Benton County Hospice

“Based on policy review, employee file review, and interview, the provider failed to ensure all staff were provided emergency preparedness (EP) training in one of five employee files reviewed (Employee #4). This deficient practice has the potential to affect all the patients served by the provider.Findings included:Review of the provider’s policy titled, “Safety and EP,” revised 08/28/2001, showed in part the following:- Each Hospice employee is responsible to be knowledgeable of their individual role in the Safety and EP program; and-The EP plan shall be rehearsed at least annually.Review of the provider’s policy titled, “Orientation, Training, Education, and Internship Programs,” revised 09/01/2022, showed in part the following:- Each department employee will be required to complete emergency plan training; and- Trainings are mandatory. Employee #4 (E-4):Review of E-4’s employee file showed a hire date of 11/16/2019. The employee file failed to show emergency preparedness training was completed during orientation and failed to show training was completed every two years as required per federal emergency preparedness guidelines.During an interview on 05/28/2025 at 11:30 AM, registered nurse (RN)-A (known to the provider as the health educator) stated that E-4 was not trained on emergency preparedness during new employee orientation and did not participate in the annual training. RN-A also stated that he/she did not know that E-4 needed the training.”

“Based on policy review, record review, home visit observation, and interview, the provider failed to ensure that accepted standards of practice to prevent the transmission of infections and communicable diseases were followed in two of four home visit observations conducted (Records/Patients #1 and #4). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s undated policy titled “Homecare Bag Technique,” showed in part the following:- Never set the bag on the floor. Always choose a place to set the bag that gives you enough workspace, is close to the patient, and is away from children and pets; and - Spread an impervious (not allowing fluid to pass through) barrier on the surface before setting the bag down. Review of the provider’s policy titled, “Infection Control,” last revised 12/02/2008, showed in part, the hospice must follow accepted standards of practice to prevent the transmission of infections and communicable diseases, including the use of standard precautions. Review of the provider’s undated policy titled “Universal Precautions for All Healthcare Workers,” showed in part the following:- Gloves should be changed after each client contact; and- When gloves are removed, thorough hand washing is required. Gloves do not take the place of hand washing. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice services on 04/24/2025 with a primary diagnosis of senile degeneration of the brain, not elsewhere classified. The patient had an additional diagnosis of surgical repair of a left hip fracture. He/she was confined to bed and lived with his/her adult child who assisted with activities of daily living (ADL’s). Review of the skilled nursing (SN) visit note, dated 05/03/2025, showed the patient’s daughter paged the nurse because she was worried about his/her left hip wound. The nurse noted that, the previously closed, left hip surgical incision had opened and had bloody drainage. Review of lab report of wound culture of the patient’s left hip wound, collected 05/16/2025, showed methicillin-resistant staphylococcus aureus (MRSA; a microorganism that has become resistant to a commonly used group of antibiotics), enterobacter cloacae complex (a multi-drug resistant bacteria naturally living in the intestines known to cause infections), and enterococcus faecalis (a species of bacteria naturally found in the intestines). Observation on 05/28/2025, beginning at 10:00 AM, showed patient was lying in bed, alert and oriented to person only and would grab the registered nurse’s (RN’s) hands while he/she provided care. The RN put on gloves, checked the patient’s multiple wounds which were covered with dressings. He/she touched the dressing on the patient’s left hip then arranged the bed covers, picked up the bed control from the floor and placed it back onto the bed, then touched the clean dressing supplies on the bedside table, showing the state agent (SA) what products were used to change the dressing. The RN failed to remove his/her soiled gloves and perform hand hygiene until after touching the clean dressing supplies. During an interview on 05/29/2025, at 11:07 AM, the administrator stated that the expectation was for the nurses to remove their gloves and wash their hands after touching the patient or patient’s dressing, prior to picking up the bed control or touching clean dressing supplies. RECORD/PATIENT #4:Review of the clinical record showed the patient was admitted to hospice services on 05/07/2025 with a terminal diagnosis of Chronic obstructive pulmonary disease, unspecified (a group of lung diseases that block airflow and make it difficult to breathe). Observation