients response and wound status, reporting any changes to the RN or Supervising Clinician. Review of Patient #2s Clinical Record revealed a Start of Care Date of 01/17/2025 with a current Certification Period of 01/17/2025 through 04/16/2025. Further review revealed admitting diagnoses, which included, in part, Hairy Cell Leukemia, Dementia, and the presence of a Deep Tissue Injury (DTI) to the Right Hip. Review of the facilitys current Inpatient Unit (IPU) Roster, as of 01/27/2025, revealed Patient #2 was currently admitted to the agencys IPU and had been since 01/17/2025. Review of the facilitys current Wound List for IPU Residents, as of 01/27/2025, revealed Patient #2 was listed as receiving treatment for a Stage II Pressure Ulcer to the Right Hip. Review of Patient #2s Plan of Care and Physician Orders, dated 01/17/2025 through 01/29/2025, revealed, in part, the following: 01/17/2025 – Hospice nurse to perform wound care to Stage II on Right Hip daily. Utilizing clean technique, cleanse with wound cleanser, apply barrier cream, cover with bordered foam. Discontinued 01/23/2025. 01/23/2025 – Right Hip wound. Cleanse with wound cleanser daily. Pat dry. Apply foam dressing. Review of Patient #2s Wound Record Report for his Stage II Pressure Ulcer to the Right Hip, dated 01/17/2025 through 01/29/2025, revealed, in part, the following: 01/19/2025 AM – Wound care not provided, refused care. 01/19/2025 PM - Wound care not performed.01/20/2025 AM - Wound care not provided, refused care. 01/20/2025 PM - Wound care not performed, not ordered this visit. 01/21/2025 AM - Wound care not provided, refused care. 01/21/2025 PM - Wound care not performed, not ordered this visit. 01/25/2025 AM - Wound care not provided, refused care. 01/25/2025 PM - Wound care not performed, not ordered this visit. 01/27/2025 AM - Wound care not provided, refused care. 01/27/2025 PM - Wound care not provided, not ordered this visit. 01/28/2025 AM - Wound care not provided, not ordered this visit.01/28/2025 PM - Wound care not provided, not ordered this visit. Review of Patient #2s SOAP Notes, Visit Notes and Coordination Notes, dated 01/17/2025 through 01/28/2025, revealed wound care for Patient #2s Stage II Pressure Ulcer to the Right Hip was not performed during any shift on the following dates: 01/19/2025;01/20/2025; 01/21/2025; 01/25/2025; 01/27/2025; and01/28/2025. An interview was conducted on 01/30/2025 at 9:45 a.m. with S4RN. S4RN confirmed she worked as the RN for the agencys IPU. S4RN confirmed Patient #2 was admitted to the IPU on 01/17/2025 with a DTI wound to his right hip that presented as a Stage II Pressure Ulcer a few days later. S4RN confirmed Patient #2 refused to allow his wound care to be performed at times. S4RN confirmed if a patient refused wound care, the nurse should attempt again after medications had been administered and other times throughout their shift. S4RN confirmed if they were not able to get the patient to allow wound care, this information should be passed along to the oncoming shift so they could continue making attempts to perform the wound care. S4RN confirmed it was not acceptable for a patient to go multiple days without receiving wound care as ordered and Patient #2 had. An interview was conducted on 01/30/2025 at 10:30 a.m. with S3DCS. S3DCS confirmed he oversaw the clinical operations of the agencys IPU. S3DCS confirmed Patient #2 was admitted to the IPU with a wound to his right hip. S3DCS confirmed he would expect Patient #2 to receive wound care per his POC and he did not. S3DCS confirmed if an IPU nurse was unable to perform wound care for any reason, including refusal, he would expect them to continue making attempts throughout their shift. He stated the nurse should pass the outstanding care needs to the oncoming shift so they could continue making attempts to perform the care and this did not happen for Patient #2. S3DCS confirmed a patients refusal of wound care did not mean nurses should stop making attempts to perform the care as ordered. An interview was conducted on 01/28/2025 at 2:40 p.m. with S2ADON. S2ADON confirmed all patients should receive wound care per their POC. An interview was conducted on 01/30/2025 at 11:00 a.m. with S1ED. S1ED confirmed he would expect his staff to follow all regulations and protocols for wounds at all times, including the performance of wound care while in the IPU.”

