Pinnacle Hospice, LLC

“Based on a review of agency policies and clinical record (CR), direct observation, and staff (EMP) interviews, the agency failed to protect the right of the patient to have a confidential clinical record four one of four home visits (CR1). Findings include: Review of agency policies on 5/20/24 at approximately 10:30 a.m. revealed: Policy titled “Confidentiality of Information” indicated... Any breach in confidentiality by hospice personnel is grounds for disciplinary action. Policy titled “Notice of Privacy Practices” indicated... this notice describes how to access your medical information and how information can be used and disclosed to others... the hospice may use patient private health information for the purposes of providing treatment... conducting healthcare operations... the hospice values patient privacy and has established a policy to guard against unnecessary disclosure of any private health information. Observation and staff interview during a home visit at the residence of CR1 on 5/14/24, at 8:23 a.m. with Registered Nurse EMP 1 indicated she did not know how to use her agency issued tablet to take photos of CR1’s wounds on her left and right elbows, she then used her personal cell phone to take pictures of the wounds on CR1’s left and right elbows, to send to the Registered Nurse Wound Care Practitioner. During an interview on 5/15/24, at 9:19 a.m. the Director of Clinical Services EMP 2 confirmed the above findings.”

“Based on review clinical record (CR) observation and staff (EMP) interviews, the hospice failed to revise and document the individualized plan of care as frequently as the patient condition requires, but not less than every 15 calendar days for one of four home visits (CR1). Findings include: A review of CR1’s Hospice Plan of Care, on 5/13/23 at approximately 3:00 p.m. for certification period 4/26/24 to 6/24/24, revealed an order dated 9/8/23, for the right lower outer leg, instructing the nurse to cleanse area with soap and water, pat dry, apply triple antibiotic ointment to wound bed, cover with non-adherent pad, wrap with kerlex, and secure with tape daily until healed. During an observation and staff interview on a home visit at the residence of CR1 on 5/14/24, at 8:23 a.m. Registered Nurse EMP 1 completed a dressing change to CR1’s left elbow skin tear, she cleaned it with a “Wet One” (hand and face wipe for sensitive skin) then applied collagen powder (applied topically to wound to keep wound moist) and a hydrogel dressing (optimizes healing by keeping wound moist). Then she completed a dressing change to CR1’s right elbow skin tear and applied a hydrogel dressing. RN EMP 1 was interviewed and indicated that CR1’s wound to her right lower outer leg healed months ago and it was not discontinued, and the Plan of Care did not contain physician orders for CR1’s left and right elbow skin tears. A review of CR1’s wound flow sheet and interview with the Director of Clinical Services EMP 2 on 5/15/24, at 9:19 a.m. revealed that CR1’s right lower outer leg wound healed on 10/30/23, and had been on the current plan of care. The Right forearm skin tear onset date was 4/3/24 and the Left forearm skin tear onset date was 5/9/24, and orders had not been added to the plan of care, and the hospice failed to update the plan of care as frequently as the patient condition requires, but not less than every 15 calendar days.”

“Based on review of agency policy, observations and staff (EMP) interviews, the agency failed to ensure staff followed accepted standards of practice to prevent the transmission of infections on one of four home visits (CR1). Findings include: Review of the Agency Policy “Universal Precautions Policy and Procedure” on 5/20/24, at approximately 10:30 a.m. revealed adherence to hand hygiene techniques including washing hands with soap and water or use of an alcohol based hand rub, reduces transmission of antimicrobial resistant organisms and overall infection rates. If hands are visibly dirty or contaminated with protein material or are visibly soiled with blood or other body fluids wash hands with... soap and water. Gloves shall be changed between tasks and procedures on the same patient after contact with material that may contain a high concentration of microorganisms... gloves are to be worn by the caregiver when direct contact with anybody substance is anticipated. Observation and staff interviews during a home visit at the residence of CR1 on 5/14/24, at 8:23 a.m. the Registered Nurse EMP 1 was observed to use a light pen, stethoscope, pulse oximeter (placed on finger measures amount of oxygen in the blood), tape measure and blood pressure cuff to complete vital signs and a head to toe assessment on CR1. At the end of the observation RN EMP 1 cleaned the light pen, stethoscope, pulse oximeter, tape measure and blood pressure cuff with a “Wet One” (hand and face wipe for sensitive skin) and placed them back into her nursing supply bag. RN EMP 1 was completing wound care to CR1’s left elbow which was observed to have serosanguineous drainage oozing from the wound with a “Wet One”, then changed her gloves failed to wash her hands and applied new gloves to complete the dressing change. During an interview on 5/15/24, at 9:19 a.m. the Director of Clinical Services EMP 2 confirmed the above findings, that staff are to use Mycolio Disinfectant Wipes (broad spectrum disinfectant) to clean medical equipment after patient assessments and not wet ones, that they were not aware RN EMP 1 was using wet ones to clean wounds with, and they have not developed a wound policy.”