Caring Professionals Hospice

“Based on interview and document review, the agency failed to provide the core services of nursing care and bereavement care as ordered by the physician. The systemic failure of not providing the ordered services placed one Patient (P)11 at risk for the lack of care and symptom management and P11s family at risk for inappropriate grieving. Findings include: The agency failed to provide nursing services as ordered by the physician for one of 14 patients (Patient (P) 11) whose records were reviewed. The failure to provide nursing services as ordered by the physician placed the patient at risk for the lack of symptom management and preparation of the family for changes in the patients health status, including impending death. Refer to L-591. The agency failed to perform a bereavement assessment and subsequent communication for one of two patients (Patient (P) 11) whose records were reviewed for bereavement concerns. The agencys failure to perform the bereavement assessment and provide subsequent communication with the bereaved placed the family at risk for inappropriate grief. Refer to L-596.”

“Based on record review and staff interview, the agency failed to perform a comprehensive bereavement assessment within five days of admission to hospice services for one of 14 patients (Patient (P) 11) whose records were reviewed. The agencys failure to perform a comprehensive assessment of P11s familys bereavement risk for inappropriate grieving placed P11s family at risk for unassessed bereavement needs. Findings include: Review of the agency’s undated Admission packet, provided to each patient and family upon admission, revealed staff were required to perform a bereavement assessment within five days of a patients admission to hospice. Review of the electronic medical record (EMR) for P11 revealed an admission date of 06/06/24 with diagnoses that included cancer of the larynx (throat). It was recorded that P11 died on 07/24/24. Review of P11’s Assessment tab of the EMR revealed no documented evidence that a comprehensive bereavement assessment was completed with the family of P11. During an interview on 02/12/25 at 3:30 PM, the Bereavement Coordinator confirmed the clinical record lacked evidence of a bereavement assessment conducted within five days of P11s admission to hospice. The Bereavement Coordinator stated that if the bereavement assessment had been done, the results would have indicated the family was a “;moderate to high risk” of inappropriate grief and may have required additional resources and support to manage the grief. The agencys failure to perform an initial bereavement assessment placed P11s family at risk for the lack of services to assist P11s family with grief.”

“Based on record review and interview, the agency failed to complete a review of the plan of care by the Interdisciplinary Group (IDG) every 15 days for one of 14 patients (Patient (P) 11) whose records were reviewed. The agencys failure to perform IDG reviews every 15 days placed P11 at risk of the lack of symptom management, lack of education regarding the disease process, and placed P11s family at risk for inappropriate grieving. Findings include: Review of the facility’s undated policy titled Interdisciplinary Group, revealed staff was to perform an IDG review of each patient on service every 15 days and as needed. Review of the electronic medical record (EMR) for P11 revealed an admission date of 06/06/24 with diagnoses that included cancer of the larynx (throat). It was recorded that P11 died on 07/24/24. Review of the IDG tab of the EMR revealed an IDG note dated 06/06/24. There was no documented evidence any other IDG review of the plan of care for P11 was completed. During an interview on 02/11/25 at 3:00 PM, the Executive Nurse confirmed the lack of IDG review and notes in P11s EMR. The agencys failure to perform an IDG review of P11 placed P11 at risk for the lack of symptom management and disease education and placed P11s family at risk for inappropriate grieving.”

“Based on record review and interview, the agency failed to provide nursing services as ordered by the physician for one of 14 patients (Patient (P) 11) whose records were reviewed. The failure to provide nursing services as ordered by the physician placed the patient at risk for the lack of symptom management and preparation of the family for changes in the patients health status, including impending death. Findings include: The agency failed to provide a policy directing staff to follow physicians orders. Review of the electronic medical record (EMR) for P11 revealed an admission date of 06/06/24 with diagnoses that included cancer of the larynx (throat). It was recorded P11 died on 07/24/24. Review of the Plan of Care tab of the EMR, revealed a physician’s order for once weekly skilled nurse visits. Review of the EMR revealed no documented evidence of skilled nurse visits from 07/07/24 through 07/23/24, a period of 20 days. It was recorded a visit was made on 07/24/24 when the patient died. During an interview on 02/11/25 at 4:30 PM, the Administrative Nurse revealed they were the skilled nurse assigned to P11 and confirmed the lack of documentation of the SN visits from 07/04/24 through 07/23/24. The Administrative Nurse stated their home was near P11, with neighborly visits made, but confirmed SN visits, as ordered by the physician, were not made. The agencys failure to follow physician orders and provide SN visit placed the patient at risk for unmanaged symptoms and lack of education of their disease process.”

“Based on document review and interview, the agency failed to perform a bereavement assessment and subsequent communication for one of two patients (Patient (P) 11) who were reviewed for bereavement concerns. The agencys failure to perform the bereavement assessment and provide subsequent communication with the bereaved placed the family at risk for inappropriate grief. Findings include: Review of the agency’s undated Admission packet, provided to each patient and family upon admission, revealed staff were required to perform a bereavement assessment within five days of a patients admission to hospice. Review of the electronic medical record (EMR) for P11 revealed an admission date of 06/06/24 with diagnoses that included cancer of the larynx (throat). It was recorded P11 died on 07/24/24. Review of P11’s EMR revealed no documented evidence of a bereavement assessment conducted with the family. During an interview on 02/12/25 at 3:30 PM, the Bereavement Coordinator confirmed a bereavement assessment had not been conducted within five days of P11s admission to hospice. The Bereavement Coordinator stated that if the bereavement assessment had been done, the results would have indicated the family was a moderate to high risk of inappropriate grief and may have required additional resources and support to manage the grief. The Bereavement Coordinator confirmed that post-death bereavement activities, including mailings and phone calls, were not done after the agency sent a sympathy card. The agencys failure to provide post-death bereavement activities for P11s family placed the family at a risk of inappropriate grieving.”

“Based on document review and staff interview, the agency failed to perform Criminal Background Checks (CBC) for one of ten staff members (Physician 1) whose personnel records were reviewed. This had the potential to place the safety and well-being of patients at risk of harm. Findings include: Review of Nevada’s Department of Health and Human Service’s website, located at https://dpbh.nv.gov/Reg/HealthFacilities/dta/FAQs/Health_Facilities_-_Background_Check_FAQ_s/, revealed all hospice agencies must perform Criminal Background Checks (CBC) on all employees. Review of the personnel file for Physician 1 revealed a hire date of 11/10/20 and a job description that included direct care for hospice patients. The personnel filed lacked evidence of a CBC upon hire. During an interview on 02/12/25 at 3:00 PM, the Executive Director confirmed the agency had failed to perform a CBC on Physician 1.”