Hospice of St Peters Comm Hosp

“Based on observation, interview and record review, the agency failed to accurately stage a Stage 2 pressure injury¹ and ensure services were provided as outlined in the plan of care for the assessment, measurement, evaluation, and the healing and treatment regimen of a Stage 2 pressure Injury, for 1 (#11) of 19 sampled patients; and failed to ensure staff used a gait belt for the safe transfer of 1 (#6) of 4 sampled patients for home visits. Findings include: 1. Inaccurately Staged Pressure Injury ¹ Pressure injury staging, using the National Pressure Injury Advisory Panel (NPIAP) system, describes staging of pressure injuries for Stage 1 and Stage 2 as:“Stage 1: Stage 1 pressure injuries are defined by intact skin with non-blanchable redness, and do not involve an open wound.Stage 2: An open shearing pressure injury is a Stage 2 pressure injury because it involves partial-thickness skin loss with an exposed dermis…”Review of patient #11’s Admission Nursing Assessment, dated 8/3/25, showed:- Wound Assessment: “left hip/trochanter, shearing wound due to bedbound status, no signs of infection, open, peeling, redness…” The Wound Assessment did not provide a staging for the open shearing pressure injury of the left hip. - Problem: Wound Care: “Clinician to perform dressing change to left hip stage 1 skin shear.” The clinician staged the open pressure injury as shearing Stage 1. Stage 1 pressure injuries as defined by the NPIAP are identified as skin is intact. The assessment showed the skin on the shearing pressure injury was open. Based on NPIAP, an open shearing pressure injury is a Stage 2 pressure injury because it involves partial-thickness skin loss with an exposed dermis. 2. Provide Services as Outlined on Plan of Care Review of patient #11’s Hospice Admission Plan of Care, dated 8/1/25, showed:- Problem: Wound Care: “perform complete wound assessment at least weekly including wound measurement, evaluation of periwound and wound bed, evaluation of healing and treatment regimen.”Review of patient #11’s Admission Nursing Assessment, dated 8/3/25, showed:- Encounter Notes, “…[Patient #11] is able to report mild/moderate discomfort, main location in left hip where skin breakdown is occurring. He describes the pain as sore, ache and sting, it is infrequent more present during movement or pressure to left side. He is bedbound and due to skin beginning to breakdown with increasing pain, QOL has decreased as he cannot seem to get comfortable when on left side. Able to visualize shearing skin injury to left hip but unable to assess back at time of visit due to company…” - Pain Assessment, “Pain reported by patient in left hip, with a severity of 3/10, since skin breakdown/shearing occurred… - Braden Scale (used to assess a patient’s risk of developing a pressure injury) showed a score of 11(A Braden score of 11 indicates a high risk for developing pressure injuries).- Wound Assessment: “left hip/trochanter, shearing wound due to bedbound status, no signs of infection, open, peeling, redness…” The Wound Assessment did not include wound measurement. Review of patient #11’s Skilled Nursing Visits on 8/5/25, 8/12/25, 8/18/25, and 8/24/25, did not show the pressure injury was assessed at least weekly, including wound measurement, evaluation of periwound and wound bed, and evaluation of healing and treatment regimen. During an interview on 8/26/25 at 3:58 p.m., staff member B stated the expectation was to follow the patient plan of care. She stated it does not appear the wound assessment for patient #11 was completed during the skilled nurse visits. She stated the interventions were checked off in the EMR when completed. She stated however, to include the wound assessment, an additional section would need to be entered into the note to complete the wound assessment documentation. A request for the agency’s policy and procedure for wound care and management was requested on 8/26/25 at 5:00 p.m. No policy and procedure for wound care and management was provided by the end of the survey. During an interview on 8/27/25 at 8:15 a.m., staff member A stated the agency did not have a policy and procedure for wound care or management. 3. Safe Patient Transfer A review of the agency’s policy and procedure titled, Safe Patient Handling, with an approved date of 7/1/25, showed, “…Procedure: 2. Safe Patient Handling and Movement Requirements:a. All patients shall be assessed using the algorithms to determine risk status.b. All algorithms of the care plan are to be adhered to by all employees when moving a patient. Failure to comply with the care plan algorithm will be subject to disciplinary action by the Director/Manager.c. Avoid hazardous patient handling and movement tasks whenever possible. Use gait belts when physical assistance is needed for all inpatients unless using a mechanical lift. If unavoidable, assess them carefully prior to completion.d. Use mechanical lifting devices and other approved patient handling aids for high-risk patient handling and movement tasks except when absolutely necessary, such as a medical emergency…”[sic]Patient #6 had a primary diagnosis of hypertensive heart disease with heart failure and congestive heart failure.A review of patient #6’s Plan of Care updated on 8/21/25, showed an MAHC-10 Assessment (Missouri Alliance for Home Care Fall Risk Assessment Tool, a standardized, validated, and multifactorial assessment used in home health care to identify older patients at risk for falls) with a score of 7. A MAHC-10 score of 7 indicates a high risk for falls in a home healthcare setting. A review of patient #6’s Plan of Care updated on 8/21/25, showed a history of falls /fall risk related to disease progression. Recent falls without injury related to disease progression. Lacks safety awareness. The plan of care showed an intervention to assess appropriate use of assistive devices, and interdisciplinary involvement with focused therapy to evaluate balance, gait, transfers, and assistive devices.During an observation on 8/26/25 at 11:35 a.m., patient #6 was seated in a recliner. She was wearing oxygen and had a walker next to her chair. Patient #6 expressed to staff member P that she was feeling weak. Staff member P attempted to assist patient #6 into a standing position from her recliner. Staff member P attempted twice to assist patient #6 from her recliner into a standing position, and both times the patient was not able to stand up and immediately sat back down into her recliner. Staff member P did not utilize a gait belt during the transfer of the patient from a sitting to a standing position, or while the patient ambulated from the living room to the bathroom located in her bedroom. Staff member P did not utilize a gait belt to assist the patient onto and off the toilet, while transferring into the shower and out of the shower, or from her chair in the bathroom and back to her recliner in the living room. During an interview on 8/26/25 at 12:23 p.m., staff member P stated she should have used a gait belt but did not have one with her during the home visit. During an interview on 8/27/25 at 5:00 p.m., staff member A stated all staff should have gait belts available for home visits and use them for the safe transfer of patients. Citations: ¹ Mondragon, N. (2024, February 28). Pressure injury. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK557868/#:~:text=A%20staging%20system%20should%20be,discoloration%20%5B1%5D%5B2%5D”

