Saint Francis Hospice

“Based on policy review, record review, and interview, the hospice provider failed to assess and measure wounds in one of five full records reviewed (Record/Patient #2). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the providers policy titled, “;Initial and Comprehensive Assessment,” dated 10/2015, showed in part: - Hospice conducts and documents a patient specific comprehensive assessment that identifies the patients needs for hospice and the patients need for physical care; - This includes all areas of hospice care related to the palliation and management of the terminal illness and related conditions; - The interdisciplinary group (IDG), in consultation with the attending physician, updates the comprehensive assessment as frequently as the patient requires, but no less frequently than every 15 calendar days; - The comprehensive assessment includes data elements that allow for measurement of patient outcomes that are used in individual care planning; and - The update to the comprehensive assessment takes into consideration changes that have taken place since the initial assessment and reassessment of the patients response to care. Review of the providers policy titled, “;Nursing Services,” dated 03/2014, showed in part: - Nursing services ensure that the nursing needs of the patient are met as identified in the patients initial assessment, comprehensive assessment, and updated assessments; - All nursing services are provided in accordance with recognized standards of practice and state specific laws and regulations governing nursing practice; - The comprehensive assessment includes and, when appropriate, triggers a more in-depth assessment, a review of skin integrity; and - Nurses complete a nursing visit note at every visit based on the needs at the time of the visit an as identified in the plan of care (POC). RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice services, on 09/16/2023, with a terminal diagnosis of Parkinsons disease and related diagnoses of a traumatic subdural hematoma (a pool of blood between the brain and its outermost covering) and falls. The patient was legally blind and lived with his/her spouse in an independent living cottage. Review of the skilled nurse (SN) notes showed, in part, the following: - On 03/16/2024, the spouse called to report the patient had a “;red area with a black spot in the center of it” and he/she “;did not know if it was bug bite or spot that may become infected” (the note failed to identify the location of skin issue) and the nurse informed the spouse that they would call “;tomrrow (tomorrow) and see if it was better or worse”; - On 03/17/2024, the SN called the patients spouse to “;check on red spot from yesterday” (the note failed to identify the location of the skin issue) and he/she stated that he/she had applied ointment to the area, and it looked “;so much better”, and SN instructed the spouse to call hospice if the area worsened; - On 03/19/2024, 03/22/2024, and 03/26/2024, the SN visit notes failed to include an assessment of the area and failed to clarify whether the red area with black spot (unknown location), previously reported by the spouse, had resolved or was still present; - On 03/29/2024, the SN note showed that the patient “;has a small sore to left lower (failed to identify location on body), area around sore is red, warm, a bit swollen, and a nodule underneath”. The SN failed to perform any further assessment of the (location unknown) area and failed to measure or give an approximate size or measurement of the area of redness, swelling, or the nodule; - On 04/02/2024 and 04/05/2024, the SN notes showed that the patient “;has a small sore to left lower (failed to identify location on body), area around sore is red with a nodule underneath. Swelling and warmth has decreased, and nodule does not appear to be as big”. The note failed to include any further assessment or measurable data regarding the size of the sore or nodule; - On 04/09/2024, the SN note showed “;sore to left lower back healed, area around is no longer red or warm however continues to have a nodule underneath” The note failed to include any measurement or approximate size of the nodule; - On 04/12/2024, the SN note showed “;nodule to left lower back continues however appears to be decreasing in size, no redness, warmth, or pain noted at this time. The note failed to include any measurement or approximate size of the nodule; - On 04/16/2024, the SN note showed the patient had “;a new skin tear and hematoma (a pool of mostly clotted blood that forms in tissue)” on his/her left leg from a fall on 04/14/2024. Silver gel and Band-aid (brand) were applied with instructions to change every 24 hours. The skin tear was open, red, and had a large amount of sanguineous (bloody) drainage. The surrounding area was swollen, purple and bruised (the note failed to contain measurements of the skin tear); - On 04/19/2024, the SN note showed the left lower extremity skin tear was red, warm, swollen, painful, had scant serosanguinous (a thin watery fluid that is pink in color due to the presence of a small amount of blood) and measured two centimeters (cm) long by one cm wide. The patient complained of pain to the left ankle with movement and bruising and swelling was noted to the left ankle. Bactroban (brand, an antibiotic ointment) was applied to the open sore with a dry dressing, and the spouse was educated to change it twice a day; - On 04/23/2024, the SN note showed the patients left leg wound “;has improved according to (named spouse)” and “;area remains red and edematous (swollen)”. The skin tear was scabbed over, had no drainage, and was left open to air; and - On 04/27/2024, the SN note showed the physician was consulted regarding “worsening” signs and symptoms of cellulitis (inflammation and infection of the skin) to left lower extremity and a skin tear that continued “;to RLE (right lower extremity)” and “;is about 2 (two) cm by 1 (one) cm, periwound is red and a nodule underneath. Small amount of drainage (failed to describe drainage). Shin below skin tear is red, warm, swollen/tight, and painful (failed to assess pain rating). Bactroban applied to open sore with dry dressing during the visit” (previous notes indicate the skin tear was on the left lower extremity). During an interview on 05/01/2024 at 9:50 AM, the administrator stated that the nurse should have followed up, at the next nursing visit, with an assessment of the red area with the black spot reported by the spouse. The nurse should have documented the assessment, even if it was that the area was no longer there or had healed, but something should have been documented. Regarding the area in the undefined left lower location, the redness and nodule on the back, and the skin tear and redness on the left lower extremity, the administrator stated that he/she would have expected to see a wound note with an assessment that contained measurable descriptors or an approximate size of the nodules so worsening or improvement could be determined. They also had a wound specialist that could have been consulted if the nurse was unsure about something or if there was something “;weird” that the nurse needed help with.”

