Mercy Health-New Life Hospice

“It is required that each patient’s individualized written plan of care: reflects patient and family goals; [and] identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 1 of 22 (5%) clinical records reviewed, the agency did not ensure that the patient’s plan of care identified planned interventions based on problems identified in the comprehensive assessments. CLINICAL RECORD 3: The patient elected hospice care on 3/19/2026 with a diagnosis of congestive heart failure (CHF). The plan of care dated 03/19/2025 through 05/17/2026 ordered: “Eliquis (anticoagulant) 2.5 mg, 1 tablet two times per day.” The plan of care safety precautions did not include documentation of bleeding precautions. During an interview and joint record review on 04/10/2026, the Alternate Director of Nursing confirmed the findings.”

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: physician orders. This standard was not met as evidenced by clinical record review, document review, interview, and observation. In 3 of 22 (14%) clinical records reviewed and home visits observed, the agency did not ensure that the patient’s record included physician orders to meet the patient’s needs. CLINICAL RECORD 1: The patient elected hospice care on 09/21/2024 with a diagnosis of malignant neoplasm of the stomach. The patient resided in a skilled nursing facility (SNF). The Skilled Nurse (SN) recertification assessment dated 03/04/2026 for the certification period 03/15/2026 through 05/13/2026 documented, “Two previously small stage 2 coccyx wounds have now progressed into one larger pressure injury measuring 3 cm x 2cm x 0.1 cm ....cleanse coccyx wound with normal saline, pat dry, apply calcium alginate, and DSD daily.” The plan of care for the certification period beginning 03/15/2026 did not include orders or interventions for wound care. During a joint review of the findings and an interview on 04/10/2026, the Administrator and the Alternate Director of Nursing confirmed the finding. CLINICAL RECORD 3/HOME VISIT 3: The patient elected hospice care on 3/19/2026 with a diagnosis of congestive heart failure (CHF). During the home visit (Medical Social Worker (MSW) site visitor) with the Social Worker (SW) [Personnel Record 3] on 04/08/2026, the patient was wearing oxygen. The plan of care dated 03/19/2026 ordered: “Encourage the patient to adopt positions that help alleviate shortness of breath. Oxygen will be ordered per MD orders for liters, flow rate, and method of delivery. Instruct on safety issues related to oxygen use by instructing on how to connect and turn on oxygen, instruct on how to apply a nasal cannula or face mask, and instruct on no smoking and the need for no-smoking signs.” The Skilled Nurse visit note dated 04/06/2026 documented that the patient uses oxygen and that oxygen saturation was 96 while on oxygen. No physician orders for the amount, route, or frequency of oxygen administration were documented in the clinical record. CLINICAL RECORD 7: The patient elected hospice care on 01/31/2026 with diagnoses of acute and chronic respiratory failure with hypoxia and hypercapnia. The SN assessment dated 01/31/2026 documented that the patient was continuously using oxygen at 2 liters per minute via a nasal cannula, a bilevel positive airway pressure (BiPAP) machine had been ordered for the patient’s use, the patient had a 9 X 2 cm coccyx wound, and a Foley catheter that had been inserted the day prior to the election of hospice. The plan of care documented oxygen precautions and oxygen supplies. A clinical record review revealed no physician orders for the amount, route, or frequency of oxygen administration, the Foley catheter, the BiPAP, or wound care for the coccyx wound. During an interview and a joint record review on 04/10/2026, the Administrator and Alternate Director of Nursing (ADON) confirmed findings.”

“It is required that each patient in the hospice inpatient facility always has an adequate supply of hot water and has plumbing fixtures with control valves that automatically regulate the temperature of the hot water used by patients. This standard was not met as evidenced by interview and observation. In 3 of 3 (100%) IPU patient rooms tested for water temperature, the agency did not ensure the water temperature was adjusted to a safe level. During the tour of the inpatient unit (IPU), the water temperature was tested: in patient room #1005 was 134 degrees Fahrenheit, patient room #1014 was 127 degrees Fahrenheit, and in patient room #1011 was 127 degrees Fahrenheit. The Office Manager and Facilities Manager, who were present during the water temperature testing, confirmed that the water was too hot and immediately lowered the temperature.”