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
111754 A. BUILDING __________
B. WING ______________ 		01/06/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
MAGNOLIA HOSPICE 1374 MANCHESTER DRIVE NE, CONYERS, GA, 30012
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)
L0545      
38989 Hospice must develop an individualized plan of care (POC) for each patient. The POC must reflect patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessment. The POC must include all services necessary for the palliation and management of the terminal illness and related conditions. Based on review of clinical records and staff interview the facility failed to meet the regulation. Findings: 1. Review of the clinical record for P # 2 revealed patient was admitted to hospice on 9/15/2019 with a terminal diagnosis of malignant neoplasm of the colon. Review of the clinical record revealed no documentation of a wound on admission. Documentation in the nurse's notes revealed a catheter was intact at the right abdomen. No documentation related to the purpose of the catheter, catheter care, or dressing noted in plan of care. A Braden skin assessment, an assessment to identify the risks of developing pressure ulcers/decutus, was documented on 9/15/2019. Braden scores range from 23 to 6, 23 being low risk and 6 being high risk. On admission P # 2 had a Braden skin assessment improperly completed with a score of 3. Further review of the clinical record revealed a sacral wound on 9/23/2019. P # 2 was transferred to another facility on 9/25/2019. 2. Review of the clinical record for P # 6 revealed. patient was admitted to the hospice on 10/24/2019 with a terminal diagnosis of malignant neoplasm of bronchus. Braden Skin Assessment was completed on admission with a score 19. On admission the skin assessment revealed no wounds. On 12/9/2019 the certified nursing assistant notified the QAPI nurse of an area of concern on right lateral heel. The QAPI nurse documented a deep tissue injury on right lateral heel. The physician was notified on 12/9/2019 with orders for the treatment of the deep tissue injury (DTI). Orders included paint wound to the right lateral heel w/skin prep, cover with foam dressing, secure with tape, and change every 3 days or as needed and floating heels or sheep skin under feet. 3. Interview on 1/6/2019 at 2:30 p.m. with the facility administrator and the QAPI nurse revealed that the reddened area was observed on 12/9/2019. The administrator and the QAPI nurse stated that the facility created a wound treatment book in December, 2019. The QAPI nurse stated the agency did not have a skin assessment policy. A policy was created on 1/6/2020. The administrator and the QAPI nurse stated that they would have 100% of all staff inserviced on the new policy by the end of January.
L0587      
38989 Based on clinical review, it was determined that the hospice failed to ensure that nursing services were sufficient to meet the wound care needs of 1 of 1 patient. Additionally, it was determined that the hospice failed to ensure that the skilled nurse's reflected documentation that clearly described the wound.
L0591      
38989 The hospice failed to ensure that the nursing needs of the patient are met as identified in the patient's initial assessment, comprehensive assessment, and updated assessments on two of six clinical records ( P #2 and P #6 ) reviewed. P # 2 and P # 6 developed pressure areas after admission to the hospice facility. Findings: 1. Review of the clinical record for P # 2 revealed patient was admitted to hospice on 9/15/2019 with a terminal diagnosis of malignant neoplasm of the colon. Review of the clinical record revealed no documentation of a wound on admission. Documentation in the nurse's notes revealed a catheter was intact at the right abdomen. No documentation related to the purpose of the catheter, catheter care, or dressing noted in plan of care. A Braden skin assessment, an assessment to identify the risks of developing pressure ulcers/decubitus, was documented on 9/15/2019. Braden scores range from 23 to 6, 23 being low risk and 6 being high risk. On admission P # 2 had a Braden skin assessment improperly completed with a score of 3. Further review of the clinical record revealed a sacral wound on 9/23/2019. P # 2 was transferred to another facility on 9/25/2019. 2. Review of the clinical record for P # 6 revealed. patient was admitted to the hospice on 10/24/2019 with a terminal diagnosis of malignant neoplasm of bronchus. Braden Skin Assessment was completed on admission with a score 19. On admission the skin assessment revealed no wounds. On 12/9/2019 the certified nursing assistant notified the QAPI nurse of an area of concern on right lateral heel. The QAPI nurse documented a deep tissue injury on right lateral heel. The physician was notified on 12/9/2019 with orders for the treatment of the deep tissue injury (DTI). Orders included paint wound to the right lateral heel with skin prep, cover with foam dressing, secure with tape, and change every 3 days or as needed, and floating heels or sheep skin under feet. 3. Interview with the Licensed Practical Nurse (LPN) caring for P # 6 revealed the patient is bedbound and is alert and oriented. The nurse stated that at times P# 6 would not keep her feet on a pillow. The nurse stated this would be documented on the treatment sheet for P # 6 in the treatment book. Review of the treatment book revealed inconsistent documentation of the heels being floated and the refusal of the patient to float her heels as ordered by the physician.