Hospice of Wilson Medical Center

“Based on agency policy, clinical record review, and staff interviews, the agency failed to develop an individualized plan of care for 1 of 2 patients with a colostomy (artificial opening in the abdominal wall for the passage of stool) (#4) and 1 of 2 patient with a mechanical lift (#17).Findings included: A policy, Plan of Care (revised 10/01/24) received on 7/15/26 at 10:15 AM from the Executive Director stated, “The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including the following… Drugs, biologicals and treatments necessary to meet the needs of the patient. Durable medical equipment, medical supplies and appliances necessary to meet the needs of the patient.”A policy, Physician’s Orders (revised 10/1/24), received on 7/15/26 at 10:15 AM from the Executive Director stated, “Services are provided according to the most recent orders updating the patient’s plan of care.”accurate…”1. Patient #4 was admitted on 6/18/26 with a diagnoses of other sequelae of other cerebrovascular disease (long-term effects following a stroke) and colostomy status (artificial opening in abdomen for the passage of stool). The plan of care for 6/18/26-8/16/26 included orders for skilled nurse (SN) visits 1 time a week for 1 week, 3 times a week for 8 weeks with 3 PRN (as needed). Review of the clinical record revealed that on 6/18/26 registered nurse (RN) #11 documented, “Patient also has a colostomy bag. Patient’s stoma (surgically created opening) is pink and moist.” On 6/22/26 RN #9 documented, “Patient has a colostomy bag noted with brown stool.” On 7/6/26 RN #9 documented, “Patient has an ostomy bag that is clean and intact.” Further review revealed that the colostomy was not included in the plan of care.During an interview conducted on 7/15/26 at 9:30 AM RN #11 stated, “I don’t see the ostomy on the plan of care, I should have added it at that time.”RN #9 was not available for an interview.2. Patient #17 was admitted on 3/10/26 with a diagnosis of motor neuron disease (progressive neurological disorder). The plan of care (POC) for 6/8/26-9/5/26 included orders for skilled nurse visits 1 time a week for 13 weeks with 3 PRN (as needed). Review of the clinical record revealed that on 6/10/26 RN #13 documented, “This RN demonstrated to daughter how to use Hoyer [brand name of a mechanical lift].” On 7/8/26 RN #13 documented, “Hoyer lift in home and daughter educated on use.” Further review revealed that there were no orders in the plan of care for a mechanical lift.During an interview conducted on 7/15/26 at 8:58 AM RN #13 stated, “I honestly do not know [if the lift included in the POC] I will need to put that in…. Normally I would create a POC for new DME.”During an interview conducted on 7/15/26 at 11:48 AM the Executive Director stated, “The plan of care should be personalized and updated as needed.””

