Bristol Hospice - North Central Texas

“It is required that the hospice maintains an emergency preparedness training program that is based on the emergency preparedness plan, risk assessment, policies and procedures, and the communication plan. The hospice EP training program includes EP training of all hospice employees and individuals providing services under arrangement at least every two (2) years; More frequent training occurs if there is a significant update of EP policies and procedures. This standard was not met as evidenced by document review, interview and personnel record review. In 1 of 17 (6%) personnel records reviewed, the agency did not ensure that all personnel completed and documented annual training on the agency’s Emergency Preparedness Plan. POLICY: The agency’s “Natural Disasters/Emergencies” policy (Policy No. 2-047, Dated May 2020) stated in part, “1. The training includes: initial training and emergency preparedness policies and procedures and their assigned emergency response roles to all new and existing staff, individuals providing service under agreement, and volunteers if applicable, 2. The training is provided annually and demonstrates staff knowledge of emergency procedures. 3. The organization will provide for orientation and annually thereafter of all personnel regarding participation in the Emergency Management Plan. Education to include: A. specifics of the Emergency management Plan, B. Specific assignment emergency response role, C. Information on developing their family’s emergency response plan, D. information regarding accessing housing and transportation for staff if necessary. D-1. All training will be documented in the personnel record of staff, individuals under arrangement and volunteers, if applicable.” PERSONNEL RECORD 15: A review of the volunteer personnel record (DOH 03/26/2024) revealed no documentation indicating that the volunteer had received annual training in 2025 on the Emergency Preparedness program, as required by the agency’s policy. The Administrator (Personnel Record 1) was interviewed on 06/05/2026 and stated, “The volunteers are assigned education to complete in the eLearning platform. She either didn’t complete it, or it wasn’t assigned in this case.””

“It is required that each patient’s individualized written plan of care includes all medical supplies and appliances necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review, interview and observation. In 3 of 24 (13%) clinical records reviewed, the agency did not ensure that the patient’s individualized written plan of care included medical supplies and appliances necessary to meet the needs of the patient CLINICAL RECORD 2: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted on 05/25/2025. The Plan of Care (POC) dated 05/20/2026-07/18/2026 included an order for “Oxygen (O2) 1 - 4 liter/min Both Nostrils PRN Chest Pain, SOB”, and Safety Measures “Fire, electric, & open flame safety”. Oxygen and oxygen-related supplies were not documented in the DME and Supplies section of the POC. CLINICAL RECORD 5: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted on 05/02/2025. The Plan of Care (POC) dated 05/02/2026-06/30/2026 included an order for “Oxygen (O2) 2 - 4 liter/min nasal continuous for Shortness of Breath”. Oxygen and oxygen-related supplies were not documented in the DME and Supplies section of the POC. CLINICAL RECORD 18: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted on 01/28/2026. The Plan of Care (POC) dated 04/28/2026-07/26/2026 included “Oxygen (O2) 2 - 4 liter/min Both Nostrils continuous PRN Shortness of Breath” on the medication list. Oxygen and oxygen-related supplies were not documented in the DME and Supplies section of the POC. The Administrator (Personnel Record 1) was interviewed on 06/05/2026 and agreed the care plans did not include all of the oxygen and oxygen related supplies”

