Wilson Hospice Care

“Based on record review, interviews, and policy review, the Hospice agency failed to ensure the plan of care (POC) developed for 18 of 18 patients (Patient (P)1, P2, P3, P4, P5, P6, P7, P8, P9, P10, P11, P12, P13, P14, P15, P16, P17, and P18) were individualized based on the problems identified in the Comprehensive and ongoing assessment. This failure had the potential to result in patients’ needs not being addressed.Findings include: 1. Review of the Comprehensive Start of Care (SOC) Assessment revealed the following:a.P1 was admitted on 09/08/25 with a diagnosis including malignant neoplasm (tumor) of the ascending colon. Documentation indicated P1 complained of (c/o) “feeling lightheaded” when walking, was experiencing nausea, and had a 30-pound (lb.) weight loss in the last few months. P1 died on 09/24/25.b. P2 was admitted on 08/19/25 with a diagnosis of end stage congestive heart failure (CHF). P2 was experiencing pain in left leg rated at 6/10 on the pain scale due to a fall three weeks prior. P2 used a walker due to an unsteady gait. P2 died on 10/31/25.c. P3 was admitted on 05/15/25 with diagnosis that included chronic obstructive pulmonary disease (COPD). Documentation indicated an irregular heart rate, shortness of breath (SOB) with minimal exertion, 1-2 plus pitting edema in both lower extremities, and decreased appetite.d. P4 was admitted on 02/26/25 with a diagnosis of COPD and lung cancer. Documentation shows c/o pain in lower back rated as 8/10. P2 was dependent on oxygen. Hospice was revoked due to moving out of the service area.e. P5 was admitted on 11/13/25 with a diagnosis of pancreatic cancer with metastasis to the liver. P5 was non-responsive and unable to swallow. P5 died on 11/19/25.f. P6 was admitted on 07/17/24 with a diagnosis of multiple sclerosis. P6 is mostly bedbound and has stage 3 pressure ulcers on buttocks. P6 has a Foley catheter. Spouse assists with care.g. P7 was admitted on 12/18/24 with a diagnosis of end stage heart disease, CHF, Parkinson’s disease, and dementia. Documentation indicates fatigue and dyspnea at rest.h. P8 was admitted on 11/26/25 with a diagnosis of vertebra-basilar artery syndrome and disc degeneration. P8 has had multiple falls. The most recent fall resulted in a cervical fracture which is “non-united” and inoperable. P8 wears a hard collar 24/7 and uses a wheelchair for safety.i. P9 was admitted on 01/12/26 with a diagnosis of nonrheumatic aortic valve insufficiency and peripheral vascular disease (PVD). P9 fell in august 2025 resulting in a fractured femur. Worsening PVD resulted in amputation of left second, third, and fourth toes due to gangrene. P9 needs assistance with all activities of daily living. P9 resides in a long-term care facility.j. P10 was admitted on 12/13/24 with a diagnosis of cerebral atherosclerosis (buildup of fats and cholesterol in the walls of an artery), severe protein calorie malnutrition, and weight loss. P10 is bedridden, non-ambulatory, and incontinent of bowel and bladder.k. P11 was admitted on 10/25/24 with a diagnosis of cerebral infarct (stroke) and dementia.l. P12 was admitted on 12/8/25 with a diagnosis of malignant neoplasm of the rectum. Ambulates with a walker and is at risk for falls.m. P13 was admitted on 12/19/25 with a diagnosis of Alzheimer’s disease. Lives with family. P13 is wheelchair dependent.n. P14 was admitted on 12/17/25 with a diagnosis of Alzheimer’s disease. Resides in a memory care unit. Wears compression hose due to non-pitting edema in lower extremities. Pureed diet.o. P15 was admitted on 11/13/25 with a diagnosis of malignant neoplasm of the vulva and muscular dystrophy, heart failure, atrial fibrillation, and advanced atherosclerosis vascular disease with bilateral above the knee amputations. P15 requires total care and has a colostomy.p. P16 was admitted on 01/05/26 with a diagnosis of non-ST elevation myocardial infarction (heart attack) and cardiomyopathy. P16 c/o dyspnea, fatigue, and nausea. P16 has a Foley catheter.q. P17 was admitted on 01/15/26 with a diagnosis of bladder cancer. P17 has three plus pitting edema of lower extremities.r. P18 was admitted on 09/15/25 with a diagnosis of severe kyphosis and a history of breast cancer. Wound care is being done