Embrace Hospice

“Observed in Record Review. In 1 of 3 bereavement records reviewed, the organization had not documented an initial bereavement assessment as required by the organization’s bereavement policy (2-010.01). The policy states that an initial assessment will be performed at the time of admission. The patient admitted on 6/10 and the first documented bereavement assessment was on 8/5, after the patient’s death. This was discussed with the Director of Operations and the Bereavement Coordinator. Observed in Record Review. In 1 of 20 patient records reviewed, the surveyor noted that the organization did not ensure they conducted and documented a patient-specific comprehensive assessment that identifies the patient’s need for hospice care. For example, in HOSNHV#12, the bereavement risk assessment was not conducted until 10 days after care was initiated. This was reviewed and verified with the Director of Clinical Operations.”

“Observed in Record Review. In 2 of 20 patient records reviewed, the surveyor noted that the organization did not ensure that education and training were provided to the patient’s caregiver based on the patient’s assessed needs. For example, in HOSRRNHV #1, there was no documentation demonstrating that the caregiver had been educated on how to perform wound care on days when the nurse was not present. In HOSRRNHV #2, there was no documentation demonstrating that the caregiver had been educated on how to provide wound care for the patient. In HOSRRNHV #4, there was no documentation demonstrating that the caregiver had been educated on how to perform wound care on days when the nurse was not present. This finding was reviewed and verified with the Director of Clinical Operations.”

“Observed in Record Review. In 4 of 20 patient records reviewed, the surveyor noted that the organization did not make sure the written plan of care was based on the patient’s goals and the time frames required to meet those goals. For example, in HHRRHV#1, the goal stated that the patient/caregiver will understand the pain assessment scale and when to administer as needed doses of pain medications to help achieve pain management goal of spending quality time with the patient. This goal was not time specific or measurable to meet the patient’s pain management needs. In HHRRHV#3 and HHRRHV#4, the pain goal stated pain is managed for patient unable to verbally report or articulate while on hospice services. The goal is not measurable or time specific for the patient’s pain needs. In HOSRRNHV#11, the patient was receiving continuous oxygen, however, there was no goal established related to the oxygen use. This was reviewed and verified with the Director of Clinical Operations.”

“Observed in Record Review. In 6 of 20 patient records reviewed, the surveyor noted that the organization did not ensure that the plan of care included all care necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments needed to meet the patient’s needs. For example, in HOSRRHV #1, medication orders included hydrocodone 10 mg/acetaminophen 325 mg every 4 hours as needed for pain and morphine 10 mg/5 mL every 4 hours as needed for pain; however, no indication was provided specifying when each medication should be taken. In HOSRRHV #2, orders for acetaminophen 500 mg every 4 hours as needed for pain and morphine oral solution 10 mg/mL, 5 to 10 mg every 4 hours as needed for pain, did not include instructions indicating when each medication should be used. In HHRRHV #6, there were orders for hydrocodone 5 mg/acetaminophen 325 mg, one tablet every 8 hours as needed for pain, and morphine concentrate 0.25 mL every 4 hours as needed for pain; however, no indications were provided to distinguish when each pain medication should be taken. In HOSRRHV #8, orders for hydrocodone 5 mg/acetaminophen 325 mg every 4 hours as needed for pain, morphine concentrate 5 mg every 6 hours as needed for pain, and Tylenol Arthritis Pain 650 mg extended-release tablets, two tablets orally every 6 hours as needed for pain, did not include indications specifying when each medication should be taken. In HOSRRNHV#9, Acetaminophen 500 mg 1-2 tabs every 8 hours as needed for pain and Oxycodone 10 mg oral 1 tablet every 6 hours as needed for pain did not include indications specifying when each medication should be taken. In HOSRRNHV#11, Acetaminophen 325 mg oral every 6 hours as needed for pain and Morphine 5 mg every 4 hours as needed for pain did not include indications specifying when each medication should be taken. These findings were reviewed and verified with the Director of Clinical Operations.”

“Observed in Record Review. In 6 of 20 patient records reviewed, the surveyor noted that the organization did not make sure that they provided complete orders for treatment necessary to meet the patient needs. For example, in HOSRRHV#2, the order to irrigate the foley catheter with sterile water did not include the amount of sterile water to be used. Additionally, there was no order for oxygen use. In HOSRRHV#4, the order stated administer enema per physician order without specific indications for use. In HOSRRHV#5, there was no order for oxygen use. In HOSRRHV #6, the intervention instructing the patient to use grab bars and remove bath mats and clutter had not been revised or updated after the patient’s condition declined and the patient became bedbound. Additionally, the plan of care included interventions to assess wounds, educate the caregiver to notify the nurse if the wound developed increased foul odor or drainage, and ensure the caregiver could demonstrate wound care. However, these interventions had not been updated or discontinued, even though the patient’s wound had healed eight months earlier. In HOSRRNHV#1, two wound orders written did not include a dressing change frequency. In HOSRRNHV#9, the wound order did not include a dressing change frequency. In HOSRRNHV#11, the order to irrigate the foley catheter with sterile water did not include an amount for irrigation. Additionally, there was no order for the oxygen. This was reviewed and verified with the Director of Clinical Operations.”

“Based on record review, observation and interview, the Hospice failed to ensure the right to be free from neglect for 1 (Patient #3) of 3 active patients whose records were reviewed were, in that: HHA G neglected to follow the plan of care and provided a shower instead of a bed bath resulting in a fall with major injury (fracture to left femur). This failure placed all Hospice patients at risk of harm, inadequate care and negative patient care outcomes including mental, physical, and emotional trauma and led to the need of hospitalization. The findings included: During presurvey preparation on 02/27/25, review of TULIP (Texas Unified Licensure Information Portal – a database utilized by the state to maintain licensing, demographic information, complaints, and self-reported incidents on home health and hospice agencies for the State of Texas) that documented Hospice had submitted a self-reported incident on 02/26/25 by RN F. The incident documented Patient #3 was “receiving her shower with the aide when the patient fell and broke her hip. The aide was not following the shower guidelines, and this caused for the patient to be transported to the [hospital] and was having surgery…” Record review of an “Admissions Report Nonduplicated” dated 02/28/25 provided by the Alt Adm/DON upon entrance to the Hospice documented Patient #3 with a date of admission as 09/27/24. Review of “Client Unduplicated Census Report” dated 02/28/25 documented Patient #3 with a start of care (SOC) 09/27/25 and a start/end of episode of 12/26/24 through 12/24/25. Record review of the Hospice’s “QI Events and Surveys – San Antonio” documented an “occurrence” on 02/25/25. Review of the “Client Occurrence Report” dated 02/24/25 documented “Patient #3, Nature of Occurrence: attended fall-major injury, Employee present: HHA 3, Description of Occurrence: Arrived at the PCH (patient care home) at 10:40 a.m., HHA G came to tell me that there was an incident in the patient fell. She stated that the patient was transferring out of the shower to a wheelchair at the time she was holding on to the shower rails and her legs buckled under her and she fell. The aide felt as though she broke her leg when she fell. Walked into the bedroom, found the patient sitting in wheelchair with left leg in an unnatural position. The patient’s left hip was elongated and appeared to be a high femur fracture. Patient and patience (sic) family wanted patient to go to the hospital to have leg evaluated, called 911 for an ambulance to come pick the patient up. When paramedics arrived, they applied traction and took the patient to [hospital] after assessment in ER (emergency room) she required surgical intervention for her leg…Physician notified on 02/24/25…Person Preparing Report: RN A on 02/25/25 at 12:33 p.m. and processed by Alt Adm/DON on 02/25/25 at 02:30 p.m.