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
741664 A. BUILDING __________
B. WING ______________ 		01/27/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
CIMA HOSPICE 4444 CORONA DR STE 234, CORPUS CHRISTI, TX, 78411
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      
36596 Based on clinical record review and interview the agency failed to ensure the patient's clinical record contained correct clinical information for 1 of 1 discharged patient record (#1) that was reviewed in that: The Hospice Skilled Nurse (HSN) incorrectly documented the location of an open wound. This failure has the potential to place Client #1 and the agency's Hospice's patients at risk of harm due to inaccurate or missing clinical information. The Findings Included: Review of discharged Patient #1's clinical record included an agency form entitled "Physician's Certification Of Terminal Illness, Hospice, Medicare/Medicaid Benefit" that revealed the certification date as 11/02/21 thru 01/30/22. His admitting terminal diagnosis were Unspecified severe protein-calorie malnutrition, Acquired Absence of Left Leg Below the Knee (BKA- Below the Knee Amputation) and encounter for change or removal of nonsurgical wound dressing / Pressure ulcer of other site stage 2. Review of discharged Patient #1's clinical record revealed Patient #1's Initial Assessment. It was dated 11/02/21 and was signed by RN B. Patient #1's clinical record included another agency form titled "Interdisciplinary Group/Update to The Comprehensive Assessment and Plan Of Care dated 12/01/21 that revealed a SN and visit frequency as three times a week. The form also contained a Physician order that Patient # 1 was to receive wound care to his Lower Right Medial Foot Wound as follows: Right Medial Foot and Right Heal. Cleanse with wound cleanser and gauze, pat dry with gauze, apply small amount of medihoney to wound base, cover with ABD pads and secure with Kerlix and tape." Patient #1's clinical record included three more agency form titled "Interdisciplinary Group/Update To The Comprehensive Assessment and Plan Of Care that were dated 12/16/21, 12/30/21 and 01/12/22 The forms all contained a Physician order for SN frequency to continue at three times per week and a Physicians order for Patient # 1 to receive wound care to his Lower Right Medial Foot Wound as follows: Right Medial Foot and Right Heal. Cleanse with wound cleanser and gauze, pat dry with gauze, apply small amount of medihoney to wound base, cover with ABD pads and secure with Kerlix and tape." Review of discharged Patient #1's clinical record revealed, Client #1's discharge summary. It was dated 01/15/22 and was signed by RN D. It revealed that the reason for discharge was that Patient #1's family member was seeking aggressive treatment for wound care/infection of his Right Medial Foot Wound. Review of discharged Patient #1's clinical record revealed a Patient #1's Initial Assessment. It was dated 11/02/21 and was signed by RN B. It also revealed that the reason for discharge was that Patient #1's family member was seeking aggressive treatment for wound care/infection of his Lower Right Medial Foot Wound. Review of the SN visits revealed that the frequency was being followed. 35 SN visits were documented. Review of 34 of the 35 SN visits revealed that wound care was done on Patient #1's Lower Right Medial Foot. Review of the SN visit note dated 01/13/22 and signed by RN C read in part: "Wound care to Right Medial Foot Wound completed, odor noted, cleared with cleansing wound. Wound is forming black eschar to 75% of wound, 25% muscle is visible, with s/s of infection. Coordination of care done with Medical Director and Clinical Manager (DON)." Review of the SN visit note dated 01/14/22 and signed by RN D read in part: "Wound care to Right Medial Foot completed at this time. Patient #1 tolerated wound care well. Eschar covering majority of Right Medial wound, serosanguinous drainage noted to foot. Edema noted to Right Lower Leg. Antibiotic to be started..." Review of the SN visit note dated 01/15/22 and signed by RN A read in part: "Foul smelling [sic] to Left Lower Extremity wound (Medial Foot Wound) and soiled wound dressing noted. Wound care preformed..." Note: Patient #1 has a Terminal diagnosis of Acquired Absence of Left Leg Below the Knee (BKA- Below the Knee Amputation). Further review of the SN visit note dated 01/15/22 and signed by RN A read in part: "Performed wound care as follows: Right Medial Foot. Cleanse with wound cleanser and gauze, pat dry with gauze, apply small amount of medihoney to wound base, cover with ABD pads and secure with Kerlix and tape..." During interview on 01/27/22 at 10:29 a.m. the Surveyor reviewed with the Adm Patient #1's entire clinical record, with special deference to the SN visit note dated 01/15/22. After reviewing the DON agreed with the following: - Patient #1's clinical record did not contain correct clinical information on the SN visit note date 01/15/22. Review of the Agency's Policy and Procedure Manual revealed s policy titled "Clinical Records", it was numbered PC.C15 but was not dated. It read it part: "A clinical record is established and maintained for every patient receiving care and services...The record is complete, promptly and accurately documented..."