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
231661 A. BUILDING __________
B. WING ______________ 		06/13/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
INTERIM HEALTHCARE OF WEST MICHIGAN 1971 EAST BELTLINE AVENUE, NE, GRAND RAPIDS, MI, 49525
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)
L0591      
37411 Based on record review and interview, it was determined that the hospice failed to ensure that skilled nursing coordinated and implemented the plan of care to meet the patient's continuous needs in 1 of 3 records reviewed (MR# 1) resulting in the potential for poor patient outcomes for all hospice patients. Findings include: **Agency policy "Chapter 6 - Care Delivery: Nursing Services" (6/21/13) stated, "2. A hospice RN (Registered Nurse) performs the initial and comprehensive assessment, as well as ongoing assessments of the patient's physical status and the psychosocial status of the patient/family. 3. A hospice RN is designated to provide coordination of care and to ensure the continuous assessment of each patient's/family's needs, as well as the implementation of the IDG (Interdisciplinary Group Services) plan of care to guide the delivery of services and achieve the goals of hospice care." MR#1: The Start of Care (SOC) was dated 1/5/22. The Plan of Care (POC) identified terminal diagnoses of Nutritional Deficiency, Major Depressive Disorder and Other Symptoms and Signs Involving Cognitive Functions and Awareness. During record review on 6/13/22, the patients wound was noted on the "RN Initial Assessment" dated 1/5/22 as "Location: Coccyx ...Odor: Foul ...Treatment: No treatment initiated prior to Hospice admission - cleaned with wound cleanser, patted dry and applied Optifoam per VO (Verbal Order) from NP#1 ...Wound Pain: 3." The following Skilled Nursing (SN) visit dated 1/7/22, documented the wound as "Location: Coccyx ...Odor: not assessed this visit. Treatment: Per POC by staff prior to SN visit ...Wound Pain: None." Additionally, on 1/7/22 a "Physicians Order" was written that stated, "SN/CG (Care Giver) to perform wound care to coccyx 3x/week and PRN (as needed) for soiling/deadhesion of dressing if dressing present.... Problems: Skin. Problem name: Risk for skin breakdown. Interventions: Assess for changes in skin integrity. Educate and/or assess for signs and/or symptoms of infection..." On 1/8/22, the SN documented the patients wound as "...Odor: Foul...Treatment: Dressing dry and intact this visit - ALF (assisted living facility) staff changed prior to SN visit". On the following SN visit dated 1/10/22, the wound was documented as "...Odor: Foul. Treatment: Per POC..." Additionally, the SN documented under "Assessment/Instruction/Performance...a foul odor coming from pressure ulcer was noted but odor resolved some after cleansing wound. Conferenced with RN#2 and NP#1 regarding wound and concerns for the foul smell. We will reevaluate on Wednesday's (1/12/22) visit..." Furthermore, a "Plan of Care Order" dated 1/10/22 stated, "...Problems: Name: Pressure ulcer to buttocks. Description: Pressure ulcer to buttocks. Goal: ....Wound(s) will remain free of infection ..." On 1/12/22, the following SN visit, the wound was documented as " ...Odor: Foul. Treatment: Per POC..." Additionally, the SN documented under "Assessment/Instruction/Performance ...When viewing the wound, we determined a new POC which has been updated. RN#2 conferenced with NP#1 regarding the need for flagyl x3 a sprinkled to wound bed NP#1 reports she will look into the treatment and notify with further orders. Patient denies any pain, but if you watch patient for any period of time he is constantly noted moving back and forth and trying to lift buttocks off the bed. We discussed me talking with his wife about scheduling pain meds and he was on board with plan." On 1/14/22, the following SN visit, the wound was documented as "...Odor: Foul. Treatment: Per POC. Patient Response to Treatment: Patient denies pain but cried out and yelled with intervention. Morphine given..." Furthermore, the SN documented under "Assessment/Instruction/Performance...cleansed and changed his coccyx wound dressing per POC but patient was crying out and very painful with intervention despite saying he didn't have any pain. I educated patient on pain meds available and encouraged him to be honest with staff when he is painful, so pain is better controlled. Med Tech administered morphine per my request for patients' painful response with dressing change and reposition." Following the SN visit, a "Physician Order" was completed by RN#1 stating, "Orders:...Flagyl Oral Tablet 250 MG... Instructions: Skilled nursing to sprinkle crushed medicine to coccyx wound bed 3x/week with dressing change..." The following SN visit was on 1/17/22 after the patient had passed. The agency failed to timely address the POC goals to meet the patient's needs, which could have potential negative outcomes.