Guardian Angel Hospice

“Based on interview and record reviews, the agency failed to revise the plan of care to reflect services provided for a patient’s wound for 1 (Patient #3) of 3 sampled patients reviewed for comprehensive plans of care requirements. Findings: Review of Patient #3’s Nurses Note dated 09/28/2025 revealed Patient #3 had a stage II pressure ulcer (wound caused by unrelieved pressure which causes a break in the skin) to the right buttock. Review of Patient #3’s record revealed Patient #3 continued to have the right buttock wound until 11/10/2025. Review of Patient #3’s Comprehensive Plan of Care for the certification period of 10/18/2025 through 12/16/2025 revealed, in part, no documented evidence the plan of care included wound care interventions for Patient #3’s stage II pressure ulcer to the right buttock. Review of Patient #3’s record revealed no documented evidence of any physician’s orders for Patient #3’s right buttock stage II pressure ulcer. On 11/13/2025 at 11:25AM, the surveyor requested S2DON present any documentation that Patient #3 had wound care orders and/or a revised plan of care for the treatment of Patient #3’s right buttock stage II pressure ulcer. In an interview on 11/13/2025 at 11:28AM, S2DON indicated Patient #3’s plan of care was not updated to include wound care orders and/or treatment of Patient #3’s right buttock stage II pressure ulcer as required.”

“Based on interviews and record reviews, the agency failed to have a coordinated agency-wide program for the surveillance of infections for 4 (Patient #1, Patient #5, Patient #9, Patient #12) of 14 sampled patients records reviewed for infection surveillance requirements. Findings: Patient #1Review of Patient #1’s Patient Order Report dated 08/01/2025 revealed an order for Bactrim (antibiotic used to treat infections) DS one tablet crushed via percutaneous gastrostomy tube twice a day for seven days for a urinary tract infection (bladder infection) Patient #5Review of Patient #5’s Medication Profile Detail dated 09/06/2025 revealed an order for Azithromycin (antibiotic used to treat infections) 500mg one tablet by mouth once a day for 5 days. Patient #9Review of Patient #9’s Patient Order Report dated 08/03/2025 revealed an order for Macrobid (antibiotic used to treat infections) 100mg one tablet by mouth twice a day for seven days for urinary tract infection symptoms. Review of Patient #9’s Patient Order Report dated 08/07/2025 revealed an order for Cipro (antibiotic used to treat infections) 500mg one tablet by mouth twice a day for 7 days. Patient #12Review of Patient #12’s Medication Profile Detail dated 04/25/2025 revealed an order for Dapsone (antibiotic used to treat infections) 100mg one tablet by mouth daily. Review of the agency’s Infection Control Logs for 01/01/2025 through 09/30/2025 revealed no evidence the above mentioned patients and their medications/infections were captured on the agency’s infection control logs. In an interview on 11/12/2025 at 2:58PM, S1Administrator indicated once an infection was identified and the patient was placed on antibiotics, infection surveillance included that the nurse was to discuss the medication and infection in the interdisciplinary team meetings held every 2 weeks. S1Administrator further indicated she would use this information to develop monthly infection control logs which are used to identify trends which require intervention. S1Administrator indicated the agency had not captured Patient #1, Patient #5, and Patient #12’s infections on the infection control logs as required.In an interview on 11/13/2025 at 12:51PM, S1Administrator indicated the agency had not captured Patient #9’s infections as required; therefore, the agency was not effectively tracking and trending infections for the above mentioned patients as required.”

“Based on interview and record reviews, the agency failed to ensure the registered nurse assessed a wound weekly to assess for wound healing for 1 (Patient #3) of 3 sampled patients reviewed with wounds. Findings: Review of Patient #3’s Comprehensive Assessment Patient Assessment Report dated 10/22/2025 revealed, in part, Patient #3 was assessed as having a right buttock pressure ulcer measuring 1 cm by 2 cm. Further review revealed no documentation that the nurse assessed the stage of the wound, the type of tissue present, and/or if there was wound drainage present. Review of Patient #3’s Comprehensive Assessment Patient Assessment Report dated 10/23/2025 revealed, in part, no documentation that the nurse assessed the stage of the wound, the type of tissue present, and/or if there was wound drainage present. On 11/13/2025 at 11:28AM, the surveyor requested S2DON present any documentation that the nurse had assessed Patient #3’s right buttock pressure ulcer’s stage of the wound, the type of tissue present, and/or if there was wound drainage present to Patient #3’s wound for the week of 10/20/2025 through 10/26/2025. In an interview on 11/13/2025 at 11:28AM, S2DON indicated the agency did not have the above mentioned documentation for Patient #3’s right buttock pressure ulcer for the week of 10/20/2025 through 10/26/2025 and did not have anything to present to dispute the above mentioned deficient practice. 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.”

