Compassus Green Bay

“It is required that the documented comprehensive assessment includes a drug profile that contains the patient’s current: Prescription and over-the-counter (OTC) drugs; Supplements; Herbal remedies; Other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: The effectiveness of drug therapy; Drug side effects; Actual or potential drug interactions; Duplicate drug therapy; Drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added, or changes are made to existing medication. This standard was not met as evidenced by clinical record review and interview. In 1 of 7 (14%) clinical records reviewed, in which oxygen was ordered, it was revealed that the agency did not ensure that the drug profile included all of the patient’s current medications that could affect drug therapy. CLINICAL RECORD 10: The patient was admitted on 03/18/2025 with Chronic Obstructive Pulmonary Disease and a history of lung cancer. The initial nursing assessment documented the patient required continuous oxygen at 10L per face mask. Oxygen was not included in the patient’s medication profile, thus was not included in the review of medications that could affect drug therapy. Reviewed clinical record with Area Director of Clinical Services on 04/01/2025 who confirmed and agreed that oxygen was not included on the medication profile.”

“It is required that each patient’s individualized written plan of care include drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 1 of 7 (14%) clinical records reviewed, in which oxygen was ordered, it was revealed that the agency did not ensure that the plan of care included all of drugs and treatment necessary to meet the needs of the patient. CLINICAL RECORD 10: The patient was admitted on 03/18/2025 with a diagnosis of Chronic Obstructive Pulmonary Disease and a history of lung cancer. The initial nursing assessment dated 03/18/2025, documented that the patient was using continuous oxygen at 10 L/per minute per face mask. The plan of care, effective 03/18/2025 to 06/15/2025, included oxygen safety interventions but did not include oxygen as a medication or treatment. The Area Director of Clinical Services confirmed findings in an interview on 03/31/2025 and 04/ 01/2025.”

“It is required that each patient’s individualized written plan of care include the medical supplies and appliances necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 2 of 19 (11%) clinical records reviewed revealed that the agency did not ensure that the needed medical equipment and supplies were listed on each individualized plan of care. CLINICAL RECORD 9: The patient was admitted on 03/07/2025 with a diagnosis of malignant neoplasm of the breast. The nursing assessment on 03/07/2025 documented that the patient had a wound on the left heel with dressing changes, a Foley catheter in place and required a Hoyer lift. The plan of care (POC), effective 03/07/2025 to current, listed “NONE” under durable medical equipment (DME) and supplies. The POC did not include the Hoyer lift, wound care supplies, or the Foley catheter supplies necessary to meet the needs of the patient. CLINICAL RECORD 10: The initial nursing assessment, dated 03/18/2025, documented the patient had Chronic Obstructive Pulmonary Disease and required continuous oxygen at 10L per face mask, had a g-tube, a wound on the coccyx, a nebulizer, a suction machine, and requested a Hoyer lift. The plan of care, dated 03/18/2025-06/15/2025, included a Hoyer lift but did not include oxygen supplies, g-tube supplies, suction supplies, nebulizer supplies, or wound care supplies. The Area Director of Clinical Services stated in an interview on 03/31/2025, “I see that, it will be updated in IDG (interdisciplinary group) tomorrow.””

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. Each patient’s record includes, at a minimum, physician orders. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed revealed that the agency did not ensure that the clinical record contained current physician orders for to meet he needs of the patient. CLINICAL RECORD 6: A skilled nursing note on 03/26/2025 read in part, “Patient reports since taking more morphine he is constipated and going a little bit with hard pellets, education completed on how to relieve constipation. His wife gave him a dose of MiraLAX while the nurse was in the home.” The record did not include orders for MiraLAX. The Area Director of Clinical Services stated in an interview on 03/31/2025, “The nurses struggle with getting orders for over-the-counter medications.””

