Kindful Health

“Based on record review and interview, the agency failed to include physician orders in patient records for 2 (#1, #9) of 3 patient records reviewed that received wound care. The failure placed the agency’s clients at risk of omission of wound care or inappropriate wound care that could result in deterioration of the wounds. Patient #1:Record review of Patient #1’s record revealed a Plan of Care dated 5/31/2023 to 8/28/2023. The Plan of Care indicated that Patient #1 started on the agency’s services on 5/31/2023. The Plan of Care listed Unspecified Sequelae of Cerebral Infarction (disrupted blood flow to the brain that can cause parts of the brain to die) as the primary diagnosis. The Plan of Care indicated that Patient #1 lived at an assisted living facility, Facility X. Hospice Aide D conducted a hospice aide visit on 6/23/2023. Hospice Aide D documented “bottom sore reopen.” Registered Nurse C conducted a skilled nurse visit on 6/26/2023. Registered Nurse C documented that Patient #1 had a “Stage 2 to sacrum.” Registered Nurse C documented that Patient #1 was starting to develop a wound in the sacral area and that foam dressing had been ordered on Friday but had not been delivered. Registered Nurse C documented that education had been provided to the staff at the assisted living facility to apply a 3 x 3 dressing to the sacral area. Patient #1’s clinical record did not contain orders for wound care to the sacrum. Patient #9:Record review of Patient #9’s revealed a Plan of Care dated 9/1/2023 to 11/29/2023. The Plan of Care indicated that Patient #9 started on the agency’s services on 9/1/2023. The Plan of Care listed Senile Degeneration of the Brain (decline and death of nerve cells of the brain) as the primary diagnosis. The Plan of Care indicated that Patient #9 lived at an assisted living facility, Facility Y. Registered Nurse C conducted an as needed skilled nurse visit on 9/24/2023 due report that Patient #9 had a deep wound on the great toe. Registered Nurse C documented upon arrival, that Patient #9 was agitated and walking around the facility smearing blood throughout the facility. Registered Nurse C documented cleaning an abrasion and then wrapped the wound with gauze and tape.Registered Nurse E conducted a skilled nurse visit on 9/27/2023. Registered Nurse E documented that Patient #9 had an abrasion to the right great toe. Registered Nurse E documented cleaning the wound with soap and water and then applied a band-aid (wound care was different from the wound care that was performed on 9/24/2023). Patient #9’s clinical record did not contain orders for wound care. During an interview on 11/14/2023 at approximately 1:00 p.m. with the Administrator, the Alternate Administrator/Alternate Supervising Nurse, the Supervising Nurse, the Chief Executive Officer, and an Area Director of Clinical Services, the surveyor discussed the wound care performed on Patient #1 and Patient #9, and that there were no orders for wound care in the clinical record. The Supervising Nurse reviewed the records and informed the surveyor that the Supervising Nurse “didn’t see orders for wound care.” During an interview on 11/15/2023 at 11:38 a.m. with Registered Nurse C, the surveyor discussed the wound care that Registered Nurse C performed on Patient #1 and Patient #9 and that there were no orders for wound care in the clinical records. Registered Nurse C informed the surveyor that Registered Nurse C used the written order at the assisted living facilities. Registered Nurse C stated, “I did not put the orders in the chart.” During an interview on 11/15/2023 at 12:15 p.m. with Registered Nurse E, the surveyor discussed the wound care that Registered Nurse E performed on Patient #9 and that there were no orders for wound care in the clinical record. Registered Nurse E informed the surveyor that the order was received from the physician; Registered Nurse E was new to the computer system; and that the wound care was a “one off and if it had required more, it would have triggered [Registered Nurse E] to include the order in the chart.” During an interview on 11/15/2023 at 2:07 p.m. with the Administrator, Alternate Administrator/Alternate Supervising Nurse, the Supervising Nurse, the Chief Executive Officer, and the CNO-CCO (unknown), the agency did not present evidence to dispute the findings. The agency had a policy titled “Timeline” that was labeled IM.40 and last reviewed on 10/1/2021. The policy read in part; “Purpose To establish timely parameters for all medical record information. Policy The Hospice will ensure timely provision of care to meet patient’s needs in compliance with all federal and state laws and regulations. Procedure I. All Hospice staff, physician(s) and/or non-physician practitioner(s) and physician office staff as appropriate, will be oriented to the following parameters...G. Supplemental verbal orders may be obtained before care is provided and are written within 24 hours of receiving the orders...””