Angels Care Hospice

“Based on observation, interview, and record review, the hospice failed to ensure the ongoing sharing of information between all disciplines providing care and services in all settings for 1 of 3 (Patient #1) patients reviewed. This failure resulted in development of a wound with tendon and bone exposed for Patient #1 and placed all hospice patients at risk for harm related to unmet needs not identified and addressed by the appropriate hospice discipline. The findings included: Record review of Intake #461052, dated 10/30/23, indicated the hospice self-reported this incident to HHSC on 10/30/23. The intake indicated on 10/27/23 the hospice was notified by Nursing Facility #1 that Patient #1 had a wound to the back of the foot which was so significant bone was visible. The intake indicated the hospice nurse reported this wound was a stage 4 pressure injury (a wound or injury resulting from pressure applied to the skin and underlying tissues – a stage 4 pressure injury results in a full-thickness loss of tissue with bone, muscle, or tendon visible in the wound) on 10/27/23. The intake indicated the wound was caused by tightly fitting shoes. Record review of the hospices clinical record for Patient #1 included a plan of care, for the certification period of 07/17/23 – 10/14/23, which indicated the patient had diagnoses of heart failure (a medical condition in which the heart cannot pump effectively which can result in buildup of fluid in the tissues including those of the extremities – arms and legs), dementia (a progressive condition which can result in a decline in thought processes, judgment, and reasoning), and type 2 diabetes mellitus (a condition in which the body cannot effectively regulate the amount of glucose or sugar in the blood which can result in delayed or poor healing of wounds). The plan of care indicated the hospice was to provide skilled nurse visits three times a week for one week and then twice a week for twelve weeks. The plan of care indicated the hospice RN was to evaluate the patient and develop a nursing plan of care. The plan of care further indicated the hospice nurse was to provide instruction related to prevention/management of skin breakdown. The plan of care also indicated the patient was to receive hospice aide visits once a week for one week, four times a week for one week, and then five times a week for eleven weeks. Record review of a hospice physicians recertification order, for the certification period of 10/15/23 – 01/12/24, dated 10/04/23, indicated the hospice was to provide skilled nurse visits twice a week for thirteen weeks effective 10/15/23. Record review of a hospice skilled nurses note, dated 10/10/23, signed by hospice RN C, indicated the patient, “;Has a ... heel issue from tight fitting socks and shoes ... RN met with ... the CG who states PT has ... some new LT foot issues, believed to be from tight fitting shoes/socks.” There was no documentation to indicate hospice RN C notified the patients physician/hospice medical director of the new wound/area of skin breakdown to Patient #1s left Achilles area (area to the back of the foot/ankle connecting the heel to the calf) on 10/10/23. Record review of a hospice skilled nurses note, dated 10/13/23, signed by hospice RN D, indicated, “;Was Integumentary (skin) assessed? Yes ... No Problems identified.” There was no documentation to indicate hospice RN D was aware of, assessed, or notified the patients physician/hospice medical director of the wound/area of skin breakdown to the patients left Achilles area. Record review of a hospice skilled nurses note, dated 10/16/23, signed by hospice LVN E, indicated, “;Was Integumentary assessed? Yes ... No Problems identified.” There was no documentation to indicate hospice LVN E was aware of, assessed, or notified the patients physician/hospice medical director of the wound/area of skin breakdown to the patients left Achilles area. Record review of a Hospice IDG Comprehensive Assessment and Plan of Care Update Report, dated 10/18/2023, did not include documentation regarding the wound/area of skin breakdown to Patient #1s left Achilles area to indicate ongoing sharing of information between all disciplines regarding the wound/area of skin breakdown occurred. Record review of a hospice skilled nurses note, dated 10/21/23, signed by the hospice administrator/supervising nurse, indicated the visit was a PRN visit. The note indicated, “;Was Integumentary assessed? Yes ... Bruising ... BUE [arms].” There was no documentation to indicate the hospice administrator/supervising nurse was aware of, assessed, or notified the patients physician/hospice medical director of the