Brighton Hospice

“Based on interview and document review, the hospice agency failed to immediately investigate an alleged violation involving a hospice aide and failed to immediately take appropriate action to prevent further potential violations while the alleged violation was being verified for 1 of 1 patient (P1) reviewed who fell from a mechanical lift sling and sustained a right tibia and fibula fracture. Findings include:A report submitted to the State Agency (SA) on 8/10/26, indicated on 7/30/26 hospice aide (HA)-A and skilled nursing facility (SNF-RN) were transferring P1 with a full body mechanical lift when she slipped out of the sling and fell to the floor. The report indicated HA-A did not apply the sling correctly when he failed to cross the leg straps on the divided leg sling. An x-ray confirmed P1 suffered a right tibia and fibula fracture.A facility Vulnerable Adult Reporting Form, dated 8/10/26, indicated the agency was notified of P1’s fall from the mechanical lift on 7/30/26. It indicated the agency assistant director of nursing (ADON) contacted the skilled nursing facility (SNF) director of nursing (DON).A statement written by HA-A, dated 7/31/26, indicated he hooked up the sling for the mechanical lift but did not cross the leg straps. When P1 was lifted out of bed, by HA-A and the SNF-registered nurse (RN), she slipped out of the sling feet first and fell on her right side.P1’s plan of care (POC) for certification period 6/29/26 through 8/27/26 indicated she had diagnoses of supraventricular tachycardia (a fast heart rate), hemiplegia to right dominant side following a cerebral infarction (paralysis to one side of the body due to a stroke), chronic pain, vascular dementia, failure to thrive, a compression fractures to her thoracic and lumbar vertebrae (mid to lower spine). She had contractures, was forgetful and disoriented and required two staff to use a full body mechanical lift to transfer.P1’s x-ray, dated 7/30/26, indicated she had an acute mildly displaced fracture of the proximal tibia and fibula in the metaphysis (a break in both lower leg bones, near the knee).During an interview on 8/13/26, at 11:26 a.m., certified nursing assistant coordinator (CNAC)-A stated HA-A called to notify her of P1’s fall from the lift on 7/30/26. She stated he was shaken up and offered to let him take the rest of the day off but he declined. She stated she provided additional education to HA-A on 8/4/26 and he met with a registered nurse (RN) on 8/7/26 to verify competence with mechanical lifts. CNAC-A did not investigate the incident further.During an interview on 8/13/26, at 11:39 a.m. HA-A stated he was not trained to use the sling that was available for P1’s transfer on 7/30/26. He stated as he was preparing to give P1 a shower, he placed the sling under her and connected it to the full body mechanical lift. He said he did not cross the leg straps. As HA-A and the SNF-RN were transferring P1 from her bed to her chair she slipped out the front of the sling and fell to the floor on her right side. He continued to see patients the rest of that day.During an interview on 8/13/26, at 12:44 p.m., the SNF-DON stated she went to HA-A’s room after the fall. HA-A did not cross the leg straps for the sling. She stated in interviewing her staff she learned HA-A was provided instruction on proper use of the split leg slings in the past month by three SNF staff because he “kept forgetting to cross them [the leg straps]”. She stated the hospice ADON had contacted her and they discussed the event.During an interview on 8/13/26, at 3:07 p.m., the ADON stated she became aware of P1’s fall from the lift on 7/30/26 at 8:30 a.m., when CNAC-A informed her of the incident. She did not interview HA-A. She did not observe the scene of the accident or determine which machine and sling were in use at the time of the incident. She thought HA-A was sent home and removed from the schedule for the remainder of the week.During an interview on 8/13/26, at 4:00 p.m., the director of compliance and education stated the agency removed HA-A from the SNF where the incident occurred and retrained him. She stated the agency did not conduct a root cause analysis to determine the cause of the incident so appropriate correction could be implemented.During an interview on 8/19/26, at 2:50 p.m., the DON stated it was her understanding that HA-A was “pulled from the field” following the incident. She stated she did not interview HA-A, determine the type of lift and sling used, or observe the scene. A thorough investigation was not completed, as she was unaware it was required.HA-A’s file indicated he received retraining on the use of lift on 8/4/26, by CNAC-A, but did not have a competency retest with a registered nurse (RN) until 8/7/26.The agency list of visits completed by HA-A indicated he continued to see patients after the incident on 7/30/26. He conducted 5 additional visits on 7/30/26, 12 visits on 7/31/26, and 10 visits on 8/3/26, 7 visits on 8/4/26, 9 visits on 8/5/26, and 8 on 8/6/26. 11 of the visits included patients who required the use of a mechanical lift for transfers.An agency policy, Assessment of Possible Abuse/Neglect, dated 12/2025, directed 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 following information: name of the alleged perpetrator, relationship to patient, witness to occurrence, nature of occurrence and description of the abuse/neglect. The suspected abuse/neglect investigation report with specific information relating to the occurrence is forwarded to the clinical supervisor, who will: notify the physician and referral source, review the documentation for completeness and objectivity, forward the information to the administrator. The administrator will: review all reports (incident report and follow-up investigation), conduct and further review necessary, document additional information and submit reports to the proper authorities.”

