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
341562 A. BUILDING __________
B. WING ______________ 		11/22/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
CAPE FEAR VALLEY HOSPICE AND PALLIATIVE CARE 2301 ROBESON STREET SUITE 202, FAYETTEVILLE, NC, 28305
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)
L0671      
44098 Based on policy review, clinical record review, and staff interview, the allegation that the agency omitted documentation of a wound in the clinical record for 1 of 3 records reviewed is substantiated (Patient #1). Findings included: Policy Number 2.002 Initial & Comprehensive Admission Assessment & Plan of Care effective 07/12/96 and last revised on 03/01/21 was received from Employee #1, the agency director, on 11/22/21 at 11:56 AM. This policy revealed, "The purpose of the initial assessment visit will be to evaluate the patient's physical, psychosocial, and emotional states related to the terminal illness and related conditions and to determine the patient's immediate care and support needs" and "The initial assessment performed by the RN (registered nurse) ...will include assessment of ...Integumentary (skin) system ..." Policy Number 3.029 Wound Assessment, Documentation and Photography effective 12/31/08 and last revised 03/01/21 was received from Employee #1, the agency director, on 11/22/21 at 11:56 AM. This policy revealed, "Upon initial visit and subsequently as applicable, all wounds will be assessed with appropriate documentation within the medical record." Patient #1 was admitted to the agency on 11/20/20 with a principle hospice diagnosis of emphysema (a type of chronic lung disease). Plan of Care of certification period 11/20/20 to 02/17/21 revealed orders for skilled nursing services 2 times per week for 1 week. Clinical record review revealed a skilled nursing visit note report of 11/20/20 which revealed an integumentary (skin) assessment documented as, "bruising ...poor turgor" and a wound assessment that identified a right buttock wound. A handwritten admission SBARR (acronym for situation, background, assessment, recommendations, response) scanned document dated 11/20/20 revealed, "nose 2.3 x 2.1 cm (centimeters) unstageable (a wound that has full thickness tissue loss where the base of the wound is not visible))" There is no evidence of documentation regarding a nasal wound in the clinical record from the 11/20/20 admission visit. In an interview on 11/22/21 at approximately 3:00 PM, Employee #1, the agency director, stated that the Admission SBARR document is one that the admitting nurse completes as an aid to give report regarding newly admitted patients. Employee #1 stated that this document is not intended to be part of the patient's clinical record. In an interview on 11/22/21 at approximately 3:20 PM, Employee #2, the admitting registered nurse, was unable to explain why she documented a nose wound as "unstageable" on the Admission SBARR document and stated, "I had to think real deep to remember the patient because I do so many admissions. If there was an opening, I would have put open, but it was closed ...there was no open area on her nose." When questioned about the buttock wound, Employee #2 stated, "That one I do not recall at all." In a follow up interview on 11/22/21 at approximately 3:50 PM, Employee #1 agreed that it would be unlikely for a nurse to write the word "unstageable" in notes to describe an area with closed skin.