Ambercare Hospice Inc.

“Based on record review and interview, the hospice failed to ensure that an incident of neglect was reported to the appropriate state agency responsible for investigation for are interventions being provided for 1 (Patient [P] 8) of 3 (P7-P9) hospice patients reviewed for changes in condition. This deficient practice resulted in the patient experiencing progressive deterioration of a right foot wound from a documented ulcer to necrotic (dead) tissue with tunneling, maggot infestation, exposed tissue, escalating and inadequately controlled pain, and ultimately hospitalization for a higher level of care. The findings are:A. Refer to tag L-591.B. Record review of P8’s “ED Provider Note” from the receiving hospital dated 04/28/2026 revealed the patient was transported by emergency medical services on 04/28/2026 after the hospice nurse called emergency medical services due to concerns regarding a necrotizing right foot wound with maggot infestation and worsening tunneling. The emergency department record documented that the patient had a prolonged history of right foot wounds and presented with new maggot infestation, worsening tunneling, and severe right foot pain rated 10/10 despite administration of fentanyl. The emergency department provider’s assessment documented necrotizing right foot wounds with maggot infestation, Stage II pressure injuries to the left side, poor hygiene, infrequent brief changes, and concerns for neglect and inadequate home care. Differential diagnoses included necrotizing soft tissue infection, pressure ulcers, hypoxemia, atherosclerosis, and possible neglect. Due to the severity of the patient’s condition, including necrotizing wounds, maggot infestation, persistent severe pain, hypoxemia, and concerns regarding inadequate care within the home, the patient was admitted to the hospital for wound care, pain management, and further evaluation. The emergency department provider further documented that the patient would not return to the previous home environment due to concerns for neglect and inadequate support.C. During an interview on 06/15/2026 at 1:33 PM Social Worker (SW) 8 stated that reports had been filed and they could not do anything against the patient’s wishes. The reports could not be provided to the surveyor.”

“Based on record review and interview, the hospice failed to ensure the comprehensive assessment was updated to reflect significant changes in the patient’s condition for 1 (Patient [P] 8) of 3 (P7-P9) hospice patients reviewed for change in condition requiring reassessment. This deficient practice resulted in the patient experiencing progressive deterioration of a right foot wound from a documented ulcer to necrotic (dead) tissue with tunneling, maggot infestation, exposed tissue, escalating and inadequately controlled pain, and ultimately hospitalization for a higher level of care. The findings are:A. Record review of facility policy titled, “Wound Assessment” dated 11/18/2021 stated, “The assessment of wounds will be routinely performed by the RN [registered nurse] (Admissions nurses and RN Case Manager) for patients with wounds. The nurse will document the assessment of each wound in the medical record.” The policy also stated, “1. The RN Case Manager will assess and/or review all wounds and LPN/LVN [licensed practical nurse] will complete data collection. Measurements of wounds must be documented at a minimum weekly at time of the nurse’s visit.” And “2. Assessment is to be made according to standard nursing practice and will include the following: A. Staging of the wound using standard nursing assessment terminology of Stage I Through Stage IV as follows [National Pressure Ulcer Advisory Panel] Guidelines.”B. Record review of P(patient)8’s “Hospice Certification and Plan of Care” with a start of care dated 08/22/2023 for the certification period 02/07/2026 to 04/07/2026, revealed an order dated 03/24/2026, for skilled nursing services twice a week for 13 weeks and as needed visits for symptom management and uncontrolled pain.C. Record review of P8’s “Visit Note Report” revealed that from 03/23/2026 through 04/28/2026 a progressive decline in the patient’s right foot wound and pain status. Nursing documentation identified worsening clinical findings, including increasing pain, foul odor, swelling, black discoloration of the right great toe, detachment of the toenail, new redness and ulcerations (open sores), necrotic tissue, purulent drainage (cloudy fluid), tunneling of the wound from the plantar(bottom) surface to the dorsal (top) aspect of the foot, maggot infestation, exposed tissue, and discoloration of multiple toes.The clinical record lacked evidence that the comprehensive assessment was updated to reflect the patient’s worsening wound status. Wound assessments were incomplete or absent on multiple visits and frequently overlooked wound location, measurements, wound bed characteristics, drainage, surrounding tissue assessment, staging, and evaluation of wound progression. Nursing narrative notes described substantial deterioration (decline in condition), there was no evidence the comprehensive assessment was revised to reflect the patient’s changing clinical needs or to support revision of the plan of care.D. During an interview on 06/10/2026 at 10:21 AM, Registered Nurse (RN) 5, Clinical staff member, acknowledged that RN 5 documented wound findings primarily within narrative notes instead of completing the designated wound assessment documentation. RN 5 stated they needed to do better documenting wounds and had received education regarding the proper location for documenting wound assessments.E. During an interview conducted on 06/15/2026 at 12:58 PM, Patient Care Manager (PCM) 4, stated that if nursing staff perform wound care, physician orders must be present. PCM 4 stated that nurses are expected to communicate changes in patient condition to providers and document wound findings both within the designated wound assessment section and within narrative notes.”