“Based on interview and document review, the hospice agency failed to report an allegation of neglect to the State Agency (SA) as required by State law for 1 of 4 patients (P1) reviewed for neglect of care. P1 fell from a mechanical lift sling during care provided by a hospice aide and sustained a right tibia and fibula fracture. Findings include:P1’s plan of care for certification period 6/29/26 through 8/27/26 indicated she had diagnoses of supraventricular tachycardia (a fast heart rate), hemiplegia to right dominant side following a cerebral infarction (paralysis to one side of the body due to a stroke), chronic pain, vascular dementia, failure to thrive, a compression fractures to her thoracic and lumbar vertebrae (mid to lower spine). She had contractures, was forgetful and disoriented and required two staff to use a full body mechanical lift to transfer.The State Agency (SA) report submitted on 8/10/26, identified on 7/30/26 (11 days following the incident), HA-A and SNF-RN transferred P1 using a full body mechanical lift. During the transfer, P1 slipped from the sling and fell. The report identified HA-A failed to cross the leg straps of the divided leg sling. An x-ray confirmed P1 sustained a right tibia and fibula fracture. The Vulnerable Adult Reporting Form dated 8/10/26, identified the hospice agency was notified of the incident on 7/30/26.HA-A’s written statement dated 7/31/26, identified HA-A did not cross the leg straps of the sling and P1 slipped from the sling and fell.During an interview on 8/13/26, at 11:26 a.m., certified nursing assistant coordinator (CNAC)-A stated HA-A called to notify her of P1’s fall from the lift on 7/30/26. She stated she did not make the report to the SA. She thought the ADON made a report to the SA.During an interview on 8/13/26, at 3:07 p.m., the assistant director of nursing (ADON) stated she became aware of P1’s fall from the lift on 7/30/26 at 8:30 a.m. She was a mandated reporter but did not make a report to the SA.During an interview on 8/13/26, at 4:00 p.m., the director of compliance and education stated she did not make a report to the SA but was aware of P1’s fall with injury.During an interview on 8/19/26, at 2:50 p.m., the director of nursing (DON) stated she was informed of P1’s fall from the mechanical lift on 7/30/26 but did not make a report to the SA as she thought CNAC-A was making the report. She stated she was a mandated reporter.During interview on 8/19/26 at 2:50 p.m., the DON stated a thorough investigation of the incident had not been completed because she was unaware one was required.Minnesota Statutes § 626.557, subdivision 3(a) ) — Timing of report, identified The statute requires a mandated reporter who has reason to believe a vulnerable adult is being or has been maltreated, or who knows the vulnerable adult sustained a physical injury that is not reasonably explained, to immediately report the information. An agency policy, Assessment of Possible Abuse/Neglect, dated 12/2025, directed 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 following information: name of the alleged perpetrator, relationship to patient, witness to occurrence, nature of occurrence and description of the abuse/neglect. The suspected abuse/neglect investigation report with specific information relating to the occurrence is forwarded to the clinical supervisor, who will: notify the physician and referral source, review the documentation for completeness and objectivity, forward the information to the administrator. The administrator will: review all reports (incident report and follow-up investigation), conduct and further review necessary, document additional information and submit reports to the proper authorities. Findings include:A report submitted to the State Agency (SA) on 8/10/26, indicated on 7/30/26 hospice aide (HA)-A and skilled nursing facility (SNF-RN) were transferring P1 with a full body mechanical lift when she slipped out of the sling and fell to the floor. The report indicated HA-A did not apply the sling correctly when he failed to cross the leg straps on the divided leg sling. An x-ray confirmed P1 suffered a right tibia and fibula fracture.A facility Vulnerable Adult Reporting Form, dated 8/10/26, indicated the agency was notified of P1’s fall from the mechanical lift on 7/30/26. It indicated the agency assistant director of nursing (ADON) contacted the SNF director of nursing (DON).A statement written by HA-A, dated 7/31/26, indicated he hooked up the sling for the mechanical lift but did not cross the leg straps. When P1 was lifted out of bed, by HA-A and the SNF-RN, she slipped out of the sling feet first and fell on her right side.P1’s plan of care for certification period 6/29/26 through 8/27/26 indicated she had diagnoses of supraventricular tachycardia (a fast heart rate), hemiplegia to right dominant side following a cerebral infarction (paralysis to one side of the body due to a stroke), chronic pain, vascular dementia, failure to thrive, a compression fractures to her thoracic and lumbar vertebrae (mid to lower spine). She had contractures, was forgetful and disoriented and required two staff to use a full body mechanical lift to transfer.P1’s x-ray, dated 7/30/26, indicated she had an acute mildly displaced fracture of the proximal tibia and fibula in the metaphysis (a break in both lower leg bones, near