Bristol Hospice - Tucson

“It is required that each patient’s individualized written plan of care identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 3 of 19 (16%) clinical records reviewed, the agency did not ensure that the patient’s individualized written plan of care identified planned interventions based on problems identified in the initial and updated comprehensive assessments. Clinical Record 1: The patient elected the hospice benefit on 10/12/22 with a primary hospice diagnosis of Hypertensive Heart Disease with Heart Failure. Included in the patient’s secondary diagnosis was Obstructive Sleep Apnea, which was identified on admission. In a review of the clinical record for benefit period 6 (BP#6), dated 10/7/23 to 12/5/23, it was revealed that a Nurse Practitioner conducted a face-to-face visit on 11/17/23 and documented, “Is sleeping well most nights using CPAP (continuous positive airway pressure)” and on 11/17/23 a Registered Nurse (RN) conducted a recertification visit and documented, “He rarely uses his supplemental O2, he states he only uses it sometimes, but he does use his CPAP nightly”. The plan of care for BP #6, dated 10/7/23 to 12/5/23, did not include any problems, goals, or interventions to address the patient’s sleep apnea and use of CPAP. Clinical Record 2: The patient elected the hospice benefit on 10/10/23. In a review of the clinical record for benefit period 1 (BP#1) dated 10/10/23 to 1/7/24, it was revealed that the Registered Nurse (RN) conducted a comprehensive admission and documented in a circulatory assessment, “Pt has 2-3+ pitting edema in BLE’s. But rest is helpful if they are uncomfortable. Teaching is also done about elevating legs as high as tolerated to reduce swelling.” On 10/19/23, an RN conducted a skilled nursing visit and documented that Pt does have 2+ BLE pitting edema and agrees to elevate her legs.“ The clinical record included a medication order dated 10/19/23 for Lasix 20mg tablet 1 tablet daily for fluid retention. The plan of care for BP#1, dated 10/10/23 to 1/7/24, did not include any problems, goals, or interventions to address the patient’s edema. Clinical Record 3: The patient elected the hospice benefit on 11/15/23. In a review of the clinical record for benefit period 1 (BP#1) dated 11/15/23 to 2/12/24, it was revealed that a Registered Nurse (RN) conducted a comprehensive admission visit on 11/15/23 and documented in an addendum note dated 11/28/23 “Patient pain in the abdomen, mild to L side. Pain is anywhere from 2-10; at the visit, it was 5-7/10. She does use pain medications, which, at this time, are effective. She has the pains frequently throughout the day. They come and go. The pain can be from an ache to sharp pain. She usually takes pain meds and rests.” On 11/30/23 an RN conducted an on-call visit and documented, “Call received from floor nurse this am, reporting patient is having a lot of back pain is requesting a pain pill. Pt. states her back and the area around her hips is hurting, and she would like a pain pill. The RN asks if the patient has any good pain relief with pain meds, and she reports she doesn’t usually need them and doesn’t want anything too strong. The RN calls the physician, who agrees to order Tramadol 50mg twice a day.” The medication list included an order dated 11/30/23 to 12/2/23 for Tramadol 50mg tablet 1 tablet orally 2 times a day. The plan of care for BP#1, dated 11/15/23 to 2/12/24, did not include any problems, goals, or interventions to address the patient’s back pain. In an interview conducted on 12/6/23 with the Director of Patient Care Services (DCPS), it was confirmed that in record 1, the plan of care did not include any problems, goals, or interventions to address the patient’s sleep apnea and use of CPAP, that in record 2, the plan of care did not include any problems goals or interventions to address the patient’s edema and that in record three the plan of care did not include any problems goals or interventions to address the patient’s back pain.”

“It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene. This standard was not met as evidenced by document review, interview and observation. In 2 of 4 (50%) home visits observed, the agency did not ensure that the staff members used standard precautions such as hand hygiene that followed accepted standards of practice and agency policy. Document 1: Hand Hygiene Policy No. 7-009: The agency’s policy titled Hand Hygiene, dated May 2020, stated in relevant parts; “Policy: when hands are not visibly soiled, they should be washed using an alcohol-based hand rub for routinely decontaminating hands.” “Procedure: 3. Hand decontamination using an alcohol-based hand rub should be performed: D: After contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressings if hands are not visibly soiled. E. When moving from a contaminated body site to a clean body site during patient care. G. After removing gloves.” Home Visit 2: A home visit observation was conducted with staff #6, a Registered Nurse (RN) on 12/6/23. The RN was observed twice during wound care to doff their gloves and don new gloves without first performing hand hygiene. Once after removing soiled dressings and once before accessing clean supplies. Home Visit 4: A home visit observation was conducted with staff #7, a hospice aide, on 12/7/23. The hospice aide was observed providing a shower to the patient. During the shower, the hospice aide was observed twice doffing their gloves and donning new gloves without first performing hand hygiene. The hospice aide was also observed providing perineal care and completing the shower, including rinsing the patient’s upper body, drying the patient, and dressing the patient without first performing hand hygiene. In interviews conducted on 12/6/23 and 12/7/23 with the Director of Patient Care Services, they verified that staff 6 and 7 did not follow standard precautions and established agency policy for hand hygiene.”