“Based on record review and interview, the hospice failed to ensure nursing services identified and communicated significant changes in patient condition to the hospice physician and failed to obtain physician orders for wound care interventions being provided for 1 (Patient [P] 8) of 3 (P7-P9) hospice patients reviewed for changes in condition requiring nursing assessment and physician involvement. This deficient practice resulted in the patient experiencing progressive deterioration of a right foot wound from a documented ulcer to necrotic tissue with tunneling, maggot infestation, exposed tissue, uncontrolled pain, and ultimately hospitalization for a higher level of care. The findings are:A. Record review of facility policy titled, “Verification of Physician Orders” dated 01/17/2017 stated, “Orders will be obtained from a licensed physician (or other authorized independent practitioner) for care and services to be provided to hospice patients…” The policy also indicated, “Orders will be taken only by professional, licensed hospice personnel…A qualified individual will review each order or prescription before care is provided. The sole exception for verification will be with emergency orders or prescriptions where a delay in verification would likely result in an adverse result for the patient.”B. Record review of facility policy titled, “Wound Care” dated 08/22/2024 stated, “Wound care is to be routinely performed by the RN [registered nurse] (Admissions Nurse, RN Case Manager) or LPN/LVN [licensed practical nurse] for patients with wounds. Wound care is to be performed in accordance with physician’s wound care orders. Documentation of wound status and wound care provided shall be completed for each patient visit at a minimum of once per week by the RN Case Manager or LPN/LVN. The primary goals of wound care are to ensure patient comfort and to keep wounds free from infection.”C. Record review of P(patient)8’s “Hospice Certification and Plan of Care” with a start of care date 08/22/2023 for the certification period 02/07/2026 to 04/07/2026, revealed an order dated 03/24/2026, for skilled nursing services twice a week for 13 weeks and as needed visits for symptom management and uncontrolled pain.D. Record review of P8’s “Visit Note Report” from 03/23/2026 through 04/28/2026 revealed a pattern of progressive deterioration of P8’s right foot wound without evidence of comprehensive wound assessment, physician-directed wound care orders, timely provider notification, or implementation of interventions to address the patient’s changing condition.1. On 03/23/2026, the registered nurse (RN) documented a foot ulcer (open sore) measuring 3 cm (centimeter) x 5 cm and the patient reported pain rated 8 out of 10 (Number scale used to assess severity of pain. Rating of 1 being mild and rating of 10 being the most severe pain) requiring morphine (opioid medication for pain relief) administration. There was no documentation that pain was reassessed or resolved following intervention.2. Between 03/25/2026 and 04/22/2026, the patient consistently reported severe right foot pain ranging from 8 to 9 out of 10. Morphine was administered; however, documentation of pain reassessment and effectiveness was inconsistent. During this period, the RN documented progressive changes involving the right foot, including odor, sensitivity to touch, blood beneath the right great toenail, swelling, black discoloration of the toenail, detachment of the toenail, new redness and ulcerations of the foot, and additional skin breakdown of the right lower extremity. Despite these findings, nursing documentation lacked consistent wound assessments, including location, measurements, staging, appearance of the wound bed, drainage characteristics, surrounding tissue assessment, or evidence of weekly reassessment of the wound’s progression. Wound care interventions were referenced in narrative notes; however, there was no evidence of corresponding wound assessment documentation or physician orders directing treatment.3. On 04/24/2026, the RN documented that the patient’s right great toe remained black, the plantar (bottom of foot) ulcer had become necrotic (sign of dead tissue) and painful to touch, and an accumulation of pus had developed beneath the skin on the top of the foot. The patient’s daughter expressed concern that the patient’s condition could progress to sepsis. There was no evidence that the provider was notified of these significant changes at that time.4. On 04/27/2026, the RN documented that the patient’s right foot had become necrotic that maggots were present within the wound. The ulcer located on the plantar surface of the foot had tunneled to the dorsal (top of foot) aspect of the foot. The RN documented cleansing the wound, manually removing maggots, and applying new bandages. There was no evidence of physician orders authorizing wound treatment, provider-directed interventions, or documentation of an updated wound assessment reflective of the severity of the patient’s condition.5. On 04/28/2026, the patient reported pain rated 10 out of 10 that was described as severe, cutting, shooting, stabbing, and throbbing. The RN documented that morphine failed to relieve the patient’s pain and observed exposed raw tissue following the loss of eschar (dead tissue), discoloration of the smaller toes, and continued deterioration of the right foot. Due to uncontrolled pain and worsening wound status, emergency medical services were contacted, and the patient was transferred to the hospital for a higher level of care.E. During an interview on 06/10/2026 at 10:21 AM, registered nurse (RN) 5, Clinical staff member, acknowledged that he provided wound care based on instructions reportedly relayed by the patient’s daughter and stated, “I should have had some kind of written orders or requested them.”F. During an interview on 06/15/2026 at 12:58 PM, Patient Care Manager 4, Clinical Staff stated that if nursing staff perform wound care, physician orders must be present. PCM 4 stated that nurses are expected to communicate changes in patient condition to providers and document wound findings both within the designated wound assessment section and within narrative notes.G. During an interview on 06/10/2026 at 4:20 PM, Medical Director (MD) 1, stated that they were unaware of the worsening wound condition, escalating pain, presence of maggots, or the extent of wound deterioration regarding P8 until receiving communication on 04/25/2026 by email. MD 1 stated that they had not been informed that RN 5 was independently providing wound care without physician orders and that they would have expected notification of the patient’s changing condition and the implementation of formal wound care orders. MD 1 stated, “I would expect a wound care order if a nurse were providing wound care.””