the knee).During an interview on 8/13/26, at 11:26 a.m., certified nursing assistant coordinator (CNAC)-A stated HA-A called to notify her of P1’s fall from the lift on 7/30/26. She stated she did not make a report to the SA. She thought the ADON made a report to the SA.During an interview on 8/13/26, at 11:39 a.m. HA-A stated he was not trained to use the sling that was available for P1’s transfer on 7/30/26. He stated he was planning to give P1 a shower. He placed the sling under her and connected it to the full body mechanical lift. He said he did not cross the leg straps. As HA-A and the SNF-RN were transferring P1 from her bed to her chair she slipped out the front of the sling and fell to the floor.During an interview on 8/13/26, at 12:44 p.m., the SNF-DON stated she went to HA-A’s room after the fall. HA-A did not cross the leg straps for the sling. She stated in interviewing her staff she learned HA-A was provided instruction on proper use of the split leg slings in the past month by three SNF staff because he “kept forgetting to cross them (the leg straps)”. She stated the hospice ADON had contacted her and they discussed the event.During an interview on 8/13/26, at 3:07 p.m., the ADON stated she became aware of P1’s fall from the lift on 7/30/26 at 8:30 a.m. She was a mandated reporter but did not make a report to the SA.During an interview on 8/13/26, at 4:00 p.m., the director of compliance and education stated she did not make a report to the SA but was aware of P1’s fall with injury.During an interview on 8/19/26, at 2:50 p.m., the DON stated she was informed of P1’s fall from the mechanical lift on 7/30/26 but did not make a report to the SA as she thought CNAC-A was making the report. She stated she was a mandated reporter.An agency policy, Assessment of Possible Abuse/Neglect, dated 12/2025, directed 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 following information: name of the alleged perpetrator, relationship to patient, witness to occurrence, nature of occurrence and description of the abuse/neglect. The suspected abuse/neglect investigation report with specific information relating to the occurrence is forwarded to the clinical supervisor, who will: notify the physician and referral source, review the documentation for completeness and objectivity, forward the information to the administrator. The administrator will: review all reports (incident report and follow-up investigation), conduct and further review necessary, document additional information and submit reports to the proper authorities.”

“Based on observation, interview and document review the facility failed to ensure care and services were provided in accordance with the plan of care for 1 of 4 patients (P2) observed during home visits. Findings include:P2’s plan of care (POC) for certification period 7/8/26 through 10/5/26 indicated he had diagnoses of alcohol-induced dementia, schizoaffective disorder, and was disoriented. HA services were ordered five times weekly. The interventions for the HA included: transfer bed/chair with assistance of 2 staff and mechanical lift, incontinent care, assist with dressing, clean nails every visit, file nails on Thursdays if broken or chipped nails, oral care, perineal care, apply lotion, and fall precautions.During an observation on 8/13/26, at 1:25 p.m., HA-A was assisted by the assisted living facility (ALF) aide to transfer P2 from his wheelchair to his bed, using a full body mechanical lift. P2 was checked for incontinence and then transferred back to his wheelchair with the mechanical lift. HA-A failed to observe or provide care for P2’s nails, apply lotion, or inquire with the ALF aide if P2’s oral care had been completed.A HA visit note, dated 8/13/26 from 11:00 a.m. to 11:30 a.m., indicated oral care and lotion to skin was completed by other caregivers. It indicated nails were cleaned and filed. The note was signed by HA-A.During an interview on 8/13/26, at 1:55 p.m., HA-A stated he assumed oral care was completed by the ALF staff and should have asked the ALF staff if they completed the task. He stated he should have applied lotion to P2’s arms and legs. He stated he did not look at P2’s nails or attempt to clean or file them. He stated the care plan provided the direction for the tasks and did not complete them due to feeling stressed.During an interview on 8/13/26, at 3:07 p.m., the assistant director of nursing (ADON) stated the HAs were expected to access the care plan at the time of the visit and complete the tasks listed.During an interview on 8/19/26, at 2:50 p.m., the director of nursing (DON) stated the HAs were expected to follow the care plans established by the registered nurses (RNs) and they should reach out to the RN if they are unable to complete a task or if the patient refuses the care.The agency Hospice Aide Services policy, dated 12/2025, directed hospice aide services may be included for routine care on an intermittent bases when personal care is needed. Services provided by an aide could include: bathing, shampoo, range of motion, dry dressing changes, assisting the patient to the bathroom, use of commode or bed pain, meal preparation, feeding the patient, light housekeeping and/or linen changes. These activities in accordance with the plan of care and physician’s orders will be assigned and supervised by a hospice RN.”

