Stillwater Hospice

“Based on interview and record review, the agency failed to review and update their emergency preparedness policy and procedures every two years. This deficient practice had the potential to affect all staff and patients receiving services. Findings include: Review of the agency’s Emergency Preparedness policies and procedures showed the policies were last revised May 2023. During an interview on 6/19/25 at 11:06 a.m., staff member A stated their policies and procedures were purchased and updated by and through a policy group which follows the accreditation body standards. The policies and procedures would be reviewed and updated every year in November. Staff member A stated they have not yet reviewed or updated the policies and procedures for emergency preparedness for this year.”

“Based on observation, interview, and record review, the agency failed to ensure the continued assessment and evaluation of a patient’s skin integrity was completed when a Stage 2 pressure ulcer was identified upon admission for 1 (#2) of 4 sampled home visit patients. Findings include: During an observation on 6/18/25 at 10:18 a.m., staff member G assisted with the changing of an incontinence brief for patient #2. Staff member G stated the dated bandage on patient #2’s coccyx was for protection only. Staff member G stated patient #2 had a stage 2 coccyx pressure ulcer upon admission, which was now healed. Review of patient #2’s document titled, RN Initial Assessment Visit, dated 5/14/25, showed under Integumentary Assessment:-“WNL: No,-... Skin Integrity: Wounds,-Integumentary-Documentation/Teaching: healing stage 2 coccyx,-Type of Wound: Pressure Ulcer,-Location of Wound: Healing stage 2,-Stage of Pressure Ulcer: Stage II,-Length: 1,-Width: 0.5, and-Depth: 0.1. ...” Review of patient #2’s document titled, SN Routine Visit, Service Note, dated 5/19/25, showed under Hospice Routine Skin Assessment:-“WNL: Yes, -... Number of Incision/Wound Sites: 1, and-... Wound Site #1: Not Evaluated. ...”No evaluation of the admission stage 2 pressure ulcer was documented in the skin assessment areas to be checked or in the narrative nursing note. Review of patient #2’s document titled, SN Routine Visit, Service Note, dated 5/28/25, showed under Hospice Routine Skin Assessment:-“WNL: No, and-Skin Integrity: Not evaluated. ...”No evaluation of the admission stage 2 pressure ulcer was documented in the skin assessment areas to be checked or in the narrative nursing note. Review of patient #2’s document titled, SN Routine Visit, Service Note, dated 6/3/25, showed under Hospice Routine Skin Assessment:-“WNL: Yes,-Skin Integrity: Intact, and-... Number of Incision/Wound Sites: blank. ...”No evaluation of the admission stage 2 pressure ulcer was documented in the skin assessment areas to be checked or in the narrative nursing note. Review of patient #2’s document titled, SN Routine Visit, Service Note, dated 6/4/25, showed under Hospice Routine Skin Assessment:-“WNL: No, and-Skin Integrity: Intact, and-... IDT Comments: ... Existing dressing present on coccyx removed, pressure ulcer previously reported now considered healed. Area cleansed and foam dressing placed for protection. ...” During an interview on 6/18/25 at 10:32 a.m., staff member G stated for patient #2, during the first visit of the week, a full head to toe assessment was completed and documented. During an interview on 6/18/25 at 12:41 p.m., staff member A stated if a patient had a wound, the expectation for the nurse would be assessment and documentation of the wound once a week. Staff member A stated if a wound was assessed by a nurse, there would be documentation in the assessment and/or a narrative note by the nurse.”

“Based on observation, interview, and record review, staff member G failed to adhere to proper infection control practices related to hand hygiene and changing of gloves between dirty and clean tasks, during peri-care for 1 (#2) of 4 sampled home visit patients. Findings include: Review of the agency’s policy titled, Hand Hygiene, last revised May 2023, showed: -… “3. Hand decontamination using an alcohol-based hand rub should be performed:-… G. After removing gloves. Review of the agency’s policy titled, Standard Precautions, last revised May 2023, showed: -... “1. Gloves:-... C. Gloves are to be changed:-1. Between tasks and procedures on the same patient-2. During changing or cleaning an incontinent patient. ...” During an observation on 6/18/25 at 10:17 a.m., staff member G entered patient #2’s room, doffed her gloves, then donned clean gloves. Staff member G did not perform hand hygiene before she donned the clean gloves. Staff member G assisted in the transfer of patient #2 to his bed, the changing of his incontinence brief, and the repositioning of patient #2. During an observation on 6/18/25 at 10:23 a.m., staff member G still wore the same gloves which were worn during the changing of patient #2’s incontinence brief and repositioning. Staff member G moved a pillow to the right side to patient #2’s body for offloading his hip, readjusted his sheet and blanket, and moved another pillow in between patient #2’s legs. Staff member G did not doff her dirty gloves or don new gloves before moving to a clean task. During an interview on 6/18/25 at 10:42 a.m., staff member G stated hands should be sanitized when gloves were doffed and before clean gloves were donned. Staff member G stated gloves should be changed between dirty and clean tasks. During an interview on 6/18/25 at 12:52 p.m., staff member A stated hand hygiene should be completed after the removal of gloves. Staff member A stated gloves were expected to be changed when moving from a dirty to a clean task.”