“Based on record review and interview, the agency nurses failed to meet the nursing needs for wound assessment and measurement in hospice patients with wounds in 2 of 5 wound patients (Patient #1 and #2) in a total of 11 hospice patient records reviewed. Findings include: Review of agency policy titled “;Wound Management” (dated 11/30/2018) revealed in part, “;Procedure: At each nursing visit: 2. Visualize any known wounds at least 1 time per week and more often if required for wound management. a. Size- length by width by depth, in centimeters. b. Appearance of the wound bed and wound margins. c. Presence of odor. d. Presence of exudate. e. Signs/symptoms of infection at the wound site. f. Stage of the wound if it is a pressure related wound. 3. Wound Care d. If the patient is in a facility, collaborate with the individual at the facility responsible for wound management (the hospice nurse is responsible for inspecting the wound at least 1 time per week and should plan accordingly to work with the facilitys personnel to accomplish this). During an interview on 11/13/2023 at 11:50 AM with Area Executive of Clinical Operations E, and Director of Clinical Services B and C, when asked about the agencys process for wound assessment and care of wound, Director of Clinical Services B replied, “;Once a week at a minimum do an assessment. We enter in wound care orders. May train family or staff member to do wound care but at a minimum we do once per week.” Area Executive of Clinical Operations E stated, “;Wound measurements are done every 7 days by an RN.” During an interview on 11/13/2023 at 3:20 PM with RN D, when asked the agencys process for wound assessment and care of wound, RN D replied, “;Weekly visits done every 7 days. We coordinate with facility if patient in a facility to do care and assess and measure. On admission, will assess wound and measure if a wound is known and also do skin checks.” Record review of Patient #1s “;Hospice IDG (Interdisciplinary Group) Comprehensive Assessment and POC (Plan of Care) Update Report” with start of care 10/15/2023 revealed Patient #1 had a primary diagnosis of “;Malignant Neoplasm of Overlapping Sites of Bladder” and secondary diagnoses of “;Type 2 Diabetes Mellitus without Complications.” The POC update/orders revealed in part, “;SN (Skilled Nurse) 3 times per week for 1 week, 2 times per week for 8 weeks. SN to observe and assess of integumentary status. Care for wound of left heel. Details: Patient also has a wound to left heel that is a venous stasis ulcer.” Record review of Patient #1’s record of SN visit documentation for “;Left Heel-Venous stasis Ulcer” wound assessments 10/15/2023 to 11/13/2023 revealed: 10/15/2023: “;Wound assessed- yes. Measurements taken- No. Reason- Not due.” 10/20/2023: “;Wound assessed- yes. Measurements taken- No. Reason- Not due. Patient was seen by writer today for nurse visit as patients daughter called reporting...to assess left heel wound as it is looking worse.” 10/27/2023: “;Wound assessed- No. Caregiver completed care.” 10/31/2023: “;Wound assessed- No. Caregiver completed care.” 11/03/2023: “;Wound assessed- No. Caregiver completed care.” 11/08/2023: “;Assessed- yes. Length 5.0 cm (centimeters) x Width 3.0 cm x Depth 0.3 cm.” 11/10/2023: “;Assessed- No. Measurements taken- No. Reason- Not due.” Record review of Patient #2s “;Hospice IDG Comprehensive Assessment and POC Update Report” with start of care 10/06/2023 revealed Patient #2 had primary diagnoses of “;Acute on Chronic Diastolic Congestive Heart Failure” and secondary diagnoses of “;Pressure Ulcer of Unspecified Heel Stage 4” and “;Pressure Ulcer of Right Heel, Unspecified Stage.” The POC update/orders revealed in part, “;SN frequency 2 times per week for 1 week, 1 time per week for 13 weeks. SN for administration of decubitus wound care. Details: During [Patient #2s] stay in rehab, developed a pressure injury on bilateral heels. Right heel is unstageable at this time. The left heel was recently debrided and has exposed bone showing.” Record review of Patient #2’s record of SN visit documentation for “;Left Heel- Pressure Ulcer” wound assessments 10/06/2023 to 11/07/2023 revealed: 10/06/2023: “;Wound assessed- no. Measurements taken- No. Reason- Not due.” 10/07/2023: “;Wound assessed- yes. Length 4.5 cm x Width 3.6 cm x Depth 0.5 cm.” 10/13/2023: “;Wound assessed- No. Caregiver completed care.” 10/19/2023: “;Wound assessed- yes. Length 4.5 cm x Width 3.5 cm x Depth 0.5 cm.” 10/21/2023: “;Patient refused care.” 10/24/2023: “;Wound assessed- yes. Length 2.3 cm x Width 4.2 cm x Depth 0.6 cm.” 10/27/2023: “;Wound assessed- yes. Length 2.0 cm x Width 4.0 cm x Depth 0.5 cm.” 11/01/2023: “;Wound assessed- No. Caregiver completed care.” 11/07/2023: “;Wound assessed- yes. Length 2.0 cm x Width 4.0 cm x Depth 0.5 cm.” Record review of Patient #2’s record of SN visit documentation for “;Right Heel- Pressure Ulcer” wound assessments 10/06/2023 to 11/07/2023 revealed: 10/06/2023: “;Wound assessed- no. Measurements taken- No. Reason- Not due.” 10/07/2023: “;Wound assessed- yes. Length 2.0 cm x Width 0.9 cm x Depth 0.2 cm.” 10/13/2023: “;Wound assessed- No. Caregiver completed care.” 10/19/2023: “;Wound assessed- yes. Length 2.0 cm x Width 0.9 cm x Depth 0 cm.” 10/21/2023: “;Patient refused care.” 10/24/2023: “;Wound assessed- yes. Length 1.1 cm x Width 1.7 cm x Depth 0.5 cm.” 10/27/2023: “;Wound assessed- yes. Length 2.0 cm x Width 1.0 cm x Depth 0.5 cm.” 11/01/2023: “;Wound assessed- No. Caregiver completed care.” 11/07/2023: “;Wound assessed- yes. Length 2.0 cm x Width 1.0 cm x Depth 0.5 cm.” Record review of Patient #2’s record of SN visit documentation for “;Right Lower Buttock-Pressure Ulcer” wound assessments 10/06/2023 to 11/07/2023 revealed: 10/06/2023: “;Wound assessed- no. Measurements taken- No. Reason- Not due.” 10/07/2023: “;Wound assessed- no. Measurements taken- No. Reason- Wound care not provided.” 10/13/2023: “;Wound assessed- No. Caregiver completed care.” 10/19/2023: “;Wound assessed- No. Caregiver completed care.” 10/21/2023: “;Patient refused care.” 10/24/2023: “;Wound no longer open.” Findings were reviewed with Area Executive of Clinical Operations E and Director of Clinical Services B on 11/13/2023 at 4:30 PM regarding Patient #1 missing wound assessments and/or measurement the week of 10/15/2023, 10/22/2023, and 10/29/2023, and Patient #2 missing wound assessments and/or measurements the week of 10/08/2023 and 10/29/2023. During an interview with Area Executive of Clinical Operations E on 11/14/2023 at 11:15 AM, when asked if there was any additional wound assessments and/or measurements or documentation for Patient #1s and #2s wounds, Area Executive of Clinical Operations E replied, “;No, we were not able to find anything. We had our QA (Quality Assurance) look and agreed on [not finding additional information for wound assessments and/or measurements].””