The Medical Team

“Based on record review and interview, the agency failed to ensure the interdisciplinary group (IDG) worked together to meet the needs of the patient in 1 (P-1) of 3 records reviewed, resulting in the potential for unmet care needs. Findings include: Patient #1 (P-1) was admitted to this hospice agency on 7/30/25 with terminal diagnoses of Crohn’s disease and ulcerative colitis. During record review on 2/4/26, it was noted an on-call note dated 10/11/25 indicated P-1 had been found at a store confused. A follow-up visit note on 10/13/25 by the social worker indicated P-1 drove herself to the store and did not remember how she got there. The police called P-1’s fiancé to pick her up. Education was provided regarding safety and the possibility of placement for increased care, however, the patient declined. Additionally, the note indicated P-1’s daughter, who had been providing paid help, would no longer be able to assist P-1 due to her schedule.Upon review of the interdisciplinary group (IDG) note following this event (dated 10/24/25), it was determined there was no documentation that the event above was discussed. There was also no documentation regarding the need for more assistance at home. The only issues mentioned during the meeting were increased edema and spine/abdominal pain. Additionally, review of the sign-in sheet for the IDG meeting on 10/24/25 revealed that the skilled nurse (Staff F), who had been caring for P-1, was not present during the meeting. There was no documentation of her contribution to that meeting.A review of agency policy titled “IDG CARE PLANNING PROCESS” (revised 4/3/18) revealed, “The IDG (in collaboration with the patient’s attending physician, if any) reviews, revises and documents the individualized plan as frequently as the patient’s condition requires, but no less frequently than every 15 days.” The policy also indicated that, “A. The revised care plan includes information from the patient’s updated comprehensive assessment and notes the patient’s progress toward outcomes and goals specified in the plan of care, advanced directives, effectiveness of pain and symptom management, and spiritual and psychosocial needs.”The administrator (Staff A) reviewed and acknowledged the findings above during an interview on 2/5/26 at 10:00 AM. Staff A was unsure why this event was not discussed at IDG and was not sure why the nurse was not present to contribute to this meeting.”

“Based on record review and interview, the agency failed to ensure the clinical record was complete and thorough in the documentation of patient responses to medication and symptom management in 1 (P-1) of 3 records reviewed, resulting in the potential to negatively affect the health and well-being of all patients. Findings included: Patient #1’s (P-1) Start of Care (SOC) was dated 7/30/25. The Plan of Care (POC) identified a terminal diagnosis of Crohn’s Disease and the additional diagnoses of Ulcerative Colitis with abscess, fistula of intestine, chronic abscess and bladder paralysis. During record review on 2/4/26, it was noted that Staff-E (Registered Nurse) completed a visit on 1/13/26 and stated, “Call to Staff D (Medical Director) to discuss pain management and Staff D would like the patient to start fentanyl 25mcg patch to have more consistent pain management. Discussed with RNCM (Registered Nurse Case Manager) Staff B and call into pharmacy to be delivered tonight. Hospice nurse was unable to find grandson or any other family member to notify of medication change. P-1 is agreeable and willing to try. She is encouraged to call hospice with any concerns.” There was no documented evidence of the new medication education. On 1/15/26, Staff B stated, “P-1 reports moderate pain all over and said that she does not feel like the fentanyl patch is working. PRN (as needed) morphine given. Staff D notified and received order to increase fentanyl patch from 25mcg to 50mcg patch every 72 hours. This RN ordered through pharmacy for delivery. Vitals and assessment as documented. Refills sent to pharmacy for delivery for tonight.” On 1/16/26, Staff B stated, “This RN picked up P-1 meds from pharmacy and delivered to P-1. P-1 was not awake when the delivery driver came last night. RN Delivered morphine, ativan, valium, oxycodone, fentanyl patches and baclofen. Handed meds to P-1 and reviewed meds with her.” Staff B was interviewed on 2/5/26 at 9:30am and questioned on the education provided regarding the new medication fentanyl. Staff B stated, “On the 15th (1/15/26), P-1 was still in pain and had a 25mcg patch on. Received an order to increase to 50mcg. I added another 25mcg to equal the 50mcg ordered. I called P-1’s daughter and told her that she will have to remove both patches after 72hrs and apply the new dose. On the 16th (1/16/26) visit, that was the best that she looked physically, she walked to the door. I called P-1’s daughter to educate on the new dose and educated the patient, and she repeated the education back to me. No, the education to the daughter and patient is not documented other than the 1/16/25 note.” As stated above, the 1/16/25 note by Staff B stated, “...Handed meds to patient and reviewed meds with her.” Furthermore, Staff A (Administrator) on 2/5/26 at 9:50am stated, “We should have called on the weekend to follow-up on new med.” The agency failed to document education and follow-up on the new pain medication. A review of the agency policy occurred on 2/5/26 titled “Plan for Patient/Family Education” (Reviewed 03/14/2018). The policy states, “Procedure: III. All patient/family education, the perceived comprehension, ability to demonstrate a taught skill and verbal recall will be documented in the patient’s record.”The Administrator (Staff A) reviewed and acknowledged the findings listed above in an interview on 2/5/26 at 9:50 am.”

