Caris Healthcare

“Based on policy review, medical record review, and interview, the agency failed to maintain a system of communication and integration in accordance with the hospice’s own policies and procedures by failing to ensure clinical notes were documented in a timely manner for 7 of 14 (Patient #2, #3, #5, #6, #8, #9, and #10) patients reviewed. The findings included: 1.Review of the agency policy “DOCUMENTATION REQUIREMENTS,” last revised 3/26/2024, revealed “...Members of the interdisciplinary team document the interventions provided to the patient...their response to care, services provided...Real time documentation is performed at the bedside and completed shortly after the visit using the hospice electronic charting system...” 2. Review of the medical record revealed Patient #2 was admitted to the agency on 1/28/2025, with diagnoses of Alzheimer’s Disease, Anemia, and Protein-Calorie Malnutrition. Review of the Client Coordination Note Report revealed a visit was made on 6/21/2025 at 4:30 PM. The documentation for the visit was completed on 6/23/2025 at 9:19 AM. Review of the medical record revealed Patient # 3 was admitted to the agency on 1/28/2025, with diagnoses of Alzheimer’s Disease, Hypertension, Hyperlipidemia, and Atrial Fibrillation. Review of the Coordination Note Report revealed a visit made on 6/6/2025 at 1:58 PM. The documentation for the visit was completed on 6/9/2025 at 7:11 AM. Review of the Coordination Note Report revealed a visit was made on 7/9/2025 at 4:10 PM. The documentation for the visit was completed on 7/11/2025 at 7:46 AM. Review of the medical record revealed Patient #5 was admitted to the agency on 6/11/2025, with diagnoses of Malignant Neoplasm of the Colon, Heart Failure, Protein Calorie Malnutrition, Muscle Wasting, Dysphagia, and Colostomy. Review of the Coordination Note Report revealed a visit was made on 7/30/2025 at 6:46 PM. The documentation for the visit was completed on 8/4/2025 at 4:43 PM. Review of the medical record revealed Patient #6 was admitted on 2/21/2025, with diagnoses of Alzheimer’s Disease, Muscle Wasting, Dysphagia, Dementia, Depression, and Chronic Obstructive Pulmonary Disease. Review of the Coordination Note Report revealed a visit was made on 7/31/2025 at 7:12 PM. The documentation for the visit was completed on 8/4/2025 at 12:11 PM. Review of the medical record revealed Patient #8 was admitted to the agency on 5/28/2025, with diagnoses of Heart Failure, Aortic Stenosis, Acute and Chronic Respiratory Failure, Atrial Fibrillation, and Diabetes. Review of the Coordination Note Report revealed a visit was made on 7/1/2025 at 3:13 PM. The documentation for the visit was completed on 7/3/2025 at 9:47 AM. Review of the Coordination Note Report revealed a visit was made on 7/11/2025 at 3:00 PM. The documentation for the visit was completed on 7/14/2025 at 10:29 AM. Review of the Coordination Note Report revealed a visit was made on 8/8/2025at 11:00 AM. The documentation for the visit was completed on 8/10/2025 at 7:43 PM. Review of the Coordination Note Report revealed a visit was made on 8/15/2025 at 1:04 PM. The documentation for the visit was completed on 8/18/2025 at 9:27 PM. Review of the medical record revealed Patient #9 was admitted to the agency on 5/26/2025, with diagnoses of Cerebral Infarction, Dementia, and Hypertension. Review of the Client Coordination Note Report revealed a visit was made on 6/5/2025 at 5:14 PM. The documentation for the visit was completed on 6/8/2025 at 8:47 PM. Review of the Client Coordination Note Report revealed a visit was made on 6/6/2025 at 1:15 PM. The documentation for the visit was completed on 6/9/2025 at 8:20 AM. Review of the Client Coordination Note Report revealed a visit was made on 8/14/2025 at 4:02 PM. The documentation for the visit was completed on 8/17/2025 at 11:21 PM. Review of the medical record revealed Patient #10 was admitted to the agency on 5/16/2025, with diagnoses of Chronic Obstructive Pulmonary Disease, Hyperthyroidism, Atrial Fibrillation, Hypertension, and Congestive Heart Failure. Review of the Coordination Note Report revealed a visit was made on 5/16/2025 at 1:25 PM. The documentation for the visit was completed on 5/20/2025 at 9:57 AM. Review of the Coordination Note Report revealed a visit was made on 6/11/2025 at 5:03 PM. The documentation for the visit was completed on 6/16/2025 at 9:24 AM. Review of the Coordination Note Report revealed a visit was made on 7/17/2025 at 1:12 PM. The documentation for the visit was completed on 7/21/2025 at 10:41 AM. 3. During an interview on 8/18/2025 beginning at 9:37 AM, the Regional Vice President of Clinical Care confirmed the time frame for documentation of visit notes for Patient #2, #3, #5, #6, #8, #9, and #10 were not completed timely.”

“Based on policy review, medical record review, and interview, the facility failed to ensure wound assessments were performed on 3 of 3 (Patient #2, #4, and #8) patients reviewed for wound care. The findings included: 1.Review of the agency policy “Wound Care Treatment,” dated 4/7/2020, revealed, “...If a patient already has wound or develops a wound/pressure injury, the nurse will provide care in accordance with the hospice’s infection control protocol and physician orders...If a wound/pressure injury is present, the documented findings include location, appearance, measurements, drainage, odor, and treatment orders...” 2. Review of the medical record revealed Patient #2 was admitted to the agency on 1/28/2025 with diagnoses including Alzheimer’s Disease, Anemia, and Protein-Calorie Malnutrition. Review of the Wound Record Report reveal there were no wound measurements for Resident #2 on 7/29/2025, 8/5/2025, 8/7/2025, 8/12/2025, and 8/14/2025. 3. Review of the medical record revealed Patient #4 was admitted to the agency on 7/22/2025 with diagnoses including Senile Degeneration of Brain, Dementia, Pressure Ulcer of Right Buttock, Stage 4, and Anxiety. Review of the physician order’s dated 7/28/2025, revealed, “...CLEANSE WOUND…PAT DRY, Sprinkle with Flagyl [used to treat infection], PACK WOUND…COVER WITH OBSORBANT DRESSING, CHANGE DAILY AND PRN [as needed] IF SOILED.” Review of the Wound Record Report reveal there were no wound measurements for Resident #4 on 7/28/2025 and 8/5/2025. 5. Review of the medical record revealed Patient #8 was admitted to the agency on 5/28/2025 with diagnoses including Congestive Heart Failure, Aortic Stenosis, Acute and Chronic Respiratory Failure, Atrial Fibrillation, and Diabetes. Review of the physician order dated 6/3/2025, revealed “...Hospice RN [Registered Nurse] to evaluate patient and develop a nursing plan of care...” Review of the Wound Record Report reveal there were no wound measurements for Resident #8 on 6/10/2025, 6/17/2025, 6/18/2025, 6/22/2025, 6/24/2025 and 7/1/2025. 6. During an interview on 8/18/2025 at 8:45 AM, the Regional Director of Clinical Care stated “They [staff] should measure every week as part of the wound assessment...””