Audubon Hospice Care

“Based on record review and interview, the Hospice Agency failed to ensure the chaplain completed their portion of the comprehensive assessment within 5 days of the election of hospice care for 1 (#11) of 19 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18 and #19) patients reviewed in the sample. Review of the agencys policy titled, “;Comprehensive Assessment”, revised October 2019, revealed, in part, the following: Purpose: To provide guidelines for the comprehensive assessment. Policy: A comprehensive patient assessment will be performed by the interdisciplinary group no later than 5 calendar days after the election of hospice care. Procedure: 1. During the comprehensive patient assessment, all baseline data and other relevant information will be documented in the patients clinical record, including at least the following information: T. An assessment of the patients and family/caregivers spiritual orientation, including, as appropriate, any involvement in religious group such as a church or synagogue ... and spiritual concerns or needs such as despair, suffering, guilt etc. AA. Specific, individualized patient needs/problems pertinent to the hospice care being provided. Patient #11Review of Patient #11s Medical Record revealed an admission date of 06/30/2024 for the certification period of 06/30/2024 through 09/27/2024. Further review revealed Patient #11s election of hospice care was completed on 06/30/2024. Review of Patient #11s Visit Calendar, dated 06/30/2024 through 07/04/2024, revealed no visits were conducted by an agency chaplain during the 5 day time period. An interview was conducted on 07/23/2024 at 12:20 p.m. with S2DON. He confirmed each patient admitted to the agency should receive a visit from each member of the agencys IDG team, including the chaplain, in order to perform their portion of the initial comprehensive assessment. He confirmed IDG initial visits should take place within 5 days from the patients election of hospice care. He confirmed the agency employed two chaplains; S4CH and S5CH. He confirmed Patient #11 was admitted to the agency on 06/30/2024. He confirmed neither S4CH or S5CH assessed Patient #11 within the required 5 day window and one of them should have.”

“Based on record review and interviews, the Hospice Agencys Governing Body failed to ensure an ongoing program for quality improvement and patient safety (QAPI) was defined, implemented, maintained, and evaluated annually. This deficient practice had the potential to affect a census of 115 patients. Review of the agencys Key Personnel and Staff List revealed S1ADM was the designated person in charge of managing the agencys Governing Body. Review of the agencys on-going QAPI program, dated 06/01/2023 through 06/01/2024, was attempted on 07/18/2024, 07/22/2024 and 07/23/2024 with no documented evidence produced for review. Review of the agencys Governing Body Annual QAPI Review for fiscal year 2023 was attempted on 07/23/2024 with no documented evidence produced for review. An interview was conducted on 07/23/2024 at 1:00 p.m. with S2DON. S2DON confirmed he, as the Director of Nursing, was responsible for ensuring the agencys QAPI Program was carried out. S2DON confirmed he could not provide documented evidence the agency had defined, implemented, maintained and evaluated an annual QAPI program for the previous 12 month period, 06/01/2023-06/01/2024 and should be able to. An interview was conducted on 07/23/2024 at 3:10 p.m. with S1ADM. He confirmed he was a member of and in charge of the agencys Governing Body. He confirmed the Governing Body met in 2023 and did not conduct an annual review of the agencys QAPI program and should have.”

“Based on interviews and record reviews, the hospice agency failed to ensure nursing services met the needs of the patients for 2 of 2 (#11 and #18) patients reviewed for pressure wounds. The agency failed to follow acceptable standards of practice for wound care specifically for complete wound assessments and weekly wound measurements, including the size and stage of the wounds for Patient #11 and #18. 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. Patient #11Review of Patient #11s Medical Record revealed an admission date of 06/30/2024 with a current certification period of 06/30/2024 through 09/27/2024. Review of Patient #11s Plan of Care revealed a Frequency of three times a week Skilled Nurse Visits. Review of Patient #11s Physicians Orders revealed, in part, the following: An order written on 07/03/2024 for “;Pt to receive wound care 3 times per week by skilled nurse and granddaughter to perform wound care other days staff not present”. Review of Patient #11s IDG Meeting Notes, dated 07/05/2024, revealed, in part, the following: Problem: Wounds/Skin; Identified: 06/30/2024; andProgress: 0%.Summary/Comments: IDG meeting date: 7/5/24 68 year old female admitted to hospice with sarcopenia and history of c-spine compression as a complication of surgery and resultant neurological injury. She has multiple decubitus wounds (almost 13), neurogenic bladder and bowels. She has large sacral decubitus, foley catheter and ostomy. She has had 2 hospitalization in the past several weeks with wound infections