Transitions Lifecare

“Based on agency policy, clinical record review, and staff interviews, the nurses failed to document physician’s orders to discharge 2 of 3 discharged patients (# 1 & 2). Findings included: A policy, Live Discharges (undated 1/24/26) received on 6/22/26 at 11:33 AM from the Director of Quality stated, “RNCM (registered nurse case manager) secures discharge orders from the hospice physician…”1. Patient #1 was admitted on 10/08/25 with a diagnosis of cerebral atherosclerosis (thickening and hardening of the arteries in the brain). The plan of care for 4/6/26-6/1/26 included orders for skilled nurse visits 1 time a week for 9 weeks and on 5/19/26 initiate “discharge monitoring.” Review of the clinical record revealed that on 6/1/26 RN #3 discharged the patient due to the patient no longer being terminally ill. Further review revealed that there was no documentation of a physician’s order to discharge the patient.During an interview conducted on 6/22/26 at 3:02 PM RN #3 stated, “We did [have a verbal order from the doctor]. I forgot to put the order in (the clinical record).”2. Patient #2 was admitted on 3/25/26 with a diagnosis of cerebral atherosclerosis. The plan of care for 3/25/26-6/18/26 included orders for skilled nurse visits 1 time a week for 1 week, 1 time a week for 13 weeks with 3 PRN (as needed). Review of the clinical record revealed that RN #4 discharged the patient due to the patient no longer being terminally ill. Further review revealed that there was no documentation of a physician’s order to discharge the patient.During an interview conducted on 6/22/26 at 3:07 PM RN #4 stated, “I do (get an order for a discharged), but I apparently I didn’t put it in (the clinical record), I usually do enter the orders.”An interview conducted with the Director of Quality and Compliance on 6/22/26 at 3:10 PM revealed that the expectation is for the nurses to obtain a verbal order from the hospice physician and enter it into the clinical record.”

“Based on agency policy, clinical record review, and staff interviews, the agency failed to provide effective symptom control for 2 of 6 discharged patients (#1 and 5).Findings included: A policy, Pain/Symptom Management, Assessment and Follow-up (revised 6/1/24), received on 5/12/26 at 10:22 AM from the Director of Quality and Compliance stated, “The patient has the right to receive effective pain and symptom control from the hospice… An action plan is always required when a patient’s pain is not managed to their satisfaction…”1. Patient #1 was admitted on 2/27/25 with a diagnosis of Alzheimer’s disease (impaired mental functioning). Patient #1 was a resident of a skilled nursing facility. The plan of care for 2/27/25-5/27/25 included orders for skilled nursing visits 2 times a week for 1 week with 13 PRN (as needed) and “Oxygen 6-8 LPM [liters per minute] Cont [continuously] NC [nasal cannula].” Review of the clinical record revealed that on 3/3/35 at approximately 2:15 PM registered nurse (RN) #10 documented, “Oxygen: Oxygen – liters/minute 4, nasal cannula…” and on 3/3/25 at approximately 7:33 PM RN #11 documented, “Received pt [patient] very agitated & restless, pulling O2 [oxygen] off… HR [heart rate] 104-RR [respiratory rate] 28 (labored on 4LPM). He has received a PRN dose of morphine & lorazepam at 4:00PM without change in symptoms & a scheduled dose of both meds [medications] at 6:00PM… NP [nurse practitioner name] called & received new orders… Pt passed away prior to adm [administration] of additional meds.”RN #11 was not available for an interview.During an interview on 5/12/26 at 10:25 AM the Director of Quality and Compliance stated, “She’s [nurse] going to do everything that she can to address is comfort and see what orders are available to manage any symptoms of being in distress. She should have confirmed the oxygen order and implemented it to address his needs.”2. Patient #5 was admitted on 2/13/26 with a diagnosis of Cerebral atherosclerosis (buildup of plaque in the arteries of the brain). The patient was a resident of a facility. The plan of care for 2/13/26-3/18/26 included order for skilled nurse (SN) visits 1 time a week for 1 week, 1 time a week for 13 weeks with 3 PRN (as needed) and beginning 3/1/26 SN visits 2 times a week for 11 weeks. Review of the clinical record revealed that on 3/16/26 at 11:48 AM the triage nurse documented, “Message received that [facility staff name] called to report pt [patient] has another wound on bottom and would like a nurse to assess. [facility staff name] reports pt also has pain and they have used all PRNS [as need medications], [indicating the patient was still having pain] Message sent to CM [RN #5, case manager’s name]. Thumbs up received from CM.” Further revealed that there was no documentation of any visit, call, or change to the plan of care to manage pain.During an interview conducted on 5/11/26 at 2:56 PM RN #5 stated, “I may not have documented directly, I am pretty sure I did [call them back], I went the next day.”During an interview conducted on 5/11/26 at 3:15 PM the Vice President of Clinical Services stated, “Every phone call we do to facilities should be documented. Pain should always be addressed immediately.””

