Susie Bowling Lawrence Hospice

“Based on review of staffing hours and volunteer files, and staff interview, the facility failed to ensure volunteers were used in administrative and/or direct patient care roles (refer to L644) and failed to demonstrate ongoing efforts to recruit volunteers (refer to L645). In addition, the facility to document the cost savings achieved through the use of volunteers (refer to L646). Further, the facility failed to ensure volunteers provided administrative and/or direct patient care hours in an amount that equaled, at a minimum, 5 percent of the total patient care hours of all paid employees and contract staff (refer to L647). This system failure resulted in the inability of the facility to meet the Condition of Participation for Volunteers.”

“Based on observation, staff interview, and policy and procedure review, and professional reference review the facility failed to ensure appropriate hand hygiene was done while performing wound care for 1 of 2 patients with home visits (#2). The findings were: Observation of wound care for patient #2 with registered nurse (RN) #1 on 10/15/24 at 1 PM showed the nurse donned gloves and moved the clothing, removed the old dressing, and cleaned the wound wearing the same gloves. The nurse doffed his gloves, and donned gloves with no hand hygiene. The RN assisted the patient with changing his/her clothing, and assessed the patient’s skin without changing gloves or hand hygiene. The nurse then doffed his gloves, and donned gloves without hand hygiene performed. The nurse then assisted with putting on the patient’s shoes and pulling up the pants. The RN doffed gloves and then did hand hygiene. 2. Interview with the RN on 10/15/24 at 2:05 PM revealed he would normally do hand hygiene between glove changes, and between dirty and clean dressing changes. 3. During an interview on 10/15/24 at 2:56 PM the infection preventionist stated hand hygiene should be completed before putting gloves on and again after removing gloves. 4. Review the policy “Infection Control” last revised 6/2023 showed “...2. The Five Moments for Hand Hygiene at the Point of Care. ...b. Before any procedure and between different procedures for the same patient,...even if gloves are worn. c. After body fluid exposure risk including excretions, mucous membranes, non-intact skin or wound dressings... d. After every patient contact. e. After contact with the patient surroundings, includes contact with inanimate objects e.g., medical equipment.” 5. Review of website “https://www.cdc.gov/clean-hands” accessed on 10/22/24 showed “...Key times to wash hands. You can help yourself and your loved ones stay healthy by washing your hands often, especially during these key times when you are likely to get and spread germs: Touch surfaces or objects that have germs on them. ...Before and after treating a cut or wound.””

“Based on review of volunteer files and staff interview, the facility failed to use volunteers in administrative and/or direct patient care roles. The census was 2. The findings were: 1. Review of the three volunteer files (volunteers #1, #2, #3) provided by the facility showed no evidence of hours worked in the last year. 2.During an interview on 10/16/24 at 8:55 AM the administrator stated no volunteers were used in the past year for administrative or patient care duties. He stated residents were offered, but declined, volunteer services, and the facility had not used volunteers in administrative duties.”

“Based on review of volunteer files and staff interview, the facility failed to document the cost savings by using volunteers. The census was 2. The findings were: Review of the three volunteer personnel files (volunteers #1, #2, #3) provided by the facility showed no evidence of volunteer hours in the past year. During an interview on 10/15/24 at 3:18 PM the administrator stated no volunteers were used in the last year, except maybe 3 hours for a “Turkey Trot.” He further stated the facility had not been calculating any cost savings through the use of volunteers.”

“Based on review of volunteer files and staffing hours, and staff interview, the facility failed to ensure volunteers provided administrative and/or patient care services in an amount that equaled at least 5 percent of the total patient care hours of all paid employees and contract staff. The census was 2. The findings were: Review of the three volunteer files (volunteers #1, #2, #3) provided by the facility showed no documentation of hours worked in the last year. Review of patient care hours documentation provided by the facility showed a total of 2,150.50 hours provided by paid staff or contract staff in the last year. During interviews on 10/15/24 at 3:18 PM and 10/16/24 at 8:55 AM the administrator stated no volunteers were used in the last year, except maybe 3 hours for a “Turkey Trot.” He confirmed the facility did not meet the 5% requirement.”

“Based on review of medical records and the patient handbook, and staff interview, the facility failed to provide a copy of the facility’s policy on the management and disposal of controlled drugs to the patient or patient representative for 14 of 14 sample residents (#1 through #14). The findings were: Review of the signed rights and responsibilities acknowledgement form for sample residents #1 through #14 in the medical records showed “Follow the drug and narcotic disposal and return of medications policy, which is in the Hospice Handbook.” However, review of the Hospice Handbook showed no policy related to drug and narcotic disposal. During an interview on 10/15/24 at 9:43 AM the administrator confirmed the handbook did not address the facility’s policy on controlled drug disposal.”