“Based on policy review, record review, and interview, the hospice provider failed to ensure that the patient’s record included an accurate and updated drug profile in, but not limited to, two of five full records reviewed (Records/Patients #4 and #5). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Medication, Medical Supplies, and Durable Medical Equipment (DME) Management,” dated 10/2019, showed in part, an ongoing, updated list of all medications the patient is taking, including over the counter drugs, is maintained in the patient’s clinical record and reviewed by medical director/hospice physician at scheduled interdisciplinary group (IDG) meetings. Record/Patient #4: Review of the clinical record showed the patient was admitted to hospice services on 03/09/2022 with a terminal diagnosis of Alzheimer’s type dementia with late onset (a disease marked by progressive loss of mental capacity), and related diagnoses of altered mental status, nausea, vomiting, diarrhea, recurrent major depressive disorder, and generalized abdominal pain. The patient lived in a long-term care facility (LTCF). Review of the patient’s medication profile showed the following discrepancies between the hospice provider’s and the LTCF’s medication profiles: -The provider’s medication profile showed the patient was taking Gabapentin (used to treat seizures and pain caused by shingles) take 100 milligrams (mg) by mouth three times daily. The LTCF’s medication profile showed the patient was taking Gabapentin 100 mg take one capsule by mouth one time a day for shingles pain; -The provider’s medication profile showed the patient was taking Milk of Magnesia (used to treat constipation) take 10 milliliters (mL) by mouth daily as needed for constipation. The LTCF’s medication profile showed the patient was taking Milk of Magnesia take 30 mL by mouth every 24 hours as needed for constipation; -The provider’s medication profile showed the patient was taking Lorazepam (used to treat anxiety) take 0.5 mg by mouth every two hours as needed for anxiety or agitation. This medication was not on the LTCF medication profile; -The provider’s medication profile showed the patient was taking Bactroban ointment (used to treat skin infections) apply one application topically two times a day as needed. This medication was not on the LTCF medication profile; -The provider’s medication profile showed the patient was taking nystatin powder (used to treat fungal or yeast infections of the skin) apply one application topically in the morning and one application in the evening, this medication was not on the LTCF medication profile; -The LTCF’s medication profile showed the patient was taking Acetaminophen (used to treat mild pain) 325 mg tablets, give two tablets by mouth one time a day for pain. This medication was not on the hospice provider’s medication profile; -The LTCF’s medication profile showed the patient was taking Miralax (used to treat constipation) give 17 grams by mouth every 24 hours as needed for constipation. This medication was not on the hospice provider’s medication profile; -The LTCF’s medication profile showed the patient was taking Refresh Tears solution (used to relieve eye dryness and itchiness) instill one drop in both eyes every 12 hours as needed for redness and irritation. This medication was not on the hospice provider’s medication profile; and -The LTCF’s medication profile showed the patient was taking Refresh Tears solution instill one drop in both eyes two times a day for redness and irritation. This medication was not on the hospice provider’s medication profile. During an interview on 04/29/2024 at 2:00 PM, the hospice administrator stated that he/she would expect the medications to match between the facility records and the hospice provider. RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to hospice services on 03/21/2024 with a terminal diagnosis of hypertensive heart and renal (kidney) disease with congestive heart failure (a decrease in the ability of the heart to pump blood due to chronic high blood pressure) and related diagnoses of type 2 diabetes mellitus (a group of diseases that results in too much sugar in the blood), end stage renal disease, heart failure, and history of bladder cancer. Review of skilled nursing (SN) note dated 04/25/2024, showed per [named doctor], patient will start Flomax (used to treat enlarged prostate) 0.4 mg daily. Review of the medication profile failed to show an order for Flomax. During an interview on 05/01/2024 at 9:36 AM, the hospice administrator stated that he/she would expect the Flomax order to be included on the medication list.”