on 05/28/2025 at 10:25 AM, showed the Spiritual Counselor (SC-B) placed his/her supply bag on the floor. SC-B then removed his/her prayer booklet from his/her supply bag and placed it on the patient’s bedside table without a barrier. SC-B provided spiritual support for the patient. SC-B used hand sanitizer and wiped the prayer booklet with a sanitizer wipe and returned the booklet to the supply bag and used a sanitary wipe on the bottom of the bag. Per an interview during a home visit observation on 05/28/2025, SC-B stated that he/she always tried to wipe the bag with a sanitary wipe upon leaving a patient’s home. During an interview on 05/29/25025 at 10:30 AM, the hospice registered nurse coordinator (RNC) stated that the supply bag should not be on the floor and that this is the [provider’s] policy. RNC stated that barriers should be used for all supplies used in the patient’s home. Findings included:Review of the provider’s undated policy titled, “Homecare Bag Technique,” showed in part the following:- Never set the bag on the floor; - Always choose a place to set the bag that gives you enough workspace, is close to the patient, and is away from children and pets; and - Spread an impervious (not allowing fluid to pass through) barrier on the surface before setting the bag down. Review of the provider’s policy titled, “Infection Control,” revised 12/02/2008, showed in part, the hospice must follow accepted standards of practice to prevent the transmission of infections and communicable diseases, including the use of standard precautions. Review of the provider’s undated policy titled, “Universal Precautions for All Healthcare Workers,” showed in part the following:- Gloves should be changed after each client contact; and- When gloves are removed, thorough hand washing is required. Gloves do not take the place of hand washing. RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice services on 04/24/2025 with a primary diagnosis of senile degeneration of the brain, not elsewhere classified. The patient had an additional diagnosis of surgical repair of a left hip fracture. He/she was confined to bed and lived with his/her adult child who assisted with activities of daily living (ADL’s).Review of the skilled nursing (SN) visit note, dated 05/03/2025, showed the patient’s daughter paged the nurse because he/she was worried about his/her left hip wound. The nurse noted that, the previously closed, left hip surgical incision had opened and had bloody drainage. Review of lab report of wound culture of the patient’s left hip wound, collected 05/16/2025, showed methicillin-resistant staphylococcus aureus (MRSA; a microorganism that has become resistant to a commonly used group of antibiotics), enterobacter cloacae complex (a multi-drug resistant bacteria naturally living in the intestines known to cause infections), and enterococcus faecalis (a species of bacteria naturally found in the intestines).Observation on 05/28/2025 at 10:00 AM, showed patient was lying in bed, alert and oriented to person only and would grab the registered nurse’s (RN’s) hands while he/she provided care. The RN put on gloves, checked the patient’s multiple wounds which were covered with dressings. He/she touched the dressing on the patient’s left hip then arranged the bed covers, picked up the bed control from the floor and placed it back onto the bed, then touched the clean dressing supplies on the bedside table, showing the state agent (SA) what products were used to change the dressing. The RN failed to remove his/her soiled gloves and perform hand hygiene until after touching the clean dressing supplies. During an interview on 05/29/2025 at 11:07 AM, the administrator stated that the expectation was for the nurses to remove their gloves and wash their hands after touching the patient or patient’s dressing, prior to picking up the bed control or touching clean dressing supplies. RECORD/PATIENT #4:Review of the clinical record showed the patient was admitted to hospice services on 05/07/2025 with a terminal diagnosis of chronic obstructive pulmonary disease, unspecified (COPD; a group of lung diseases that block airflow and make it difficult to breathe). The patient resided at his/her home.Observation on 05/28/2025 at 10:25 AM, showed the spiritual counselor (SC)-B placed his/her supply bag on the floor. SC-B then removed his/her prayer booklet from his/her supply bag and placed it on the patient’s bedside table without a barrier. SC-B provided spiritual support for the patient. SC-B used hand sanitizer and wiped the prayer booklet with a sanitizer wipe and returned the booklet to the supply bag and used a sanitizer wipe on the bottom of the bag. Per an interview during a home visit observation on 05/28/2025, SC-B stated that he/she always tried to wipe the bag with a sanitizer wipe upon leaving a patient’s home. During an interview on 05/29/25025 at 10:30 AM, the provider administrator (PA) stated that the supply bag should not be on the floor and that this is the [provider’s] policy. PA stated that barriers should be used for all supplies used in the patient’s home.”