“It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review, document review and interview. In 10 of 20 (50%) clinical records reviewed where the patient received hospice aide services, the agency did not ensure that the hospice aide care plan included specific instructions for care. POLICY: The agency’s “Hospice Aide Supervisory Visits” policy (Policy No. 1-037, Dated November 2021) stated in part, “3. The Case Manager will be responsible for: A. Providing written instructions to ensure compliance with the plan of care.” CLINICAL RECORD 3: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted on 03/31/2022. The Plan of Care (POC) dated 05/09/2026-07/07/2026 included orders for Hospice Aide (HA) services. The HA care plan dated 05/09/2026 included, in part, the following orders: “Empty bedside commode, adult brief change, shampoo Hair, assist with dressing patient, assist with undressing patient, change bed linens, make bed.” The HA care plan did not include specific instructions and frequencies for all personal care tasks. CLINICAL RECORD 4: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted on 04/27/2026. The Plan of Care (POC) dated 04/27/2026-07/25/2026 included orders for Hospice Aide (HA) services. The HA care plan dated 04/28/2026 included, in part, the following orders: “Meet all personal care, safety and comfort needs, Complete Bed Bath, patient prefers morning, Empty catheter bag, Bed bath, Perineal Care, Assist with dressing patient, Assist with undressing patient, Assist brush teeth, Heel protectors.” The HA care plan did not include specific instructions that included frequencies for all personal care tasks. CLINICAL RECORD 5: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted on 05/02/2026. The Plan of Care (POC) dated 05/02/2026-06/30/2026 included orders for Hospice Aide (HA) services. The aide care plan dated 05/20/2026 included, in part, the following tasks: “Perform catheter care, turning and positioning, tidy patient’s immediate area, adult brief change, assist with dressing patient, assist with undressing patient, fingernail care, foot care, mouth Care, routine hair and skin maintenance, apply moisture barrier cream to all extremities buttocks, change bed linens.” The HA care plan did not include specific instructions that included frequencies for all personal care tasks. CLINICAL RECORD 14: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted on 01/02/2026. The Plan of Care (POC) dated 04/02/2026-06/30/2026 included orders for Hospice Aide (HA) services. The aide care plan dated 04/02/2026 included, in part, the following tasks: “Transfer to chair, Assist with transfers Stand by Guard, Transfer on or off commode, Seated Shower, Perineal Care, Shampoo Hair, Assist with undressing patient, Comb or Brush Hair, Fingernail care, Brush teeth, Foot Care, Mouth Care, Routine hair and skin maintenance, Apply moisture barrier cream to Upper extremities.” The HA care plan did not include specific instructions and frequencies for all personal care tasks. CLINICAL RECORD 15: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted on 02/13/2026. The Plan of Care (POC) dated 04/14/2026-06/12/2026 included orders for Hospice Aide (HA) services. The aide care plan dated 04/14/2026 included, in part, the following tasks: “Complete bed bath, patient prefers afternoon, provide peri care, turning and positioning, adult brief change, perineal care, shampoo hair, comb or brush hair, brush teeth, routine hair and skin maintenance, change bed linens.” The HA care plan did not include specific instructions that included frequencies for all personal care tasks. CLINICAL RECORD 16: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted on 02/14/2026. The Plan of Care (POC) dated 05/15/2026-08/12/2026 included orders for Hospice Aide (HA) services. The aide care plan dated 05/11/2026 included, in part, the following tasks: “Empty catheter bag, turning and positioning, bed bath, perineal care, shampoo hair, apply lotion to back, comb or brush Hair, assist brush teeth, routine hair and skin maintenance, assist with shaving razor, apply moisture barrier cream to lower extremities, change bed linens.” The HA care plan did not include specific instructions that included frequencies for all personal care tasks. CLINICAL RECORD 18: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted on 01/28/2026. The Plan of Care (POC) dated 04/28/2026-07/26/2026 included orders for Hospice Aide (HA) services. The aide care plan dated 04/28/2026 included, in part, the following tasks: “Bed bath, perineal care, assist with dressing patient, fingernail care, brush teeth, foot care, make bed.” The HA care plan did not include specific instructions that included frequencies for all personal care tasks. CLINICAL RECORD 21: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted on 08/19/2025. The Plan of Care (POC) dated 11/17/2025-02/14/2026 included orders for Hospice Aide (HA) services. The aide care plan dated 11/17/2025 included, in part, the following tasks: “Document vital signs, patient can shower, with assist. patient prefers morning, shampoo hair, assist with dressing patient, assist with undressing patient, comb or brush hair.” The HA care plan did not include specific instructions that included frequencies for all personal care tasks. CLINICAL RECORD 22: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted on 09/11/2025. The Plan of Care (POC) dated 03/10/2026-04/24/2026 included orders for Hospice Aide (HA) services. The aide care plan dated 04/22/2026 included, in part, the following tasks: “Assist with ambulation using walker, assist with toileting, assist with bedside commode, empty bedside commode, provide peri care, adult brief change, bed bath.” The HA care plan did not include specific instructions that included frequencies for all personal care tasks. CLINICAL RECORD 24: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted on 11/11/2025. The Plan of Care (POC) dated 11/11/2025-01/05/2026 included orders for Hospice Aide (HA) services. The aide care plan dated 11/11/2025 included, in part, the following tasks: “Provide Peri Care, companionship, perform catheter care, empty colostomy bag, bed bath.” The HA care plan did not include specific instructions that included frequencies for all personal care tasks. The Administrator (Personnel Record 1) was interviewed on 06/05/2026 and stated, “The aide care plans should be specific and include the frequency of each task.””