“Based on policy review, record review, and interview, the hospice provider failed to ensure all treatments necessary to meet the needs of the patient were included on the plan of care (POC) in three of five full records reviewed (Records/Patients #3, #4, and #5). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Plan of Care - Revised,” dated 10/2015, showed, in part, the POC includes all services necessary for the palliation and management of the terminal illness and related conditions and includes: -interventions to manage pain and symptoms; -drugs and treatments necessary to meet the needs of the patient; -medical supplies and appliances necessary to meet the needs of the patient; and -prescribed and required medical equipment. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to hospice services on 03/20/2024 with a terminal diagnosis of breast cancer and related diagnoses of malignant neoplasm of bone (bone cancer that has spread from its original site), secondary cancer of the brain, vascular dementia (dementia caused by impaired blood supply to the brain), and major depressive disorder. The patient lived at home with caregivers. Review of the clinical record showed the following: -On 04/02/2024, the skilled nurse (SN) documented that four Mepilex (brand, a foam bordered dressing) were delivered to the patient to prevent skin breakdown; -On 04/09/2024, the SN documented that five Mepilex were delivered to the patient to prevent skin breakdown; and -On 04/19/2024, the SN documented that a Hoyer lift (a mechanical lift used for transferring patients) was delivered to patient’s home to assist with patient transfers. Review of the POC failed to show orders for these interventions. During an interview on 05/01/2024 at 10:00 AM, the administrator stated that he/she could not find orders for these interventions and would expect them to be included on the POC. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to hospice services on 03/09/2022 with a terminal diagnosis of Alzheimer’s type dementia with late onset (a disease marked by progressive loss of mental capacity), and related diagnoses of altered mental status, nausea, vomiting, diarrhea, recurrent major depressive disorder, and generalized abdominal pain. The patient lived in a long-term care facility (LTCF). Review of the SN notes, dated from 04/15/2024-04/22/2024, showed the patient was receiving skin prep daily to heels due to heels being “squishy”. Review of the POC failed to show an order for skin prep to bilateral heels daily. During an interview on 05/01/2024 at 10:00 AM, the administrator stated that he/she could not find an order for this treatment and would expect it to be on the POC. RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to hospice services on 03/21/2024 with a terminal diagnosis of hypertensive heart and renal (kidney) disease with congestive heart failure (a decrease in the ability of the heart to pump blood due to chronic high blood pressure) and related diagnoses of type 2 diabetes mellitus (a group of diseases that results in too much sugar in the blood), end stage renal disease, heart failure, and history of bladder cancer. Review of the clinical record showed the patient had the following skin concerns and/or hospice-provided interventions: -Sterile dressing changes to a hemodialysis catheter site in the inner jugular (side not specified); and -A heel lift boot applied to a deep tissue injury (pressure injury of purple or maroon discolored intact skin or a blood-filled blister with unknown underlying damage) on the foot (side unspecified). Review of the POC failed to show orders for the sterile dressing change to the hemodialysis catheter site and failed to show orders for the heel lift boot application. During an interview on 05/01/2024, the patient care manager stated that he/she could not find these orders and would expect them to be included on the plan of care.”

“Based on record review and interview, the hospice provider failed to obtain a discharge summary from the long-term care facility (LTCF) upon discharge from in-patient respite care in one of two in-patient records reviewed (Record/Patient #6). This deficient practice has the potential to affect the coordination of care for all patients served by the provider. Findings included: RECORD/PATIENT #6: Review of the clinical record showed the patient was admitted to the LTCF for respite care on 10/14/2023 and was discharged on 10/17/2023. The record failed to include a discharge summary from the LTCF. During an interview on 05/01/2024 at 10:00 AM, the administrator provided this surveyor with a discharge summary. The document had a fax stamp on it of 05/01/2024 at 9:18 AM. The administrator admitted the discharge summary had been received that morning.”