“Based on observation and interview, the hospice agency failed to follow accepted standards of practice for infection prevention and control, including standard precautions for hand hygiene, glove use, and handling of potentially contaminated items, for 2 of 3 patients (P2, P4) observed during home visits. Findings include:P2’s plan of care (POC) for certification period 7/8/26 through 10/5/26 indicated he had diagnoses of alcohol-induced dementia, schizoaffective disorder, and was disoriented. Hospice aide (HA) services were ordered five times weekly. The interventions for the HA included: transfer bed/chair with assistance of 2 staff and mechanical lift, incontinent care, assist with dressing, clean nails every visit, file nails on Thursdays if broken or chipped nails, oral care, perineal care, apply lotion, and fall precautions.During an observation on 8/13/26, at 1:25 p.m., HA-A was assisted by an assisted living facility (ALF) aide to transfer P2 from his wheelchair to his bed, using a full body mechanical lift. While wearing gloves, he checked P2’s brief for incontinence by opening the front of the brief and examining the brief. HA-A removed his gloves and failed to perform hand hygiene. HA-A and the ALF aide redressed P2, then transferred him back to his wheelchair using the mechanical lift. HA-A pushed P2’s wheelchair back to the community living room and then returned to the room. He gathered the trash, tied it and held the bag of trash under his right arm, against his scrubs while he wrote in P2’s journal. He brought the bag of trash to the laundry room and disposed of it. He failed to perform hand hygiene after disposing of the trash. He wrote on a communication sheet and placed it in a binder for the ALF. As he exited the building HA-A used hand sanitizer.P4’s POC for certification period 8/7/26 through 10/5/26 indicated she had diagnoses of senile degeneration of the brain, depression, was forgetful and disoriented. HA services were ordered five times weekly. Interventions for the HA included: transfer bed/chair with assistance of 2 staff and mechanical lift, incontinent care, assist with dressing, clean nails every visit, oral care, perineal care, apply lotion, fall precautions and write in the journal every visit.During an observation on 8/19/26, at 12:40 p.m., HA-C transferred P4 from her wheelchair to her bed, using a mechanical lift, assisted by the ALF aide. HA-C provided peri care and changed P4’s wet brief in her bed. Without changing her gloves, HA-C applied a clean brief, adjusted P4’s clothing and repositioned the sling for the mechanical lift. HA-C then removed her gloves and used hand sanitizer.During an interview on 8/13/26, at 1:55 p.m., HA-A stated hand hygiene was necessary upon entering and exiting patient rooms/homes, after removing gloves and in between cares. He stated he should have used hand sanitizer after he removed his gloves. He stated the garbage should not touch his clothing because it could be dirty on the outside and germs could get on his clothing.During an interview on 8/19/26, at 1:05 p.m., HA-C stated gloves should be changed after assistance with toileting, brief changes, and contact with bodily fluids so the clean items would not become contaminated.During an interview on 8/13/26, at 3:07 p.m., the assistant director of nursing (ADON) stated the HAs were expected to perform hand hygiene before and after visits, after giving personal care and after changing briefs. She stated garbage should not be held against the HAs’ scrubs as it could spread germs.During an interview on 8/13/26, at 4:30 p.m., RN-A stated hand hygiene was necessary to prevent the spread of infection from patient to patient. She stated the proper way to dispose of trash was to wear gloves, hold it away from clothing, toss it in the receptacle, remove gloves and perform hand hygiene.During an interview on 8/19/26, at 2:50 p.m., the director of nursing (DON) stated gloves should be changed when visibly soiled, after touching any open patient orifice and after peri care. Hand hygiene was necessary after removing gloves. She stated garbage bags should never come into contact with the HA’s clothing. She stated these steps were necessary to prevent spreading infection.The agency Hand Hygiene policy, dated 12/2025, directed personnel providing care in the home setting to regularly wash their hands, per the most recently published Centers for Disease Control and Prevention (CDC) regulations and guidelines for hand hygiene in healthcare settings. Hand decontamination with an alcohol-based handrub should be performed after removing gloves.The agency Personal Protective Equipment policy, dated 12/2025, directed: Powderless gloves will be worn when it can be reasonably anticipated that personnel may have contact with blood or other potentially infectious materials; when performing vascular access procedures; and when handling or touching contaminated items or surfaces. Any variety of powderless latex or vinyl glove is acceptable as long as they are impervious to liquids and strong enough to withstand the rigors of the tasks to be performed. Personnel who are allergic to latex or vinyl gloves should notify their Program Supervisor so that hypoallergenic gloves, glove liners, or other similar alternatives may be provided to them. Gloves must not be so large and loose fitting as to easily slip off during use. Disposable gloves will be removed and discarded after contact with each person, fluid item, surface, if torn or punctured, or when their ability to function as a barrier is compromised. Hands must be decontaminated immediately, or as soon as feasible, after removal of gloves or any other personal protective equipment. A new set of gloves will be used for contact with each patient. Gloves may not be washed or disinfected for reuse. When utility gloves are used, they may be decontaminated for reuse as long as the integrity of the glove is not compromised. However, they must be discarded if they are cracked, peeling, torn, punctured, or exhibit other signs of deterioration or when their ability to function as a barrier is compromised.The CDC Clinical Safety: Hand Hygiene for Healthcare Workers, dated 2/27/24, indicated cleaning hands reduces the potential spread of deadly germs to patients, the spread of germs and the risk of healthcare personnel colonization or infection caused by germs received from the patient. Gloves are not a substitute for hand hygiene. If a task requires gloves, perform hand hygiene before donning gloves and touching the patient or the patient’s surroundings. Always clean hands after removing gloves. It instructed healthcare personnel to change gloves and clean hands if gloves become soiled with blood or body fluids after a task and when moving from work on a soiled body site to a clean body site on the same patient.”