requiring IV antibiotics. She has non-healing wounds, frequent infections, and has been referred to hospice care. Review of Patient #11s Skilled Nursing Visit Notes-Wound Care Worksheet revealed, in part, wound measurements were documented during Patient #11s initial nursing assessment on 06/30/2024. Further review revealed, in part, the followingWound #1 – Sacrum Stage 4 Pressure Ulcer07/03/2024 – No wound measurements; 07/04/2024 – No wound measurements; 07/08/2024 – No wound measurements; 07/09/2024 – No wound Measurements; and 07/10/2024 – No wound Measurements. Wound #2 – Left Ischial Stage 4 Pressure Ulcer07/03/2024 – No wound measurements; 07/04/2024 – No wound measurements; 07/08/2024 – No wound measurements; 07/09/2024 – No wound Measurements; and 07/10/2024 – No wound Measurements. Wound #3 – Right Ischial Stage 4 Pressure Ulcer07/03/2024 – No wound measurements; 07/04/2024 – No wound measurements; 07/08/2024 – No wound measurements; 07/09/2024 – No wound Measurements; and 07/10/2024 – No wound Measurements. Wound #4 – Left Heel Unstageable Pressure Ulcer07/03/2024 – No wound measurements; 07/04/2024 – No wound measurements; 07/08/2024 – No wound measurements; 07/09/2024 – No wound Measurements; and 07/10/2024 – No wound Measurements. Wound #5 – Right Heel Unstageable Pressure Ulcer07/03/2024 – No wound measurements; 07/04/2024 – No wound measurements; 07/08/2024 – No wound measurements; 07/09/2024 – No wound Measurements; and 07/10/2024 – No wound Measurements. Wound #6 - Right Inferior Back Unstageable Pressure Ulcer07/03/2024 – No wound measurements; 07/04/2024 – No wound measurements; 07/08/2024 – No wound measurements; 07/09/2024 – No wound Measurements; and 07/10/2024 – No wound Measurements. Wound #7 - Left Posterior Knee Unstageable Pressure Ulcer07/03/2024 – No wound measurements; 07/04/2024 – No wound measurements; 07/08/2024 – No wound measurements; 07/09/2024 – No wound Measurements; and 07/10/2024 – No wound Measurements. Wound #8 - Posterior Right Shoulder Stage 3 Pressure Ulcer07/03/2024 – No wound measurements; 07/04/2024 – No wound measurements; 07/08/2024 – No wound measurements; 07/09/2024 – No wound Measurements; and 07/10/2024 – No wound Measurements. Wound #9 - Left Lateral Lower Leg Unstageable Pressure Ulcer07/03/2024 – No wound measurements; 07/04/2024 – No wound measurements; 07/08/2024 – No wound measurements; 07/09/2024 – No wound Measurements; and 07/10/2024 – No wound Measurements. Wound #10 - Right Lateral Lower Leg Stage 4 Pressure Ulcer07/03/2024 – No wound measurements; 07/04/2024 – No wound measurements; 07/08/2024 – No wound measurements; 07/09/2024 – No wound Measurements; and 07/10/2024 – No wound Measurements. Wound #11 - Medial Back Unstageable Pressure Ulcer07/03/2024 – No wound measurements; 07/04/2024 – No wound measurements; 07/08/2024 – No wound measurements; 07/09/2024 – No wound Measurements; and 07/10/2024 – No wound Measurements. Wound #12 - Left Superior Back Unstageable Pressure Ulcer07/03/2024 – No wound measurements; 07/04/2024 – No wound measurements; 07/08/2024 – No wound measurements; 07/09/2024 – No wound Measurements; and 07/10/2024 – No wound Measurements. Patient #18Review of Patient #18s Medical Record revealed an admission date of 01/22/2024 with a current certification period of 07/20/2024 through 09/17/2024. Review of Patient #18s Plan of Care revealed a Frequency of one time per week Skilled Nurse Visits. Review of Patient #18s IDG Meeting Notes, dated 01/25/2024, revealed, in part, the following: Summary/Comments: She has a Stage 2 Pressure Ulcer Sore to 2nd Right Toe that is healing well. Review of Patient #18s Skilled Nursing Visit Notes-Wound Care Worksheet revealed, in part, wound measurements were documented during Patient #18s initial nursing assessment on 01/22/2024. Further review revealed, in part, the following:Wound #1 – Right 2nd Toe Stage 2 Pressure Ulcer01/23/2024 – No wound measurements; 01/29/2024 – No wound measurements;02/05/2024 – No wound measurements;02/12/2024 – No wound measurements;02/19/2024 – No wound measurements;02/21/2024 – No wound measurements;02/26/2024 – No wound measurements;03/06/2024 – No wound measurements; and 03/11/2024 – No wound measurements. An interview was conducted on 07/23/2024 at 11:00 a.m. with S2DON. He confirmed wound assessments, including wound measurements, were documented in the agencys computer charting system within their skilled nurse visit section. He confirmed there was no other location wound assessments and measurements would be documented. He confirmed wounds should be assessed, measured and documented in the skilled nurse visit every 7 days. S2DON confirmed he was unable to locate documentation of wound measurements for Patient #11s 12 wounds at any time since they were initially measured on 06/30/2024. He confirmed all 12 of Patient #11s wounds should have been reassessed, re-measured and documented 7 days later, 07/07/2024, and they were not. He confirmed he was unable to locate and provide documentation of wound measurements for Patient #18s wound at any time since it was initially measured on 01/22/2024. He confirmed Patient #18s wound should have been reassessed, re-measured and documented every 7 days and it was not.”