for a fungating tumor (advanced cancerous mass that breaks through the skin, forming a non-healing, often cauliflower-shaped wound with symptoms like pain, bleeding, and malodor).2. The 18 sampled POC’s all included the following:a. “DME [durable medical equipment] and Supplies:Equipment – Macy Catheter, Equipment – DME as needed for Patient/Caregiver comfort and safety, Equipment – Oxygen and supplies…b. Procedure Orders:Nursing: Specimen collection Urine …UA [urine analysis] and reflex micro [microscopic} and C&S [culture and sensitivity] PRN [as needed] for clinical signs of UTI [urinary tract infection] (i.e. confusion R41.82, dysuria [difficulty urinating] R30.0, hematuria [blood in urine] R31.9, frequency R35.0) – PRN:3; Urinary Catheter Foley [flexible tube inserted into the bladder to drain urine] …External catheter, Straight or foley as needed. Foley catheter 16-18 Fr with 5 ml balloon catheter. May irrigate urinary catheter with Sterile NS [normal saline] as needed for retention. May change foley as needed. – PRN: 9; Suctioning Oral … Oral-pharyngeal suctioning as needed – PRN: 9; Disimpaction/Enema Fleets Enema … RN may remove impaction as needed. Fleets enema rectal as needed for constipation. – PRN: 9c. Health Management Orders:Nursing: Monitoring Pulse Oximetry … SN [skilled nursing] to monitor pulse oxygen as needed.; Teaching … Oral-pharyngeal suctioning as needed.Equipment Macy catheter … RN [Registered Nurse] may insert Macy Catheter when patient unable to take symptom control medications orally.Physician Notification Notice of Death … Attending Physician agrees to release the body to the funeral home at time of death.Other Physician Care – RN may initiate Respite Level of Hospice Care as caregiver relief. RN may initiate In-Patient Level of Hospice Care to manage acute Medical or psychosocial crisis. RN may initiate Continuous Care for crisis intervention for uncontrolled pain, uncontrolled anxiety and/or pt’s uncontrolled symptoms while in the passing process. All of which require frequent medicating and close skilled monitoring.Equipment DME as needed for Patient/Caregiver comfort and safety … RN may initiate pressure relief prevention with alternating pressure pad as needed.Equipment Oxygen and supplies … Oxygen at 3 liters/nasal cannula as needed for Shortness of breath. Durable Medical Equipment as needed for patient/family comfort and safety. Hospice staff to change oxygen tubing and humidifier bottle weekly as needed. Label to be applied with date and initials.”3. Review of patient goals identified in the POC revealed the following:a. 18 of 18 POC’s included “Symptoms problematic to patient (pain, dyspnea, discomfort) will be addressed to meet patient goal of comfort.”b. 16 of 18 POC’s included “Patient/caregiver will report that patient pain is at or below 4/10 on numeric pain scale.”c. 17 of 18 POC’s included “Patient/family/caregiver will receive support with grieving process.”d. 18 of 18 POC’s included “Patient/caregiver will express faith and feelings within context of their faith tradition.”e. 18 of 18 POC’s included “Patient/caregiver will understand hospice services available to them.f. 15 of 18 POC’s included “Provide meaningful and requested external resources to assist with patient’s life closure desires.”g. 16 of 18 POC’s included “Patient/family/caregivers will have necessary information, support, and direction and counsel to make meaningful end of life decisions.”h. 18 of 18 POC’s included “Patient to have stable social environment and knowledge of community resources.”During an interview on 01/21/26 at 11:00 AM, the Director of Home Care and Hospice confirmed the POC’s did not appear to be individualized or did not reflect the findings identified in the Comprehensive Assessment or patient reassessment. He/She stated, “The medical record system we have automatically enters our hospice standing orders onto the plan of care which is why it is on every plan of care.”Review of the agency’s policy titled, “Care Planning – Policy 40,” dated 07/23/24, revealed, “The plan of care shall be individualized based on the diagnosis and patient assessment. The patient or patient representative will be involved in the development and implementation of the patient’s plan of care.””