“It is required that a hospice aide provides services included in the plan of care. This standard was not met as evidenced by clinical record review, document review and interview. In 4 of 20 (20%) clinical records reviewed where the patient received Hospice Aide services, the agency did not ensure that the aide provided services included in the plan of care. POLICY: The agency’s “Hospice Aide Services” (Policy No. 0-020, Dated 09/2024) stated in part, “5. Hospice aides will document care provided in accordance with the Hospice Aide assignment. 6. Hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities.” POLICY: The agency’s “Missed Visits” policy (Policy No. 1-027, Dated May 2020) stated in part, “3. If an aide visit is missed, the aide will contact the Hospice Case Manager or clinical management. The Direct of Patient Care Services/Clinical Supervisor will take the appropriate measures stated above.” CLINICAL RECORD 2: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted on 05/25/2025. The Plan of Care (POC) dated 05/20/2026-07/18/2026 included orders for Hospice Aide (HA) services with a visit frequency of 3 visits per week for 1 week (05/20/2026-05/23/2026), 5 visits per week for 8 weeks (05/24/2026-07/18/2026), 4 visits per week for 1 week (05/26/2026-05/30/2026) and 5 visits per week for 7 weeks (05/31/2026-07/18/2026). 2 HA visits were performed and documented on both 05/20/26 and 05/21/2026, and 1 HA visit was documented on 05/22/2026 (totaling 5 HA visits from 05/20/2026 through 05/22/2026), exceeding the visit frequency of 3 visits as written in the POC. An interim order was documented on 05/25/2026, changing the HA visit frequency to 4 visits per week for 1 week (05/26/2026-05/30/2026), then 5 visits each week for 7 weeks (05/31/2026-07/18/2026). 2 HA visits were documented each day on 05/26/2026, 05/27/2026, 05/28/2026, and 05/29/2026, totaling 10 visits. The provided visits exceeded the weekly HA visit frequency for the week of 05/26/2026 through 05/30/2026 by 4 visits. The HA provided visits that were not included in the care plan. CLINICAL RECORD 3: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted on 03/31/2022. The Plan of Care (POC) dated 05/09/2026-07/07/2026 included orders for Hospice Aide (HA) services at a frequency of 5 visits per week for 10 weeks. There were 4 documented HA visits during the week of 05/17/2026, and 3 documented visits and 1 missed visit during the week of 05/24/2026. There was no documentation of HA missed visits, nor of any communication between the HA and the RN Case Manager regarding the missed visits. CLINICAL RECORD 8: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted on 10/10/2025. The Plan of Care (POC) dated 04/08/2026-06/06/2026 included orders for Hospice Aide (HA) services at a frequency of 3 visits per week for 1 week, then 5 visits per week for 8 weeks. There were only 4 documented HA visits during the weeks of 05/11/2026 and 05/26/2026. There was no documentation of HA missed visits, nor of any communication between the HA and the RN Case Manager regarding the missed visits. CLINICAL RECORD 9: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted on 04/08/2026. The Plan of Care (POC) dated 04/08/2026-06/06/2026 included orders for Hospice Aide (HA) services at a frequency of 2 visits per week for the first week, then 5 visits per week for 13 weeks. There were only 4 documented HA visits during the weeks of 04/13/2026 and 05/04/2026. There was no documentation of HA missed visits, nor of any communication between the HA and the RN Case Manager regarding the missed visits. The Administrator (Personnel Record 1) was interviewed on 06/05/2026 and stated, “The aide didn’t visit the patient as ordered in the care plan.””

