Delta Hospice LLC

“Based on record review and interview the agency failed to protect patients and be free from neglect including injuries of unknown sources in that:Certified Nurses Aide (CNA A) neglected (Patient#1) by failing to protect Patient#1 from being exposed of an injury to the skin during the shower. This resulted in patient#1 having 2nd degree burns to 25% total body surface area, with resultant Hospital Emergency Room (Hospital A) visit and transfer to acute care general Hospital Burn Unit (Hospital B) for treatment of burns. Findings include: Review of Texas Uniform Licensure Portal (TULIP-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) showed Intake 496254. Review of Intake 496254, read in part, “;...Received VIA (by means of) Phone Call Received Date 4/10/2024...Caller Agency Director of Nursing...General Intake Notes...On 4/9/2024, CNA A took Patient#1 to bathroom to shower...sat the Patient#1 down in her shower chair....CNA A stepped away for less than one minute to grab a towel....As the CNA began wiping the Patient#1 down, the patient indicated pain and was pointing to her chest. CNA then realized that Patient#1had redness and skin peeling on her chest. The CNA does not recall if the burns were present before the Patient was showered...Alleged Perpetrator Name: CNA A. Hospital Record Review:Hospital (A) Emergency Department record review dated 04/09/2024 read in part, “Name: Patient#1...Visit Information...Date of birth...7/13/1943...Arrival Date/Time: 04/09/2024 4:24 PM...Discharge information Date/Time 04/09/2024 6:30 PM Disposition: Transfer to Acute Care General Hospital(Hospital B)...Reason for Visit...Burn (Major) (Chest, abd(abdomen), bilateral upper legs, groin)...Visit Diagnoses...Burn due to contact with hot water Yes...Physical Exam...1% 2nd degree burn to pubic mound...Skin: Findings: Burn present. Comments: 16% 2nd degree burns to chest and abdomen 2% 2d degree burn to LUE (left upper extremity) 2% 2nd degree burn to L(left) anterior proximal thigh 4% 2nd degree burn to R(right) proximal groin 1% 1st degree burn to R anterior elbow 1% 1st degree burn to R proximal palmar forearm...” Agency admission pack review: The admission pack provided to agency clients contained:1. Form titled “;Rights and Responsibilities” dated 050123, read in part, “;Patient Rights...The law provides certain rights to all hospice patients. Each patient has a right to be informed of his or her rights, to exercise his or her rights, as well as have his or her rights protected and promoted. These include the right to...15. Be free from mistreatment, neglect...including injuries of unknown source...Hospice Responsibilities 1. To protect and promote the exercise of the patients rights.”2. Form titled “;Texas Human Resources Code Title 6. Services for the Elderly Chapter 102. Rights of Elderly dated 120115, read in part,” ...Definitions...5. “;Elderly individual” means an individual 60 years of age or older...RIGHTS OF THE ELDERLY...b. has the right to be free from abuse, neglect...” Discharge List Review:The list was provided by the Director of Nursing. Review of the list revealed Client #1 with a SOC (start of care) Date- 09/26/2022, Admission Date- 09/26/2022, Discharge Date- 04/09/2024 and Reason For Discharge- Discharge for cause (i.e. patient/staff safety). Patient Record Review:Patient#1 agency record review contained a Plan of Care digitally signed and dated by physician, MD (A) on 3/20/2024 read in part, “;...#1...Benefit Period: 03/19/2024-05/17/2024... Diagnosis...Senile degeneration of brain (Senile also known as Senile dementia is the mental deterioration (loss of intellectual ability) that is associated with or the characteristics of old age)....Unspecified dementia(refers to a condition where cognitive functioning—such as thinking, remembering, and reasoning—is impaired to an extent that it interferes with daily life and activities)...Repeated falls...Chronic obstructive pulmonary disease (is a type of progressive lung disease characterized by long-term respiratory symptoms and airflow limitation)....Care Type...Hospice Aide Provide grooming and hygiene, follow POC(plan of care), provide privacy and safety during care...Hospice Aide 2/wk 9/wk (two times a week for nine weeks)... Review of Agency Complaint/Incident binder contained:1. A report titled “;Intake Report Child Protective Services” read in part, “;Date Reported: 4/9/2024...Notes...Hospice Care Attendant...General Information/Description...PRIMARY CONCERNS...Medical staff determined the burns were caused (in certainty) by hot water. PRs (provider) explanation of a reaction to soap is not consistent