“It is required that each patient’s individualized written plan of care identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 15 of 19 (79%) clinical records reviewed, it was revealed that the agency did not ensure that the individualized written plans of care included interventions based on problems identified in the initial and updated comprehensive assessments. CLINICAL RECORD 1: The Plan of Care (POC) dated 07/15/2025 included the following intervention: “SN may insert Foley catheter as needed for incontinence or retention and change as needed for leakage, occlusion, and dislodgement. SN may perform and instruct family/CG (caregiver) on Foley irrigation technique as ordered.” The POC did not include the size or type of catheter to be used, the volume for balloon inflation, or the type and volume of irrigation. There were no additional orders after 07/15/2025 in the record, indicating the size or type of catheter to be used or the volume for balloon inflation. The Administrator (Personnel Record 1) was interviewed on 08/21/2025 and verified that the order for the Foley catheter was incomplete. A Mini Nutritional Risk Assessment was documented by the Registered Nurse (RN) during the initial comprehensive assessment dated 04/16/2025 and recertification assessment dated 06/30/2025, which revealed the patient was at Risk of Malnutrition. There were no interventions or goals related to nutrition documented in the POC or in the physician’s orders. CLINICAL RECORD 2: A Mini Nutritional Risk Assessment was documented by the Registered Nurse (RN) during the documentation of the comprehensive assessments dated 01/07/2025, 03/04/2025, 05/21/2025, and 07/21/2025. Documentation in the assessments indicated that the patient was “At Risk of Malnutrition”. There were no interventions or goals related to nutrition documented in the POC or in the physician’s orders. CLINICAL RECORD 3: A Mini Nutritional Risk Assessment was documented by the Registered Nurse (RN) during the initial comprehensive assessment visit dated 01/21/2025. Documentation in the assessment indicated that the patient was “At Risk of Malnutrition”. There were no interventions or goals related to nutrition documented in the POC or in the physician’s orders. CLINICAL RECORD 4: The Plan of Care (POC) dated 07/05/2025 included the following interventions: “SN may insert Foley catheter as needed for incontinence or retention and change as needed for leakage, occlusion, and dislodgement. SN may perform and instruct family/CG on Foley irrigation technique as ordered.” The POC did not include the size or type of catheter to be used, the volume for balloon inflation, or the type and volume of irrigation. There were no additional orders in the record indicating the size or type of catheter to be used or the volume for balloon inflation, nor Foley irrigation orders. The Administrator (Personnel record 1) was interviewed on 08/21/2025 and stated, “The order for the catheter care was not complete”. CLINICAL RECORD 5: A Mini Nutritional Risk Assessment was documented by the Registered Nurse (RN) during the initial comprehensive assessment visit dated 06/27/2025. Documentation in the assessment indicated that the patient was “At Risk of Malnutrition”. There were no interventions or goals related to nutrition documented in the POC or in the physician’s orders. CLINICAL RECORD 8: A Mini Nutritional Risk Assessment was documented by the Registered Nurse (RN) during the initial comprehensive assessment dated 04/09/2025. Documentation in the assessment indicated that the patient was “At Risk of Malnutrition”. There were no interventions or goals related to nutrition documented in the POC or in the physician’s orders. CLINICAL RECORD 9: A Mini Nutritional Risk Assessment was documented by the Registered Nurse (RN) during the comprehensive assessment visits dated 03/12/2025, 05/30/2025, and 07/25/2025. Documentation in the assessments indicated that the patient was “At Risk of Malnutrition”. There were no interventions or goals related to nutrition documented in the POC or in the physician’s orders. CLINICAL RECORD 10: A Mini Nutritional Risk Assessment was documented by the Registered Nurse (RN) during the initial comprehensive assessment visit dated 06/19/2025. Documentation in the assessment indicated that the patient was “At Risk of Malnutrition”. There were no interventions or goals related to nutrition documented in the POC or in the physician’s orders. CLINICAL RECORD 11: A Mini Nutritional Risk Assessment was documented by the Registered Nurse (RN) during the initial comprehensive assessment visit dated 02/25/2025. Documentation in the assessment indicated that the patient was “At Risk of Malnutrition”. There were no interventions or goals related to nutrition documented in the POC or in the physician’s orders. CLINICAL RECORD 12: A Mini Nutritional