…” Record review of Form 3613 “Provider Investigation Report” dated 03/03/25 provided by Alt Adm/DON documented, “Description of Allegation: While hospice aide completed ADL care for patient, patient sustained a fall resulting in major injury…Alleged perpetrator: HHA G…Description of injury and assessment: per RN CM (RN A) assessment/intake report by: RN A, RN arrived at the PCH at 10:40 a.m., HHA [HHA G] came to tell me that there was an incident in the patient fell. She stated that the patient was transferring out of the shower to a wheelchair at that time she was holding on to the shower rails and her legs buckled under her and she fell…Treatment location: Hospital…” Record review of Patient #3 electronic medical record (EMR) included a “Hospice Recertification Plan of Care Update” (POC) with an order date of 12/11/24, signed and dated 12/26/24 that documented a certification period of 12/26/24 through 03/25/25. Furthermore, the POC documented a primary diagnosis of “malignant neoplasm of ovrlp (overlapping) sites of the right female breast (cancer that affects multiple sites of the female right breast). The POC documented the following orders: SN (skilled nurse) effective 12/29/24, 1 time a week for 12 weeks (1wk12) and 3 as needed (prn) for change in condition. HHA (home health aide) effective 12/26/24, 1 time a week for 1 week (1wk1), 3 times a week for 12 weeks (3wk12) and 1 time a week for 1 week (1wk1) Hospice to provide routine level of care for palliation and management of terminal illness and related conditions in coordination with the interdisciplinary group, each hospice discipline will visit as ordered to meet the patient’s and/or family’s needs and as approved by the hospice interdisciplinary group (IDG). Hospice aide services for assistance with ADL (activities of daily living) and personal care needs. Hospice nurse to provide oversight of the hospice POC and communicate changes with facility staff, the hospice IDG team, and patient family. Hospice aide to assist patient with hygiene and personal care needs. Record review of Patient #3 EMR included a “Aide Care Plan Report” with an effective date of 02/12/25 that documented SOC 09/27/24 and a start of care episode of 12/26/24 through 02/24/25. The report documented the following care plan category/service and frequency: Standby assistance with ambulation – every visit Assist to bedside commode – every visit Bathing (bed bath) – every visit Shampoo – every visit Hair care – every visit Skin care, apply moisturizer – every visit Perineal care apply barrier cream to intact skin – every visit Oral care – every visit Nail care – every visit Ear care – every visit Dressing – every visit Record review of Patient #3’s EMR included a “Client Calendar Report” that documented the following home health aide visits performed: 12/27/24, 12/30/24, 01/30/25, 01/06/25, 01/08/25, 01/10/25, 01/13/25, 01/15/25, 01/17/25, 01/2025, 01/22/25, 01/24/25, 01/27/25, 01/29/25, 01/31/25, 02/05/25, 02/07/25, 02/10/25, 02/12/25, 02/14/25, 02/17/25, 02/19/25, 02/21/25, and 02/24/25. Review of this report documented the following RN hospice with sup (supervisory) visits performed: 12/31/24, 01/08/25, 01/15/25, 01/28/25, 02/04/25, 02/10/25, 02/19/25, and 02/24/25. Record review of Patient #3’s EMR included Home Health Aide Visit notes dated 12/27/24 through 02/10/25 that documented “Service: Bathing (shower) completed Y (yes)” and 02/24/25 that documented “Service: Bathing (bed bath) completed N (no)”, notes: “client refused RN/CM (registered nurse/case manager) notified”. Record review of Patient #3’s EMR included RN Hospice Subsequent w/Sup (supervisory) visits dated 12/31/24 through 02/24/25 that documented “supervisory functions…is there an LPN (licensed practical nurse) or Aide that sees the patient? Yes…Indicate the discipline of employee being evaluated: HHA… Does the aide follow the plan of care? Yes…” Record review of Patient #3’s hospital records dated 02/26/25 included a “History and Physical/Admission Notes” dated 02/24/25 that documented “Chief complaint: Per EMT and Caregiver at bedside, patient twisted her leg when transitioning from wheelchair to bathtub…History of present illness: Patient is a 67-year-old female with a Hx (history) of metastatic breast cancer to bone (cancer in the breast that has spread to the bone) who is currently under palliative care. Per report patient twisted her leg when transitioning to wheelchair to the bathtub…XR (x-ray) reveals left femur fracture… Diagnostic results: XR femur… Impression…1. Acute fracture of the proximal femoral shaft (fracture of the left thigh/upper leg)” Further review of Patient #3’s hospital records included a “history and Physical/Admission Notes…Consultation Notes” dated 02/24/25, that documented, “Assessment/Plan…I had a prolonged discussion with the family about both surgical and nonsurgical options…In this case, I expressed to the family that intramedullary fixation I believe would be a palliative procedure. It would help alleviate her pain for turning and transfers. I would not anticipate it would restore function in terms of mobility but again could help her pain by stabilizing the fracture. After prolonged discussion of the risks and benefits of both he (FM A) elected to proceed with surgical intervention…” Record review of HHA G personnel file included an “Application for Employment” signed and dated 08/03/17 and a “Job Description/Evaluation Hospice Aide”, signed, and dated 09/21/17 that documented “lines of authority: reports to supervising nurse…essential functions…provide services according to the Hospice Aide Care Plan…” Furthermore, review of HHA G personnel file included an “Orientation – General”, signed, and dated 09/21/17 that documented HHA was oriented to “Patient Rights and Responsibilities… Abuse, Neglect, Exploitation…Patient safety…Policies and Procedures…” HHA G personnel file included an “Annual Competency Assessment Skills Checklist Addendum”, signed, and dated 04/23/24 that documented HHA demonstrated competency to “Adheres to plan of care...” Review of HHA G personnel file included a “Nurse Aide Registry (NAR) and Medication Aide Registry (MAR) dated 06/13/24 that documented HHA G had a certification expiration date of 09/13/25, was “employable”, and “not listed on Employee Misconduct Registry”. In an interview on 03/03/25 at 12:50 p.m., the Alt Adm/DON stated the only “Major Incident” reported to the Hospice had been in February 2025 involving Patient #3 and HHA G. Alt Adm/DON stated HHA G was pulled from seeing patients “pending investigation and will be terminated”. In an interview on 03/03/25 at 01:00 p.m., the Alt Adm/DON stated incident was reported to RN F by RN A and RN F reported the incident to HHSC. In an interview on 03/04/24 at 08:45 a.m., the Alt Adm/DON confirmed the incident occurred on 02/24/25. The Alt Adm/DON stated HHA G reported she was assisting patient to the shower and reported the incident to RN A. In an interview on 03/04/25 at 10:50 a.m., RN A confirmed Patient #3 with a SOC of 09/27/24 and a certification period of 12/26/24 through 03/25/25. RN A stated Patient #3 was under his care during this period and visited with patient one time per week in the group home she resided in. RN A stated HHA G assisted Patient #3 times a week on Monday, Wednesday, and Friday in the mornings before noon per facility request. RN A stated HHA G reported directly to him twice a month and performed supervisory visits one time a week when he visited the patient. RN A stated he would make sure to supervise HHA G in person once a month, but this was not required by the Hospice. RN A stated his supervisory visits included ensuring the family or patient was happy with the services being provided and asking questions “was a big thing”. RN A stated he documented HHA G was following POC because there was a verbal