wound/area of skin breakdown to the patients left Achilles area. Record review of a hospice skilled nurses note, dated 10/23/23, signed by hospice LVN E, indicated, “;Was Integumentary assessed? No ... Indicate reason integumentary not assessed: Not applicable.” There was no documentation to indicate hospice LVN E was aware of, assessed, or notified the patients physician/hospice medical director of the wound/area of skin breakdown to the patients left Achilles area. Record review of a hospice skilled nurses note, dated 10/25/23, signed by hospice RN D, indicated, “;Was Integumentary assessed? Yes ... No Problems identified.” There was no documentation to indicate hospice RN D was aware of, assessed, or notified the patients physician/hospice medical director of the wound/area of skin breakdown to the patients left Achilles area. Record review of a hospice skilled nurses note, dated 10/27/23, signed by hospice RN C, indicated the visit was a PRN visit. The note indicated, “;Was Integumentary assessed? Yes ... Pt has ... wounds D/T ill fitted shoes ... Pt has left lower ext wounds, Echilles (sic) tendon exposed ...” Record review of a hospice client coordination note, dated 10/30/23, signed by hospice RN C, indicated, “;RN received message from -------- [name of Nursing Facility #1 LVN I] at --------------- [name of Nursing Facility #1] on 10/27/23 in regards to -------------- [name of Patient #1]s left foot ... Posterior Echilles (sic) 4X3 opened to ligament/bone ... Received orders for antibiots (sic) ... ------------ [name of Nursing Facility #1 LVN I] ... This is the first RN is hearing ot (sic) being notified of the state of the wound.” Record review of a picture of Patient #1s left Achilles area, taken on 10/27/23, by Nursing Facility #1 LVN I, showed an open wound with exposed tendon. Record review of a hospice physicians order, dated 10/27/23, indicated, “;Wound Care Orders ... Left Achilles Heel ... Cleanse with wound cleanser, pat dry with gauze, apply calcium algenate (sic) [a type of absorbent wound dressing] and cover with bordered foam dressing [a type of absorbent wound care dressing sometimes used for padding or protection of the wound]. Wound care to be completed by hospice staff if caregiver/facility staff unable Monday/Wednesday/Friday and PRN.” Record review of a hospice physicians order, dated 11/01/23, verbal order date 10/27/23, indicated the physician ordered Doxycycline (an antibiotic medication used to treat or prevent infection) 100 mg by mouth twice a day for ten days. During an interview conducted on 11/03/23 at 8:47 a.m., with the hospice administrator/supervising nurse, when asked how many of the hospices current patients had wounds, the hospice administrator/supervising nurse said two. When asked how many of the hospices current patients would be at risk for skin breakdown, the hospice administrator/supervising nurse said all of them, as hospice patients often have poor nutrition and decline in their conditions. When asked how many of the hospices current patients resided in nursing facilities, the administrator/supervising nurse said, four, including Patient #1. When asked when the wound to Patient #1s left Achilles area was first identified, the hospice administrator/supervising nurse said she did not know and said the hospice was notified of the wound on 10/26/23 by staff from Nursing Facility #1. The hospice administrator/supervising nurse said on 10/26/23 the hospice received a message from Nursing Facility #1 indicating the wound to the patients left Achilles area had been discovered and the nursing facility needed orders to treat the wound. The hospice administrator/supervising nurse said she was not aware the patient had a wound to the left Achilles area until 10/26/23. The hospice administrator/supervising nurse further said she now knew, since the surveyors investigation had begun, that there was a wound documented to the patients left Achilles area on 10/10/23. The hospice administrator/supervising nurse said as far as she could tell the wound documented on 10/10/23 to the patients left Achilles area was different from the wound to the patients left Achilles area on 10/26/23. The hospice administrator/supervising nurse said in speaking with hospice RN C, who identified the skin breakdown on 10/10/23, hospice RN C felt the issue to the left Achilles area on 10/10/23 was bruising and a tissue wound from improperly fitting clothing or from the patient banging her feet on the wheelchair. The hospice administrator/supervising nurse said a wound or area of skin breakdown to the patients left Achilles area was first identified by the hospice RN C on 10/10/23. When asked what actions were