“Based on policy review, job description review, record review, home visit observation, and interview, the provider failed to ensure the clinicians followed the hospice’s wound assessment policies and procedures (P&P) in two of five full records reviewed (Records/Patients #1 and #4). This deficient practice has the potential to affect all the patients served by the provider. RECORD/PATIENT #4:Review of the clinical record showed the patient was admitted to hospice services on 05/07/2025, with a terminal diagnosis of chronic obstructive pulmonary disease, (COPD - a group of lung diseases that block airflow and make it difficult to breathe). Record showed the patient had a stage II (two) pressure injury (a partial thickness loss of the skin) with a wound measurement of 1.5 X 0.2 cm. The patient resided at his/her sister’s home, with the sister being his/her primary caregiver. The patient is no longer able to ambulate and is bedboundReview of the document titled, “Skilled Nurse (SN) Visit,” dated 05/08/2025 and 05/13/2025, failed to show a wound measurement to the left buttock.Review of the document titled, “SN Visit,” dated 05/16/2025, showed a wound measurement of 1.2 X 0.2 cm to the left buttock.Review of the document titled, “SN Visit,” dated 05/20/2025, 05/23/2025, and 05/27/2025, failed to show a wound measurement to the left buttock.During an interview on 05/29/2025 at 9:25 AM, the registered nurse coordinator (RNC) stated that he/she did not know the clinicians could bypass the wound measurements in the software system and he/she could not find any additional wound measurements in the system for the patient. He/she stated that they should measure the wounds every week per their policy, but he/she expected them to measure the wounds at every visit. Findings included:Review of the provider’s undated policy titled, “Would Assessment Policy,” showed in part, the assessment of patient wounds included evaluation and obtaining measurements once a week or whenever changes occurred in the wound. Review of the undated job description of the registered nurse (RN), showed in part, that all functions shall be performed in accordance with the established policies and practices of [named provider] and/or the particular program in which the RN is assigned. RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice services on 04/24/2025 with a primary diagnosis of senile degeneration of the brain, not elsewhere classified. The patient had an additional diagnosis of surgical repair of a left hip fracture. He/she was confined to bed and lived with his/her adult child who assisted with activities of daily living (ADL’s). Review of the clinical record showed the following wounds were identified and measured on the following skilled nursing (SN) visit dates:- Wound #1 – a pressure ulcer (skin injury caused by unrelieved pressure) on the sacrum (an area of the lower back above the tailbone) was identified on 04/24/2025 * 04/24/2025 = 1 x 0.5 centimeters (cm)* 05/03/2025 = 1.4 x 1.9 cm* 05/20/2025 = healed* The SN failed to obtain weekly wound measurements- Wound #2 – a pressure ulcer on the left inner calf was identified on 04/24/2025* 04/24/2025 = 1 x 1 cm* The SN failed to obtain weekly wound measurements- Wound #3 – a pressure ulcer on the right lateral foot was identified on 04/24/2025 * 04/24/2025 = 1.5 x 1 cm* 05/16/2025 = 0.5 x 0.5 cm* The SN failed to obtain weekly wound measurements - Wound #4 – a pressure ulcer on the right lateral foot was identified on 04/24/2025* 04/24/2025 = 1 x 1 cm* 05/16/2025 = 0.5 x 0.5 cm*The SN failed to obtain weekly wound measurements- Wound #5 – a skin tear on the left forearm was identified on 04/29/2025* 04/29/2025 = 9 x 1 cm* 05/02/2025 = 9 x 1 x 0 cm* 05/03/2025 = 4 x 1.2 cm* 05/27/2025 = 3 x 0.5 cm* The SN failed to obtain weekly wound measurements- Wound #6 – a pressure ulcer on the coccyx (tailbone) was identified on 05/03/2025* 05/03/2025 = 1 x 6 cm* 05/20/2025 = healed* The SN failed to obtain weekly wound measurements Observation and interview on 5/28/2025, beginning at 10:00 AM, showed the RN failed to measure the patient’s wounds during the home visit and stated that the wounds were supposed to be measured once a week. During an interview on 5/29/2025, at 9:25 AM, the administrator stated that he/she did not know the clinicians could bypass the wound measurements in the software system and he/she could not find any additional wound measurements in the system for the patient. He/she stated that they should measure the wounds every week per their policy, but he/she expected them to measure the wounds at every visit.”

“Based on policy review, record review, and interview the hospice provider failed to forward a copy of the hospice discharge summary to the patient’s attending physician in one of four records reviewed for discharge/revocation (Record/Patient #10). This deficient practice has the potential to impact the continuity of care for all the patients who are live discharges from the provider.Findings included:Review of the provider’s policy titled, “Nursing Discharge Summary and Narrative,” revised 02/2013, showed in part the following:- The physician shall be notified in all instances of discontinuance of hospice care;- The notification shall be documented in the patient record;- The original [discharge summary] is to be incorporated within the patient’s medical record upon discharge; and- A copy of the nursing discharge narrative will be forward to the patient’s physician. RECORD/PATIENT #10:Review of the clinical record showed the patient was admitted to hospice services on 12/07/2023 with a terminal diagnosis of Alzheimer’s disease (a disease marked by progressive loss of mental capacity). The patient was discharged on 03/04/2024 due to no longer having a terminal prognosis of six months or less. The patient resided in his/her home.Review of the interdisciplinary group (IDG) meeting notes, dated 03/02/2024, failed to show documentation that the attending physician was notified.During an interview on 05/29/2025 at 10:00 AM, the administrative assistant (AA) stated that there was not a discharge summary for the patient. AA stated that the information was not sent to the patient’s attending physician, but it should have been sent. He/she stated that he/she had drafted a new procedure for discharge summaries at the beginning of 05/2025, but had not started the in-service training. During an interview on 05/29/2025 at 11:50 AM, the administrator stated that they should be including all elements of the discharge summary and that the administrative assistant had created a checklist for a new procedure for the discharge summaries and were awaiting implementation of the new process.”