“Based on policy review, record review, and interview, the hospice provider failed to notify the physician of missed visits and failed to follow physician orders in one of five full records reviewed (Record/Patient #1) and failed to notify the physician of low blood pressure in one of five full records reviewed (Record/Patient #3). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Registered Nurse” dated 02/07/2024, showed, in part, the registered nurse relays all pertinent health information to attending physician. RECORD/PATIENT #3: Review of the clinical record showed patient admitted to hospice services on 03/20/2024 with a primary diagnosis of breast cancer and secondary diagnoses of malignant neoplasm of bone (a disease in which abnormal cells divide uncontrollably and destroy body tissue), secondary cancer of the brain, vascular dementia, and major depressive disorder. The patient lived at home with caregivers. Review of the skilled nurse (SN) note dated 04/16/2024 showed the patient had a blood pressure of 102/50; Review of the SN note dated 04/23/2024 showed the patient had a blood pressure of 89/35; and Review of the SN note dated 04/26/2024 showed the patient had a blood pressure of 98/48. Review of the clinical record failed to show notification of physician of the abnormal blood pressure readings. During an interview on 04/30/2024 at 9:00 AM, the hospice administrator stated that he/she would have expected the physician to be notified of the change in condition at the following IDG meeting or would have expected the nurse to recheck the blood pressure to ensure accuracy. RECORD/PATIENT #1: Review of the providers policy titled, “;Physician Orders,” dated 09/2014, showed visit frequencies on the plan of care (POC) are considered physician orders for visits. Review of the clinical record showed the patient was admitted to hospice services on 03/28/2024 with a terminal diagnosis of chronic hypoxic respiratory failure (occurs when there is not enough oxygen in the bloodstream) with related diagnoses of sarcoidosis (the growth of tiny collections of inflammatory cells in different parts of the body) and pulmonary fibrosis (scarring of the lungs that make it difficult to breathe). The patient was dependent on continuous supplemental oxygen and lived in a long-term care facility (LTCF) initially and was able to return home with his/her spouse on 04/24/2024. Review of the POC, dated 03/28/2024, showed physical therapy (PT), one visit a week for 04/04/2024 to 04/06/2024 then one to two visits a week for two weeks effective 04/07/2024. Review of the case communication note, dated 04/04/2024, showed the PT arrived at the LTCF and the patients spouse stated that the patient had already walked that day and they did not want to do any further activity. The PT offered to see the pt the following day, but they declined because they planned to change rooms the following day and all agreed to seeing the patient the following week. Review of the PT visit notes showed, in part: - On 4/10/2024, the patient worked with PT and was given instructions that the patient would be seen by PT one to two times a week for two weeks for home exercise program instruction, mobility regarding gait and transfers, and bed mobility as patient is able; - On 04/11/2024, a missed visit note that showed the patients spouse met the PT at the door and informed the PT “;that they are just going to continue exercises and activity on their own”; and - The PT failed to notify the physician that the patient and family had refused the initial evaluation visit on 04/04/2024 and had requested to end further visits. Review of the interdisciplinary group (IDG) / POC update, dated 04/24/2024, showed PT goals and interventions were resolved on 04/24/2024 but failed to show the physician was notified that the patient only received one PT visit. During an interview on 05/01/2024 at 9:50 am, the administrator stated that the expectation is for the team to be notified in IDG so the doctor is made aware when orders cannot be fulfilled. He/she believed the physician was told but could not find where it was documented. Review of the providers policy titled, “;Nursing Services,” dated 03/2014, showed in part, nursing services ensure that the nursing needs of the patient are met as identified in the patients initial assessment, comprehensive assessment, and updated assessments. All nursing services are provided in accordance with recognized standards of practice and state specific laws and regulations governing nursing practice. Review of the POC, dated 03/28/2024, and POC updates dated 04/10/2024 and 04/24/2024, showed the following wound assessment orders to be performed at each nursing visit (for the wound on the patients coccyx (tailbone)): - Assess drainage for serous (clear watery fluid), serosanguinous (a thin watery fluid that is pink in color due to the presence of a small amount of blood), sanguineous (bloody), purulent (containing pus), mucoid (containing mucus) noting color, character, and odor; - Assess for signs and symptoms of infection such as color changes, redness, swelling, warmth, pain, fever; - Assess peri-wound (skin immediately surrounding the wound) and surrounding tissue noting maceration (skin softening from exposure to moisture), erythema (redness), edema (swelling), ecchymosis (bruising), warmth, induration (thickening of the skin), denuded (loss of skin and underlying layers), excoriation (abrasion), hemosiderin staining (dark patches on skin caused by blood leaking from small vessels); and - Assess and observe wound tissue or incision healing status noting eschar (dead tissue that forms over healthy skin), slough (yellow/white material in a wound bed), granulation (the development of new tissue and blood vessels), hypergranulation (excessive formation of new tissue), epithelial (pink tissue that occurs in the final stage of healing), scabbing. Review of SN notes showed, in part, the following: - On 03/29/2024, the SN failed to assess the wound for drainage, the periwound and surrounding tissue, or the wound tissue and healing status; - On 04/04/2024, the SN failed to assess the wound for signs and symptoms of infection, wound drainage, periwound and surrounding tissue, and the wound tissue and healing status; - On 04/11/2024, the SN failed to assess the wound drainage, periwound and surrounding tissue, and the wound tissue and healing status; and - On 04/18/2024, the SN failed to assess for signs of infection, wound drainage, periwound and surrounding tissue, and the wound tissue and healing status. During an interview on 04/30/2024 at 11:54 AM, the administrator stated that he/she would have expected the nurse to do the assessments at every visit as ordered by the physician.”