“Based on interviews and record review, the hospice agency failed to immediately investigate all alleged abuse violations for 1 (#1) of 3 (#1, #2, and #3) patients reviewed for abuse. The agency failed to investigate an allegation of abuse when nursing home staff witnessed S3CNA speaking loud and aggressive to Patient #1. Review of the agencys policy titled, “;Assessment of Possible Abuse/Neglect” revealed the following, in part:Purpose: To provide guidelines for identification of suspected abuse victims. Procedure:2. The clinician will submit a verbal report of the suspected abuse/neglect to the proper authorities in accordance with state law and complete a suspected abuse and or neglect investigation report within 24 hours of the incident, with the addition of the following information: Name of alleged perpetrator, Relationship to patient and Information regarding suspected abuse/neglect. 4. The suspected abuse/neglect investigation report with specific information relating to the occurrence is forwarded to the Clinical Supervisor, who will notify the physician, review the documentation for completeness and objectivity and forward the information to the Executive Director/Administrator. 5. The Executive Director/ Administrator will review all reports, conduct additional information and submit reports to the proper authorities. Review of the agencys policy titled, “;Incident Reporting” revealed the following, in part:Purpose: To define the reporting follow-up and feedback process for incidents involving patients and organization personnel. Policy: The Organization will maintain a process for generating incident reports and follow-up corrective action, if applicable.5. Investigate and respond to serious adverse events in accordance with accrediting bodies standardsExamples of Specific Events or Occurrences that must be reported 4. Patient Endangerment- Suspected abuse by caregiver Review of the agencys policy titled, “;Complaint Management/Resolution” revealed the following, in part:Policy: The hospice agency complaint management and resolution process will be implemented whenever a complaint is received.Procedures: 5. All alleged violations involving mistreatment, neglect or verbal, mental, sexual and physical abuse are reported immediately by hospice employees to the Hospice Administrator. 8. A documented investigation is conducted by appropriate personnel of all written or verbal complaints received. This investigation is to be completed as soon as possible but no later than 5 days. If greater than 5 days are required to gather appropriate information, a written update of progress will be included in the complaint binder. Review of Patient #1s Clinical Record revealed she was admitted on 11/17/2023 with diagnoses which included Encephalopathy, Cognitive Decline, Major Depressive Disorder, Dementia and Chronic Kidney Disease. Review of Patient #1s Plan of Care revealed she received Hospice Aide services three times a week. Review of the Hospice Aide visit notes for Patient #1 dated 11/17/2023 revealed S3CNA provided care to Patient #1 at a local nursing home where she resided. Review of the local nursing home investigation report dated 11/17/2023 revealed the following, in part:Incident occurred: 11/17/2023Accused: S3CNASummary of incident: Patient #1 is a resident of a local nursing home. She allegedly experienced abuse during care this morning at the hands of S3CNA. A CNA employed with the nursing home overheard S3CNA speaking “;aggressively” to Patient #1. Patient #1 pointed in fear at S3CNA. The nursing home CNA went got another employee of the nursing home and they reportedly stood by the door and heard S3CNA speaking aggressively. Review of the Hospice Agencys Complaint and Grievance Report dated 11/17/2023 revealed the following, in part:Part 1. Arrived at 7:30 a.m. to the local nursing home. I went into the room to bath Patient #1 and did what we have to do. “;Told her that I come to take care of her, not hurt her.” Door is always open when I take care of Patient #1, closed curtain. I didnt holla at her this morning or raise my voice. I may talk loud but never mistreat a patient. Signed by S3CNA. Part 2. Investigation of Concern or Grievance- page left blank. Review of the Hospice Agencys Critical Incident log dated November- December 2023 revealed no Critical Incident Report involving Patient #1. An interview was conducted on 12/04/2023 at 11:25 a.m. with S1DON. She verified Patient #1 resided in a local nursing home and was provided Hospice Aide services. She said on 11/17/2023, she was notified by the nursing home administrator of an incident involving Patient #1 and S3CNA. She said the nursing home administrator reported two CNA staff members witnessed S3CNA speaking “;loudly and roughly” to Patient #1. She said she did not report the allegations of verbal abuse to the administrator until 10 days after receiving the verbal abuse allegation. She said she did not initiate an investigation regarding the alleged incident of verbal abuse because she was waiting for the nursing home to contact her to set up a meeting. She said she thought the nursing home was responsible for initiating an investigation. She said she thought S2HR would investigate the incident. She confirmed an investigation should have been initiated and had not been. An interview was conducted on 12/04/2023 at 11:30 a.m. with S2HR. She confirmed she was notified of an incident which occurred on 11/17/2023 between S3CNA and Patient #1. She said the administrator of the nursing home where Patient #1 resided reported S3CNA verbally abused Patient #1. She verified the agency had not investigated the incident as of this time because she was waiting for the nursing home to get back with her for a meeting. She confirmed she was responsible for initiating an investigation. She confirmed an investigation should have been initiated and had not been.”