DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		 (X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER		 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED
101510 A. BUILDING __________
B. WING ______________ 		11/04/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
TREASURE COAST HOSPICE OF MARTIN 1201 SE INDIAN ST, STUART, FL, 34997
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See reverse for further instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation
LABORATORY DIRECTOR’S OR PROVIDER/SUPPLIER REPRESENTATIVE’S SIGNATURE

 TITLE

 (X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
(X4) ID
PREFIX
TAG		 SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY SHOULD BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
L0543      
25404 Based on review of the Hospice's Policies and Procedures, record review and interview, the Hospice failed to ensure care for 1 of 3 sampled patients was provided as per the written Plan of Care as evidenced by the Hospice Nurse's failure to complete a skin evaluation related to incontinence, with each comprehensive assessment for a patient who was assessed as having altered elimination (Patient #1). The findings included: Review of the Hospice's Policy titled, "Nursing Services" effective 10/31/18 documented, "12) Nurses complete a nursing visit note at every visit based on the needs at the time of the visit and as identified in the POC (plan of care)." Review of the record revealed Patient #1 was admitted for Hospice services on 03/04/19. Review of the "Care Plan Problems" documented Patient #1 had "Altered Elimination" related to bladder and bowel incontinence. Interventions on this "Care Plan" included a Skilled Nursing evaluation and monitoring of the patient's skin integrity, related to the incontinence. A side-by-side review of the record for Patient #1 and interview was conducted on 11/04/19 beginning at approximately 11:00 AM with the Compliance Nurse who confirmed that each visit documented as a "Nursing Visit" in the Electronic Medical Record (EMR), was a "Comprehensive Assessment" and confirmed that the "Comprehensive Assessment" would be a head-to-toe assessment of the patient, specific to the areas of concern identified in the patient's care plans. Review of the "Nursing Visit Notes," from 10/02/19 through 10/21/19 lacked any evidence of documentation of a skin evaluation related to incontinence and documented the following: On 10/02/19 at 1:05 PM, Staff A, a Registered Nurse (RN) made a visit, and Patient #1 was observed sitting up in their wheelchair; this "assessment" documented Patient #1 was incontinent of both bladder and bowel and needed total assistance for Activities of Daily Living (ADLs) and the "skin assessment" documented the patient's skin as warm, dry and fragile. On 10/09/19 at 9:00 AM, Staff A made a visit to Patient #1, who was going to an activity. This "assessment" documented Patient #1 was incontinent of both bladder and bowel, needed total assistance for ADLs and Patient #1 was bed/chair bound. The "skin assessment" documented the patient's skin as warm, dry and fragile. On 10/15/19 at 3:00 PM, Staff B, a Licensed Practical Nurse (LPN) made a visit. Patient #1 who was up in their wheel chair in the court yard and brought back to their room by an aide who reported Patient #1 had a bowel movement. This "note" documented Patient #1 was incontinent of both bladder and bowel and that the patient's skin was warm, dry, and fragile. On 10/21/19 at 8:42 AM, a Certified Nursing Assistant (CNA) "Visit Note" documented, "Patient has a red area on ... (location). Apply cream that the nurse gave me. Get patient out of bed. Sit outside with ... (Patient #1)." On 10/21/19 at 10:10 AM, Staff A, the RN, made a visit to Patient #1 at 10:10 AM. This "note" revealed the "facility nurse" informed the Hospice RN that the adult family member of Patient #1 was requesting that "A&D Ointment" be applied to the patient's ... (location) every shift to help prevent breakdown; documented the Hospice CNA was there earlier in the day and provided a bath; documented Patient #1 was evaluated by the "facility's wound doctor" earlier that day and that the Hospice RN would visit the patient after lunch to assess the patient's skin; upon return after lunch, Patient #1 was in their room with the adult family member and a visitor and documented, "Unable to assess at this time but CNA and nurse report no open areas when patient was checked today." During a telephone interview on 11/04/19 beginning at 1:15 PM, Staff A, the RN, explained that she completes a "head-to-toe assessment of the patients, specific to the care plan;" when asked if that assessment included the visualization of a patient's buttock and perineum (inner area between the thighs), the RN stated, "It depends on the patient;" further explained that if the patient needed the use of a Hoyer lift for transfers, she would speak with the "facility nurse" and if there weren't any wounds, she would not necessarily put the patient back to bed to complete an assessment; when asked specifically about Patient #1, Staff A explained Patient #1 was confused, but could answer questions with "yes or no" responses at times and would sometimes hold a limited conversation; when asked if she assessed (evaluated and monitored) the patient's buttock and perineum with each visit, the RN stated she did not. and explained Patient #1 would do their "own thing," was often outside and would refuse to go back to their room. Further review of the record lacked any evidence of documentation of Patient #1's refusal to be assessed.
L0671      
25404 Based on record review and interview, the Hospice failed to ensure a complete and accurate record for 1 of 3 sampled patients as evidenced by the Nursing Visit Notes with conflicting documentation and lacking a Certified Nursing Assistant (CNA) Visit Note (Patient #1). The findings included: Review of the record revealed Patient #1 was admitted to the Hospice for services on 03/04/19 for the provision of care to include Skilled Nursing and Aide services. Review of the "Nursing Visit Notes" and "Certified Nurse Assistant Notes," from 10/02/19 through 10/21/19 documented the following: On 10/02/19 at 1:05 PM, Staff A, a Registered Nurse (RN) made a visit to Patient #1 and documented an "area of pain" on the patient's ... (location), yet documented, "patient denies (pain) today." The RN further documented direct supervision of the CNA, yet no CNA visit was made on that day. On 10/09/19 at 9:00 AM, Staff A made a visit to Patient #1, documented an "area of pain" on the patient's ... (location), yet documented "patient denies (pain) today." The RN further documented direct supervision of the CNA, yet no CNA visit was made on that day. On 10/21/19, Staff A made two visits to Patient #1, one at 10:10 AM and another "after lunch; documented direct supervision of the CNA, yet the CNA visit was documented as being made at 8:42 AM. A side-by-side review of the record for Patient #1 and interview was conducted on 11/04/19 beginning at approximately 11:00 AM with the Compliance Nurse who agreed with the conflicting information and confirmed a direct supervision of the CNA would be when the nurse actually observed the CNA providing care. Review of the "Care Plan," for Patient #1 revealed the CNA was to make visits twice weekly. Review of the record lacked a second visit during the week of 09/15/19. On 11/04/19 at 1:44 PM, during an interview, the Compliance Nurse explained the regular CNA was "off" for part of that week and the visit was completed by a CNA from their "Inpatient Unit" and would have been completed on paper; the Compliance Nurse agreed the patient's record lacked evidence of documentation of that CNA's visit.