understanding Patient #3 could shower on “good days”. RN A stated Patient #3’s family was aware of the HHA POC orders were. RN A stated Patient #3’s family wanted patient to get up and, in the shower, whenever she was able to get up. RN A stated that on the days Patient #3 was not feeling good or had “bad days” Patient #3’s family was ok with her having a bed bath. RN A stated the POC originally had showers and then switched the orders to bed baths. RN A stated that on 02/24/25 he was ahead of schedule, and he arrived at Patient #3’s residence at 10:40 a.m. RN A stated he walked into the residence, HHA G came out and told him “we have a big problem”. RN A stated he followed HHA G to Patient #3’s bathroom where he observed Patient #3 sitting in a wheelchair with her hair wet indicative she had just been showered. RN A stated Patient #3 was sitting on the edge of the wheelchair in a reclined position with her left leg positioned off to the side “clearly with a fracture”. RN A stated he asked facility staff to call 911 and proceeded to assess the patient. RN A stated Patient #3 did not appear to be confused, distressed or in pain at the time. RN A stated Patient #3’s mentation was “the same”. RN A stated the HHA G reported to him she had assisted Patient #3 to the wheelchair when the patient fell. RNA stated HHA G reported Patient #3 was holding onto the grab bars in the restroom. RN A stated HHA G reported she had finished showering Patient #3 and was transferring the patient from the shower chair to the wheelchair in the narrow standing bathroom. RN A stated he did not think to ask the HHA if she had any assistance from the facility personnel to help bathe the patient on that day. RN A stated the PCH CG had offered assistance from their staff to assist Hospice staff when caring for Patient #3. RN A stated after his assessment, and calling emergency services, he then called FM A to inform him of the incident. RN A stated emergency personnel arrived at the home, assessed Patient #3, put her leg on traction (medical device used to immobilize and align a fractured femur by applying gentle, steady traction to the leg), and transported her to the hospital. RN A stated he then called Alt Adm/DON to inform her of the incident.In an interview on 03/04/25 at 03:15 p.m., the Alt Adm/DON confirmed the SOC date 09/27/24 and a certification period of 12/25/24 through 03/25/25 for Patient #3. The Alt Adm confirmed the incident as a fall that happened on 02/24/25. The Alt Adm stated the incident was initially reported to RN A at a home visit he was conducting to Patient #3 by HHA G. The Alt Adm/DON stated RN A then called RN F who did not respond to the call and then called her to report the incident and obtain directives. The Alt Adm/DON stated RN A provided her with only very limited information about the fall including Patient #3 fell while in the care of HHA G and the leg appeared fractured. The Alt Adm/DON stated she instructed RN A to send Patient #3 to the hospital for higher level of care. The Alt Adm/DON stated she then called HHA G and instructed her to not see any other patients until after she came to the office. The Alt Adm/DON stated HHA G came to the office later that day and provided the Hospice with information regarding the incident. The Alt Adm/DON stated HHA G was placed on “administrative leave pending investigation”. The Alt Adm/DON confirmed Patient #3’s POC contained the following orders: 1 skilled nurse visit per week for 12 weeks and 3 home health aide visits per week on Monday, Wednesday, and Friday for 12 weeks. The Alt Adm/DON stated Patient #3’s HHA POC order for bathing was a “bed bath”. The Alt Adm/DON stated the family and the PCH CG requested to have Patient #3 get up to shower on “good days”. The Alt Adm/DON stated the HHA should have performed a bed bath but that was the “discrepancy and tried to justify with what the family was saying and requesting”. The Alt Adm/DON stated the family’s request and the change in service provided to Patient #3 was never reported to her. The Alt Adm/DON stated RN A did not document HHA G was not following the POC in his supervisory visits. The Alt Adm/DON stated RN A “indicated incorrectly” that she was following the POC and did not know if he “had her side”. The Alt Adm/DON acknowledged the HHA POC documented bathing (bed bath) and Home Health Aide Visit notes dated 12/27/24 through 02/10/25 that documented “Service: Bathing (shower) completed Y (yes)”. The Alt Adm/DON acknowledged RN supervisory notes dated 12/31/24 through 02/24/25 that documented “supervisory functions…is there an LPN (licensed practical nurse) or Aide that sees the patient? Yes…Indicate the discipline of employee being evaluated: HHA… Does the aide follow the plan of care? Yes…” The Alt Adm/DON stated the documentation RN A submitted on supervisory visits 12/27/24 through 02/24/25 was not accurate. The Alt Adm stated, there should have been “potential documentation that showed proper communication with family to the nurse supervising”. The Alt Adm/DON stated HHA G “basically could not make an assessment or plan of care updates”. The Alt Adm/DON stated, “what was done was not the correct way, but we have a way to go about it to document”. The Alt Adm/DON stated there was only a verbal understanding and no documentation that showed the “understanding between the Hospice, the facility, and the patient or caregiver that Patient #3 could have a shower instead of a bed bath on good days”. In a telephone interview on 03/05/25 at 08:00 a.m., HHA G stated she had been employed with the Hospice for 6 to 7 years and had cared for Patient #3 since her start of care or approximately 6 months. HHA G stated the Alt Adm/DON was responsible for ensuring trainings were conducted and staff were up to date on their trainings, which were one time a month on topics that included abuse, neglect, exploitation, and infection control. HHA G confirmed she was the aide present on 02/24/25 caring for Patient #3. HHA G stated she would perform her home visits to Patient #3 in the morning per facility request. HHA G stated she arrived at the home at approximately 10:00 a.m. and found Patient #3 sitting in a wheelchair at the kitchen table. HHA G stated that when she explained to Patient #3 what she would be doing (bed bath), Patient #3 started crying and verbalized “not today”. HHA G stated she encouraged Patient #3 to “let her change her brief” and led her into the Patient’s restroom. HHA G stated Patient #3’s POC indicated for Patient #3 to have a bed bath, but the “RN CM (RN A) told her it was ok to shower if Patient #3 tolerated a shower”. HHA G stated the PCH CG always wanted for Patient #3 to shower, rather than take a bed bath. HHA G stated that after bringing Patient #3 to the restroom that morning Patient #3 stated she would take a “bath” and wanted for HHA G to fill the tub. HHA G stated she told Patient #3 she could not fill the tub, “you have to take a shower”. HHA G stated, “the patient is never dirty, she takes a shower three times a week”. HHA G stated her “employment has been at risk in the past because she does not do what they ask her to do” by not following the POC. HHA G stated FM A had asked her to shower Patient #3 in the past. HHA G stated the PCH CG asked her to shower Patient #3 that day, so she took her to the shower and showered the patient. HHA G stated Patient #3 was standing and holding onto the 2 grab bars on the shower wall when she had finished showering the patient. HHA G stated Patient #3 “dropped her weight” into a squatting position, and without letting the patient, HHA G stated she yelled for help. HHA G stated Patient #3 was put back into the wheelchair when the caregiver arrived to assist her. HHA G stated she noticed Patient #3’s left thigh was popped in an upwards position. HHA G stated 911 was called and RN CM (RN A) arrived simultaneously to perform his home visit. HHA G stated the Hospice’s policy regarding POC is to follow the POC. HHA G stated, “but they (family, caregiver, nurses, and supervisors) ask us to go beyond my expectations from the POC. HHA G stated the nurse agreed to it. HHA G stated Patient #3 had been showered before and she started saying she was having issues (not wanting a shower). HHA G stated she sent a message to RN A and her supervisor (RN F) to notify them of those issues. HHA G stated the PCH CG continued to ask her to shower the