Beloit Regional Hospice

“Based on record review and interview hospice staff failed to keep patient free from mistreatment in 1 (Patient #1) of 1 patient record in a total sample of 11 patients reviewed. Findings Include:Agency policy titled, “Abuse, Neglect, Mistreatment, and Exploitation” dated 10/2022, revealed in part, “Definitions: Mistreatment: To treat someone or something roughly, wrongly, or badly…1. During orientation (and annually thereafter), all new employees receive instruction regarding: b. a review of the State’s legal definitions of abuse, neglect, and exploitation and mandatory reporting requirements and processes. 2. During the admission process and throughout the course of care, hospice personnel assess the potential/likelihood of abuse, neglect, mistreatment, or exploitation in the patient’s environment. 3. Alleged violations of abuse, neglect, mistreatment and/or exploitation involving hospice employee or contractor are brought to the attention of the hospice administrator immediately. 4. The administrator or designee immediately investigates alleged violations involving persons providing services on behalf of the hospice and immediately takes action to prevent potential further violation during the investigation.” Record review of Patient #1’s medical record revealed in part, a start of care date of 12/17/2024 with a Terminal Diagnosis of Senile degeneration of brain. Patient #1’s Physician Certification of Terminal Illness was dated 06/11/2025. Clinical note dated 07/14/2025 revealed Certified Nursing Assistant (CNA) C provided “partial cares done today, Administrator A called during cares and this CNA was dismissed from room by staff at ALF (Assisted Living Facility).” Clinical note dated 07/14/2025 revealed Registered Nurse (RN) D completed a visit on Patient #1 due to “Received message that patient has 3 new-onset skin tears to her right forearm…Skin Integrity: Patient has 3 new skin tears to her right forearm, measuring 3.5cm x 0.2cm x 0.1sm to her dorsal forearm, 2.3cm x 0.2cm x 0.1cm to lateral wrist, and 7cm x 0.2cm x 0.1cm to her dorsal hand. Wound cares provided. Orders written out and given to facility Wellness Director H. Visit frequency increased to 2x/week for wound cares.” RN Supervisory visit was completed (aide not present) with documentation noted, “Change in service, new aide assigned.”Record review of CNA C’s personnel record indicated a date of hire of 02/02/2024. CNA C’s personnel record did not contain any evidence of any orientation or training regarding Patient Rights or Abuse, Neglect, and Mistreatment. A performance evaluation dated 03/07/2025 did not reveal any concerns with care or performance.Also in CNA C’s personnel file was a document (dated 07/18/2025) detailing the 07/14/2025 incident revealing in part, “I went to pull the covers and she [Patient #1] grabbed them and became verbally abusive telling me to go away, she hates me and she wished I would die. I slowly and calmly started to take off her sleeping gown, it has a zipper in the front. I managed to get it off one are and was going to the other side to roll her and get the gown and she started hitting me and yelling. She was grabbing the gown and hitting my hands at the same time but I got the gown away from her. I was continuing with my cares when I noticed blood on my hands and that is when I discovered the large skin care on her right hand, at this point I am not sure what caused it, but I think it might have been the zipper on the gown. I applied pressure and put her call light on, I attempted to call one of my coworkers for help but she was already gone. I waited and when no one came in the room I went out into the hallway and asked the male CNA for a nurse stating I was needing help pretty quickly. I waited longer and then [Wellness Director H] came into the room and I was pretty frazzled at that point, the patient was yelling saying she hated me and to get me out of there. [Wellness Director H] told me it was all in my approach to the patient (she wasn’t there to see my interactions with her) and then she dismissed me from the room stating she would take care of all of it herself…” During an interview with Administrator A on 07/21/2025 at 1:25 PM Administrator A stated that she was made aware of a situation involving Patient #1 and CNA C when she received a phone call from CNA C on 07/14/2025. Administrator A stated CNA C reported she was at the assisted living facility and had been providing aide cares to Patient #1 when #1 became combative and CNA C requested assistance. CNA C stated that Wellness Director H came into the room to assist and H instructed CNA C to leave and she would provide the necessary cares to Patient #1. Administrator A stated that she briefly spoke with Wellness Director H and H informed her that CNA C was clearly angry with Patient #1 and was handling #1 in a rough manner causing three skin tears on Patient #1 and she wanted CNA C to leave the facility immediately. Administrator A agreed and instructed CNA C to leave the facility and she was not to provide cares to any patient at the facility and her patients would be reassigned to someone else. During an interview with Wellness Director H on 07/22/2025 at 10:27 AM, Wellness Director H stated that on 07/14/2025, she was told CNA C needed help with Patient #1, so she went to Patient #1’s room to assist. Wellness Director H stated, “As soon as I entered [Patient #1’s] room I could tell [CNA C] was upset and very frustrated and said, ‘I can’t do this alone. I need two people. She’s being very combative.’ I then told her that maybe it was her approach. I have worked with [Patient #1] and I’m comfortable with her. Then [CNA C] went up to [Patient #1] and grabbed her right forearm with both of her hands gripped around it and said, ‘She’s being very combative.’ I went up to [Patient #1] and said good morning and asked her if there was anything I could do for her. [Patient #1] said, ‘Good morning. Not too good I don’t know what I did to this woman to hurt me like this.’ [Patient #1] then showed me her right arm and I saw three new skin tears. It was fresh blood and had just started to drip down. That’s when I asked [CNA C] what happened. [CNA C] said, ‘I don’t know I was just getting her ready for the day.’ I then told [CNA C] she needed to leave and I would finish the cares on [Patient #1]. She continued to wring out the washcloth as if she was going to continue to provide cares so I told her again she needed to leave. That’s when she called [Administrator A] and told her that one of the staff from here was in the room accusing her and yelling at her. [CNA C] asked for my name and that’s when I asked to speak with [Administrator A] on the phone. Then I told [Administrator A] what happened and that I told [CNA C] to leave. Administrator A agreed and said they would meet up later and discuss later. I finished cares on [Patient #1] and she was very upset and kept repeating, ‘Please don’t let her come back.’ I contacted [POA/Family Member I], my director, and her provider Inclusa, and explained the situation to all of them. I have not had any more communication with [CNA C]. I did speak with [RN D] that same morning when he came in and assessed [Patient #1] and cleaned the wounds and applied dressings.” When asked if she was aware of any prior issues or concerns with CNA C, Wellness Director H stated that CNA C had previously requested [Patient #1] be medicated with Lorazepam prior to morning cares. Director H stated that her request was discussed and denied because they felt like it was not needed, and it was all in the approach with Patient #1.”