“Based on observation, interview, and record review, the agency failed to ensure standard precautions for hand hygiene and glove changes were used to prevent the potential of infection transmission for 1 (#6) of 4 patients observed during home visits. Findings include: During an observation on 8/26/25 at 11:35 a.m., staff member P donned gloves and went to patient #6’s laundry room, where she checked the patient’s dirty laundry for a night gown. While wearing the same gloves, staff member P turned up the patient’s oxygen concentrator and assisted the patient to a standing position and assisted her onto the toilet in the bathroom. Staff member P flushed the toilet and assisted the patient off the toilet and onto a chair in the bathroom. Staff member P assisted with undressing the patient before helping the patient into the shower. Staff member P did not change her gloves or perform hand hygiene between any of the observed tasks.During an interview on 8/26/25 at 12:23 p.m., staff member P stated she did not change her gloves until the patient was in the shower.During an interview on 8/27/25 at 5:00 p.m., staff member A stated staff have received training on hand hygiene and glove changes.A review of the agency’s policy and procedure titled, Home Health and Hospice Infection Control Plan, with a approved date of 12/26/24, showed, “…Procedure: 1. Hand Hygiene:a. Hand hygiene includes both handwashing with either plain or antiseptic-containing soap and water, and use of alcohol-based products that do not require the use of water.b. Hand hygiene should be performed at a minimum: Before contact with a patient; before performing an aseptic task; after contact with the patient or objects in the immediate vicinity of the patient; after contact with blood, body fluids or contaminated surfaces; moving from a contaminated body site to a clean body site during patient care; and after removal of personal protective equipment (PPE)…””

“Based on interview and record review, the agency failed to document and demonstrate the viable and ongoing efforts to recruit and retain volunteers for the hospice program. Findings include: During an interview on 8/26/25 at 11:36 a.m., staff member G stated the agency did not have documentation which supported the agency’s efforts for recruitment of volunteers for the hospice program.A request was submitted for the documentation of the volunteer program recruitment efforts on 8/26/25. No additional documentation was provided by the end of survey.During an interview on 8/27/25 at 8:15 a.m., staff member A stated she checked with staff member G and he did not have supporting documentation of the agency’s volunteer recruitment efforts.”