“Based on record review, interview, and policy review, the Hospice agency failed to ensure the plan of care (POC) for 18 of 18 patients (Patient (P)1, P2, P3, P4, P5, P6, P7, P8, P9, P10, P11, P12, P13, P14, P15, P16, P17, and P18) included detailed identification of the scope and frequency of services to be provided. This failure had the potential for patients not to receive services that would have been beneficial and necessary for symptom management based on the concerns identified in the comprehensive and updated assessment.Findings include: 1. Review of P1’s POC dated 09/08/25 to 12/06/25 revealed, “Aide PRN [as needed]:12, Spiritual Counselor PRN:13, Reason: Emotional and/or spiritual support … Complimentary Therapy: PRN:13. Reason: Comfort and relaxation through music and/or massage therapy.”2. Review of P2’s POC dated 08/19/25 to 11/16/25 revealed there was no visit frequency for the Spiritual counselor. The POC did include goals and interventions for spiritual concerns and identified the Spiritual Counselor as the “Resource Class.”3. Review of P3’s POC dated 05/15/25 to 08/12/25 revealed, “Spiritual Counselor PRN:13, Reason: Emotional and/or spiritual support … Complimentary Therapy: PRN:13. Reason: Comfort and relaxation through music and/or massage therapy.”4. Review of P4’s POC dated 02/26/25 to 05/26/25 revealed, “Spiritual Counselor PRN:13, Reason: Emotional and/or spiritual support … Complimentary Therapy: PRN:13. Reason: Comfort and relaxation through music and/or massage therapy.”5. Review of P5’s POC dated 11/13/25 to 02/10/26 revealed, “Spiritual Counselor PRN:13, Reason: Emotional and/or spiritual support … Complimentary Therapy: PRN:13. Reason: Comfort and relaxation through music and/or massage therapy.”6. Review of P6’s POC dated 01/08/26 to 03/08/26 revealed, “Spiritual Counselor PRN:13, Reason: Emotional and/or spiritual support … Complimentary Therapy: PRN:13. Reason: Comfort and relaxation through music and/or massage therapy.”7. Review of P7’s POC dated 12/13/25 to 02/10/26 revealed, “Spiritual Counselor PRN:13, Reason: Emotional and/or spiritual support … Complimentary Therapy: PRN:13. Reason: Comfort and relaxation through music and/or massage therapy.”8. Review of P8’s POC dated 11/26/25 to 01/24/26 revealed, “Spiritual Counselor PRN:13, Reason: Emotional and/or spiritual support … Complimentary Therapy: PRN:13. Reason: Comfort and relaxation through music and/or massage therapy.”9. Review of P9’s POC dated 01/12/26 to 04/11/26 revealed, “Spiritual Counselor PRN:13, Reason: Emotional and/or spiritual support … Complimentary Therapy: PRN:13. Reason: Comfort and relaxation through music and/or massage therapy.”10. Review of P10’s POC dated 12/08/25 to 02/05/26 revealed, “Spiritual Counselor PRN:13, Reason: Emotional and/or spiritual support … Complimentary Therapy: PRN:13. Reason: Comfort and relaxation through music and/or massage therapy.”11. Review of P11’s POC dated 12/19/25 to 02/16/26 revealed, “Spiritual Counselor PRN:13, Reason: Emotional and/or spiritual support … Complimentary Therapy: PRN:13. Reason: Comfort and relaxation through music and/or massage therapy.”12. Review of P12’s POC dated 12/08/25 to 03/07/25 revealed, “Spiritual Counselor PRN:13, Reason: Emotional and/or spiritual support … Complimentary Therapy: PRN:13. Reason: Comfort and relaxation through music and/or massage therapy.”13. Review of P13’s POC dated 12/06/25 to 03/07/26 revealed, “Spiritual Counselor PRN:13, Reason: Emotional and/or spiritual support … Complimentary Therapy: PRN:13. Reason: Comfort and relaxation through music and/or massage therapy.”14. Review of P14’s POC dated 12/17/25 to 03/16/25 revealed, “Spiritual Counselor PRN:13, Reason: Emotional and/or spiritual support … Complimentary Therapy: PRN:13. Reason: Comfort and relaxation through music and/or massage therapy.”15. Review of P15’s POC dated 11/13/25 to 02/10/26 revealed, “Spiritual Counselor PRN:13, Reason: Emotional and/or spiritual support … Complimentary Therapy: PRN:13. Reason: Comfort and relaxation through music and/or massage therapy.”16. Review of P16’s POC dated 01/05/26 to 04/04/26 revealed, “Spiritual Counselor PRN:13, Reason: Emotional and/or spiritual support … Complimentary Therapy: PRN:13. Reason: Comfort and relaxation through music and/or massage therapy.”17. Review of P17’s POC dated 01/15/26 to 03/15/26 revealed, “Spiritual Counselor PRN:13, Reason: Emotional and/or spiritual support … Complimentary Therapy: PRN:13. Reason: Comfort and relaxation through music and/or massage therapy.”18. Review of P18’s POC dated 11/29/25 to 01/27/26 revealed, “Spiritual Counselor PRN:13, Reason: Emotional and/or spiritual support … Complimentary Therapy: PRN:13. Reason: Comfort and relaxation through music and/or massage therapy.”During an interview on 01/22/26 at 8:45 AM, the Clinical Supervisor stated he/she did not realize that a specific frequency was required for all disciplines providing care and that the agency has always written frequency for the Spiritual Counselor, music therapy, and massage therapy this way.During an interview on 01/22/26 at 11:30 AM, the Director of Home Care and Hospice stated he/she has been in this position for a few months and is working on some issues that have been identified as needing improvement including documentation of the POC. He/she confirmed the POC needs to identify specific frequency of services and updated with any changes in frequency.Review of the agency’s policy titled, “Care Planning,” dated 07/23/24, provided by the Director of Home Care and Hospice, revealed the policy did not include any reference to the requirement for a detailed statement of frequency of services being provided.”