with the injuries. ADDITIONAL CONCERNS: It was noted that the PR has been CLs (Client) aid for the past three months and she is the only one who bathes her(client) (2x weekly) ...”2. A typed statement signed and dated by the agency CNA Supervisor on April 10, 2024. The statement read in part, “;On 04/09/2024 at approximately 15:20...received a phone call and a picture of the patient in the shower from CNA A...CNA A explained she was giving a shower...and the patients (Patient#1) skin started to peel...” Interviews: In an interview with Family Member #1 on 04/16/2024 at approximately 2:07 PM, the surveyor asked was Family Member #1 present when CNA A was showering Patient#1. Family Member #1 stated, “;No, I was at our family business down the street from the house. I got a frantic call from CNA A, saying something was wrong with patient#1. I arrived at the house in about 10 minutes. Patient#1 had fell to the floor in the shower and was asking for oxygen. The aide was on the phone with the agency supervisor. I had to calm the aide down because she was panicking and crying. CNA A went to her car to calm down. Then the paramedics showed up.” Surveyor asked Family Member #1 was the shower water still running and was it hot in the bathroom. Family Member #1 stated, “;The water was off. It wasnt hot in the bathroom, but the mirrors were fogged up from steam.” In an interview with the agency CNA Supervisor on 04/17/2024 at approximately 10:39 AM, the surveyor asked what was said during the call from CNA A on 04/09/2024 about the incident with patient#1. CNA Supervisor stated, “;CNA A called and said something was wrong with patient#1s skin, that it was peeling and red. So, I hung up and called RN A. RN A said he didnt know what was going on with patient# 1s skin. I called CNA A back and told her to call 911. The DON asked was anyone else in the room. CNA A said Family Member #1 was there. CNA A was upset and crying, so I was trying to calm her down. She went to her care to calm down and wait for 911 to arrive.” In an interview with the agency Director of Nursing on 04/17/2024 at approximately 10:51 AM, the surveyor presented the above findings. The Director of Nursing stated, “;The next morning CNA A came into the office for a conference with me, CNA Supervisor, and Human Resources. CNA A said she gave the shower as she always did and did nothing different. CNA A said she didnt have a washcloth, so she stopped the water and went to get a towel and started the bath back and noticed Patient#1s skin was peeling.” In an interview with the agency CNA A on 04/17/2024 at approximately 12:06 PM, the surveyor asked CNA A to explain the shower incident on 4/9/2024. CNA A stated, “;Im so glad you called so that I can explain what happened. I gave the shower like I always did, nothing different. I checked the water temperature before wetting Patient#1 down and it was fine. Usually, the family have everything ready for the shower. I started showering her and noticed the towel was missing. I cut the water off and went to tell Family Member #2 if I could get a towel. I went back and cut the shower back on and checked the water again and it was fine. As I started wiping and rinsing the soap off her I noticed her skin started peeling off. I thought it was soap film at first. I stopped and realized it was her skin and she was turning red. I called Family Member #1 and the supervisor, and she told me to call 911. The surveyor asked did Patient#1 scream or cry out in pain. CNA A stated, “;No she just kept saying hurt under her breath, you know in a low voice.” The surveyor asked CNA A what she thought caused the skin peeling and redness. CNA A stated, “;I dont know because I made sure the water temperature wasnt too hot. The paramedics said it looked like chemical burns.” The surveyor asked was a new soap used. CNA A stated, “;No, but the bottle I get from the agency had a different label. The paramedics looked at the bottle and said both bottles had the same ingredients.” In an interview with the agency Director of Nursing and Administrator on 04/17/2024 at approximately 12:31 PM, the surveyor presented the above findings. The Director of Nursing stated, “;We are using the same soap.” The Administrator stated, “;We have not changed the supplies provided to the aides. The aide said she did everything the same thing during the showers.” The surveyor asked to see the soap provided to CNA A. The Administrator provided both bottles of soap to the surveyor. Surveyor reviewed both bottles and noted one of the bottles of body wash contained moisturizer and the other bottle of body wash did not contain moisturizer.”