“Based on interview and document review, the agency failed to report allegations of misappropriation of property to the State Agency (SA) immediately, but no more than 24 hours, when family member (FM)-A reported drug diversion by the hospice nursing assistant (NA). Findings include: A facility document, complaint form, dated 8/1/25, indicated registered nurse (RN)-A spoke with the certified nursing assistant coordinator (CNAC) on 8/1/25 at 3:07 p.m., to report FM-A told him NA-A took four morphine pills.A report made to the SA on 8/20/25 at 11:05 a.m., indicated the hospice agency had received a complaint from FM-A alleging NA-A removed four tablets of morphine from P1’s home. The report to the SA lacked a date of the incident. An agency document, Vulnerable Adult (VA) Reporting Form, dated 8/20/25, indicated the hospice agency became aware of the complaint of four missing morphine pills by FM-A on 8/1/25, following cares provided by NA-A and notified the SA on 8/20/25.P1’s plan of care (POC) for certification period 6/27/25 through 9/24/25 indicated she had a diagnosis of lung cancer with metastases (spread) to the bone. The POC indicated the aide care plan included assistance with personal cares. On 9/3/25 at 12:22 p.m., the director of nursing assistant services (DNAS) stated on 8/1/25, registered nurse (RN)-A informed certified nursing assistant coordinator (CNAC) of a complaint made by FM-A alleging NA-A took four tablets of P1’s morphine. She stated the allegation of drug diversion was not reported to the SA until 8/20/25 because NA-A was off work on a leave of absence and unavailable to interview on the issue.On 9/3/25, at 12:43 p.m., CNAC stated on 8/1/25 registered nurse (RN)-A informed her of a complaint made by FM-A alleging NA-A removed four tablets of morphine from P1’s medication bottle and placed them in her pocket. She stated RN-A made a visit to P1’s home and confirmed with FM-A that four tablets of morphine were unaccounted for. CNAC stated she immediately reported the incident to the DNAS. On 9/3/25 at 2:33 p.m., NA-A stated she provided personal care to P1 on 8/1/25, in her home. She denied removing any of the morphine from the prescription bottle. On 9/3/25 at 2:40 p.m., FM-A stated he frequently counted the quantity of medications and there were four tablets missing, following NA-A’s visit to their home on 8/1/25. He stated he immediately called RN-A to inform him of the incident. On 9/4/25 at 8:02 a.m., RN-A stated FM-A called him on 8/1/25 to report four missing morphine 5 milligrams (mg) tablets following NA-A’s visit to P1’s home. RN-A stated he made a visit to P1’s home and reviewed the medication counts and log along with FM-A, determining four missing tablets. RN-A stated he immediately informed the CNAC.On 9/4/25 at 11:10 a.m., the director of clinical services (DCS) stated she was not immediately involved with the incident but that it should have been reported to the SA immediately.On 9/4/25 at 11:25 a.m., the administrator stated the allegations of drug diversion “should have been reported within 24 hours” to the SA. On 9/4/25 at 11:40 a.m., the regional director of operations (RDO) stated the hospice agency should have reported the alleged drug diversion by NA-A immediately.A facility document, Assessment of Possible Abuse/Neglect, dated 11/2024 directed hospice will report all suspected cases of abuse, neglect, or exploitation in compliance with appropriate state statutes to appropriate protection organizations. The policy directed 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.”

“Based on interview and document review, the hospice agency failed to report an allegation of abuse to the hospice administrator immediately after becoming aware of the situation for 1 of 3 patients (P1) reviewed for abuse. Findings include: P1s Hospice Plan of Care (POC), dated 11/1/24, indicated P1 was admitted to hospice on 7/31/24 with a primary diagnosis of Alzheimers Disease. During an interview on 11/18/24 at 11:39 a.m., the assisted living director of nursing (AL DON) of the facility where P1 resided stated she was notified by two nursing assistants (NAs) at the facility on 11/12/24 that they had witnessed nursing assistant (NA)-A “;getting rough” with P1 when NA-A “;forcefully pushed” P1 into her chair when she was not cooperating with sitting down. The AL DON stated the NAs reported to her that NA-A was talking “;aggressively” with P1 telling P1 to “;knock it off.” The AL DON further stated P1 had bruising on her inner thigh, knee, and shoulder. During an interview on 11/18/24 at 12:35 p.m., NA-A stated on 11/12/24 she was at the AL giving P1 a tub bath. NA-A stated P1 was a two-person pivot transfer. NA-A stated staff would assist P1 to stand up out of the tub, have her take a few steps backwards until the backs of her legs were touching her wheelchair, and then NA would place an arm under P1s arm and put “;gentle pressure” on her hip to guide her down into her chair. NA-A stated P1 had tried to hit her a few times during the transfer in which NA-A stated “;No” and “;Stop that” to P1. NA-A stated P1 was also trying to stand up out of her wheelchair and NA-A was worried P1 would fall on the wet bathroom floor. During an interview on 11/18/24 at 1:18 p.m., registered nurse (RN)-A stated she was made aware by the AL DON on 11/13/24 of the alleged abuse that occurred between NA-A and P1. RN-A stated her direct supervisor and SW-A were also present during the conversation with the ALF DON. RN-A stated she had a statement from the facility NAs that stated NA-A “;pushed” P1 into her wheelchair and there “;may be bruising” when P1 would not take a few steps back towards her wheelchair. RN-A stated she assessed P1s skin on 11/14/24 and there was some generalized, yellowing bruising on P1s legs but nothing on her hips or inner thighs. RN-A further stated she assessed P1 again on 11/18/24 and all the bruising was gone. During an interview on 11/18/24 at 2:15 p.m., the administrator stated he was made aware of the alleged abuse involving NA-A and P1 on 11/15/24 between 2:00 p.m., and 2:30 p.m. The administrator stated he recognized the gap in being notified since RN-A, her direct supervisor and SW-A were aware of the alleged abuse on 11/13/24. The administrator stated once he was made aware, an internal investigation was started and the event was reported.”