“Based on policy review, record review, and interview the hospice provider failed to ensure the discharge summary that was sent to the attending physician included a summary of the patient’s stay including treatments, symptoms and pain management, a current plan of care, and the latest physician orders in four of four live discharge records reviewed (Records/Patients #7, #8, #9, and #10). This deficient practice has the potential to impact the continuity of care for all the patients who are live discharges from the provider.Findings included:Review of the provider’s policy titled, “Nursing Discharge Summary and Narrative,” revised 02/2013, showed in part the following:- The registered nurse (RN) shall complete a discharge summary and narrative upon the transfer, revocation or discharge of a Hospice patient;- Purpose: to give [the] physician a complete and concise report of the patient’s condition and care to ensure physician notification of patient’s discharge from Hospice service;- The physician shall be notified in all instances of discontinuance of hospice care and such notification shall be documented in the patient record; and- The report includes a summary of the patient’s stay including treatments, symptoms and pain management, the patient’s current plan of care, the patient’s latest physician order, other documentation that will assist in the post-discharge continuity of care or requested by the attending physician or receiving facility. RECORD/PATIENT #7:Review of the clinical record showed the patient was admitted to hospice services on 02/11/2025 with a terminal diagnosis of congestive heart failure (CHF - a decrease in the ability of the heart to pump blood). The patient was discharged on 04/08/2025 when the patient was sent to the emergency department (ED) due to food lodged in the patient’s throat. The patient resided in his/her home.Review of the discharge visit, dated 4/08/2025, failed to show the following documents were sent to the hospital:- The current plan of care; and- A summary of the patient’s stay and treatments.RECORD/PATIENT #8:Review of the clinical record showed the patient was admitted to hospice services on 04/23/2025 with a terminal diagnosis of acute kidney failure. The patient was discharged on 04/30/2025 when the patient and the patient’s spouse both required medical assistance and were both transported by ambulance to the hospital. The patient resided in his/her home.Review of the discharge visit, dated 04/30/2025, failed to show the following:- The current plan of care sent to the hospital;- Notification to the hospital that medical records were available upon request; and- A summary of the patient’s stay and treatments sent to the hospital.RECORD/PATIENT #9:Review of the clinical record showed the patient was admitted to hospice services on 09/30/2023 with a terminal diagnosis of liver cancer. The patient was discharged on 10/07/2023 when he/she moved out of state to live with his/her adult child. Review of the journal notes, dated 10/06/2023, failed to show the following were sent to the receiving hospice services:- The current plan of care; - A summary of the patient’s stay and treatments; and- Recent physician’s orders.RECORD/PATIENT #10:Review of the clinical record showed the patient was admitted to hospice services on 12/07/2023 with a terminal diagnosis of Alzheimer’s disease (a disease marked by progressive loss of mental capacity). The patient was discharged on 03/04/2024 due to no longer having a terminal prognosis (life expectancy) of six months or less. The patient resided in his/her home.Review of the interdisciplinary group (IDG) meeting notes, dated 03/02/2024, failed to show the following were sent to the attending physician: - The patient’s treatments, symptoms and pain management; - The current plan of care; and - Latest physician orders.During an interview on 05/29/2025 at 10:00 AM, the administrative assistant (AA) stated that there was not a discharge summary for the patient. The AA stated that he/she had drafted a new procedure for discharge summaries at the beginning of 05/2025 but had not started the in-service training. During an interview on 05/29/2025 at 11:50 AM, the administrator stated that they should be including all elements of the discharge summary and that the administrative assistant had created a checklist for a new procedure for the discharge summaries and were awaiting implementation of the new process.”

“Based on policy review, record review, home visit observation, and interview, the provider failed to provide the skilled nursing facility (SNF) with all the required hospice documentation in one of one SNF patient records reviewed (Record/Patient #2). This deficient practice has the potential to affect all the patients residing in nursing facilities served by the provider. Findings included:Review of the provider’s policy titled, “Hospice Care for Acute Care, Skilled Care or Residential Care Facility,” dated 12/02/2008, showed in part the agency (provider) will provide the following documents to the SNF:- Physician certification and recertification; and- Hospice physician and attending physician orders. RECORD/PATIENT #2:Review of the clinical record showed the patient was recertified for hospice services on 05/17/2025 with a terminal diagnosis of acute and chronic respiratory failure (a condition where the lungs cannot adequately exchange oxygen and carbon dioxide in the blood) and hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions). The patient resided at a SNF. Observation on 05/28/2025 at 3:10 PM, showed the hospice binder at the SNF failed to include the following documentation:- Physician certification and recertification; and- Hospice physician and attending physician orders. Per an interview conducted during observation, the hospice registered nurse coordinator (RNC) confirmed that the documents were missing from the hospice binder and stated that the binder should have included the proper documents.”