taken by the hospice following identification of a wound or area of skin breakdown on 10/10/23, the hospice administrator/supervising nurse said hospice RN C visited with the staff at Nursing Facility #1 and asked them to remove the patients shoes as hospice RN C felt the shoe was the cause of the wound/skin breakdown. The hospice administrator/supervising nurse said hospice RN C felt the area was a deep tissue injury (a type of pressure injury to the tissues under the skin in which the skin may appear purple or dark red) caused by pressure from the patients shoe. The hospice administrator/supervising nurse said she did not know if hospice RN C notified Patient #1s physician/hospice medical director, Physician K, on 10/10/23 of the new wound/area of skin breakdown to the left Achilles area. When asked if the hospice had received physicians orders to treat the wound/area of skin breakdown to the left Achilles area, the hospice administrator/supervising nurse said the hospice received orders for wound care to Patient #1s left Achilles wound on 10/27/23 after Nursing Facility #1 notified the hospice of the wound. When asked who would be responsible for notifying the physician of new wounds when a patient resided in a nursing facility, such as Patient #1, the hospice administrator/supervising nurse said the hospice nurse would still be responsible for notifying the physician, but the nursing facility would also complete the task. When asked the hospices policy on notification to the patients physician/hospice medical director for new wounds, the hospice administrator/supervising nurse said the hospice would require the hospice nurse to notify the physician/hospice medical director of new wounds to receive orders. When asked who would be responsible for notifying the physician/hospice medical director of new wounds, the hospice administrator/supervising nurse said the hospice RN or hospice nurse who identified the wound would be responsible. When asked the hospices policy on the timeframe for the hospice nurse to notify the physician/hospice medical director of a new wound, the hospice administrator/supervising nurse said the notification should be made within twenty-four hours of identifying the wound. When asked if the hospices policy regarding notification of the physician/hospice medical director of a new wound within twenty-four hours was followed for Patient #1, the hospice administrator/supervising nurse said no one notified the patients physician/hospice medical director of the wound/area of skin breakdown on 10/10/23 but the hospice did notify the patients physician/hospice medical director (Physician K) and obtain orders when Nursing Facility #1 notified the hospice of the wound on 10/26/23. The hospice administrator/supervising nurse also said she felt the wound to the patients left Achilles area got worse between 10/10/23 and 10/27/23 if it was the same wound on both dates. When asked if there was any impact on Patient #1 related to the hospice nurses failure to notify the physician of the new wound on 10/10/23, the hospice administrator/supervising nurse said the patient probably had some discomfort and altered skin integrity. When asked if there could be an impact on other patients related to this failure, the hospice administrator/supervising nurse said, yes, if the issues were not corrected. The hospice administrator/supervising nurse further said the hospice nurse failed to report the wound/area of skin breakdown to the left Achilles area to the patients physician/hospice medical director on 10/10/23. During an interview conducted on 11/03/23 at 10:20 a.m., hospice LVN E said no one notified her of a wound to Patient #1s left foot. Hospice LVN E said if a nurse noted a new wound, it would be the nurses responsibility to notify the patients physician. Hospice LVN E said the hospices policy was to notify the physician as soon as possible and should do so before the nurse left the facility. Hospice LVN E said if the patient resided in a nursing facility the hospice nurse was still responsible for notifying the physician of new wounds. During an interview conducted on 11/03/23 at 12:08 p.m., with hospice RN C, when asked regarding the visit she conducted with Patient #1 on 10/10/23, hospice RN C said the patients caregiver said the patient had a problem with her left foot. Hospice RN C said what she observed on 10/10/23 was an area of irritated, blanchable (when pressure is applied the area turns white or paler in color – if the skin did not blanch it would indicate increased damage to the skin), pink skin to the left Achilles area. Hospice RN C said she did not observe any open areas to the patients left foot