“Based on observation, interview and document review, the agency failed to complete a comprehensive medication review for 2 of 6 patient’s (P13, P15) observed on home visits. P12’s plan of care (POC) dated 11/723 through 2/4/24, identified a start of care date 11/7/23, with primary diagnosis of heart and kidney disease. The POC identified multiple medications including lorazepam (an antianxiety) 2 milligrams (mg)/milliliter give 0.5 mg by mouth (po) every four hours as needed (prn), morphine 100 mg/5 ml po every two hours prn, haloperidol 2 mg/ ml 0.5 mg po every four hours prn, hyoscyamine (to dry secretions) 0.125 mg sublingual one tab every four hours prn, acetaminophen 500 mg tablet one tablet po at bedtime and prn, albuterol inhaler two puffs every six hours prn, furosemide (diuretic) 40 mg po two times per day, loratadine 10 mg one tablet daily, omeprazole 20 mg one cap daily, terazosin (for prostate) 2 mg capsules give two capsules two times per day, melatonin 3 mg one tablet at bedtime for sleep, Clobetasol 0.05% to apply to affected areas two times per day prn for eczema, Desonide cream to affected area three times per day for rash, latanoprost 0.005% ophthalmic (for eyes) one drop to both eyes at night. Bisacodyl 10 mg suppository one suppository rectally every day as needed for constipation. Nursing notes indicated continuing education on prn medications and support services. Safety measures included medication safety and storage, patient would receive prescribed medications at correct times and patient/caregiver would safely administer medications during care. A home visit was conducted on 11/28/23, at 10:30 a.m. registered nurse (RN)-A assessed P12 general condition and comfort. Family member (FM)-C indicated she set up and administered P12’s medications. The medication bottles in the home were compared to the list on P12’s POC. Among P12’s medication bottles included the medication Zocor 40 mg po every evening. The medication Zocor (treat high cholesterol) was not listed on P12’s POC. FM-C stated she gave P12 Zocor every evening and he had been on the medication for quite awhile. During interview on 11/28/23 at 11:00 a.m. RN-A verified P12’s POC did not list the medication Zocor and stated if the patient was taking the medication, it should have been listed on the POC when he was admitted. She typically did not have patient or caregivers bring out all their medication bottles each visit to review, as that was done with the start of care visit. RN-A stated medications to treat cholesterol were typically stopped when admitted to hospice. She felt stopping the medication had probably been discussed with FM-A when P12 was admitted and FM-A may have not heard or had misunderstood and had not stopped the medication. P15’s POC dated 11/28/23 through 2/17/23, identified a SOC date 11/20/23, and primary diagnosis of Alzheimer’s disease. The POC identified multiple medications including prednisone 5 mg daily, duloxetine (antidepressant) 60 mg daily, Lisinopril (for blood pressure) 5 mg daily, Miralax 17 gram daily, senna laxative 8.5 mg daily, quetiapine (antipsychotic medication) 12.5 mg every evening, melatonin 3 mg every night, vitamin D 25 microgram (mcg) every night, oxygen 2 liters as needed, acetaminophen 500 mg two tablets prn, ipratropium-albuterol nebulizer treatment every four hours prn, quetiapine 6.25 mg prn, hydromorphone 1 mg every hour prn, lorazepam 0.5 mg every four hours prn, haloperidol 0.5 mg every four hours prn, hyoscyamine sulfate 0.125 mg every four hours prn, bisacodyl suppository 10 mg daily prn, and morphine 2.5 mg daily. Safety measures included medication safety and storage, with goal patient would receive prescribed medications at correct times with caregiver to administer drugs and biologicals during care. A home visit was conducted on 11/28/23, at 9:00 a.m. RN-B assessed P15’s general condition and comfort. RN-B discussed P15’s care and treatment with the assisted living staff who were his primary care providers. P15’s medication administration record (MAR) was compared to the list on P15’s POC. Morphine solutab 2.5 mg was listed on P15’s MAR to be given sublingually every two hours prn for shortness of breath. Prn morphine was not listed on P15’s POC. During interview on 11/28/23, at 2:15 a.m. RN-B stated she had contacted P15’s primary provider and had received an order to clarify the prn morphine should be discontinued. The medication should have been discontinued on his admission to hospice and had been missed, RN-B stated when a patient resided in an assisted living, their medications and MAR would be reviewed weekly, as it was important to know all the medications the patient was receiving. When interviewed on 11/29/23, at 9:45 a.m. the administrator stated overall the nurses go through a patient’s medications in the home with the caregiver and provide any needed education to the caregiver. Nurses were expected to review patient’s medications at every visit. When a patient resides in an assisted living the agency’s general practice was to review a patient’s medication list and MAR with a facility staff member. The agency’s policy Medication Regimen Review dated 11/1/13, indicated the agency conducted a medication review to identify potential clinically significant medication issues such as drug reactions, ineffective drug therapy, side effects, drug interactions, duplicate therapy, omissions, dosage errors, or noncompliance at the time of admission and with a new medication.”

