Pax Et Vita Hospice Agency, LLC

“Based on record reviews and interviews, the agency failed to ensure a Patient’s right to be free from neglect by the agency’s employee (HA A) for 1of 3 Patients (Patient #1) in that, on 1/21/2026 HA A failed to request for a facility staff’s assistance to safely transfer Patient #1 who required 2-persons transfer from a shower chair to the bed and it resulted in the Patient falling and the HA A failed to notify the Nursing Facility Administration as well as the Hospice Administration of the incident. This failure placed Patient #1 at risk for fall and potential injuries. Findings include: Review of hospice agency’s TULIP (- a database utilized by the State of Texas to maintain licensing, demographic information, complaints, and self-reported incidents for home health and hospice agencies.) account on 03/11/2026 at 08:38am revealed a self-reported incident #1063989 that was called in to Health and Human Services Commission by the hospice Alternate Administrator on 01/21/2026 at 1:10pm. Review of the self-reported incident revealed that the Nursing Facility Executive Director called the Hospice Director of Nursing to report that Patient fell on 01/21/2026 in the morning while HA A attempted to transfer Patient #1 from the shower chair to the bed without assistance. The Facility Executive Director reported that HA A did not inform them of the fall, but the Facility representative found out about the fall through a “Fall Dictator” system installed in the facility. Continued review of the self-reported incident revealed that HA A denied the Patient fall when the Hospice DON inquired about the incident from HA A, but upon review of the camera footage of the incident during a home visit of the Patient by the Hospice Alternate Administrator, the Bereavement Coordinator, and the RN A on 01/21/2026 at 10:40am, it was discovered that HA A did not follow standard safety precautions while transferring Patient #1 from Shower chair to the bed and that caused the Patient to fall in the process. The Camera footage also revealed that HA A only called for the facility staff assistance, after the Patient had fallen, to help lift the Patient from the floor to bed. Review of the agency’s document titled “Adverse Event Report” dated 01/21/2026 revealed that the facility where Patient #1 resides has an internal surveillance system embedded in the light fixtures in all of the Patient care areas and that was how the facility was able to discover that Patient#1 had fallen on 01/21/2026 while HA A was providing service. The video footage showed HA A attempting to transfer the Patient from the Shower chair to the bed, but the Patient’s foot got entangled with the shower chair legs. The Hospice Aide was unable to lift or reposition the Patient safely and she suddenly dropped the Patient on the floor and left the Patient seated on the floor uncovered and then called a facility staff to help her lift the Patient from the floor to the bed. Continued review of the agency’s Adverse Event Report under the subheading “Discussion and Findings” further revealed that the agency’s representatives (The Alternate Administrator, the Bereavement Coordinator, and the Registered Nurse) unanimously agreed that: 1) Patient #1’s fall occurred due to an improper transfer attempt by the HA A. 2) The Patient required a two-person transfer, and assistance should have been requested prior to attempting the transfer.3) Following the fall, proper incident reporting procedures were not followed, including immediate notification of the facility staff, agency administration, and completion of a fall report. After putting the Patient to bed HA A left the facility without reporting the fall to facility Administration and the Hospice Administration. Review of the agency’s Provider Investigation Report, dated 01/21/2026, revealed that RN A performed a comprehensive assessment of the Patient and no injuries were noted, but HA A employment was immediately terminated that day. Review of Agency’s incident/Complaint log on 03/13/2026 at 1:59pm revealed another incident report dated 06/27/2025 which showed that Patient #1 had fallen while HA A was giving Patient a bath. During that fall the Patient sustained a deep cut above her eyebrow that had to be stitched in the emergency room. During interview with agency’s DON on 03/13/2026 at 2:13pm, the DON was asked about a fall incident that involved Patient #1 and HA A on 06/27/2025 that caused the Patient to be taken to the hospital. The DON stated that HA A had called the DON to report that Patient fell in the bathroom when HA A reached for a towel to dry the Patient after she was done bathing the Patient. The DON was asked if the agency investigated that incident for Abuse and Neglect if the Hospice agency reported the incident to HHSC. The DON replied, “No.” stating that it was an accident and not an act of negligence of HA A. During interview with Patient #1’s family on 03/16/2026 at 2:41pm surveyor