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
671622 A. BUILDING __________
B. WING ______________ 		01/23/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
HOSPICE SELECT 8330 LYNDON B JOHNSON FWY SUITE B290, DALLAS, TX, 75243
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      
36748 Based on record review and interview, the agency Supervising Nurse (Employee C) failed to ensure the Plan of Care (POC) was executed as written in 1 of 1 patient records reviewed. Citing Patient #1. The skilled nurse failed to follow the POC by not assessing and monitoring the patient's skin integrity on each Skilled Nursing visit. The failure of the Supervising Nurse to ensure the staff followed the plan of care placed Patient #1 at risk of harm from insufficient care and services. Findings Agency policy titled "RESPONSIBILITIES OF THE SUPERVISING NURSE, revised date 01018" , read in part, "...POLICY The Supervising Nurse...is responsible for the daily direction of patient care and participates in activities relevant to professional services furnished...PROCEDURE I. The responsibilities of the Supervising Nurse include, but are not limited to:...C. Ensuring that a patient's plan of care is executed as written..." Review of the agency's complaint binder revealed a complaint investigation regarding the lack of skin assessments for Patient #1. Upon review of this complaint a document titled "PATIENT/FAMILY COMPLAINT INVESTIGATION." This document was dated 12/9/2019. Review of this document read, in part, "...Circumstances of Complaint Family called and reported no follow up on skin care issues...Investigation and Action Taken Spoke with RN CM (Registered Nurse/Case Manager) and reviewed charting from nurses. No skin assessments documented on 3 different visits. Instructed to all nursing staff that weekly skin assessments have to be completed and documented..." This document was signed by Employee C and dated 12/9/2019. Further review of the complaint investigation revealed a document titled "OCCURRENCE REPORT." Review of this document read, in part, "... Describe Occurrence Family called and reported that patient's genitalia wasn't checked during a nurse visit on 11/23/19 from the male nurse. Patient was sent to hospital on 12/5/19 due to increased blood sugar. Pt. now has stage IV decubs on his body is what the hospital reported..." Review of the "Textbook of Palliative Nursing" Edited by Betty R. Ferrell and Nessa Coyle, reveals Chapter 16 A titled "Skin Disorders: Pressure Ulcers Assessment and Management." Page 303 reads, in part, "...Risk Factors for Pressure Ulcers Pressure ulcers are physical evidence of multiple causative influences. Factors that contribute to pressure ulcer development can be thought of as those that affect the pressure force over the bony prominence and those that affect the tolerance of the tissues to pressure. Mobility, sensory loss, and activity level are related to the concept of increasing pressure. Extrinsic factors including shear, friction, and moisture, as well as intrinsic factors such as nutrition, age, and arteriolar pressure, relate to the concept of tissue tolerance. Several additional areas may influence pressure ulcer development, including emotional stress, temperature, smoking, and interstitial fluid flow... Immobility, inactivity, and decreased sensory perception affect the duration and intensity of the pressure..." Record Review: Patient #1 The clinical record contained an initial Plan of Care (POC) with a start of care date 3/22/2019. The POC contained orders for the nurse. The order read "Nurse to evaluate/monitor/assess need: 1X wkly (one time per week)." Further review of the clinical record revealed documents titled "IDG (Interdisciplinary Group) Comprehensive Assessment Details." Four of these documents were dated 9/4/2019, 11/13/2019, 11/20/2019 and 12/4/2019. On all four documents it read, in part, "...Additional Comprehensive Assessment Comments Pt (Patient) is at increased risk for falls, infections, skin breakdown, and malnutrition..." Further review of the clinical record revealed documentation of skilled nursing visits on 11/23/2019, and 11/26/2019. Nowhere on these visits is there any documentation of any skin integrity assessments. An interview was conducted with Employee C on 1/22/2020 at approximately 12:15 PM. The surveyor asked Employee C why the nurses failed to assess Patient #1's skin integrity. Employee C stated that when she found out that they had not been assessing the skin she inserviced all of the staff on the importance of skin assessments.