“It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by clinical record review, interview and observation. In 2 of 20 (10%) records reviewed where the patient received Hospice Aide services, the agency did not ensure that the hospice aide reported patient changes related to the plan of care. CLINICAL RECORD 1: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted on 10/09/2025. The Plan of Care (POC) dated 04/07/2026-06/05/2026 included orders for Hospice Aide (HA) with a visit frequency of 4 visits for 1 week, then 5 visits each week for 8 weeks. The Aide care plan dated 04/07/2026 included instructions, in part, as follows: “Bed bath M, W, F, Shampoo Hair M W F, Change bed linens M W F.” The HA note dated Tuesday, 06/02/2026 included documentation that the HA performed a bed bath, shampooed his hair, and changed the bed linens. These tasks were assigned by the Registered Nurse (RN) on the aide care plan for each Monday, Wednesday, and Friday. There was no additional documentation in the aide’s note indicating that the RN was notified of changes in the patient’s condition that required a deviation from the aide care plan. CLINICAL RECORD 2: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted on 05/25/2025. The Plan of Care (POC) dated 05/20/2026-07/18/2026 included orders for Hospice Aide (HA) services. The HA care plan was updated on 05/20/2026 and included personal care tasks for the HA to perform at each visit. The HA noted dated 06/02/2026 included a note in the “Narrative” section that stated, “Sweet Dreams Visit (SDV)”. There was no other documentation in the note indicating interventions that were performed or omitted during the visit. There was no documentation in the note indicating that the HA contacted the Registered Nurse to notify them of changes in the patient’s condition that required a deviation from the aide’s care plan. The Administrator (Personnel Record 1) was interviewed on 06/04/2026 and stated, “The aides are instructed to contact the nurse whenever there is a change in the patient’s plan of care.””

“It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. A review of the agency’s volunteer program and volunteer utilization statics provided by the Administrator (Personnel Record 1), revealed the agency did not ensure that hospice volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. Volunteer Program: The Administrator (Personnel Record 1) provided data regarding volunteer utilization. In calendar year 2024, the percentage of volunteer utilization was 5.71%; in calendar year 2025, it was 1.35%; and year-to-date in 2026, it was 0.16%. The agency did not maintain volunteer use of at least five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The Administrator (Personnel Record 1) was interviewed on 06/05/2026 and stated, “We changed our volunteer program in 2025 and have seen a decrease in volunteer use. We have a PIP in place to work on increasing use.” A review of the agency’s Volunteer program and Volunteer utilization statics provided by the Administrator (Personnel Record 1), the agency did not ensure that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff.”

“It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. The hospice has written policies and procedures describing the method(s) of assessing competency and maintains a written description of the in-service training provided during the previous 12 months. This standard was not met as evidenced by document review, interview and personnel record review. In 4 of 17 (24%) personnel records reviewed, the agency did not ensure that clinical competencies were performed and documented as required by the agency’s policies. POLICY: The agency’s “Competency Program” (Policy No. 3/001-HR, Dated May 2020) stated in part, “5. A preceptor will be assigned to each new staff member as part of the orientation process. The preceptor supervisor will observe and deem proficient the indicated skills and core competencies. If necessary, additional training, or in service education will be provided to the staff member. Hospice personnel will not provide the care or service independently until satisfactory completion of a required skilled competency 6. After the completion of orientation, competency will be monitored annually thereafter as part of the annual performance evaluation process. POLICY: The agency’s “Annual Core Competence” policy (Policy No. 3-005-HR, Dated May 2020) stated in part, “1. Hospice personnel will demonstrate proficiency in the performance criteria/skills during the orientation, and at least annually thereafter as part of the annual performance evaluation process.” PERSONNEL RECORD 7: A review of the Registered Nurse (RN) personnel record (DOH 09/17/2025) revealed no documentation of an initial skills competency. PERSONNEL RECORD 10: A review of the Hospice Aide (HA) personnel record (DOH 04/23/2025) revealed no documentation that an initial skills competency was completed. PERSONNEL RECORD 13: A review of the Bereavement Coordinator personnel record (DOH 11/29/2021) revealed documented competencies dated 03/29/2023 and 09/04/2024. There was no documented annual competency in 2025. PERSONNEL RECORD 15: A review of the Volunteer personnel record (DOH 03/26/2024) revealed a documented initial competency dated 04/09/2024. There was no documented annual competency for 2025. The Administrator (Personnel Record 1) was interviewed on 06/04/2026 and stated, “The competencies were done, we just can’t locate them right now.””