introduced self and informed Patient #1’s family member the reason for the call was to ask questions about the services that Patient #1 was receiving from the hospice agency. The family member just started talking and stated that she was not happy with the way that HA A provided services to Patient #1, because Patient #1 had fallen twice since HA A started providing services to the Patient. Patient #1’s family member informed the Surveyor that after Patient #1’s last fall on 01/21/2026, she opted out of the hospice aide services but kept the Nursing services to provide continuity and stability for the Patient. During interview with HA A on 03/17/2026 at 3:39pm the Surveyor asked the hospice Aide to tell her about Patient 1’s fall that happened on 01/21/2026. HA A stated that after she had given the Patient a bath on 01/21/2026, she attempted to transfer the Patient from the Shower chair to her bed. HA A stated that during the process of the transfer, the Patient started to fall, but she gently helped the Patient to slide down to the floor. HA A stated that Patient #1 was a tall and heavyset woman and was too heavy for her to transfer by herself. HA A was asked what her agency’s policy was regarding transferring Patients that are taller and heavier than her. HA A stated that agency’s policy was for her to get help from the facility staff to assist in transferring the Patient safely from chair to bed or vice versa. HA A was asked why she did not get help when she wanted to transfer Patient #1 from the shower chair to the bed. HA A stated that whenever she needed help transferring the Patient the facility staff were usually not available or willing to help. Surveyor then asked HA A if she lifted Patient #1 by herself from the floor to the bed after the Patient fell from her hands. HA A said, “No, I called one of the facility staff to help me lift the Patient from the floor.” HA A was asked if she reported the incident to the facility management or the hospice DON after the Patient was safely transferred to her bed. HA A stated that she did not report the incident to anyone since she helped the Patient to slide gently to the floor, she did not regard it as a fall. During continued interview with HA A on 03/17/2026 the Hospice Aide was asked if that was the first time that Patient had fallen while she was providing services to the Patient. HA A said, “No.” stating that sometime last year in 2025 when she newly started working with Patient #,1 there was a day the Patient fell “while I tried to stretch to get a towel to dry the Patient after giving her a shower.” Did the Patient get injured when she fell. HA A stated that the Patient had a small scratch on her forehead.HA A stated again that the Patient just had a small scratch on the forehead. Surveyor explained the difference between a scratch and a cut to HA A. A scratch is a scrape of the top layer of the skin that most time there is usually no blood while a cut is usually deeper past the top layer of the skin and there is usually bleeding. HA A was asked about the kind of injury Patient #1 sustained during the first fall. HA A stated that Patient #1 had a small cut on the forehead. HA A was asked if she was aware that Patient #1 was sent to the ER to get stitches on that cut. The Hospice Aide stated that the Patient was not sent to ER but that there was a band aide over that cut on the Patient’s forehead. On continued interview with HA A the hospice Aide was asked if agency performed competency evaluation upon hire before she started providing services. HA A replied, “No.” but review of hospice Aide personnel file revealed Hospice Aide A’s competency evaluation documentation dated 06/21/2024 when she was hired. HA A was asked if the agency conducted any in-service training to retrain her on transfer techniques after Patient #1 fell on 06/21/2025. HA A said, “No that the agency did not conduct any in-service training for her after the Patient fell on 06/27/2025.” During interview with the DON and the agency’s Alternate Administrator on 03/17/2026 4:15pm. The DON was asked if the agency provided competency evaluation for HA A upon hire before she was sent to provide services to agency Patients. The DON stated that agency performed competency evaluation for HA A when she was hired and they also did what the Agency called, “Ride along” that is a kind of on-the -Job training when HA A had to ride along with one of the agency’s tenured staff to observe how agency’s Patients were taken care of. The Competency – On-site Hospice Aide Training dated 06/21/2024 – The hospice personnel term the experience as “ride along” was also intended to afford the tenured staff the opportunity to observe HA A provide care services to agency’s Patients under supervision before she would be allowed to provide services to agency’s Patients independently. Review of HA A personnel file revealed that HA A was hired on 06/20/2024. Continued review of the HA A’s employee’s file further