patient, “and you get kicked out of homes, it can affect your employment, and they had already counseled me”. HHA G stated, “I would go along with what the patient wanted, she would cry, and I would send messages to inform the nurse, she does not want to shower, and they finally changed it to bed bath”. HHA G stated if she would have followed the POC it would have prevented Patient #3 from falling. HHA G stated she was the one responsible for performing the shower, but they [the family, PCH CG, and nurse] are the ones who requested the shower. HHA G stated, “all of them told me that it was ok that if she could tolerate a shower, let her take a shower”. HHA G stated she did not notify the DON regarding this issue, but stated she had notified RN F, her supervisor. During a home visit to Patient #3, on 03/05/25 at 09:35 a.m., RN A and the surveyor were escorted through the living room and kitchen to a private bedroom with a hospital bed and a private restroom where the fall on 02/24/25 occurred. As you walked into the bedroom, the restroom was located to the left side. The restroom door swung inside to the right. On the left side of the door was a bathroom vanity and mirror. As you walked into the right a smal l walkway led to the interior restroom. The toilet and shower were located at the end of the walkway and was separated by a door frame. The toilet and shower were on the same side of the wall opposite of the door (right side). The shower had tile flooring, a shower chair and two grab bars. RN A and Surveyor A were then escorted out the bedroom, past the kitchen in the opposite direction and up a narrow flight of stairs accommodated with a lift. At the end of the stairs was a different bedroom, where Patient #3 was laying comfortably in a hospital bed, awake, alert, and oriented x 1. Patient #3 was propped up with pillows and covered with a light blanket. The skin on her exposed arms and legs appeared thin and frail. She had multiple bruises and scabs and her arms. RN A exposed her left leg to show 2 surgical incisions covered with 4x4 adhesive bandages. Patient #3 answered incoherently when directed to her. In an interview on 03/05/25 at 09:45 a.m., the PCH CG stated Patient #3 had cancer in the bones. The PCH CG stated Patient #3 would be bathed depending on how Patient #3 was feeling. PCH CG stated Patient #3 wanted to shower on 02/24/25. The PCH CG stated the incident on 02/24/25 was an accident and “no bad intentions” were meant. The PCH CG stated she was Patient #3’s caregiver. In a follow up interview on 03/05/25 at 09:50 a.m., RN A stated there was a verbal understanding Patient #3 could shower on “good days” per family and PCH CG request. RN A stated Patient #3 would ambulate with assistance. RN A stated bathing was provided by HHA 3 times a week on Monday, Wednesday, and Friday and did not require 2 people to assist. RN A stated not following the POC would “not have prevented Patient #3’s fall because the fall did not happen in the shower”. RN A stated the fall happened while Patient #3 was in transition from the shower chair to the wheelchair. RN A stated Patient #3’s HHA POC contained “pivot transfer, standby assist and ambulate with assistance”. In an interview on 03/05/25 at 12:17 p.m., FM A stated he was informed of the incident on 02/24/25. FM A stated he was not present when the incident happened but was informed HHA G had performed a shower and was being transferred from the chair to dry and dress when Patient #3 fell. FM A stated he was informed Patient #3 was under the care of HHA G when the incident occurred, and he was unsure if Patient #3 had “slipped or her knees had buckled”. FM A stated he had been informed the incident occurred in the morning between 10:00 a.m. to 11:00 a.m. FM A stated Patient #3 was now more disoriented and was not sure if it was medication related. FM A stated, “we did not have a doctor’s order, we have an understanding she could have a shower”. FM A stated Patient #3 was “oriented to make decision to shower or bathe”. In a telephone interview on 03/05/25 at 01:15 p.m., RN F stated she had been employed by the Hospice for over 5 years. RN F confirmed Patient #3’s SOC as 09/27/24 and certification period of 12/25/24 through 03/25/25. RN F stated she was responsible for completing the provider investigation report submitted to HHSC. RN F stated the incident was reported to her on 02/25/25 by Alt Adm/DON who directed her to initiate the report. RN F stated she was informed on 02/25/24 that HHA G was removed from the field pending investigation. RN F stated the report she received from various sources including HHA G, RN A, Alt Adm/DON and the PCH CG was Patient #3 was “gotten up to the shower, was transferred back to the wheelchair, was holding onto the safety rails in her restroom when her knees buckled, and she fell”. RN F stated HHA G called for help and put the patient to the wheelchair. RN F stated when RN A arrived to complete the assessment, he initiated the call to emergency medical services 911 and the patient was transferred to the [hospital]. RN F stated HHA G was not following the POC while providing the shower. RN F stated HHA G reported there was an “understanding between family, CG and RN that was not documented. RN F stated that was not the proper protocol, the patient may have been having a “good day” but any changes must be reported to RN A. RN F stated there was still a margin Patient #3 could have fallen with other orders on the HHA POC because patient could transfer to and from a chair. RN F Stated it was RN A’s responsibility to perform weekly supervisory visits to ensure the HHA was following the POC. RN F stated there was harm that resulted in major injury, “she had a fall”, caused to the patient because the POC was not followed. RN F stated the Hospice had “approved to proceed with termination of HHA G through the Hospice’s HR and compliance departments”. In a follow up interview on 03/05/25 at 01:40 p.m., the Alt Adm/DON stated the incident happened on 02/24/25 at Patient #3’s residence. The Alt Adm/DON stated the incident was reported the same day by RN A, who was not present at the time of the incident but arrived after the fact. The Alt Adm/DON stated RN A reported the incident to her at 10:47 a.m. with minimal details and she instructed him to send the patient “out for higher level of care, call 911 and get her treated”. The Alt Adm/DON stated she then reached out to HHA G at 10:50 and instructed her to go to the office and “no more patient care” until “we finalize” an internal investigation. The Alt Adm/DON stated the HHA POC indicated for bed bath and HHA G was not following the POC the “way it is written”. The Alt Adm/DON stated RN A indicated in his supervisory visits HHA G was following the POC. The Alt Adm/DON stated the POC indicated bed bath and/or shower verbally but on the EMR it was documented as bed bath. The Alt Adm/DON stated it was “hard to say” if the fall could have been prevented if HHA G followed the POC because Patient #3 was allowed to transfer and was weight bearing. The Alt Adm/DON stated if the patient “fell in the shower then yes, but if the patient fell while transferring and the care plan says she can transfer”. The Alt Adm/DON stated, “I fault that back on the nurse for not having a clearer plan for the aide”. The Alt Adm/DON stated Patient #3 could have potentially gotten injured in the shower. The Alt Adm/DON stated it was RN A’s responsibility to ensure HHA G followed the plan of care by performing his supervisory visits every 14 days. The Alt Adm/DON stated there was harm caused to Patient #3 because the POC was not followed. The Alt Adm/DON stated the Hospice ensured patient’s policies regarding patient’s rights were being followed but the POC was “poorly documented”. The Alt Adm/DON stated there was an “understanding by the family, the case manager, and the caretaker, who all agreed if Patient #3 was having a good day the HHA could get the patient up out of bed”. The Alt Adm/DON stated HHA G was asked to get the patient out of bed, everyone was in agreement, but it was poorly documented. The Alt Adm/DON stated, “our policy they are following, the NPOA, they are requesting the shower”. The Alt Adm/DON stated, “I am advocating they are requesting the shower and they can choose, the HHA cannot force them, if they NPOA are requesting something different, staff are respecting their rights”. The