Compassus-Memphis

“It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as: hand hygiene. This standard was not met as evidenced by document review and observation. Agency policy #IPC.11_A2 “Infection Control: Bag Technique and Standard Precautions” (reviewed 01/01/2025) stated in part, “Hand Hygiene 1. Appropriate hand hygiene is the gold standard and primary method of basic infection control practice. Hand hygiene is divided into two (2) aspects... Hand washing using soap and water. b. Use of alcohol-based hand gel (sanitizer) when soap and water are not available or feasible for use... When washing hands with soap and water... wet hands with clean, running water (warm or cold), turn off tap, and apply soap...lather your hands by rubbing them together.....rinse your hands under clean, running water...dry your hands using a clean paper towel... faucet to be turned off with paper towel used to dry hands. If the air-dry method is used, turn the faucet off with the elbow... Repeat process 1-5 before and after patient contact, before and after entering your bag, before and after donning and doffing gloves, before and after any patient contact, or after contact with inanimate objects in the patient environment.” In 1 of 4 (25%) home visit observations, the agency did not ensure that hand hygiene was performed correctly, when indicated per the agency’s policy and procedure.. Home Visit 1: During the home visit with the Hospice Aide (HA) [Personnel Record 5] on 07/09/2025, the HA washed their hands in the assisted living facility (ALF) memory care unit’s dining room. There were no paper towels, so one of the ALF’s attendants went to get paper towels. While waiting for the paper towels, the HA turned off the faucet using their elbow, then held their hands out of the sink (hands pointing down), dripping water on the floor. After drying their hands, the HA walked to the patient’s room. While walking to the patient’s room, the HA pulled out their phone from their pocket and stated, “I have to start my visit when I walk in and see the patient.” Outside of the patient’s room was a utility cleaning cart, so the HA pulled one glove out of a box of gloves and used this glove to open the patient’s door. Once in the room, the HA walked over to the patient’s bed, touched the patient’s blanket by the patient’s left shoulder, walked over to the patient’s dresser, opened a blue pad, put their cell phone on the blue pad, and then donned two pairs of gloves without sanitizing their hands. During a review of the home visit on 07/09/2025, the Administrator/Area Executive of Clinical Operations stated, “They have had in-service after in-service on hand hygiene.””

“It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to: Assess the quality of care and services provided by the hospice aide, ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical record reviews of patients who received Hospice Aide (HA) services, the agency did not ensure that the Registered Nurse (RN) supervised the HA services no less frequently than every 14 days. Clinical Record 15: The patient elected hospice care on 06/04/2024 with a diagnosis of malignant neoplasm of the prostate and hypertension and expired at home on 11/20/2024. The plan of care dated 10/02/2024 ordered HA services one time a week. The HA completed the weekly visit as ordered. The RN completed HA supervisory visits on 10/15/2024 and 10/31/2024, with 16 days outstanding. During the joint record review on 07/11/2025, the Area Director of Quality Improvement stated, “It was 2 days late; they must have put a Licensed Practical Nurse (LPN) visit on the date the RN was to go for the supervisory visit.””

“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 and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure that the patient’s clinical record included the physician’s orders for the care and services provided. Clinical Record 3: The patient elected hospice care on 05/22/2025. The benefit period dated 05/22/2025 through 08/19/2025 included the diagnoses of malignant neoplasm of unspecified main bronchus, acute respiratory distress, and essential primary hypertension. The plan of care ordered oxygen at six (6) liters, continuous via nasal cannula. The Registered Nurse (RN) visit note dated 05/29/2025 documented in the narrative, “Patient states that he got out of bed and took his oxygen off. Unable to tolerate being off oxygen. Patient situated in bed. Oxygen increased to 8 liters.” The skilled nurse (SN) visit note dated 06/02/2025 documented in the narrative, “Oxygen (O2) 3-6 liters intermittent for shortness of breath.” The Licensed Practical Nurse (LPN) visit note dated 06/06/2025 documented, “O2 at 4 liters per nasal cannula, nurse titrated to 6 liters.” The interdisciplinary group (IDG) note identified the following for the patient’s O2 saturation (sat) and oxygen rate: 05/29/2025 O2 sat 79%/O2 8 liters (L), 06/02/2025 O2 sat 97%/O2 at 3L, O2 sat 77%/O2 4 L. There was no evidence of a physician’s order for the change in the oxygen liter flow during the skilled nursing visits. During an interview on 07/10/2025, the Director of Clinical Services (DCS) stated, “Normally, oxygen orders are written for titrations, based on the patient’s needs. I have written an order to update the plan of care for titration of the oxygen based on the needs of the patient.” The written updated order was included in the clinical record after the interview with the DCS.”