on 10/10/23. Hospice RN C said it appeared the irritation to the patients left foot on this date was from a tight-fitting shoe and she advised the nursing facility staff and the patients caregiver not to put the shoe on the patient again. Hospice RN C said she thought despite this the shoe had been placed back on the patient. Hospice RN C said it was possible the area to the patients left Achilles was a deep tissue injury, but she did not believe it was a stage 1 (a type of pressure injury which results in an area of reddened, non-blanchable skin without an open area to the skin) or stage 2 (a type of pressure injury with a partial thickness loss of skin which can present as a shallow crater or blister) pressure injury at that time. Hospice RN C said she had experience working with wounds and a great deal of previous training on wounds. Hospice RN C said the area where she noted the irritated, pink, blanchable skin to the patients left Achilles area on 10/10/23 was the same area where the stage 4 pressure injury was now located. Hospice RN C said she did not notify the patients physician of the bruising and area of irritation on 10/10/23 because she did not notify the physician for bruises or non-open areas. During an interview conducted on 11/03/23 at 12:35 p.m., Patient #1’s physician/hospice medical director, Physician K, said it was 10/27/23 at 9:22 a.m. when he was first notified by the hospice nurse of the wound to Patient #1s left Achilles area. The hospice medical director/Physician K said if he had been notified of the area on 10/10/23 he would have ordered offloading of the area and turning and repositioning. The hospice medical director/Physician K said they probably did not realize the level of seriousness of the wound on 10/10/23. Record review of Nursing Facility #1s clinical record for Patient #1 included a nursing facility physicians order, dated 10/08/23, which indicated “;Clean ... ulcers to ... L foot, apply hydroactive dsgs every day shift every 3 days ...” Record review of Nursing Facility #1s clinical record for Patient #1 included a weekly skin assessment form, dated 10/10/23, signed by Nursing Facility #1 LVN I, which indicated Patient #1 had a wound to the posterior (back of) left foot which measured 2 cm X 1 cm and indicated Nursing Facility LVN I was unable to determine depth of the wound as the wound was covered by necrotic (dead) tissue (slough – yellow/white dead tissue which is usually wet and soft and/or eschar – dry, dead tissue presenting as a scab or crust in a wound) and indicated the wound was being treated with a hydroactive dressing (a type of absorbent wound dressing). Record review of Nursing Facility #1s clinical record for Patient #1 included a weekly skin assessment form, dated 10/24/23, , signed by Nursing Facility #1 LVN I, which indicated Patient #1 had a wound to the posterior left foot which measured 2 cm X 1 cm and indicated Nursing Facility LVN I was unable to determine depth of the wound as the wound was covered by necrotic tissue and indicated the wound was being treated with a hydroactive dressing. Record review of Nursing Facility #1s clinical record for Patient #1 indicated the wound to Patient #1s left Achilles area was an arterial ulcer (an ulcer or wound that develops due to poor blood flow to the bodys tissues). During an interview conducted on 11/03/23 at 4:10 p.m., Nursing Facility #1 RN H said Patient #1 had issues with her foot and had some irritated areas that were about to breakdown when she was admitted to Nursing Facility #1 on 08/28/23. Nursing Facility #1 RN H said at the time the patient was admitted to the nursing facility the area to the left Achilles was about a stage 1 or 2. Nursing Facility #1 RN H said the patient had very tight socks and her legs would swell when she was sitting up. Nursing Facility RN H said the area to the left Achilles stayed about the same until the patient went home with her family for the weekend about two or three weeks ago. Nursing Facility #1 RN H said when the patient came back from the weekend pass with her family the wound to the left Achilles area was a lot worse. Nursing Facility RN H said when the patient came back from the weekend pass the wound to the left Achilles was about a stage 3 (a pressure injury with a full thickness loss of tissue – fat under the skin may be visible, but bone, muscle, and tendon are not visible). Nursing Facility #1 RN H said at that time the wound smelled horrible and smelled like “;rotten potatoes.” Nursing Facility #1 RN H said the patient was very confused with end stage dementia. Nursing Facility #1 RN H said the patient had very fragile skin. Nursing Facility RN H said the