“Based on interview and observation, the agency failed to ensure services were provided in accordance with the plan of care for 3 of 18 patients (P1, P4, P11) reviewed. P1’s Patient Profile form indicated P1 enrolled in hospice on 11/10/23. P1’s hospice plan of care (POC) dated 11/10/23, indicated P1 had a diagnosis of Parkinson’s disease and required a nursing assistant (NA) twice a week starting 11/12/23. P1’s hospice physician order dated 11/10/23, indicated the NA was to visit twice a week starting 11/12/23, for activities of daily living (ADL) management. P1’s hospice physician order dated 11/12/23, indicated the NA was to visit three times a week for ADL assistance and was electronically signed on 11/27/23. P1’s hospice physician order dated 11/19/23, indicated the NA was to visit three times a week for ADL management effective 11/19/23. P1’s hospice physician order dated 11/28/23, indicated the NA was to visit one time a week for one week and then three times a week for five weeks for ADL management effective 11/28/23. P1’s interdisciplinary group (IDG) meeting review dated 11/21/23, indicated the NA was to visit twice a week for eight weeks starting 11/12/23. P1’s home health aide visit notes in the patient chart indicated P1 had the following NA visits:11/13/23, 11/15/23, 11/17/23, 11/20/23, and 11/22/22. During interview on 11/29/23, at 12:10 p.m., the assistant director of clinical services (ADOCS) stated she wondered if there was a computer glitch and would have to check if the NA had a missed visit. No additional information was provided. P4’s hospice POC dated 11/17/23, indicated P4 elected hospice on 11/17/23, and had the following diagnoses: unspecified severe protein calorie malnutrition, unspecified dementia, full incontinence of feces and unspecified urinary incontinence and required a NA twice a week for 12 weeks starting on 11/19/23. P4’s hospice physician order dated 11/17/23, indicated the NA was to visit twice a week for 12 weeks starting 11/19/23. P4’s IDG meeting review dated 11/29/23, indicated the NA was to visit twice a week for 12 weeks starting 11/19/23. P4’s home health aide visit notes in the patient chart indicated P4 had the following NA visits: 11/24/23, and 11/28/23. During interview on 11/29/23 at 12:23 p.m., the ADOCS verified P4 did not have a second visit documented for the week starting 11/19/23. P11’s certification of terminal illness indicated P11 elected hospice on 11/9/23 with a diagnosis of Alzheimer’s disease and was dependent on staff assistance for all ADLs. P11’s hospice physician order dated 11/9/23, indicated P11 required NA visits three times a week starting on 11/12/23 for ADL management. P11’s home health aide visit notes in the patient chart indicated P11 had the following NA visits: 11/13/23, 11/14/23, 11/20/23, 11/21/23, and 11/22/23. During interview on 11/29/23 at 2:24 p.m., the ADOCS verified P11 did not have NA visits three times a week. During interview on 11/29/23 at 11:58 a.m., the assistant administrator stated staff documentation including missed visits were completed within 24 hours. During interview on 11/29/23 at 12:02 p.m., ADOCS stated missed visits were documented under the nursing clinical notes and showed up as a missed visit and visit orders were entered under hospice physician orders and were also in the IDG meeting review notes and orders were according to the most recent order and were based on need and the reason would be included in the physician order. A policy, Plan of Care dated 12/15/14, indicated hospice services provided to patients and caregivers were in accordance with a written plan of care established by the hospice interdisciplinary team in collaboration with the patient’s attending physician. The agency collaborates with the patient, family and or primary care giver or inpatient care when developing and implementing a patient family specific plan of care. The plan of care is implemented and developed to meet the needs of the patient and family primary caregiver based on the findings of the assessments and reassessments that identify the patient and family strengths and weaknesses and needs. The care, services and treatment is provided in accordance with the plan of care that may include ancillary staff that may be provided by the agency employees, volunteers or contracted staff. Physician orders are incorporated in the plan of care. The plan of care is reviewed and updated by the IDG every fifteen days or more frequently as needed.”