“Based on interviews and record reviews, the hospice agency failed to ensure nursing services met the needs of the patients for 1 (#2) of 3 (#1, #2 and 3) patients reviewed in the sample. The agency failed to follow acceptable standards of practice for wound care specifically for complete wound assessments and weekly wound measurements, including the size of the wounds for Patient #2. Review of the Louisiana State Board of Nursing Declaratory Statement Scope of Practice for Registered Nurses - Wound Care Management adapted 02/1999 revealed the following in part: Registered nurses render care that is directed towards the prevention and treatment of wounds. Wounds are a common health care challenge that often occur with or result from chronic disorders such as impaired circulation and malnutrition. Nursing care of skin/wound conditionsinvolves the identification, assessment, management, and ongoing evaluation of patients with alterations in skin/tissue integrity that includes but is not limited to draining wounds, pressure ulcers, and vascular ulcers, and conditions resulting from incontinence, surgical procedures, and/or trauma. Scope of Practice - The Louisiana State Board of Nursing recognizes that assessment, planning,intervention, teaching, evaluation, and supervision are the major responsibilities of the registered nurse in the practice setting. The registered nurse is responsible for performing a nursing assessment and physical examination for preventative and restorative nursing and for providing patient/family teaching. Recognizing that the physician must always prescribe wound care, the following roles are defined to delineate the scope of practice for each member of the nursing team members. The registered nurse initiates appropriate wound preventative measures, stages wounds and collaborates with the wound care team in the implementation and evaluation of nursing interventions as prescribed by an authorized prescriber. Review of the National Pressure Ulcer Advisory Panel Prevention and Treatment of Pressure Ulcers: Quick Reference Guide revealed, in part, the following:Pressure Ulcer Assessment 1. Assess the pressure ulcer initially and re-assess it at least weekly.1.1. Document the results of all wound assessments. Assess and document physical characteristics including: location, Category/Stage, size, tissue type(s), color, peri-wound condition, wound edges, sinus tracts, undermining, tunneling, exudate, and odor. Review of the agencys policy, “;Wound Care Protocol”, created 10/19/2020, revealed, in part, the following: Purpose: To provide clinical guidance on wound care with the goal to prevent further wound deterioration while maintaining the patients dignity and respect. Process: The Registered Nurse (RN) will assess the wound bed of the patient and collaborate with the Hospice Medical Director to establish the most appropriate plan of care (POC) to meet the palliative goals in coordination with the patient/family and all contracted care providers. Wound care treatment and interventions will be individualize and may include, but not be limited to the following: 3. Weekly wound measurements by the RN in coordination with the facility staff. The wound care assessment will contain the documentation below, but is not limited to: Measurement – measure in centimeters, length times width time depth. Review of Patient #2s Clinical Record revealed a Start of Care Date of 01/17/2025 with a current Certification Period of 01/17/2025 through 04/16/2025. Further review revealed admitting diagnoses, which included, in part, Hairy Cell Leukemia, Dementia, and the presence of a Deep Tissue Injury (DTI) to the Right Hip. Review of the facilitys current Inpatient Unit (IPU) Roster, as of 01/27/2025, revealed Patient #2 was currently in the agencys IPU and had been since his admission on 01/17/2025. Review of the facilitys current Wound List for IPU Residents, as of 01/27/2025, revealed Patient #2 was listed as receiving treatment for a Stage II Pressure Ulcer to the Right Hip. Review of Patient #2s Plan of Care and Physician Orders, dated 01/17/2025 through 01/29/2025, revealed, in part, the following: 01/17/2025 – Hospice nurse to perform wound care to Stage II on Right Hip daily. Utilizing clean technique, cleanse with wound cleanser, apply barrier cream, and cover with bordered foam.01/23/2025 – Right Hip wound. Cleanse with wound cleanser daily. Pat dry. Apply foam dressing. Review of Patient #2s Wound Record Report for his Stage II Pressure Ulcer to the Right Hip, dated 01/17/2025 through 01/28/2025, revealed, in part, the following: 01/17/2025 Admit - No measurements documented.01/18/2025 a.m. - No measurements documented. 01/18/2025 p.m. – No measurements documented. 01/19/2025 a.m. - No measurements documented. 01/19/2025 p.m. - No measurements documented. 01/20/2025 a.m. - No measurements documented. 01/20/2025 p.m. - No measurements documented. 01/21/2025 a.m. - No measurements documented. 01/21/2025 p.m. - No measurements documented. 01/22/2025 a.m. - No measurements documented. 01/22/2025 p.m. - No measurements documented. 01/23/2025 a.m. - No measurements documented. 01/23/2025 p.m. - No measurements documented. 01/24/2025 a.m. - No measurements documented. 01/24/2025 p.m. - No measurements documented. 01/25/2025 a.m. - No measurements documented. 01/25/2025 p.m. - No measurements documented. 01/26/2025 a.m. - No measurements documented. 01/26/2025 p.m. - No measurements documented. 01/27/2025 a.m. - No measurements documented. 01/27/2025 p.m. - No measurements documented. 01/28/2025 a.m. - No measurements documented. 01/28/2025 p.m. - No measurements documented. Review of Patient #2s SOAP Notes, Visit Notes and Coordination Notes, dated 01/17/2025 through 01/28/2025, revealed no documented wound measurements for the Stage II Pressure Ulcer to the Right Hip. An interview was conducted on 01/30/2025 at 9:45 a.m. with S4RN. S4RN confirmed she worked as the RN for the agencys IPU. S4RN confirmed she was not aware wounds should be measured every 7 days. S4RN confirmed she admitted Patient #2 to the IPU on 01/17/2025. S4RN stated when Patient #2 was admitted to the IPU on 01/17/2025, he had a DTI wound to his right hip that presented as a Stage II Pressure Ulcer a few days later. S4RN confirmed she did not perform wound measurements for Patient #2s wound from his time of admission on 01/17/2025 through 01/28/2025. An interview was conducted on 01/30/2025 at 10:30 a.m. with S3DCS. S2DCS confirmed he oversaw the clinical operations of the agencys IPU and was familiar with Patient #2. S2DCS confirmed he would expect an RN to perform and document wound measurements immediately upon admission and every 7 days thereafter while a patient was admitted to the IPU, and Patient #2s were not. He confirmed wound measurements for IPU patients would be documented in one of two places, Visit Notes or Coordination Notes. An interview was conducted on 01/28/2025 at 2:40 p.m. with S2ADON. She confirmed wounds should be measured and documented by an RN every 7 days. She confirmed she would expect the policy for wound measurements to be followed for pressure ulcers and DTIs, whether they were stageable or not. An interview was conducted on 01/30/2025 at 11:00 a.m. with S1ED. S1ED confirmed he would expect his staff to follow all regulations and protocol for wounds at all times, including wound measurements while IPU.”