“Based on interview and record reviews, the agency failed to provide volunteer services at a minimum of five percent or greater of the total paid hospice care hours. Findings: On 11/10/2025 at 9:00AM, the agency was presented with a document request form which included, in part, volunteer services and level of activity reports. On 11/12/2025 at 9:30AM, S1Administrator was provided with a request for any/all documentation related to volunteer documentation for level of services. Review of the agency’s Volunteer Services policy, revised on 05/09/2011, revealed, in part, volunteer services were provided as needed and as ordered by the patient’s plan of care. Review of the agency’s Monthly Volunteer Cost Savings for April 2022 through 10/31/2025 revealed the last documented volunteer services were provided in July 2023. In an interview on 11/12/2025 at 3:45PM, S1Administrator indicated the agency had not provided any volunteer hours since July 2023. S1Administrator further indicated the agency had not provided volunteer services in the amount of five percent or greater since July 2023, as required.”

“Based on interview and record review, the agency failed to ensure documentation corrections were completed in accordance with accepted standards of practice for 1 (Patient #12) of 14 sampled patients records reviewed for documentation requirements. Findings: Review of Nursing 2025 Journal October 2023 article for Handling Documentation Errors revealed, in part, when paper documenting, charting errors should be corrected using the following, in part, draw a single line through the erroneous entry and write either “mistaken entry”, “delete”, or “void”, then draw a single line through the error and write the time date and your name. Review of Patient #12’s Medication Disposal Form dated 06/26/2025 revealed, in part, Morphine (a narcotic, medication used to treat severe pain) 20mg/ml was destroyed with the quantity present and the amount of medication destroyed documented with a number written then another number written on top of the first number. In an interview on 11/13/2025 at 1:20PM, S2DON indicated the documentation correction for the above mentioned morphine destruction was not completed correctly and staff did not follow accepted standards of practice by drawing a single line through the error, write void, initial the entry, and then record the correct amount next to the error.”

“Based on interview and record review, the agency failed to ensure the agency completed and/or forwarded a discharge summary to the receiving provider who assumed care for 1 (Patient #12) of 2 sampled patients reviewed for discharge summaries upon discharge. Findings: Review of Patient #12’s Hospice Revocation Statement Form dated 05/18/2025 revealed Patient #12 revoked hospice services on 05/18/2025 to pursue curative treatment. On 11/13/2025 at 9:00AM, the surveyor requested from S1Administrator and S2DON, Patient #12’s discharge summary. On 11/13/2025 at 10:30AM, the surveyor requested from S1Administrator and S2DON, Patient #12’s discharge summary. On 11/13/2025 at 1:15PM, the surveyor requested from S2DON, Patient #12’s discharge summary. In an interview on 11/13/2025 at 1:20PM, S2DON indicated she did not have any information to present which showed that Patient #12’s discharge summary was completed and/or forwarded the discharge summary to the receiving facility as required.”

“Based on interviews and record review, the hospice agency failed to obtain a criminal background check on an unlicensed employee who had direct patient contact for 1 (S7Chaplain) of 8 sampled personnel records reviewed for criminal background check requirements. Findings: Review of Louisiana’s R.S. 40:1203.2’s law revealed, in part, the employer shall request in writing that the office or authorized agency conduct a criminal history and security check on non-licensed persons prior to an offer of employment. Review of S7Chaplain’s personnel record revealed, in part, a hire date of 07/15/2025. Review of S7Chaplain’s criminal background check revealed S7Chaplain’s criminal background check was completed on 07/17/2025. In an interview on 11/13/2025 at 12:44PM, S8Office Manager indicated S7Chaplain was hired prior to the criminal background check being completed. In an interview on 11/13/2025 at 12:52PM, S1Administrator indicated the agency should have completed the criminal background check prior to the offer of employment.”