Southerncare New Beacon - Jasper

“Upon patient record review, 4 of 19 (Patient #1, #2, #5, #9) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. Patient #1-On 10/17/23 a comfort call was placed to the patient and the writer documents the patient states Ativan is helping with sleep. Ativan is not listed on the medication profile. On 10/26/23 the nurse documents in IDG the patient had recently been treated with an antibiotic for cellulitis. An antibiotic is not listed as an active or discontinued medication on the medication profile. (corrected on site) Patient #2- On 11/08/23 the nurse documents the patient has prn Oxygen orders for dyspnea. Oxygen is not listed on the medication profile. (corrected on site) Patient #5-The medication profile includes the following medications ordered as needed for pain without differentiation/parameters for administration: Alleve 220 mg 1 -2 capsules q4h prn pain; Hydrocodone 5 mg-Acetaminophen 325 mg tab 1 tab q6h prn pain; Morphine 20 mg/ml .25-.5 ml po q4h prn pain and Tylenol Extra Strength 500 mg 1 tab q6h prn pain. (corrected on site) Patient #9-The medication profile includes Mecobalamin (vitamin B12) 10,000mcg solution, 1000mcg subQ monthly. Upon interview this is an error as the patient is not on this medication. (corrected on site)”

“Upon patient record review, 2 of 19 (Patient #1, #3) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #1- On 09/28/23 the nurse documents the patient has sacral redness. On 10/23/23 the nurse documents the patient has a rash groin and on 11/06/23 documentation includes cellulitis to the right arm. The plan of care does not include goals/interventions for altered skin integrity. (corrected on site) Patient #3-The 09/23/23 plan of care includes goals and interventions which are not applicable to the patient regarding ventilator management and actions to take in a hemorrhagic event. The patient is not on a ventilator. The record does not include medications or assessments to indicate patient is at risk for a hemorrhagic event. (corrected on site)”

“Upon patient record review, 7 of 19 (Patient #1, #2, #3, #5, #6, #9, #11) did not have evidence the plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions, including specific orders for all medications and treatments. Patient #1-On 10/17/23 a comfort call was placed to the patient and the writer documents the patient states Ativan is helping with sleep. Ativan is not listed on the plan of care. On 10/26/23 the nurse documents in IDG the patient had recently been treated with an antibiotic for cellulitis. The plan of care does not include orders for an antibiotic. (corrected on site) Patient #2- On 11/08/23 the nurse documents the patient has prn Oxygen orders for dyspnea. Oxygen is not ordered on the plan of care. (corrected on site) Patient #3-Orders received 09/25/23 to update the plan of care read: Cleanse wound with VASHE, Pat dry with 4x4. Apply Xeroform and wrap with gauze. Change daily. The orders do not include the wound location(s). (corrected on site) Patient #5-The 11/07/23 plan of care includes the following medications ordered as needed for pain without differentiation/parameters for administration: Alleve 220 mg 1 -2 capsules q4h prn pain; Hydrocodone 5 mg-Acetaminophen 325 mg tab 1 tab q6h prn pain; Morphine 20 mg/ml .25-.5 ml po q4h prn pain and Tylenol Extra Strength 500 mg 1 tab q6h prn pain. (corrected on site) Patient #6-The plan of care includes orders for the Hospice nurse or Facility nurse to perform pulse oximetry prn dyspnea. The patient does not reside in a facility. (corrected on site) Patient #9-The 09/17/23 plan of care includes Mecobalamin (vitamin B12) 10,000mcg solution, 1000mcg subQ monthly. Upon interview this is an error as patient was not on the injection at the time of admission. (corrected on site) Patient #11-The patient was admitted 08/17/23 with a cast to the left arm. The plan of care does not address management of the cast.”

“Upon patient record review, 2 of 19 (Patient #2, #7) did not have evidence the plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient #2-The 11/09/23 IDG indicates the patient has a 02 concentrator and hospital bed. The plan of care does not include a hospital bed or Oxygen as part of the equipment. (corrected on site) Patient #7-The 10/03/23 IDG indicates the patient has a 02 concentrator, hospital bed, CPAP machine, and overbed table. The plan of care does not include the equipment. (corrected on site)”