“Based on interview and document review, the agency failed to maintain a copy of advanced directives for 3 of 18 patients (P12, P13, P14) reviewed for advanced directives. P14’s Patient information form indicated a start of care date of 11/6/23, and do not resuscitate was indicated on the form. P14’s medical record was reviewed and lacked an advanced directive signed by P14. During interview on 11/29/23 at 2:10 p.m., the assistant director of clinical services (ADOCS) stated the physician order for life sustaining treatment (POLST) should be scanned in the computer because if it is not uploaded immediately, staff won’t know what a patient’s code status is. During interview on 11/29/23 at 2:19 p.m., ADOCS verified P14 did not have an advanced directive located in P14’s electronic medical record (EMR). A policy, Advance Directives dated 5/7/18, indicated upon admission, or at the time of hospital evaluation, patients will be asked whether or not they have prepared advanced directives. If a patient has prepared such documents, the agency will obtain a copy and retain it in the patient’s medical records; if the patient has not signed or has not been advised regarding advanced directives, they would be read and explained to the patient during the hospital evaluation or upon admission. The patient’s medical record will reflect whether or not advanced directives have been executed or whether the patient chooses not to execute advanced directives. P12’s plan of care (POC) 10/11/23 through 1/8/24, identified a start of care (SOC) date 10/11/23, with a primary diagnosis of malnutrition. Advanced directives were listed on the POC as do not resuscitate (DNR) and do not intubate (DNI) with effective start date 10/11/23. P12’s medical record lacked documentation of an advanced directive signed by P12 or designee. P13’s POC 11/7/23 through 2/4/24, identified a SOC date 11/7/23, with a primary diagnosis of heart and kidney failure. Advanced directives were listed on the POC as DNR and DNI with effective start date 11/7/23. P13’s medical record lacked documentation of an advanced directive signed by P13 or designee. During interview on 11/29/23, at 12:15 p.m. the assistant director of clinical services (ADOS) stated it was the agency’s usual practice to upload a patient’s advanced directive to their medical record, even if it had not yet been signed by the physician. Their goal was to have the physician sign all advanced directives the same day as the patient was admitted, however, the advanced directive should be scanned into the patient’s medical record regardless. ADOS stated it was important to have the scanned document in the patient’s medical record to ensure all staff would be able to locate the form and identify the patient’s wishes quickly.”

“Based on interview and document review, the agency failed to ensure a comprehensive discharge summary of the patients stay was completed for 2 of 2 patients (P19, P20) reviewed for discharge. P19’s plan of care (POC) dated 9/27/23 through 12/25/23, identified a start of care (SOC) date 6/29/23, with diagnosis a unspecified severe protein-calorie malnutrition. Skilled nurse documentation dated 11/7/23 indicated P19 had a steady increase in her weight and improved condition with a plan to discharge for no longer terminally ill within the next two weeks with an anticipated discharge date of 11/10/23. A Hospice Discharge Summary form (HIS) dated 11/10/23, identified an admission date 6/29/23, as well as P19 was in her second hospice benefit period with principal diagnosis of malnutrition. The HIS identified P19’s primary physician was consulted and agreed with the discharge. Education and instruction was provided to P19’s primary caregiver. Care summary in the above identified the hospice interdisciplinary group had discussed P19’s care and condition and all agreed P19 was no longer considered terminally ill. Hospice medications were destroyed per agency protocol and a notice of Medicare non-coverage was signed by P19’s care giver. P19’s medical record lacked documentation of all the required components for discharge summary to P19’s provider, including a summary of P19’s episodes of care, services received, treatments, symptoms, pain management, current drug profile, physician order and other pertinent information needed to provide care for P19. P20’s POC 8/10/23 through 11/7/23, identified a SOC date 8/10/23 with diagnosis of Huntington’s disease. Skilled nurse note dated 11/7/23 indicated P20 remained appropriate for hospice services, was dependent with activities of daily living, had muscle spasms, needed assistance to manage oral secretions and was fed through a feeding tube. Social worker visit note dated 11/20/23, identified a face-to-face visit was made as P20’s primary caregiver, family member-B had elected to revoke P20 from hospice services. A reason for the revocation was not identified. A Hospice Benefit Revocation form dated 11/20/23, identified P20’s FM-B had elected to revoke hospice, effective 11/20/23. A Hospice Discharge Summary Non-Visit form dated 11/20/23, identified admission date 8/10/23, and reason for record as discharged 11/20/23, however the remainder of the form had not been completed. P20’s medical record failed to identify if P20’s attending physician had been consulted and agreed with the discharge and had received a discharge summary which included; discharge instructions, disciplines and services received, a summary of P19’s episodes of care, services received, treatments, symptoms, pain management, current drug profile, physician order and other pertinent information needed to provide care for P19. During interview on 11/29/23, at 9:45 a.m. the assistant administrator stated it was the agency’s usual practice to complete a discharge summary when a patient left hospice. The agency’s discharge summary form contained all the required components needed in the summary and the expectation was for the entire discharge summary to be completed within 24 hours after the patient’s discharge. A discharge policy was requested, however was not received.”