Hospice of Sweetwater County

“Based on observation, medical record review, staff interview, and policy and procedure review the agency failed to ensure the plan of care (POC) included all pertinent information for 9 of 14 sample patients (#3, #4, #6, #7, #8, #9, #10, #11, #12). The findings were: 1. Review of the POC for patient #3 showed diagnoses including Cachexia, Parkinson’s disease, repeated falls, muscle weakness, chronic obstructive pulmonary disease (COPD), and paroxysmal atrial fibrillation. Observation during the CNA home visit on 9/3/25 at 3:30 PM showed the patient had briefs, wipes, shower chair, toilet riser with handles, grip bars, oxygen, nasal cannula, wheelchair, and a 4-wheel walker. The POC failed to include the frequency of the CNA visits.2. Review of the medical record for patient #4 showed diagnoses including sepsis, COPD, pneumonia, and dementia. Review of the POC failed to include all services necessary and frequency of visits. 3. Review of the medical record for patient #6 showed diagnoses of malignant neoplasm of left ovary, and malignant neoplasm of retroperitoneum and peritoneum. Review of the POC under active items showed oxygen use, urinary incontinence, diminished strength, wound under left breast, wound under right breast, shortness of breath and risk of pressure sores. The POC failed to include all necessary services and frequency of visits.4. Review of the medical record for patient #7 showed diagnoses of melanoma neck and scalp, and malignant neoplasm of the lung. Review of the POC showed issues were functional needs, anxiety, bathing, confusion, edema, and shortness of breath. The POC failed to include all necessary services and frequency of visits.5. Review of the medical record for patient #8 showed diagnoses of prostate cancer and metastasis to bone. Review of the POC showed issues of air hunger, bathing, confusion, depression, diminished strength, edema, oxygen use, shortness of breath, urinary incontinence, and pain. The POC failed to include all necessary services and frequency of visits.6. Review of the medical record for patient #9 showed diagnoses of advanced COPD chronic and anemia. Review of the POC showed issues of shortness of breath, oxygen use, confusion, edema, air hunger, and depression. The POC failed to include all necessary services and frequency of visits. 7. Review of the medical record for patient #10 showed diagnoses of malignant neoplasm of retroperitoneum. Review of the POC showed issues of anxiety, nausea, pain, and shortness of breath. The POC failed to include all necessary services and frequency of visits.8. Review of the POC for patient #11 showed diagnoses of chronic systolic congestive heart failure, falls, dizziness, giddiness, mood disorder, and urinary tract infection. The POC failed to include all necessary services and frequency of visits.9. Review of the POC for patient #12 showed diagnoses of malignant melanoma of left lower limb, including hip. The POC failed to include all necessary services and frequency of visits.10. Interview with the administrator on 9/5/25 at 10 AM confirmed the POC’s did not include the services and the frequency of visits. 11. Review of policy “Plan of Care - Content” hand delivered on 9/4/25 at 3:44 PM by the administrator showed “...2.The plan of care includes, but not limited to:...b. a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs...””

“Based on medical record review, staff interview, and policy and procedure review the agency failed to ensure drugs and treatment necessary to meet the patient needs were included in the plan of corrections (POC) for 7 of 14 patients (#2, #4, #6, #7, #8, #9, #10). The findings were: 1.Review of the POC for patient #2 showed diagnoses including acute respiratory failure with hypoxia, pneumonia, and muscle weakness. Further review showed the agency failed to include all the patient medications on the POC. During the home visit on 9/3/25 at 11 AM, RN# 1 stated the medications, she just delivered to the patient were metoprolol (beta blocker), ondansetron (serotonin 5-HT3 receptor antagonists), nystatin (polyene antifungal medication), morphine (opiate), and docusate (laxative). The medications were not included on the POC.2. Review of the medical record for patient #4 showed diagnoses including sepsis, COPD, pneumonia, and dementia. Review of the POC failed to include the patients list of medications.3. Review of the medical record for patient #6 showed diagnoses of malignant neoplasm of left ovary, and malignant neoplasm of retroperitoneum and peritoneum. Review of the POC showed oxygen use, urinary incontinence, diminished strength, wound under left breast, wound under right breast, shortness of breath and risk of pressure sores. The POC failed to include the patients list of medications. 4. Review of the medical record for patient #7 showed diagnoses of melanoma neck and scalp, and malignant neoplasm of the lung. Review of the POC showed anxiety, bathing, confusion, edema, and shortness of breath. The POC failed to include the patients list of medications.5. Review of the medical record for patient #8 showed diagnoses of prostate cancer, and metastasis to the bone. Review of the POC showed issues of air hunger, bathing, confusion, depression, diminished strength, edema, oxygen use, shortness of breath, urinary incontinence, and pain. The POC failed to include the patients list of medications. 6. Review of the medical record for patient #9 showed diagnoses of advanced COPD chronic, and anemia. The POC failed to include the patients list of medications.7. Review of the medical record for patient #10 showed diagnosis of malignant neoplasm of retroperitoneum. The POC failed to include the patients list of medications. 8. Interview with the administrator on 9/5/25 at 10 AM revealed the POC the facility was currently using did not include the medications.9. Review of police “Plan of Care - Content” hand delivered on 9/4/25 at 3:44 PM by the administrator showed “...2. The plan of care includes, but is not limited to:...d. drugs and treatments necessary to meet the needs of the patient...””