Alt Adm/DON stated the Hospice did not implement the verbal understanding into the plan of care because RN A confirmed they failed to do that. The Alt Adm/DON stated this did affect the patient because the “if the nurse documented the conversation that would not have prevented the patient from a fall”. The Alt Adm/DON stated, “it is not a reflection of the injury the patient had, the injury would have happened regardless of the documentation happened or not”. The Alt Adm/DON stated proper documentation and in-person supervisory visits would prevent this from happening again. The Alt Adm/DON stated not following a plan of care affects patient care “for this reason, prevent patient injury” and I say it as an umbrella to all patients. She continued by saying, “this patient would have gotten injured because she was standby assist”. Record review of Hospice policies titled, “Assessment of Possible Abuse/Neglect -Texas, Policy No. 9-013.1”, with a revised date 05/11/20, quoted in part, “The organization will report all suspected cases of abuse, neglect, or exploitation in compliance with appropriate state statutes to appropriate protection organizations…The organization will investigate complaints regarding treatment or care, mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and/or misappropriation of patient of patient property by anyone furnishing services on behalf of the organization. The organization shall be responsible for asking the necessary questions to determine cause of injuries…Neglect – Failure of a caretaker to supply the patient with the necessary food, clothing, shelter, health care or supervision; or the absence or likelihood of an absence of the necessary food, clothing, shelter, health care, or supervision for a patient…” Record review of Hospice policies titled, “The Plan of Care – Texas, Policy No. 9-017.1”, with a revised date 05/11/20, quoted in part, “The interdisciplinary group, in consultation with the patient’s attending physician (and the patient, patient’s legal representative, and primary caregiver, should they desire) will develop a written individualized plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care. The plan of care will meet the documentation requirements of the physician-directed medical orders and the care planning process… (14) Care provided to the patient will be in accordance with the plan of care…”Record review of Hospice policies titled, “Internal Control Systems/Accountabilities, Policy No. 8-025.1, with a revised date 05/11/20, quoted in part, “An ongoing evaluation process will be established utilizing existing and new monitoring procedures to assure compliance… (6) Hospice Aide Services, This includes the following…(C) Plan of care matches orders, aide schedule matches orders and services provided matches documentation, orders and bill generated…””

“Based on record review, observation, and interview, the supervising nurse failed to assess the home health aides (HHA) ability to continue satisfactory performance; in that the aide care plan was not followed as assigned and the RN supervision documentation was not accurate for 1 (Patient #3) of 3 active patients whose records were reviewed for aide supervision. The RN A failed to conduct a thorough assessment of HHA by demonstrating for competency with assigned tasks for Patient #3 as detailed in the home health aides plan of care. The supervisory visits showed the aide was following the plan of care when the tasks were not completed as assigned. This failure placed all Hospice patients at risk of harm, inadequate care, negative patient care outcomes resulting in a fracture of Client #3s femur (longest bone in the leg) and a subsequent hospitalization. The findings included: During presurvey preparation on 02/27/25, review of TULIP (Texas Unified Licensure Information Portal – a database utilized by the state to maintain licensing, demographic information, complaints, and self-reported incidents on home health and hospice agencies for the State of Texas) that documented Hospice had submitted a self-reported incident on 02/26/25 by RN F. The incident documented Patient #3 was “receiving her shower with the aide when the patient fell and broke her hip. The aide was not following the shower guidelines, and this caused for the patient to be transported to the [hospital] and was having surgery…” Record review of an “Admissions Report Nonduplicated” dated 02/28/25 provided by the Alt Adm/DON upon entrance to the Hospice documented Patient #3 with a date of admission as 09/27/24. Review of “Client Unduplicated Census Report” dated 02/28/25 documented Patient #3 with a start of care (SOC) 09/27/25 and a start/end of episode of 12/26/24 through 12/24/25. Record review of the Hospice’s “QI Events and Surveys – San Antonio” documented an “occurrence” on 02/25/25. Review of the “Client Occurrence Report” dated 02/24/25 documented “Patient #3, Nature of Occurrence: attended fall-major injury, Employee present: HHA 3, Description of Occurrence: Arrived at the PCH (patient care home) at 10:40 a.m., HHA G came to tell me that there was an incident in the patient fell. She stated that the patient was transferring out of the shower to a wheelchair at the time she was holding on to the shower rails and her legs buckled under her and she fell. The aide felt as though she broke her leg when she fell. Walked into the bedroom, found the patient sitting in wheelchair with left leg in an unnatural position. The patient’s left hip was elongated and appeared to be a high femur fracture. Patient and patience (sic) family wanted patient to go to the hospital to have leg evaluated, called 911 for an ambulance to come pick the patient up. When paramedics arrived, they applied traction and took the patient to [hospital] after assessment in ER (emergency room) she required surgical intervention for her leg…Physician notified on 02/24/25…Person Preparing Report: RN A on 02/25/25 at 12:33 p.m. and processed by Alt Adm/DON on 02/25/25 at 02:30 p.m.…” Record review of Form 3613 “Provider Investigation Report” dated 03/03/25 provided by Alt Adm/DON documented, “Description of Allegation: While hospice aide completed ADL care for patient, patient sustained a fall resulting in major injury…Alleged perpetrator: HHA G…Description of injury and assessment: per RN CM (RN A) assessment/intake report by: RN A, RN arrived at the PCH at 10:40 a.m., HHA [HHA G] came to tell me that there was an incident in the patient fell. She stated that the patient was transferring out of the shower to a wheelchair at that time she was holding on to the shower rails and her legs buckled under her and she fell…Treatment location: Hospital…” Record review of Patient #3 electronic medical record (EMR) included a “Hospice Recertification Plan of Care Update” (POC) with an order date of 12/11/24, signed and dated 12/26/24 that documented a certification period of 12/26/24 through 03/25/25. Furthermore, the POC documented a primary diagnosis of “malignant neoplasm of ovrlp (overlapping) sites of the right female breast (cancer that affects multiple sites of the female right breast). The POC documented the following orders: SN (skilled nurse) effective 12/29/24, 1 time a week for 12 weeks (1wk12) and 3 as needed (prn) for change in condition. HHA (home health aide) effective 12/26/24, 1 time a week for 1 week (1wk1), 3 times a week for 12 weeks (3wk12) and 1 time a week for 1 week (1wk1) Hospice to provide routine level of care for palliation and management of terminal illness and related conditions in coordination with the interdisciplinary group, each hospice discipline will visit as ordered to meet the patient’s and/or family’s needs and as approved by the hospice interdisciplinary group (IDG). Hospice aide services for assistance with ADL (activities of daily living) and personal care needs. Hospice nurse to provide oversight of the hospice POC and communicate changes with facility staff, the hospice IDG team, and patient family. Hospice aide to assist patient with hygiene and personal care needs. Record review of Patient #3 EMR included a “Aide Care Plan Report” with an effective date of 02/12/25 that documented SOC 09/27/24 and a start of care episode of 12/26/24 through 02/24/25. The report documented the following care plan category/service and frequency: Standby assistance with ambulation – every visit Assist to bedside commode – every visit Bathing (bed bath) – every visit Shampoo – every visit Hair care – every visit Skin care, apply moisturizer – every visit Perineal care apply barrier cream to intact skin – every visit Oral care – every visit Nail care – every visit Ear care – every visit Dressing – every visit Record review of Patient #3’s EMR included a “Client Calendar Report” that documented the following home health aide visits performed: 12/27/24, 12/30/24, 01/30/25, 01/06/25, 01/08/25, 01/10/25, 01/13/25, 01/15/25, 01/17/25, 01/2025, 01/22/25, 01/24/25, 01/27/25, 01/29/25, 01/31/25, 02/05/25, 02/07/25, 02/10/25, 02/12/25, 02/14/25, 02/17/25, 02/19/25, 02/21/25, and 02/24/25. Review of this report documented the following RN hospice with sup (supervisory) visits performed: 12/31/24, 01/08/25, 01/15/25, 01/28/25, 02/04/25, 02/10/25, 02/19/25, and 02/24/25. Record review of Patient #3’s EMR included Home Health Aide Visit notes dated 12/27/24 through 02/10/25 that documented “Service: Bathing (shower) completed Y (yes)” and 02/24/25 that documented “Service: Bathing (bed bath) completed N (no)”, notes: “client refused RN/CM (registered nurse/case manager) notified”. Record review of Patient #3’s EMR included RN Hospice Subsequent w/Sup (supervisory) visits dated 12/31/24 through 02/24/25 that documented “supervisory functions…is there an LPN (licensed practical nurse) or Aide that sees the patient? Yes…Indicate the discipline of employee being evaluated: HHA… Does the aide follow the plan of care? Yes…” Record review of Patient #3’s hospital records dated 02/26/25 included a “History and Physical/Admission Notes” dated 02/24/25 that documented “Chief complaint: Per EMT and Caregiver at bedside, patient twisted her leg when transitioning from wheelchair to bathtub…History of present illness: Patient is a 67-year-old female with a Hx (history) of metastatic breast cancer to bone (cancer in the breast that has spread to the bone) who is currently under palliative care. Per report patient twisted her leg when transitioning to wheelchair to the bathtub…XR (x-ray) reveals left femur fracture… Diagnostic results: XR femur… Impression…1. Acute fracture of the proximal femoral shaft (fracture of the left thigh/upper leg)” Further review of Patient #3’s hospital records included a “history and Physical/Admission Notes…Consultation Notes” dated 02/24/25, that documented, “Assessment/Plan…I had a prolonged discussion with the family about both surgical and nonsurgical options…In this case, I expressed to the family that intramedullary fixation I believe would be a palliative procedure. It would help alleviate her pain for turning and transfers. I would not anticipate it would restore function in terms of mobility but again could help her pain by stabilizing the fracture. After prolonged discussion of the risks and benefits of both he (FM A) elected to proceed with surgical intervention…” Record review of HHA G personnel file included an “Application for Employment” signed and dated 08/03/17 and a “Job Description/Evaluation Hospice Aide”, signed, and dated 09/21/17 that documented “lines of authority: reports to supervising nurse…essential functions…provide services according to the Hospice Aide Care Plan…” Furthermore, review of HHA G personnel file included an “Orientation – General”, signed, and dated 09/21/17 that documented HHA was oriented to “Patient Rights and Responsibilities… Abuse, Neglect, Exploitation…Patient safety…Policies and Procedures…” HHA G personnel file included an “Annual Competency Assessment Skills Checklist Addendum”, signed, and dated 04/23/24 that documented HHA demonstrated competency to “Adheres to plan of care...” Review of HHA G personnel file included a “Nurse Aide Registry (NAR) and Medication Aide Registry (MAR) dated 06/13/24 that documented HHA G had a certification expiration date of 09/13/25, was “employable”, and “not listed on Employee Misconduct Registry”. In an interview on 03/03/25 at 12:50 p.m., the Alt Adm/DON stated the only “Major Incident” reported to the Hospice had been in February 2025 involving Patient #3 and HHA G. Alt Adm/DON stated HHA G was pulled from seeing patients “pending investigation and will be terminated”. In an interview on 03/03/25 at 01:00 p.m., the Alt Adm/DON stated incident was reported to RN F by RN A and RN F reported the incident to HHSC. In an interview on 03/04/24 at 08:45 a.m., the Alt Adm/DON confirmed the incident occurred on 02/24/25. The Alt Adm/DON stated HHA G reported she was assisting patient to the shower and reported the incident to RN A. In an interview on 03/04/25 at 10:50 a.m., RN A confirmed Patient #3 with a SOC of 09/27/24 and a certification period of 12/26/24 through 03/25/25. RN A stated Patient #3 was under his care during this period and visited with patient one time per week in the group home she resided in. RN A stated HHA G assisted Patient #3 times a week on Monday, Wednesday, and Friday in the mornings before noon per facility request. RN A stated HHA G reported directly to him twice a month and performed supervisory visits one time a week when he visited the patient. RN A stated he would make sure to supervise HHA G in person once a month, but this was not required by the Hospice. RN A stated his supervisory visits included ensuring the family or patient was happy with the services being provided and asking questions “was a big thing”. RN A stated he documented HHA G was following POC because there was a verbal understanding Patient #3 could shower on “good days”. RN A stated Patient #3’s family was aware of the HHA POC orders were. RN A stated Patient #3’s family wanted patient to get up and, in the shower, whenever she was able to get up. RN A stated that on the days Patient #3 was not feeling good or had “bad days” Patient #3’s family was ok with her having a bed bath. RN A stated the POC originally had showers and then switched the orders to bed baths. RN A stated that on 02/24/25 he was ahead of schedule, and he arrived at Patient #3’s residence at 10:40 a.m. RN A stated he walked into the residence, HHA G came out and told him “we have a big problem”. RN A stated he followed HHA G to Patient #3’s bathroom where he observed Patient #3 sitting in a wheelchair with her hair wet indicative she had just been showered. RN A stated Patient #3 was sitting on the edge of the wheelchair in a reclined position with her left leg positioned off to the side “clearly with a fracture”. RN A stated he asked facility staff to call 911 and proceeded to assess the patient. RN A stated Patient #3 did not appear to be confused, distressed or in pain at the time. RN A stated Patient #3’s mentation was “the same”. RN A stated the HHA G reported to him she had assisted Patient #3 to the wheelchair when the patient fell. RNA stated HHA G reported Patient #3 was holding onto the grab bars in the restroom. RN A stated HHA G reported she had finished showering Patient #3 and was transferring the patient from the shower chair to the wheelchair in the narrow standing bathroom. RN A stated he did not think to ask the HHA if she had any assistance from the facility personnel to help bathe the patient on that day. RN A stated the PCH CG had offered assistance from their staff to assist Hospice staff when caring for Patient #3. RN A stated after his assessment, and calling emergency services, he then called FM A to inform him of the incident. RN A stated emergency personnel arrived at the home, assessed Patient #3, put her leg on traction (medical device used to immobilize and align a fractured femur by applying gentle, steady traction to the leg), and transported her to the hospital. RN A stated he then called Alt Adm/DON to inform her of the incident.In an interview on 03/04/25 at 03:15 p.m., the Alt Adm/DON confirmed the SOC date 09/27/24 and a certification period of 12/25/24 through 03/25/25 for Patient #3. The Alt Adm confirmed the incident as a fall that happened on 02/24/25. The Alt Adm stated the incident was initially reported to RN A at a home visit he was conducting to Patient #3 by HHA G. The Alt Adm/DON stated RN A then called RN F who did not respond to the call and then called her to report the incident and obtain directives. The Alt Adm/DON stated RN A provided her with only very limited information about the fall including Patient #3 fell while in the care of HHA G and the leg appeared fractured. The Alt Adm/DON stated she instructed RN A to send Patient #3 to the hospital for higher level of care. The Alt Adm/DON stated she then called HHA G and instructed her to not see any other patients until after she came to the office. The Alt Adm/DON stated HHA G came to the office later that day and provided the Hospice with information regarding the incident. The Alt Adm/DON stated HHA G was placed on “administrative leave pending investigation”. The Alt Adm/DON confirmed Patient #3’s POC contained the following orders: 1 skilled nurse visit per week for 12 weeks and 3 home health aide visits per week on Monday, Wednesday, and Friday for 12 weeks. The Alt Adm/DON stated Patient #3’s HHA POC order for bathing was a “bed bath”. The Alt Adm/DON stated the family and the PCH CG requested to have Patient #3 get up to shower on “good days”. The Alt Adm/DON stated the HHA should have performed a bed bath but that was the “discrepancy and tried to justify with what the family was saying and requesting”. The Alt Adm/DON stated the family’s request and the change in service provided to Patient #3 was never reported to her. The Alt Adm/DON stated RN A did not document HHA G was not following the POC in his supervisory visits. The Alt Adm/DON stated RN A “indicated incorrectly” that she was following the POC and did not know if he “had her side”. The Alt Adm/DON acknowledged the HHA POC documented bathing (bed bath) and Home Health Aide Visit notes dated 12/27/24 through 02/10/25 that documented “Service: Bathing (shower) completed Y (yes)”. The Alt Adm/DON acknowledged RN supervisory notes dated 12/31/24 through 02/24/25 that documented “supervisory functions…is there an LPN (licensed practical nurse) or Aide that sees the patient? Yes…Indicate the discipline of employee being evaluated: HHA… Does the aide follow the plan of care? Yes…” The Alt Adm/DON stated the documentation RN A submitted on supervisory visits 12/27/24 through 02/24/25 was not accurate. The Alt Adm stated, there should have been “potential documentation that showed proper communication with family to the nurse supervising”. The Alt Adm/DON stated HHA G “basically could not make an assessment or plan of care updates”. The Alt Adm/DON stated, “what was done was not the correct way, but we have a way to go about it to document”. The Alt Adm/DON stated there was only a verbal understanding and no documentation that showed the “understanding between the Hospice, the facility, and the patient or caregiver that Patient #3 could have a shower instead of a bed bath on good days”. In a telephone interview on 03/05/25 at 08:00 a.m., HHA G stated she had been employed with the Hospice for 6 to 7 years and had cared for Patient #3 since her start of care or approximately 6 months. HHA G stated the Alt Adm/DON was responsible for ensuring trainings were conducted and staff were up to date on their trainings, which were one time a month on topics that included abuse, neglect, exploitation, and infection control. HHA G confirmed she was the aide present on 02/24/25 caring for Patient #3. HHA G stated she would perform her home visits to Patient #3 in the morning per facility request. HHA G stated she arrived at the home at approximately 10:00 a.m. and found Patient #3 sitting in a wheelchair at the kitchen table. HHA G stated that when she explained to Patient #3 what she would be doing (bed bath), Patient #3 started crying and verbalized “not today”. HHA G stated she encouraged Patient #3 to “let her change her brief” and led her into the Patient’s restroom. HHA G stated Patient #3’s POC indicated for Patient #3 to have a bed bath, but the “RN CM (RN A) told her it was ok to shower if Patient #3 tolerated a shower”. HHA G stated the PCH CG always wanted for Patient #3 to shower, rather than take a bed bath. HHA G stated that after bringing Patient #3 to the restroom that morning Patient #3 stated she would take a “bath” and wanted for HHA G to fill the tub. HHA G stated she told Patient #3 she could not fill the tub, “you have to take a shower”. HHA G stated, “the patient is never dirty, she takes a shower three times a week”. HHA G stated her “employment has been at risk in the past because she does not do what they ask her to do” by not following the POC. HHA G stated FM A had asked her to shower Patient #3 in the past. HHA G stated the PCH CG asked her to shower Patient #3 that day, so she took her to the shower and showered the patient. HHA G stated Patient #3 was standing and holding onto the 2 grab bars on the shower wall when she had finished showering the patient. HHA G stated Patient #3 “dropped her weight” into a squatting position, and without letting the patient, HHA G stated she yelled for help. HHA G stated Patient #3 was put back into the wheelchair when the caregiver arrived to assist her. HHA G stated she noticed Patient #3’s left thigh was popped in an upwards position. HHA G stated 911 was called and RN CM (RN A) arrived simultaneously to perform his home visit. HHA G stated the Hospice’s policy regarding POC is to follow the POC. HHA G stated, “but they (family, caregiver, nurses, and supervisors) ask us to go beyond my expectations from the POC. HHA G stated the nurse agreed to it. HHA G stated Patient #3 had been showered before and she started saying she was having issues (not wanting a shower). HHA G stated she sent a message to RN A and her supervisor (RN F) to notify them of those issues. HHA G stated the PCH CG continued to ask her to shower the patient, “and you get kicked out of homes, it can affect your employment, and they had already counseled me”. HHA G stated, “I would go along with what the patient wanted, she would cry, and I would send messages to inform the nurse, she does not want to shower, and they finally changed it to bed bath”. HHA G stated if she would have followed the POC it would have prevented Patient #3 from falling. HHA G stated she was the one responsible for performing the shower, but they [the family, PCH CG, and nurse] are the ones who requested the shower. HHA G stated, “all of them told me that it was ok that if she could tolerate a shower, let her take a shower”. HHA G stated she did not notify the DON regarding this issue, but stated she had notified RN F, her supervisor. During a home visit to Patient #3, on 03/05/25 at 09:35 a.m., RN A and the surveyor were escorted through the living room and kitchen to a private bedroom with a hospital bed and a private restroom where the fall on 02/24/25 occurred. As you walked into the bedroom, the restroom was located to the left side. The restroom door swung inside to the right. On the left side of the door was a bathroom vanity and mirror. As you walked into the right a small walkway led to the interior restroom. The toilet and shower were located at the end of the walkway and was separated by a door frame. The toilet and shower were on the same side of the wall opposite of the door (right side). The shower had tile flooring, a shower chair and two grab bars. RN A and Surveyor A were then escorted out the bedroom, past the kitchen in the opposite direction and up a narrow flight of stairs accommodated with a lift. At the end of the stairs was a different bedroom, where Patient #3 was laying comfortably in a hospital bed, awake, alert, and oriented x 1. Patient #3 was propped up with pillows and covered with a light blanket. The skin on her exposed arms and legs appeared thin and frail. She had multiple bruises and scabs and her arms. RN A exposed her left leg to show 2 surgical incisions covered with 4x4 adhesive bandages. Patient #3 answered incoherently when directed to her. In an interview on 03/05/25 at 09:45 a.m., the PCH CG stated Patient #3 had cancer in the bones. The PCH CG stated Patient #3 would be bathed depending on how Patient #3 was feeling. PCH CG stated Patient #3 wanted to shower on 02/24/25. The PCH CG stated the incident on 02/24/25 was an accident and “no bad intentions” were meant. The PCH CG stated she was Patient #3’s caregiver. In a follow up interview on 03/05/25 at 09:50 a.m., RN A stated there was a verbal understanding Patient #3 could shower on “good days” per family and PCH CG request. RN A stated Patient #3 would ambulate with assistance. RN A stated bathing was pro vided by HHA 3 times a week on Monday, Wednesday, and Friday and did not require 2 people to assist. RN A stated not following the POC would “not have prevented Patient #3’s fall because the fall did not happen