“It is required that the hospice obtains a criminal background check on all hospice employees who have direct patient contact or access to patient records. Criminal background checks are obtained in accordance with state requirements. This standard was not met as evidenced by interview and personnel record review. In 1 of 17 (6%) personnel records reviewed, the agency did not ensure that criminal background checks were performed and documented as per state requirements on all employees who have direct patient contact or access to patient records. POLICY: The [state] Health and Human Services Handbook, Appendix VIII (Dated 06/2019, Accessed 06/05/2026) stated in part, “Chapter 250, Health and Safety Code, requires that persons convicted of certain crimes may not be employed in direct contact with an individual in specified facilities and agencies providing care to the aged and disabled. Therefore, criminal history checks on certain employees must be performed prior to an offer of permanent employment with the facility or agency except in emergency situations.” and “Criminal history checks are required for providers listed below...Home and community support services agencies licensed by HHSC under Chapter 142, Health and Safety Code.” PERSONNEL RECORD 7: A review of the Registered Nurse (RN) personnel record (DOH 09/17/2025) revealed no documentation indicating that a criminal background check had been completed and documented per state requirements. The Administrator (Personnel Record 1) was interviewed on 06/05/2026 and stated, “We know it was done, but we can’t find it.””

“Based on record review and interview, the agency failed to comply with the provisions of the Texas Human Resources Code, Chapter 102 on 1of 3 active patients (Patient#1), to which the Patient #1 refused to be bathed by the hospice HHA. This failure placed the agency’s Patients at risk for ANE and inadequate care. Findings include: Record Review of the State of Texas regulation titled, “Texas Human Resource Code § 102.003 Section 102.003 - Rights of the Elderly,” revealed “(b) An elderly individual has the right to be treated with dignity and respect for the personal integrity of the individual, without regard to race, religion, national origin, sex, age, disability, marital status, or source of payment. This means that the elderly individual: (1) has the right to make the individual’s own choices regarding the individual’s personal affairs, care, benefits, and services;” During record review and interview with the family member of Patient #1 on 3/28/2025 at 7:00 p.m., the family member of Patient #1 presented a video with low audio of the hospice HHA visit on 9/30/2024 with Patient #1 from a camera in Patient #1’s room. The camera revealed while HHA was touching Patient #1, Patient #1 began to scream and yell for a facility staff member. During the interview of the family member of Patient #1, the family member stated that she feels felt Patient #1 did not have her rights adhered to during the visit with the hospice HHA. During home visit to Patient #1’s home on 3/21/2025 at 11:30 a.m., Patient #1 expressed that she did not want a shower when the hospice HHA came to her room. Patient #1 stated that she was trying to inform the hospice HHA during the visit that she only wanted her dress changed because she already washed herself up. Patient #1 stated that she felt that her rights were violated by the hospice HHA. During a record review of Patient #1’s clinical records revealed that Patient #1 was admitted to hospice on 5/16/2023 with a terminal diagnosis of chronic obstructive pulmonary disease (long term damage to lungs). Further record review revealed that Patient #1 lived in a skilled nursing facility since 5/15/2023. Further record review of clinical records reveal Patient #1 received skilled nursing visits once weekly, hospice HHA twice weekly, chaplain visits once monthly, and social worker visits once monthly. During an interview with HHA A on 10/31/2024 at 4:35 p.m., HHA A stated that she went Patient #1’s room to give her a bath and Patient #1 agreed. HHA A also stated, ‘I could not really understand what she was saying. The other aide from the facility said to give her a bed bath. This was the first time I ever saw her. I wish I had known more about her.” During an interview with the Administrator on 3/31/2025 at 3:00 p.m., the Administrator was informed of the above findings. The Administrator stated she stated that HHA was educated on ANE and removed from the case. During a review of the agency’s policy titled, “Bristol Hospice Companies,” dated 5/2022, revealed, “The Bill of Rights statement defines the right of the patient to…F. Refuse care or treatment.””