Risk Assessment was documented by the Registered Nurse (RN) during the initial comprehensive assessment visit dated 07/17/2025. Documentation in the assessment indicated that the patient was “At Risk of Malnutrition”. There were no interventions or goals related to nutrition documented in the POC or in the physician’s orders. CLINICAL RECORD 13: A Mini Nutritional Risk Assessment was documented by the Registered Nurse (RN) during the initial comprehensive assessment visit dated 07/16/2025. Documentation in the assessment indicated that the patient was “At Risk of Malnutrition”. There were no interventions or goals related to nutrition documented in the POC or in the physician’s orders. CLINICAL RECORD 14: A Mini Nutritional Risk Assessment was documented by the Registered Nurse (RN) during the initial comprehensive assessment visit dated 08/05/2025. Documentation in the visit note indicated that the patient was “At Risk of Malnutrition”. There were no interventions or goals related to nutrition documented in the POC or in the physician’s orders. CLINICAL RECORD 16: A Mini Nutritional Risk Assessment was documented by the Registered Nurse (RN) during the initial comprehensive assessment visit dated 01/15/2025. Documentation in the assessment indicated that the patient was “At Risk of Malnutrition”. There were no interventions or goals related to nutrition documented in the POC or in the physician’s orders. CLINICAL RECORD 18: A Mini Nutritional Risk Assessment was documented by the Registered Nurse (RN) during the initial comprehensive assessment visit dated 07/10/2025. Documentation in the assessment indicated that the patient was “At Risk of Malnutrition”. There were no interventions or goals related to nutrition documented in the POC or in the physician’s orders. CLINICAL RECORD 19: A Mini Nutritional Risk Assessment was documented by the Registered Nurse (RN) during the initial comprehensive assessment visit dated 06/20/2025. Documentation in the assessment indicated that the patient was “At Risk of Malnutrition”. There were no interventions or goals related to nutrition documented in the POC or in the physician’s orders. The Administrator (Personnel Record 1) was interviewed on 08/21/2025 and stated that the medical record had an available Care Plan Problem called “Need for interventions related to nutrition/hydration” that addressed weight loss with the dying process and nutritional needs. However, this pathway is not consistently pulled into the plan of care.”

“It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene, use of gloves, mask, eye protection, or face shield depending on anticipated exposure. This standard was not met as evidenced by document review, interview and observation. In 2 of 4 (50%) home visit observations it was revealed that the agency did not ensure that clinical staff performed hand hygiene per the agency’s policy. POLICY: The agency’s “Hand Hygiene and Compliance Program” policy (Policy IC.07, Undated) stated in part, “Indications for hand hygiene are: I. Before re-entering the nursing bag or patient’s clean supplies” and “Bacteriostatic foam/gel/liquid is the preferable hand hygiene method. When using bacteriostatic foam/gel/liquid, the procedure is as follows: A. Place adequate amount of foam/gel/liquid on hands. Follow manufacturer’s recommendations regarding the volume of the product to use. B. Using friction, clean between fingers, around and under nails, palms and backs of hands until hands are completely dry.” HOME VISIT 1: A home visit observation was conducted with the Registered Nurse (RN) (Personnel Record 4) on 08/18/2025. During the visit, the RN disinfected her hands and removed the equipment required for the visit (blood pressure cuff, pulse oximeter, stethoscope, and thermometer) from the clinical bag. The RN put on gloves and performed an assessment using the items from the clinical bag. After the assessment was complete, the RN disinfected the items while still wearing the gloves used to assess the patient. She returned the disinfected items to the clinical bag, still wearing the dirty gloves. The RN did not disinfect her hands before returning the items to the clinical bag per the agency’s policy. HOME VISIT 2: A home visit observation was conducted with the Registered Nurse (RN) (Personnel Record 3) on 08/18/2025. During the visit, the RN disinfected her hands and removed the equipment required for the visit (blood pressure cuff, pulse oximeter, stethoscope, and thermometer) from the clinical bag. After the assessment was complete, the RN disinfected the items and returned them to the clinical bag. However, the RN did not disinfect her hands before returning the items per the agency’s policy. The Administrator (Personnel Record 1) was interviewed on 08/18/2025 and stated, “The nurses should have disinfected their hands before going into the bag.””