“Based on record review and interview, agency failed to ensure all staff completed patient rights, abuse, neglect, and mistreatment training in 3 (Certified Nursing Assistant (CNA) C, Registered Nurse (RN) D, and Hospice Aide G) in a total of 5 personnel files reviewed. Findings Include:Review of agency policy titled, “Staff Education and Training”, dated 11/2024, revealed in part, “New staff members will complete an orientation training process that will identify their level of competency and establish an action plan to assure competency in their key job functions. Educational topics to be included in the initial orientation are: Patient Rights and ethics, Abuse and Neglect…”Record review of CNA C’s personnel record indicated a date of hire of 02/02/2024. CNA C’s personnel record did not contain any evidence of any orientation or training regarding Patient Rights or Abuse, Neglect, and Mistreatment.Review of personnel record for RN D revealed in part, a date of hire of 04/15/2024. There was no evidence of any patient rights, abuse, neglect, and mistreatment completed trainings in RN D’s personnel file. Review of Hospice Aide G’s personnel record revealed in part, a date of hire of 02/21/2024. There was no evidence of any patient rights, abuse, neglect, and mistreatment completed trainings in Hospice Aide G’s personnel file.During an interview with Administrator A on 07/22/2025 at 9:38 AM, when asked if CNA C, RN D, and Hospice Aide G had completed Patient Rights, Abuse, Neglect, and Mistreatment as part of orientation or other training, Administrator A stated, “No. It looks like there was some miscommunication between our education department and Human Resources (HR) and those specific trainings were never assigned to a few new staff...””

“Observed in Record Review. In 2 of 19 patient records reviewed, the assessment had not been updated with progress toward goals. For example, in the chart for RRHV#1, a social work goal on the plan of care identified upon admission was the patient/caregiver would identify final arrangements with a date approximately three months into the future. There was no information in the interdisciplinary group documentation which address any progress toward this goal. In the chart for RRHV#2, there was no documented progress toward the goal of reduction in the patient’s anxiety for more than three IDG meetings.”

“Observed in Record Review. In 5 of 19 patient records reviewed, the plan of care did not include patient specific goals. In the chart for RRHV#1, the patient had oxygen ordered upon admission as part of the comfort medications. There was no goal on the plan of care for oxygen safety. In the chart for RRHV#2, the patient was admitted with a skin tear. There was no goal on the plan of care related to the wound. The Spiritual Care goal was a statement of what the Spiritual Care Counselor was going to provide to the patient rather than a goal and did not include a measurable time frame. In the charts for RRHV#3 and RRHV#4, the patients had oxygen upon admission. There was never a goal related to safe oxygen use on the hospice plans of care. In the chart for RRNHV#5, there was no time frame for the goal of ___ and family will verbalize understanding of use of Norco and Morphine in the home. This was confirmed with the nursing supervisor and Administrator.”

“Observed in Record Review. In 4 of 19 patient records reviewed, the hospice plan of care did not include all services needed to meet the patient’s needs. In the charts for RRHV#3 and RRHV#4, the patients were admitted on oxygen, yet the plans of care did not include any teaching interventions related to safe use of oxygen. In the chart for RRHV#2, the patient was admitted with a skin tear. The wound care order was missing the frequency that the wound care was to be performed. In the chart for RRNHV#5, the RN assessed the patient was using oxygen continuously at 2lpm at the time of admission. There was no order for oxygen on the hospice plan of care. This was discussed with the DON”