“Based on agency policy clinical record review, and staff interviews, the registered nurses and medical social workers failed to provide accurate documentation in the clinical record in accordance with the agency’s policy for 5 of 13 active patients with record reviews conducted (#4, 6, 11, 12, &17).Findings included: A policy, Hospice Medical Record (revised 10/1/24), received on 7/13/26 at 10:57 AM from the business office manager stated, “All entries in the hospice record must be legible and accurate…”1. Patient #4 was admitted on 6/18/26 with a diagnoses of other sequelae of other cerebrovascular disease (long-term effects following a stroke), colostomy status (artificial opening in abdomen for the passage of stool), and do not resuscitate (DNR). The plan of care for 6/18/26-8/16/26 included orders for skilled nurse (SN) visits 1 time a week for 1 week, 3 times a week for 8 weeks with 3 PRN (as needed), medical social worker (MSW) visits 1 time a month for 1 month and “Do Not Resuscitate (medical directive that indicates that the patient does not want cardiopulmonary resuscitation if the heart stops beating).” Review of the clinical record revealed the following:During the MSW visit on 7/6/26 MSW #10 documented, “Patient remains a Full Code [the patient wants cardiopulmonary resuscitation if the heart stop beating].”During the SN visit on 7/6/26 registered nurse (RN) #9 documented, “Patient’s urostomy (artificial opening bypassing the bladder to drain urine) is draining clear yellow urine.” Further review revealed that patient #4 did not have a urostomy.During an interview conducted on 7/13/26 at 3:20 PM MSW #10 stated, “He [patient] is a DNR, I made a mistake, he’s been a DNR.”RN #9 was not available for an interview.2. Patient #6 was admitted on 8/14/25 with a diagnosis of acute chronic systolic diastolic heart failure. The plan of care for 6/10/26-8/8/26 included orders for skilled nurse (SN) visits 1 time a week for 1 week, 2 times a week for 8 weeks with 3 PRN (as needed) and home hospice aide (HHA) visits 2 times a week for 1 week and 3 times a week for 8 weeks. Review of the clinical record revealed the following:During the SN visit on 6/18/26 RN #7 documented a home hospice aide (HHA) supervisory visit for HHA #8 and documented, “Does not meet requirements” for the following: Does the Hospice aide observe standard precautions and body mechanics;Does the Hospice aide notify the patient/family in a timely fashion of any schedule changes;Does the Hospice aide respect patient’s rights…;Does the Hospice aide utilize equipment effectively…;Does the hospice aide maintain patient’s personal hygiene?During the SN visit on 7/2/26 RN #7 documented, “Recognizes her name when called…” Further review revealed that patient #6 is and identifies as a male.During the SN visit on 7/9/26 RN #10 documented an HHA supervisory visit for HHA #8 and documented, “Does not meet requirements” for Does the Hospice aide notify the patient/family in a timely fashion of any schedule changes?During an interview conducted on 7/15/26 at 9:01 AM RN #7 stated, “That was just an accident [HHA #8’s name] meets or exceeds expectations.” RN #7 stated, “[patient #6 name] is a Mister not a her.” 3. Patient #11 was admitted on 5/21/26 with a diagnosis of multiple sclerosis (disease affecting the central nervous system). The plan of care for 5/21/26-7/19/26 included orders for skilled nurse (SN) visits 2 times a week for 1 week, 3 times a week for 8 weeks with 3 PRN (as needed) and, “Insert 16F, 10mL suprapubic (device inserted through the abdominal wall into the bladder to drain urine). Catheter to continuous bedside drainage related to retention of urine. Catheter to be changed every 2 weeks and PRN…”Review of the clinical record revealed that on 5/29/26 RN #14 documented a suprapubic catheter change as follows, Indicate insertion date: “5/29/26”, Indicate Catheter Size: “18” Indicate date of scheduled catheter change: “Changed today…”During an interview conducted on 7/15/26 at 9:39 RN #14 stated, “He always gets a 16F I don’t know why I put an 18F.”4. Patient #12 was admitted on 6/23/26 with a diagnosis of acute leukemia (cancer effecting the blood and bone marrow). The plan of care for 6/23/26-9/20/26 include orders for skilled nurse (SN) visits 2 times a week for 13 weeks with 3 PRN (as needed), home hospice aide (HHA) 2 times a week for 1 week, 3 times a week for 8 weeks, and “Insert 16F, 10mL Foley [name brand] catheter (device inserted through the urethra into the bladder to drain urine). Catheter to continuous bedside drainage related to retention of urine. Catheter to be changed every 2 weeks and PRN.” Review of the clinical record revealed the following:During the SN visit on 6/24/26 RN #11 documented, “RN made visit patient’s asthma being red and swollen…” Further review revealed that the patient did not have a documented diagnosis of asthma.During the SN visit on 6/29/26 RN #7 documented that the catheter size was 18.During the SN visit on 7/9/26 RN #7 documented an HHA supervisory visit for HHA # 15 and stated, “Does not meet requirements” for the following task; Does the hospice aide report abnormal findings to the appropriate staff; Does the hospice aide notify the patient/family in a timely fashion of any schedule changes; Does the hospice aide respect patient’s rights…; and does the hospice aide utilize equipment effectively…” Further review revealed that RN #7 also documented that the patient resides in a facility and the patient/caregiver was, “unwilling” to provide care.During an interview conducted on 7/15/26 at 9:15 AM RN #11 stated, “That was a typo, it should have been eyes [not asthma].”During an interview conducted on 7/15/26 at 9:09 AM RN #7 stated, “It [catheter] was not changed to a different size.” RN #7 stated, “[HHA #15 name] definitely meets the requirements.” RN #7 also stated, “That’s not accurate [caregiver is willing to provide care].”5. Patient #17 was admitted on 3/10/26 with a diagnosis of motor neuron disease (progressive neurological disorder). The plan of care for 6/8/26-9/5/26 included orders for medical social worker visits 1 time a month for 3 months with 3 PRN (as needed). Review of the clinical record revealed that on 6/11/26 MSW #16 documented, “Daughter expresses she has reached out to 1 year but she was both note.”During an interview conducted on 7/15/26 at 10:21 AM MSW #16 stated, “I was talking to text and I missed fixing that… It was the lawyer was booked up.”During an interview conducted on 7/15/26 at11:50 AM- the Executive Director stated, “They [all staff] should review documentation to ensure accuracy.””

“Based on clinical record reviews and staff interviews the social worker failed to make visits in accordance with the plan of care for 1 of 3 patients [#1]. The findings included: Patient # 1 had a Start of Care [SOC] date of 8/20/24 with a terminal diagnosis of senile degeneration of brain [progressive decline in cognitive function that can lead to memory loss, impaired thinking and loss of independence]. Review of the plan of care [POC] for the certification period 8/20/24-11/17/24 included orders for MSW [medical social worker] 1 time a month for 1 month, 2 times a month for 1 month, 3 times a month for 1 month and 1 time a month for 1 month. A supplemental order was written on 10/1/24 for MSW 1 time a month. Review of the clinical record revealed the only MSW visits was made on 8/21/24. During an interview the director of the agency on 11/20/24 at approximately 9 am, the director stated, “;The social worker just quit without a notice. So, the visits were not made in accordance with the POC.””