hospice nurse changed the patients dressing on 11/03/23. During an observation conducted on 11/03/23 at 4:20 p.m., Patient #1 was observed to have a dressing to the left foot, labeled 11/03/23, and wrapped in rolled gauze. Patient #1 was observed to make a low moaning sound when Nursing Facility #1 RN H pulled the blankets off the patient and moved the patients left leg. The dressing to Patient #1s left foot was not removed as it was a new dressing which had been placed on 11/03/23. Patient #1 was soundly sleeping and did not rouse during the observation and was unable to be interviewed. During an interview conducted on 11/03/23 at 4:38 p.m., Patient #1s Family Member #2 said Patient #1 came to her home for a visit about 3 - 4 weeks ago and then on Sunday (10/08/23) when they were getting the patient ready to go back to the nursing facility she (Patient #1s Family Member #2) was removing a sock from the patients left foot and the patient said “;Ouch” and so she looked at the patients left foot and noted a wound there. Patient #1s Family Member #2 said the area didnt look infected at that time and said it looked like maybe the sock had gotten embedded in the skin and rubbed the area creating a wound. Patient #1s Family Member #2 said the wound to the patients left Achilles area on 10/08/23 was a shallow crater. Patient #1s Family Member #2 said she did not think the wound to the left Achilles area was deep at that time. Patient #1s Family Member #2 said she had not personally seen the wound to the left Achilles area since 10/08/23. Patient #1s Family Member #2 said she visited the patient daily but there was always a dressing over the wound when she was there. Patient #1s Family Member #2 said when she brought the patient back to the nursing facility on 10/08/23, she let the nursing facility know about the wound and the next day she noted there was a dressing on the area. Patient #1s Family Member #2 said she was not sure if the wound to the left Achilles area was present before the patient went home on 10/07/23 – 10/08/23 or not. Patient #1s Family Member #2 said the patient was diabetic. Patient #1s Family Member #2 said she hadnt seen the wound to the left Achilles area for about 3 weeks. During an interview conducted on 11/03/23 at 4:53 p.m., Nursing Facility LVN I said when Patient #1 was admitted to Nursing Facility #1 she had some skin tears, bruises, and discoloration to the skin. Nursing Facility #1 LVN I said the wound to her left Achilles was noted when she came back from being on pass with her family. Nursing Facility #1 LVN I said when the patient returned to the nursing facility after the pass with her family, the patients Family Member #2 said the patient had complained of something when she was putting her sock on. Nursing Facility LVN I said when he assessed the area, he noted a dry, black, hard eschar to the back of the patients left foot/heel Achilles area. Nursing Facility LVN I said he called the patients physician for Nursing Facility #1, Physician L, and got an order for debridement (a treatment to remove dead or non-viable tissue from a wound) and dressing of the wound. Nursing Facility #1 LVN I said when the eschar came off the wound to the back of the left foot/Achilles area, the wound looked really deep. Nursing Facility #1 LVN I said he could not say when the patient went on pass and the eschar to the left Achilles area was first noted or how long it was between when the eschar was first noted and when the eschar came off. Nursing Facility #1 LVN I said the nursing facility did weekly wound assessments. Nursing Facility #1 LVN I reviewed Nursing Facility #1s weekly skin assessment documentation for Patient #1 and said the weekly skin assessment documentation indicated on 10/10/23 the nursing facility staff noted black eschar to the back of the patients left foot/Achilles area and on 10/24/23 the nursing facility staff noted slough to the patients left Achilles wound. Nursing Facility #1 LVN I said the slough must have begun coming off between 10/17/23 and 10/24/23. During an interview conducted on 11/03/23 at 5:45 p.m., the Nursing Facility #1 administrator said she had only been with the nursing facility for about 3 weeks and the issue with Patient #1 occurred before she started employment. The Nursing Facility #1 administrator said she would check the nursing facilitys sign in/out logs to see when Patient #1 left with her family for the weekend pass home. The Nursing Facility #1 administrator said the patient had a wound to the back of her left foot at the time she was admitted to Nursing Facility #1 but said the nursing facility had healed that area within a few days. The Nursing Facility #1 