“Upon patient record review, 3 of 30 (Patient #6,11,12) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #6-1/7/25 Hydrocortisone cream, apply 1 thin layer TID, no evidence of location to apply cream on the medication profile. Corrected on Site. Patient #11-1/2/25 Nystatin powder, apply small amount thin layer BID, no evidence of location to apply powder on the medication profile. Corrected on Site. Patient #12-5/2/25 Fluconazole orders for 5 days PO and Cipro for 3 days PO, no evidence that medication was discontinued on the medication profile. Corrected on Site.”

“Upon patient record review, 1 of 30 (Patient #5) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family’s needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient #5-3/3/25, wound care orders for upper left arm in place, SN on 3/17/25 states skin tear is healed and skin in intact, no evidence of updated skin assessment. Corrected on Site.”

“Upon patient record review, 3 of 30 (Patient #6,11,12) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #6-1/7/25 Hydrocortisone cream, apply 1 thin layer TID, no evidence of location to apply cream on the plan of care. Corrected on Site. Patient #11-1/2/25 Nystatin powder, apply small amount thin layer BID, no evidence of location to apply powder on the plan of care. Corrected on Site. Patient #12-5/2/25 Fluconazole orders for 5 days PO and Cipro for 3 days PO, no evidence that medication was discontinued on the medication profile. Corrected on Site”

“Upon patient record review, 2 of 15 (Patient #5,12) did not have evidence that a revised plan of care includes information from the patient’s updated comprehensive assessment and must note the patient’s progress towards outcome/goals from the plan of care. Patient #5-3/3/25 wound care orders for upper left arm in place, SN on 3/17/25 states skin tear is healed and skin in intact, no evidence of revised POC for integumentary. Corrected on Site. Patient #12-5/2/25 Fluconazole orders for 5 days PO and Cipro for 3 days PO, no evidence that medication was discontinued on the medication profile and POC updated. Corrected on Site”

“Based on agency policy, clinical record review, and staff interviews the agency failed to report an allegation of abuse to the health care personnel registry within 24 hours after learning of the allegation and failed to submit a finding of the investigation within 5 days for 1 of 1 patient who alleged he had been kissed by the nursing assistant [#1]. The findings included: A policy, Reporting Violations Involving Mistreatment, Neglect or Abuse [12/3/24], was provided by the RN # 2 on 4/28/25 at 1:41 pm. The policy stated, “_____ [agency name] ensures that verified violations are reported to ________ [deeming body] and DHSR [Division of Health Service Regulation within 5 business days...” Patient # 1 had a Start of Care date of 3/6/25 with terminal diagnoses of other malignant neuroendocrine tumors [a cancerous growth that originates from neuroendocrine cells], secondary carcinoid of liver, and secondary carcinoid tumors of the bone. The patient was admitted to _______ [inpatient hospice unit]. Review of the agency’s incident log on 4/28/25 revealed an incident report [no date]. Review of the incident report revealed the patient had reported to the RN [on 4/3/25] who was administering his medications that nursing assistant # 1 had kissed him that morning. The patient reported the nursing assistant kissed him on his lips and indicated the aide had come into his room that morning to give him a hug and “swooped in and kissed him on the lips.” The patient went on to state this action “made him very uncomfortable”. Further review of the incident report revealed the agency failed to notify the health care personnel registry of the alleged incident. The agency also failed to report the alleged incident within 24 hours of the patient reporting the incident. The agency also failed to submit their findings after the investigation within 5 days. During a phone interview with the agency’s chief compliance officer on 4/28/25 at approximately 12:15 pm, the compliance officer stated, “Yes, I knew we had to do that. I just failed to take care of it.””