“Based on observation, medical record review, staff interview, and policy and procedure review the agency failed to ensure the plan of care (POC) included all pertinent information for 12 of 14 sample patients (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12). The findings were: 1.Review of the POC for patient #1 showed diagnoses including Alzheimer’s disease, repeated falls, and history of urinary tract infections. Observation on 9/4/25 at 9:30 AM showed the patient had a shower chair, hospital bed, wheelchair, grab bars, briefs. The POC failed to include the durable medical equipment (DME) and the safety precautions.2. Review of the POC for patient #2 showed diagnoses including acute respiratory failure with hypoxia, pneumonia, and muscle weakness. Observation during the home visit on 9/3/25 at 11 AM showed the patient had a hospital bed, oxygen, nasal cannula, shower chair, grab bars, wheelchair, bed pain, briefs, incontinent pads, foley catheter, and a medication minder. The POC failed to includes the DME and safety precautions.3. Review of the POC for patient #3 showed diagnoses including cachexia, Parkinson’s disease, repeated falls, muscle weakness, chronic obstructive pulmonary disease (COPD), and paroxysmal atrial fibrillation. Observation during the home visit on 9/3/25 at 3:30 PM showed the patient had briefs, wipes, shower chair, toilet riser with handles, grip bars, oxygen, nasal cannula, wheelchair, and a 4-wheel walker. The POC failed to include the DME and safety precautions.4. Review of the medical record for patient #4 showed diagnoses including sepsis, COPD, pneumonia, and dementia. Review of the POC failed to include the diagnoses, DME and safety precautions.5. Review of the POC for patient #5 showed a diagnosis of disseminated malignant neoplasm. The POC failed to include the DME and safety precautions.6. Review of the medical record for patient #6 showed diagnoses of malignant neoplasm of left ovary, and malignant neoplasm of retroperitoneum and peritoneum. Review of the POC showed under active items was oxygen use, urinary incontinence, diminished strength, wound under left breast, wound under right breast, shortness of breath and risk of pressure sores. The POC failed to include the DME and safety precautions.7. Review of the medical record for patient #7 showed diagnoses of melanoma neck and scalp, and malignant neoplasm of the lung. Review of the POC showed under issues was functional needs, anxiety, bathing, confusion, edema, and shortness of breath. The POC failed to include diagnoses, DME and safety precautions.8. Review of the medical record for patient #8 showed diagnoses of prostate cancer and metastasis to the bone. Review of the POC showed issues of air hunger, bathing, confusion, depression, diminished strength, edema, oxygen use, shortness of breath, urinary incontinence, and pain. The POC failed to include diagnoses, DME and safety precautions.9. Review of the medical record for patient #9 showed diagnoses of advanced COPD chronic and anemia. Review of the POC showed issues of shortness of breath, oxygen use, confusion, edema, air hunger, and depression. The POC failed to include diagnoses, DME and safety precautions. 10. Review of the medical record for patient #10 showed diagnosis of malignant neoplasm of retroperitoneum. Review of the POC showed issues of anxiety, nausea, pain, and shortness of breath. The POC failed to include diagnoses, DME and safety precautions.11. Review of the POC for patient #11 showed diagnoses of chronic systolic congestive heart failure, falls, dizziness, giddiness, mood disorder, and urinary tract infection. The POC failed to include the DME and safety precautions.12. Review of the POC for patient #12 showed a diagnosis of malignant melanoma of left lower limb, including hip. The POC failed to include DME and safety precautions.13. Interview with CNA #1 on 9/4/25 at 9:30 AM she did not know the DME and safety precautions for patient #1 and would have to ask other staff. 14. Review of policy “Plan of Care - Content” had delivered on 9/4/25 at 3:44 PM by the administrator showed “...2.The plan of care includes, but not limited to:...e. medical supplies, equipment, and appliances necessary to meet the needs of the patient.”