“Observed in Record Review. In 14 of 14 patient records reviewed, for active home hospice patients the nurse surveyor noted that the goals were not consistently measurable. For example, “Patient’s constipation is controlled,” and “Pain will be controlled at a level acceptable to patient”. Additionally, goals were mostly the same from patient to patient with minimal individualization. There were no short-term goals at start of care to address issues of immediate needs such as understanding medication management, symptom management, pain management, or safety and there were no time frames for completion of goals. Findings were discussed by the Executive Director, Director of Compliance, Assistant Director of Nursing, and Social Work/Clinical Supervisor.
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“Observed in Patient Home. In 2 of 4 home visits conducted, it was observed by the Nurse Surveyor that the organization did not implement the infection prevention and control activities it had planned per “Hand Hygiene Policy No. 9-009.1”. For example, during RRHV#1 the hospice nurse went in and out of her nursing bag several times without performing hand hygiene. She documented on her tablet, talked on her phone, then touched the patient all without performing hand hygiene. During RRHV#3 with a social worker, she was not observed performing hand hygiene at any time during the visit. During the visit she went into the facility’s nursing station, documented in the patient’s folder, went itnot the dining room, visited with the patient, documented on her device, called that patients daughter all without performing hand hygiene. Findings were discussed with the Executive Director, Director of Compliance, and Assistant Director of Nursing. Observed in Patient Home. In 1 of 4 home visits conducted, it was observed by the nurse surveyor that the nurse did not clean her equipment per agency policy, “Bag Technique Policy No. 9-014.1”. For RRHV#1 the nurse cleaned her equipment (BP cuff, stethoscope, thermometer, pulse oximeter) with alcohol wipes and immediately dropped the items into her bag without allowing them to dry per the recommended product dry time of one minute and per policy. Finding was discussed with the Executive Director, Director of Compliance, and Assistant Director of Nursing.”

“Observed in Record Review. In 2 of 14 patient records reviewed, for home patients, it was noted by the nurse surveyor that the hospice aide care plan did not contain all the necessary information. For RRHV#2, the patient was on continuous oxygen, yet the care plan did not address what the aide should do regarding the oxygen while performing the bed bath. Additionally, there were no instructions regarding when the aide should notify the nurse. For RRNHV#1, the patient had wounds that were being dressed by the nurse but there were no instructions to the aide regarding what to do if she found the dressings to be soiled or dislodged. Additionally, there were no instructions regarding when the aide should notify the nurse. Findings were verified by the Executive Director, Director of Compliance, and Assistant Director of Nursing.”

“Observed in Patient Home. In 1 of 4 home visits conducted, it was noted by the nurse surveyor that for RRHV#2 the hospice aide did not provide care according to the hospice aide plan of care. The hospice aide care plan instructed the hospice aide to shampoo the patient’s hair once a week on Monday. During the home visit which was on a Tuesday, the hospice aide washed the patient’s hair and when asked she said she washed his hair two to three times a week, the patient affirmed that statement. Findings were discussed with the Executive Director, Director of Compliance, and Assistant Director of Nursing upon return to the office.”

“Observed in Tracer Visit. After review of the Admission Packet the nurse surveyor noted that included in the packet was an “At Risk Registry Evaluation Form”. The form is filled out on all patients and if they meet the criteria set by the State of Louisiana for either needing help to evacuate in an emergency or refusing to evacuate, the information is entered into the Louisiana Registry. An interview with the Executive Director, Director of Compliance, and Assistant Director of Nursing revealed that the agency did not have a process in place to provide information, education, or documentation regarding the development of an individualized emergency plan for patients not meeting the criteria.”

“Observed in Building Tour. It was noted by the nurse surveyor during a tour of the “Carpenter House” inpatient unit that there were expired fruit juice cans in the patient nourishment refrigerator at nursing station #1. In the meal prep kitchen freezer, there was a bag of unsealed, open sausage patties, and a package of opened unsealed pancakes. There were several cans of expired vegetables on the pantry shelf and two packages of expired Ramen noodles. The Executive Director and the Social Work/Clinical Supervisor was present during the tour and all expired items were disposed of on-site.”