“Based on record review, interview, and policy review, the Hospice agency failed to document the patient’s or representative’s involvement and agreement with the plan of care (POC) for 18 of 18 patients (Patient (P)1, P2, P3, P4, P5, P6, P7, P8, P9, P10, P11, P12, P13, P14, P15, P16, P17, and P18). Failure to include the patient and caregivers in the development of the POC had the potential to result in miscommunication and lack of follow-up to meet the patient’s needs.Findings include: Review of the POC for P1, P2, P3, P4, P5, P6, P7, P8, P9, P10, P11, P12, P13, P14, P15, P16, P17, and P18 revealed there was no documentation to indicate the patient, family, or caregiver was involved in the development of the POC or agreed with the POC.During an interview on 01/21/26 at 11:00 AM, the Director of Home Care and Hospice confirmed that the reviewed POC’s did not include documentation of the patient’s, family, or caregivers involvement in the development of the POC.Review of the agency’s policy titled, “Care Planning – 40,” revealed it did not include documentation of the patient’s, family, or caregivers level of understanding, involvement, or agreement with the POC.”

“Based on record review, observation, interview, and policy review, the Hospice agency failed to identify which provider is responsible for providing wound care for one of two patients (Patient (P)9) during a home visit observation at a long-term care (LTC) facility. This failure had the potential to result in further deterioration of the wound.Findings include: During a patient visit at a long-term care (LTC) facility on 01/21/26 at 8:00 AM with Registered Nurse (RN)2 an interaction between RN2 and the facility RN who was working on the unit was observed. During their conversation, the LTC unit RN stated, “We do the patient’s wound care.” RN2 stated, “No, we will do the patient’s wound care unless you have already done it when we arrive.”Review of the “Start of Care Assessment,” provided by the facility, revealed P9 was admitted on 01/12/26 with a diagnosis of nonrheumatic aortic valve insufficiency and peripheral vascular disease (PVD).Review of P9’s plan of care (POC) dated 01/12/26 to 04/11/26 revealed, “Wound care Lt [left] foot – per visit – Wound care completed to amputated site of toe 2,3,4 – Cleanse with wound cleanser. Collagen powder to open wound beds. Bacitracin to gauze over wound bed. Cover with wettened gauze. Wrap with kerlex [an absorbent, cotton, gauze] and secure with Coban [a breathable, elastic, nonwoven material that sticks to itself and not to skin/hair]. Wound care Lt elbow, Rt [right] inner ankle – Daily wound care to skin tears – cleanse with wound cleanser/N.S. [normal saline]. Apply Medi honey [a wound gel that supports removal of necrotic tissue and aids wound healing]. Cover with [a] foam bordered dressing.” The POC identified hospice skilled nursing (SN) visits three times a week. The POC did not show often the wound care to the amputation site is to be done and did not include which provider (hospice RN or LTC facility RN) was responsible for the patient’s wound care.During an interview on 01/21/26 at 8:30 AM, RN2 was unable to identify where the hospice agency documents which provider is responsible for the patient’s wound care.During an interview on 01/22/26 at 8:45 AM, the Clinical Supervisor confirmed the POC did not include identification of who was responsible for P9’s wound care.Review of the agency’s standard LTC contract revealed, “The Hospice Plan of Care will reflect the participation of the Hospice, Facility, a Hospice Patient and his or her family to the extent possible. Specifically, the Hospice Plan of Care includes: (i) identification of the Hospice Services, including interventions for pain management and symptom relief, and Facility Services needed to meet a Hospice Patient’s needs and the related needs of his or her family; (ii) a statement of the scope and frequency of such Hospice Services and Facility Services …””