administrator said the wound to the left Achilles area with the eschar occurred after the patient returned from the weekend pass. During an interview conducted on 11/03/23 at 6:00 p.m., the Nursing Facility #1 administrator said she had reviewed the nursing facilitys sign in/out logs and said Patient #1 was out on pass with her family from 10/07/23 – 10/08/23. During an interview conducted on 11/06/23 at 12:20 p.m., Hospice Aide M said she first noticed some type of wound/skin breakdown to Patient #1s left foot area about a week or so after she was admitted to Nursing Facility #1 (08/28/23). Hospice Aide M said the wound to the patients left Achilles area got worse over time, but she did not recall specific dates. Hospice Aide M said Nursing Facility #1 was providing treatment to the wound and said she first noted treatments/dressings to the left Achilles wound about 2-3 weeks after it started to get bad. When asked if that was around 10/27/23, Hospice Aide M said, yes. Hospice Aide M said she notified the hospice nurse of the wound but said several nurses had seen Patient #1, so she did not know who the patients RN case manager was, so she notified the hospice by sending a message through the hospices electronic messaging system. Hospice Aide M said all hospice staff should have access to this system. During an interview conducted on 11/06/23 at 12:31 p.m., hospice RN C said what she documented on her skilled nurses note for Patient #1 on 10/10/23 was 100% what she observed during that visit. Hospice RN C said she saw the patient in the common area at Nursing Facility #1 on 10/10/23 and knelt down and looked at the patients feet and wrote what she saw on her paper. Hospice RN C said she did not observe any eschar or scabbing to the left heel/Achilles area on 10/10/23. When asked if she was aware Nursing Facility #1 was providing debridement to the left Achilles wound beginning on 10/08/23, RN C said, “;No Maam.” RN C said when she spoke with Nursing Facility #1 LVN I on 10/27/23 he told her Nursing Facility #1 had recently been applying something to the area and said he told her the wound had only gotten bad sometime between that Tuesday (10/24/23) and that Thursday (10/26/23). Hospice RN C said on 10/10/23 the wound to Patient #1s left foot Achilles area was pink and irritated but not open. Hospice RN C said she did not recall seeing a message from the hospice aide regarding a wound/skin breakdown to Patient #1s left Achilles area in the hospices electronic messaging system. During an interview conducted on 11/06/23 at 1:10 p.m., with the hospice regional director and hospice administrator/supervising nurse, the hospice regional director said the messages in the agencys electronic messaging system were not part of the hospice patient record. The hospice regional director said the messages would go to all members of the hospice team and the team would consist of all employees for the hospice. During an interview conducted on 11/06/23 at 1:31 p.m., the hospice regional director said they were unable to print the messages from the hospices electronic messaging system, but she had reviewed them and there was nothing regarding a wound for Patient #1. Record review of the hospices electronic messaging system did not include a message from Hospice Aide M regarding the wound to Patient #1s Achilles area. During an interview conducted on 11/07/23 at 9:15 a.m., with the hospice administrator/supervising nurse and hospice regional director, the hospice regional director said the hospice found no documentation to indicate the hospice aide notified the hospice nurse of the wound to Patient #1s left Achilles area. The hospice regional director and hospice administrator/supervising nurse said the hospices expectation was that the hospice aide would call the RN case manager for the patient with changes in condition, such as new wounds, and said if the hospice aide did not know who the RN case manager was for that patient the hospices expectation would be that the hospice aide would contact the hospice administrator/supervising nurse. Record review of a hospice policy titled, “;Care/Service Coordination,” dated May 2023, indicated, “;Timely and ongoing communication is the responsibility of each team member ... The clinician/technician will be responsible for facilitating communication about changes in the patients status among the assigned personnel ... Organization personnel will communicate changes in a timely manner via telephone, one-on-one meetings, case conferences, and home visits. Documentation of all communications will be included in the clinical record on a communication note, case conference summary, or clinical note ...””