Mayo Clinic Hospice

“Based on the number of deficiencies cited and the severity, the hospice agency failed to meet the Condition of Participation: L500 at 42 CFR 418.52. The agency failed to immediately investigate alleged abuse and take action to prevent further potential violations during the investigation. They also failed to report allegations of abuse to the State Agency (SA) within 5 working days. Refer to L509: Based on interview and document review the hospice agency failed to immediately investigate allegations of abuse and failed to take action to prevent further violations when an allegation was made for 1 of 4 patients (P1) reviewed for abuse. Refer to L511: Based on interview and document review the hospice agency failed to report an allegation of abuse to the State Agency (SA) within 5 working days of becoming aware of the allegation for 1 of 4 patients (P1) reviewed for abuse.”

“Based on interview and document review the hospice agency failed to immediately investigate allegations of abuse and failed to take action to prevent further violations when an allegation was made for 1 of 4 patients (P1) reviewed for abuse. Findings include:P1’s hospice plan of care (POC) for benefit period 4/9/26 through 7/7/26 identified P1 was on hospice with diagnoses of Alzheimer’s Disease, and dementia with moderate agitation. P1 required assistance of one person with all activities of daily living and transfers.P1’s aide visit note on 5/11/26, from 12:56 p.m. – 1:23 p.m., indicated P1 refused all cares and became physically aggressive with cares.During an interview on 5/21/26, at 11:11 a.m., the assisted living manager stated P1 resided in their memory care unit and on 5/11/26, and between 1:00 p.m. and 1:30 p.m., a staff member reported witnessing the hospice aide (HA)-A transfer P1 by herself and throw P1 into the bed “like a ragdoll”. The incident was reported to the hospice agency and to P1’s family member (FM) on 5/11/26.During an interview on 5/21/26, at 3:55 p.m., administrator / nurse manager (NM)-A stated she received a call from the assisted living manager on 5/11/26 reporting rough care by HA-A. On 5/12/26 NM-A informed NM-B of the allegations and instructed her to notify the nurse administrator/DON. NM-A stated HA-A continued to work on 5/12/26 and visited four patients that day. She was off work 5/13/26 and 5/14/26, then placed on administrative leave on 5/15/26.During an interview on 5/21/26, at 4:05 p.m., the nurse administrator (director of nursing) stated on 5/15/26, NM-B informed her there was a report of rough care on 5/11/26 by HA-A. She stated she should have been informed immediately when the hospice agency became aware of the allegations. She stated HA-A should have been removed and put on administrative leave upon receiving the report. NM-B was not available for interview at the time of survey.During an interview on 5/22/26, at 10:25 a.m., registered nurse (RN)-A stated she learned of the incident from a staff member at the assisted living on 5/12/26. They stated it happened on 5/11/26. She said the assisted living staff called the hospice agency and informed a nursing supervisor of the rough care.During an interview on 5/22/26, at 1:35 p.m., family member (FM)-A stated the assisted living staff informed him “a hospice person flung her on the bed”. FM-A was unable to recall the date of the incident. FM-A stated the hospice agency did not talk to him about the incident.The hospice agency Investigation Report, dated 5/21/26, indicated on 5/11/26 the assisted living staff reported concerns about an interaction that occurred between HA-A and P1. The hospice agency began their investigation and placed HA-A on administrative leave effective 5/15/26.The hospice agency filed a report with SA on 5/22/26 at 2:10 p.m., indicating the assisted living caregiver witnessed HA-A transfer P1 independently by pulling on P1’s wrists to a standing position, causing P1 to be unstable and swung her on to her bed causing her to fall backwards. The report indicated pulling the patient from the wheelchair and aggressively swinging her into her bed was a violation of the agency’s code of conduct.The agency Abuse, Neglect or Exploitation of Vulnerable Adults and Minors Procedure, dated 4/28/26, directed when a mandated reporter knows or has reason to believe maltreatment of a vulnerable adult has occurred, the reporter must make a report externally. The personnel interacting with the patient must make a report to the common entry point immediately (no later than 24 hours) after becoming aware of the suspected maltreatment. Report immediately to the hospice administrator, or designee, when filing an official abuse/neglect report. The policy lacked direction to take action to prevent further potential abuse during the investigation of abuse allegations.”

“Based on interview and document review the hospice agency failed to report an allegation of abuse to the State Agency (SA) within 5 working days of becoming aware of the allegation for 1 of 4 patients (P1) reviewed for abuse. Findings include:P1’s hospice plan of care (POC) for benefit period 4/9/26 through 7/7/26 identified P1 was on hospice with diagnoses of Alzheimer’s Disease, and dementia with moderate agitation. P1 required assistance of one person with all activities of daily living and transfers.P1’s aide visit note on 5/11/26, from 12:56 p.m. – 1:23 p.m., indicated P1 refused all cares and became physically aggressive with cares.During an interview on 5/21/26, at 11:11 a.m., the assisted living manager stated P1 resided in their memory care unit and on 5/11/26, and between 1:00 p.m. and 1:30 p.m., an assisted living caregiver reported witnessing the hospice aide (HA)-A transfer P1 by herself and throw P1 into the bed “like a ragdoll”. The incident was reported to the hospice agency and to P1’s family member (FM) on 5/11/26.During an interview on 5/21/26, at 3:55 p.m., administrator / nurse manager (NM)-A stated she received a call from the assisted living manager on 5/11/26 reporting rough care by HA-A. On 5/12/26 she informed NM-B of the allegations and instructed her to notify the nurse administrator /director of nursing (DON). NM-A stated she was a mandated reporter but the agency instructed her not to file a vulnerable adult abuse report.During an interview on 5/21/26, at 4:05 p.m., the nurse administrator / DON stated she was informed there was a report of P1 receiving rough care on 5/15/26 by NM-B. The hospice did not make a report to the SA as their team assigned to investigate would determine if a vulnerable adult abuse report was needed.During an interview on 5/22/26, at 10:25 a.m., registered nurse (RN)-A stated she learned of the incident from a staff member at the assisted living on 5/12/26. They stated it happened on 5/11/26. She said the assisted living staff called the hospice agency and informed a nursing supervisor of the rough care. She stated she was a mandated reporter but did not make a report to the SA.The hospice agency Investigation Report, dated 5/21/26, indicated on 5/11/26 the assisted living staff reported concerns about an interaction that occurred between HA-A and P1.The hospice agency filed a report with SA on 5/22/26 at 2:10 p.m., indicating the assisted living caregiver witnessed HA-A transfer P1 independently by pulling on P1’s wrists to a standing position, causing P1 to be unstable and swung her on to her bed causing her to fall backwards. The report indicated pulling the patient from the wheelchair and aggressively swinging her into her bed was a violation of the agency’s code of conduct.The agency Abuse, Neglect or Exploitation of Vulnerable Adults and Minors Procedure, dated 4/28/26, directed when a mandated reporter knows or has reason to believe maltreatment of a vulnerable adult has occurred, the reporter must make a report externally. The personnel interacting with the patient must make a report to the common entry point immediately (no later than 24 hours) after becoming aware of the suspected maltreatment. Report immediately to the hospice administrator, or designee, when filing an official abuse/neglect report.”