“Based on record review and interview, the facility failed to ensure 1 (P (patient)1) of 6 (P1-P6) patients received pain medication either immediately or within 2 hours of reports of pain. This deficient practice could likely lead to the patient suffering pain that could have been prevented with pain medication and could lead to other patients suffering pain that could be relieved with access to pain medication. The findings are: A. Record review of P1s medical record demographic sheet revealed a start of care date of 11/03/2023. 1) Medication order dated 11/03/2023: Morphine Concentrate 100 milligrams/5 milliliters (100mg/5ml) oral solution (a concentrated liquid form of a pain medication commonly used to relieve hospice patients pain, shortness of breath, and discomfort during the dying process. This is considered one of the comfort medications to be administered for pain related to the dying process). Dose 0.5 ml every 2 hours as needed for pain/sob (shortness of breath). B. Record review of P1s medical record nursing note visit number 2, dated 11/07/2023 at 2:34 pm, revealed no medication reconciliation (going over the medication list with the patient/agent to identify which medications are ordered, present, or need to be obtained) was documented in the narrative note by the nurse and, as a result, there was no verification of whether the Morphine Concentrate 100mg/5ml oral solution was available in the patients home for use in case of pain related to the dying process. C. Record review of nursing note visit number 3, dated 11/09/2023 at 1:56 pm, revealed the following: 1) “;Have the patient indicate the phrase that best describes the current level of pain: MODERATE PAIN” 2) “Narrative Note: ...Patient stated she has pain to lower abdomen (belly) and right leg. Pain is increasing. Tramadol (a pain medication) used. Patient’s son requested something stronger for pain.” D. Record review of nursing note visit number 4, revealed a nurse prn (as needed) visit, dated 11/11/2023 at 12:17 am, revealed: 1) “;What is the reason for the prn visit? CHEST PAIN.” 2) “;Narrative Note: Patient c/o (complained of) mild chest pain/discomfort. Pain started a couple of hours prior to visit. Patient is tachycardic (a fast heart rate) at 125BPM (beats per minute). Son reports that patient states it feels like. “Heart attack is coming on.” No comfort meds in the home. Advised to take pain medication available...On call nurse will order medications for family to pick up.” E. Record review of (name of pharmacy) medication history report for P1 showed Morphine Concentrate 100mg/5ml oral solution was not picked up by anyone until 11/11/2023, despite an order for this medication on 11/03/2023. F. Record review of nursing note visit number 5, dated 11/12/2023 at 10:52 am, revealed patient death from natural causes. G. Record review of the Nursing Resource hand-out form from the Nursing Resource Binder “;Medication & Reconciliation Resource”, “;Revised 10/1/2023”, (a collection of nursing education, directions and resources that are provided to the nurses) revealed: 1) “;A medication reconciliation is going over all medications with patient/agent for accurateness and comparing: 1. The medication profile in HCHB (HomeCare HomeBase-the computerized patient charting system used by the hospice) to the 2. Medication profile provided by the hospice pharmacy...” 2) “;A medication reconciliation must be completed: at 24/48 HR. (hour) visit by RNCM (registered nurse case manager) or prior to first IDG (Interdisciplinary Group meeting).” “;The medication reconciliation must be documented: In narrative of 24/48 HR visit.” H. During an interview on 05/09/2024 at 9:55 am, with Staff (S)1 Area Vice President, S1 confirmed that the Nursing Resource Binder is physically provided to all nurses. S1 confirms this reference is the educational resource for the nurses and the expectation is that the nurses will follow these directions. S1 confirmed that that the nurse should have made sure that the family had the morphine solution on 11/09/2023, “;but it looks like they didnt.””