revealed HA A’s competency evaluations records for written examination dated 06/20/2025 and the “Ride-Along hands-on training evaluation that was performed by the DON on 06/21/2024. The DON was asked if she had spoken to HA A after the first incident that led to Patient #1’s first fall on 06/27/2025. The DON and Alternate Administrator replied, Yes and they produced documentation to prove that in-service training was conducted for HA A after Patient #1’s first fall. Upon review of the in-service training surveyor noticed that in-service training was dated November 2025 whereas the fall incident happened in June 2025. Surveyor brought this to the DON and Alternate Administrator’s attention and then asked if the DON had at least spoken to HA A immediately after the incident to let her know the seriousness of Patient’s fall and that the Patient had to be sent to the ER for stitches on the deep cut that the Patient sustained as a result of that fall. The DON stated that she and another Hospice RN had spoken to HA A regarding the incident shortly after the incident happened and told HA A to always request assistance whenever she had to transfer Patient 1 and any other Patient that she deemed too heavy to transfer by herself. Surveyor requested to see the documentation of that conversation. The DON checked Patient #1’s clinical record and was unable to provide the requested record and stated that she may have forgotten to document it. During interview with the Alternate Administrator on 03/17/2026 at 4:23pm the Alternate Administrator stated that when she became aware of Patient #1’s fall incident the facility Executive Director invited her to watch the surveillance video clips that made them know that the Patient had fallen while HA A was providing care for the Patient. The Alternate Administrator decided to go with the RN A, and the Bereavement Coordinator to see the patient and see the video footage of what actually happened. The Alternate Administrator stated that after watching the incident video footage it was very evident that Patient #1 actually fell and did not slide down as HA A stated when she was questioned about the incident. The Alternate Administrator stated that Patient #1 fell because HA A did not request help from the facility staff to help her safely transfer the Patient from the shower Chair to the bed. Surveyor requested to see the video footage of the incident and the agency Alternate Administrator stated that the agency did not have the video footage of the incident that they were only allowed to view the video while they were at the facility by the Executive Director of the agency with the permission of the Patient’s family. The Administrator was asked what Agency’s policy was for Patient’s that Hospice Aide could not safely transfer by themselves. The Alternate Administrator stated that the Hospice Aides and other staff had been instructed to always call for help from the facility staff when they know that they cannot lift or transfer a Patient safely by themselves. The Alternate Administrator was asked if agency provided any in-service training for HA A after the first time Patient #1 fell while HA A was providing care to the Patient. The Alternate Administrator stated that agency conducted in-service training for all Hospice Aides in November 2025 and HA A participated in that in-service training. Surveyor brought it to the Alternate Administrator’s attention that agency conducted in-service training five (5) months after the incident had already taken place. The Alternate Administrator then stated that she had taken note of that would ensure Hospice Aides and other clinical staff are undergo in-service trainings shortly after an incidence and she would update agency’s policy regarding in-service training. Surveyor requested to speak with RN A that assessed Patient #1 after the fall and was informed that RN A was unavailable.Surveyor was also unable to speak with the Facility staff that assisted HA A to transfer Patient #1 after the fall. Review of agency’s administrative manual titled, “Personnel Safety” states in part, “…Never carry heavy or large items without proper assistance… Immediately contact your supervisor in the event of any health, safety or environment emergency including, but not limited to, injuries, medical emergencies, accidents, chemical leaks or spills, fire, equipment safety issues or any other situation deemed to be hazardous in any way…” Review of agency’s administrative policy titled, “Abuse, Neglect, and Exploitation” last reviewed on 09/01/2023 states in part, “…The hospice must promote and protect the Patient right to be free from abuse, neglect, and exploitation including injuries of unknown source, and misappropriation of Patient property…Neglect is the failure to provide for one’s self the goods or services, including medical services, which are necessary to avoid physical or emotional harm or pain or the failure of a caretaker to provide such goods or services…””