“Based on policy review, record review, and interview, the hospice provider failed to obtain physician orders for wound treatment in one of five full records reviewed (Record/Patient #2). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the providers policy titled, “;Physician Orders,” dated 09/2014, showed in part, only a physician may provide orders for the patient. Review of the providers policy titled, “;Nursing Services,” dated 03/2014, showed in part, nursing services ensure that the nursing needs of the patient are met as identified in the patients initial assessment, comprehensive assessment, and updated assessments. All nursing services are provided in accordance with recognized standards of practice and state specific laws and regulations governing nursing practice. RECORD/PATIENT #2: Review of the SN notes showed, in part, the following: - On 03/16/2024, the spouse called to report the patient had a “;red area with a black spot in the center of it” and he/she did not know if it was bug bite or spot that may become infected (the note failed to identify the location of skin issue) and the nurse instructed the spouse to apply triple antibiotic ointment (TAO- an antibiotic ointment that contains neomycin, bacitracin, and polymixin) to the area; - On 03/17/2024, the SN called the patients spouse to “;check on red spot from yesterday” (the note failed it identify the location of the skin issue) and he/she stated that he/she had applied TAO to the area, and it looked “;so much better” and SN instructed the spouse to continue to apply the TAO to the area and call hospice if the area worsened; and - The record failed to contain a physician order for the TAO. During an interview on 05/01/2024 at 9:50 AM, the administrator stated that the nurse should have gotten a physician order for the TAO before instructing the patient to apply it to the wound.”

“Based on policy review, record review, and interview, the hospice provider failed to send a copy of the patients discharge summary to the patients attending physician in two of two revocation records reviewed (Records/Patients #8 and #9). This deficient practice has the potential to affect the continuity of care for all patients discharged from hospice services. Findings included: Review of the providers policy titled, “;Discharge or Transfer of Care Summary,” dated 11/2021, showed in part, the hospice provides the attending physician with a discharge summary when a patient revokes or is discharged from hospice. RECORD/PATIENT #8: Review of the clinical record showed the patient was admitted to hospice on 01/30/2024, with a terminal diagnosis of intra-abdominal abscess (a swollen area in the abdomen containing pus). He/she lived at home with his/her elderly parent. The patient made the decision to revoke hospice so he/she could continue to go to his/her doctor appointments and seek treatment for his/her condition on 01/31/2024. The hospice failed to send a discharge summary to the patients attending physician. RECORD/PATIENT #9: Review of the clinical record showed the patient was admitted to hospice on 01/06/2024, with a terminal diagnosis of acute respiratory failure with hypoxia (low oxygen in the bloodstream). The patients condition improved, and he/she made the decision to revoke hospice on 03/15/2024. The hospice failed to send a discharge summary to the patients attending physician. During an interview on 05/01/2024 at 9:55 AM, the administrator stated that they sent a message to the attending physician informing him/her of the revocation, but they did not have proof that it was sent. Their software would not allow them to send a summary of the hospice stay and he/she contacted the information technology (IT) department to build something into their system to generate a summary of the patients stay. They are working on fixing the problem.”

“Based on policy review, observation, and interview, the hospice provider failed to provide the long-term care facility (LTCF) with a copy of the physician certification of terminal illness (CTI) and hospice election form in one of one home visits conducted in a LTCF (Record/Patient #4). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Coordination of Care - Nursing Facility,” dated 09/2014, showed, in part, the following: Hospice provides the facility with the following information for each hospice patient: -Hospice election form; and -Physician certification and recertification of the terminal illness. RECORD/PATIENT #4: Observation on 04/28/2024 showed the LTCF hospice binder failed to contain a copy of the hospice election form and the physician certification/recertification of terminal illness. During an interview on 04/28/2024 at 12:00 PM, the hospice administrator stated that he/she would expect those items to be in each patient’s facility binder.”