in the shower”. RN A stated the fall happened while Patient #3 was in transition from the shower chair to the wheelchair. RN A stated Patient #3’s HHA POC contained “pivot transfer, standby assist and ambulate with assistance”. In an interview on 03/05/25 at 12:17 p.m., FM A stated he was informed of the incident on 02/24/25. FM A stated he was not present when the incident happened but was informed HHA G had performed a shower and was being transferred from the chair to dry and dress when Patient #3 fell. FM A stated he was informed Patient #3 was under the care of HHA G when the incident occurred, and he was unsure if Patient #3 had “slipped or her knees had buckled”. FM A stated he had been informed the incident occurred in the morning between 10:00 a.m. to 11:00 a.m. FM A stated Patient #3 was now more disoriented and was not sure if it was medication related. FM A stated, “we did not have a doctor’s order, we have an understanding she could have a shower”. FM A stated Patient #3 was “oriented to make decision to shower or bathe”. In a telephone interview on 03/05/25 at 01:15 p.m., RN F stated she had been employed by the Hospice for over 5 years. RN F confirmed Patient #3’s SOC as 09/27/24 and certification period of 12/25/24 through 03/25/25. RN F stated she was responsible for completing the provider investigation report submitted to HHSC. RN F stated the incident was reported to her on 02/25/25 by Alt Adm/DON who directed her to initiate the report. RN F stated she was informed on 02/25/24 that HHA G was removed from the field pending investigation. RN F stated the report she received from various sources including HHA G, RN A, Alt Adm/DON and the PCH CG was Patient #3 was “gotten up to the shower, was transferred back to the wheelchair, was holding onto the safety rails in her restroom when her knees buckled, and she fell”. RN F stated HHA G called for help and put the patient to the wheelchair. RN F stated when RN A arrived to complete the assessment, he initiated the call to emergency medical services 911 and the patient was transferred to the [hospital]. RN F stated HHA G was not following the POC while providing the shower. RN F stated HHA G reported there was an “understanding between family, CG and RN that was not documented. RN F stated that was not the proper protocol, the patient may have been having a “good day” but any changes must be reported to RN A. RN F stated there was still a margin Patient #3 could have fallen with other orders on the HHA POC because patient could transfer to and from a chair. RN F Stated it was RN A’s responsibility to perform weekly supervisory visits to ensure the HHA was following the POC. RN F stated there was harm that resulted in major injury, “she had a fall”, caused to the patient because the POC was not followed. RN F stated the Hospice had “approved to proceed with termination of HHA G through the Hospice’s HR and compliance departments”. In a follow up interview on 03/05/25 at 01:40 p.m., the Alt Adm/DON stated the incident happened on 02/24/25 at Patient #3’s residence. The Alt Adm/DON stated the incident was reported the same day by RN A, who was not present at the time of the incident but arrived after the fact. The Alt Adm/DON stated RN A reported the incident to her at 10:47 a.m. with minimal details and she instructed him to send the patient “out for higher level of care, call 911 and get her treated”. The Alt Adm/DON stated she then reached out to HHA G at 10:50 and instructed her to go to the office and “no more patient care” until “we finalize” an internal investigation. The Alt Adm/DON stated the HHA POC indicated for bed bath and HHA G was not following the POC the “way it is written”. The Alt Adm/DON stated RN A indicated in his supervisory visits HHA G was following the POC. The Alt Adm/DON stated the POC indicated bed bath and/or shower verbally but on the EMR it was documented as bed bath. The Alt Adm/DON stated it was “hard to say” if the fall could have been prevented if HHA G followed the POC because Patient #3 was allowed to transfer and was weight bearing. The Alt Adm/DON stated if the patient “fell in the shower then yes, but if the patient fell while transferring and the care plan says she can transfer”. The Alt Adm/DON stated, “I fault that back on the nurse for not having a clearer plan for the aide”. The Alt Adm/DON stated Patient #3 could have potentially gotten injured in the shower. The Alt Adm/DON stated it was RN A’s responsibility to ensure HHA G followed the plan of care by performing his supervisory visits every 14 days. The Alt Adm/DON stated there was harm caused to Patient #3 because the POC was not followed. The Alt Adm/DON stated the Hospice ensured patient’s policies regarding patient’s rights were being followed but the POC was “poorly documented”. The Alt Adm/DON stated there was an “understanding by the family, the case manager, and the caretaker, who all agreed if Patient #3 was having a good day the HHA could get the patient up out of bed”. The Alt Adm/DON stated HHA G was asked to get the patient out of bed, everyone was in agreement, but it was poorly documented. The Alt Adm/DON stated, “our policy they are following, the NPOA, they are requesting the shower”. The Alt Adm/DON stated, “I am advocating they are requesting the shower and they can choose, the HHA cannot force them, if they NPOA are requesting something different, staff are respecting their rights”. The Alt Adm/DON stated the Hospice did not implement the verbal understanding into the plan of care because RN A confirmed they failed to do that. The Alt Adm/DON stated this did affect the patient because the “if the nurse documented the conversation that would not have prevented the patient from a fall”. The Alt Adm/DON stated, “it is not a reflection of the injury the patient had, the injury would have happened regardless of the documentation happened or not”. The Alt Adm/DON stated proper documentation and in-person supervisory visits would prevent this from happening again. The Alt Adm/DON stated not following a plan of care affects patient care “for this reason, prevent patient injury” and I say it as an umbrella to all patients. She continued by saying, “this patient would have gotten injured because she was standby assist”. Record review of Hospice policies titled, “Responsibilities/Supervision of Clinical Services – Texas, Policy No. 1-031.1”, with a revised date 05/11/20; quoted in part, “The Supervising Nurse/Clinical Director will participate in activities relevant to services furnished, be responsible for the clinical direction of the organization and take reasonable steps to assure that… (2) The patient’s plan of care is executed as written…(5) Policies and procedures, which guide and support the provision of care and services, are developed and implemented…” Record review of Hospice policies titled, “Hospice Aide Supervisory Visits – Texas, Policy No 1-037.1”, with a revised date 05/11/20, quoted in part, “Nursing personnel (or therapists as appropriate) must be available to the hospice aide for consultation at all times during the aide’s working hours. The hospice Case Manager will conduct supervisory visits to the patient’s residence at regular intervals…The Case Manager will be responsible for …Supervision of all services provide for in the plan of care…” Record review of Hospice policies titled, “The Plan of Care – Texas, Policy No. 9-017.1”, with a revised date 05/11/20, quoted in part, “The interdisciplinary group, in consultation with the patient’s attending physician (and the patient, patient’s legal representative, and primary caregiver, should they desire) will develop a written individualized plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care. The plan of care will meet the documentation requirements of the physician-directed medical orders and the care planning process… (14) Care provided to the patient will be in accordance with the plan of care…”Record review of Hospice policies titled, “Internal Control Systems/Accountabilities, Policy No. 8-025.1, with a revised date 05/11/20, quoted in part, “An ongoing evaluation process will be established utilizing existing and new monitoring procedures to assure compliance… (6) Hospice Aide Services, This includes the following…(C) Plan of care matches orders, aide schedule matches orders and services provided matches documentation, orders and bill generated…””