“Upon patient record review, 3 of 19 (Patient #2, #3, #6) did not have evidence that a revised plan of care includes information from the patient’s updated comprehensive assessment and must note the patient’s progress towards outcome/goals from the plan of care. Patient #2-The revised plan of care/IDG documentation 09/28/23, 10/11/23, and 10/25/23 do not address the nursing progress towards outcome/goals from the plan of care. Each of the updates from the nurse only documents no significant change in the past 2 weeks. Patient #3- The Social worker visited the patient and developed a plan of care on 09/27/23. On 10/04/23 the revised plan of care/IDG documentation states the social worker has not seen the patient yet. The 10/18/23 IDG documentation only states the patient was not seen in the past 2 weeks. The initial assessment findings and goals/expected outcomes were not documented. Patient #6-The Chaplain visited the patient and developed a plan of care on 08/14/23 to visit the patient 1m1 2m2. The 08/23/23 revised plan of care/IDG documentation did not document the Chaplain findings from the initial comprehensive assessment. The Chaplain documented the patient declined in the IDG notes.”

“Upon patient record review, 4 of 19 (Patient #1, #7, #8, #9) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1-On 09/28/23 the nurse documents the patient has redness on the sacrum and Mepilex was applied. There are no orders on record for Mepilex. Patient #7-On 09/21/23 orders were received for the patient to receive Oxygen at 3 liters per minute continuously. The record also includes orders for the nurse to assess the appropriateness of the patients Oxygen. On 10/25/23 and 11/01/23 the nurse documented the patient is utilizing Oxygen at 4 lpm. Patient #8-On 08/23/23 the social worker was ordered to visit 1q2m2 (once every 2 months). The Social Worker visited monthly on 08/25, 09/11 and 10/06/23. Patient #9-On 09/17/23 the social worker is ordered to visit 1q2m2 (once every 2 months). The Social Worker visited monthly on 09/19 and 10/11/23”

“Upon patient record review 2 of 19 (Patient #1 and #6) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Patient #1-The patient’s history and physical, plan of care dated 08/21/23 and medication profile document the patient is allergic to Acetaminophen/Hydrocodone(Norco) and Tramadol. The medications result in itching. On 09/09/23 the patient was ordered Tramadol for pain. On 10/11/23 the patient was ordered Hydrocodone-Acetaminophen for pain. There is no documentation to indicate when the nurse reported the patients pain and received the medication orders that Allergies were identified and the physician was made aware that the patient had allergies to the prescribed medications. (late entry clarification/correction on site) Patient #6-The patients plan of care 08/10/23 and medication profile document the patient is allergic to Morphine which causes hallucinations. On 08/22/23 the nurse documented the patient has a hard area to the left side of the neck. The finding was reported to the physician and Morphine was prescribed. There is no documentation to indicate the nurse identified or discussed the the patients Allergy with the physician. (late entry clarification/correction on site)”

“Upon patient record review, 3 of 19 (Patient #1, #3, #10) did not have evidence in the patient record that hospice aide assignments and duties are: • Complete written patient care instructions prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76. Patient #1-The Aide care plan does not include Aspiration Precautions which were applicable to the patients plan of care. (corrected on site) Patient #3-The Aide care plan does not include Fall Precautions which were applicable to the patients plan of care. (corrected on site) Patient #10-The Aide care plan does not include aspirations precautions, fall precautions, skin breakdown precautions, R BKA or sacral wound dressing to be left in place which are applicable to the plan of care.”

“Upon patient record review, 2 of 19 (Patient #2, #7) did not evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group and included in the plan of care. Patient #2- On 09/17/23 the Aide was ordered to visit twice weekly. Visits were performed five times weekly between 09/18/23-09/22/23 and 09/24/23-09/29/23. The Aide is assigned to perform a shave and shampoo weekly. The Aide documented performing a shave and shampoo on all visits between 09/17/23 and 09/29/23. Patient #7-The Aide is ordered to visit the patient twice weekly. The week of 10/15/23-10/21/23 the Aide visited once on 10/18. On 10/19 a missed visit is documented as “could not find home”. There is no documentation the Aide coordinated with the other team members to re-attempt a visit during the week. (late entry correction on site)”

“Upon patient record review, 3 of 19 (Patient #1, #2, #4) did not have evidence that all entries are clear, accurate and complete. Patient #1- On 10/25/23 the Social Worker documented the patient has DNR and FA. FA is not an agency approved abbreviation. Patient #2- The MD narrative on the 09/16/23 CTI documents patient on service because of a “pad a sailor” (unclear) carcinoma has mets to the lungs. (corrected on site) Patient #4- On 08/11/23 the nurse documents the patient takes Lasix and HCTZ for edema. HCTZ is not included in the plan of care. Upon interview, HCTZ was a documentation error as the patient was never prescribed HCTZ. (late entry clarification/correction on site)”