“Based on record review and interview, the agency, whose records were reviewed, failed to enforce written policies addressing a definitive line of authority in that: 1. The hospice agency did not have a designated Alternate Administrator for the agency’s one parent agency and two branches (Branch #2 and Branch #3) between 1/29/2025 and 3/21/2025. 2. The hospice agency did not report a designated Alternate Administrator to HHSC during the period of 1/29/2025 and 3/21/2025. This failure placed the agency’s patients at risk for inadequate care. Findings included: During a presurvey record review on 3/20/2025 at 10:00 am in TULIP, revealed that the agency’s Alternate Administrator listed a previous employee. During an entrance interview with the Administrator on 3/20/2025 at 1:00 pm, when asked who the Alternate Administrator was, the Administrator stated that they don’t currently have an Alternate Administrator. The Administrator further revealed that the previous Alternate Administrator that was based in Branch #2, no longer works for the agency as of 1/29/2025. During an interview on 3/31/2025 at 2:30 p.m. with RVPCO, the RVPCO stated that addressing the Alternate Administrator designation and reporting to HHSC failure was overlooked during the period of 1/29/2025 to 3/21/2025. Record review of an agency email by the Administrator, no title, dated 3/28/2025, read in part, “Our process is for the RVPO to contact GB, Licenses and Credentialing to notify state of TX within 7 days (per their State regs.) All 3 are to be notified for a vacancy and new Admin hire…””

“Based on 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 to ensure that the care and services provided are based on all assessments of the patient and family needs for 1 of 2 discharged patients (Patient #5), in that: 1. The hospice nurse assessed Patient #5 four and a half hours after the agency received the call that Patient #5 was experiencing signs of a stroke. 2. Patient #5’s family member was not notified by the agency at the time of the discovery of the onset of stroke symptoms. This deficient practice placed the agency’s patients at risk for receiving inadequate and timely care. The findings included: Review of Patient #5’s hospice Plan of Care, certification dates between 12/13/2023 to 2/10/2024, revealed a terminal diagnosis of Alzheimers disease (a progressive disease that destroys mental functions) with Patient #5 living in a skilled nursing facility. Further review of the plan of care revealed that Patient #5 received hospice nursing visits twice weekly for eight weeks with one visit as needed for a vital sign assessment. Review of Patient #5s clinical record revealed on 12/25/2023 at 7:30 a.m., nursing facility staff called the agencys on-call nurse (RN C) to inform RN C regarding symptoms of a possible stroke. Record review further revealed that RN C informed the caller that someone will be out to assess Patient #5. Further review revealed Patient #5 was assessed by RN A for stroke symptoms. When she arrived at the nursing facility at 12:00 pm. RN A spoke with the family member of Patient #5 regarding stroke symptoms after an assessment was made. Further review revealed that Patient #5 was sent to the emergency room after the assessment where it was confirmed that Patient #5 did experience a stroke. During an interview with the phone triage nurse RN C on 12/29/2023 at 3:40 p.m., RN C stated that she worked the phone triage the night of 12/24/2023 with her shift ending at 8 am on 12/25/2023. RN C stated that she received a phone call from the skilled nursing facility staff regarding Patient #5 having a blood pressure of 160 over 101 and an oxygen saturation of 94%. RN C stated she was also informed by the facility staff of the facial weakness and Patient #5 “;leaning to the left.” RN C stated “;This was at 7:32 a.m. I then sent an email to all staff regarding the nursing facilitys phone call.” When asked if the family member was called, RN C stated “;No, because it was shift change so I sent out a blast email so everyone can see it. It is not unusual for people to think that the patient is having a stroke with possible stroke symptoms. Besides, I didnt know who to call.” During an interview on 12/29/2023 at 4:00 p.m., with Nursing Supervisor RN D, the Nursing Supervisor RN D was asked why the family member was not called at the time of discovery of Patient #5s stroke symptoms on 12/25/23 at 7:30 a.m. Nursing Supervisor RN D stated that the family member was not informed until (Patient #5) was assessed at 12 noon, however she now understands that a phone call should have been made to the family member as part of the plan of care and the decision making. Nursing Supervisor RN D had no explanation as to the cause of the time lapse in assessing Patient #5. During an interview with the Administrator on 12/29/2023 at 4:00 p.m., the Administrator was informed of the above findings. The Administrator acknowledged the above findings and stated there is really no excuse for the four and a half hour time span that Patient #5 was not assessed. The Administrator also stated that the agency takes full responsibility for the incident and takes patient care very seriously. Record review of an agency policy titled, “On-Call/Weekend Services,” dated 5/2020, read in part, “Purpose: To establish the process by which patients have access to hospice services 24 hours per day...Procedure: 5. The on-call nurse will provide follow-up appropriate to the call a. Call the...family/caregiver b. Visit the patient...6. The on-call nurse will document each patient/family interaction in a clinical note...8. On-call staff will respond to a call within 15 minutes and must be able to reach a patient within one hour...””