Beacon of Hope Hospice

“Upon patient record review, 6 of 14 (Patients #1, 3, 4, 5, 6, and 8) 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. This review includes, but is not limited to: Patient #1: Patient had oxygen in the home which was not included on the medication profile. Patient #3: Patient had oxygen in the home which was not included on the medication profile. Patient #4: Metronidazole was ordered for wound care but did not include the location to apply medication on the medication profile. Patient #5: Patient has the following medications on the medication profile: Acetaminophen 650mg suppository every 6 hours as needed; Acetaminophen 500mg tablets, 1-2 tablets every 6 hours as needed; and Hydrocodone/Acetaminophen 5/325mg 1 tablet every 4 hours as needed. None of these acetaminophen entries indicate not to exceed maximum dose of 4000 mg daily. Patient #6: Patient has order for Triple Antibiotic Cream to be applied to stage 2 skin tear. This medication is not on medication profile. Patient #8: Patient has order for Miralax on medication profile but does not include directions for reconstitution.”

“Upon patient record review, 3 of 14 (Patients #3, 6, and 8) did not have evidence that a Registered Nurse was designated to ensure continuous assessment of the patient and family’s needs, and to coordinate activities with other members of the interdisciplinary group (IDG): Patient #3: Received a prn visit on 08/31/24. During the visit the patient reported pain at 10/10 and had a foley catheter that was not draining. Foley was replaced by nurse and Tylenol was administered for pain. There was no follow up phone call or visit to evaluate patient status until a routine scheduled nursing visit on 09/04/24. Patient #6: Received a prn visit on 8/28/24 for c/o painful urination. RN did urine dipstick which showed UTI. Orders received to start antibiotic. On 8/29/24 a call was received from facility staff stating patient had a choking episode and they requested thick-it. An RN supply drop visit was made to deliver thick-it. There was no further follow up phone calls or visits to evaluate the patient status, painful urination, response to antibiotic, or if there were further choking episodes until 9/05/24. Patient #8: Received a prn visit on 08/09/24 after call from patient’s spouse stating that patient catheter was not draining. Visit was made and catheter was replaced. On 8/10/24 spouse called stating catheter replacement from 08/09/24 had not been effective and patient developed level 10/10 pain. Spouse states after 2 hours of reported pain level of 10/10, she removed the indwelling catheter and attempted straight catheterization, as that was the treatment plan prior to the indwelling catheter, with no success. RN visit was made and new indwelling catheter was placed with 1000 ml return of urine and patient pain returned to 0/10. There was no follow up phone call or visit to evaluate patient status with catheter and pain until routine visit scheduled 08/13/24.”

“Upon patient record review, 2 of 14 (Patient #9, 10) 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 #9: Patient utilizes a nebulizer. Respiratory/nebulizer use is not included in nursing for problems/goals/interventions on the plan of care. Patient #10: Patient utilizes a nebulizer. Respiratory/nebulizer use is not included in nursing for problems/goals/interventions on the plan of care.”

“Upon patient record review, 4 of 14 (Patients #1, 3, 5, 6) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments: Patient #1: Patient had oxygen in the home. There was no order for oxygen in the medical record. Patient #3: Patient had oxygen in the home. There was no order for oxygen in the medical record. Patient #5: Patient has 2 separate orders for Morphine on medication profile. First order reads Morphine 10mg/0.5ml, 1ml every 3 hours prn pain/shortness of breath. The second order reads “Morphine 20mg/ml, 0.25mg every hour as needed for mild pain/shortness of breath 0.5mg moderate pain shortness of breath 0.75mg severe pain shortness of breath.” This is also unclear as to which order to use under specific circumstances. Patient #6: Wound care order reads, “Stage 2 skin tear to R lower distal leg calf, clean with wound cleanser, pat dry, apply triple antibiotic ointment, cover with non adherent dressing every 3 days or prn.” This order does not specify who is to change the dressing outside RN scheduled visits. This order also does not specify an indication for the prn dressing changes.”

“Upon patient record review, 2 of 14 (Patient #1, 3) did not have evidence that the plan of care included all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs: Patient #1: Patient has an indwelling foley catheter. However, catheter supplies were not included on the plan of care. Patient had oxygen equipment in the home which was not included on the plan of care. Patient #3: Patient had oxygen equipment in the home which was not included on the plan of care”

“Upon patient record review, 1 of 14 (Patient #4) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • There is evidence in the patient record that the plan of care indicates what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable: Patient #4: Current aide plan of care assigns the following task: “May file (patient name) long or uneven fingernails at each on 1st first of every week.” A task, whether for personal care or non-personal care needs to be specific without leaving the task to the discretion of the aide.”

“Upon patient record review 3 of 14 (Patients #2, 5, and 9) did not have documented evidence in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care Patient #2: The aide plan of care assigned “Skin care after shower. Apply lotion”. Showers were assigned for the first and third visits of each week, however, skin care/application of lotion was performed on second visits of the week when showers were not performed. Patient #5: The aide plan of care states aide will change linens first visit of each week. Visit on Monday, 9/2/24 was a missed visit, therefore, first visit of week was completed on Wednesday, 9/4/24 and linens were not changed per plan of care. Patient #9: The aide plan of care states change linens each visit. On 08/20/24, 09/03/24, the aide documented that they were unable to document and that this task was not applicable to this visit. On 08/23/24, the aide documented that linen change was refused by patient. The aide plan of care states electric razor to be used each visit to shave patient. On 09/06/24, the aide documented unable to document, not applicable to visit.”

“Upon patient record review 1 of 14 (Patient #13) did not have evidence documented in the patient record that a Registered Nurse made an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient’s needs: Patient #13: This patient received an RN visit with aide supervision on 01/17/2024. There was no further aide supervision up to and including date of death on 02/06/24.”

“Upon patient client record review, 1 of 14 (Patients #4) did not have evidence that all entries were legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice: Patient #4: On multiple aide visits, aide documents that the patient is signing to authenticate the visit date and time. This patient is alert and oriented only to person, is in a facility, and has an active DPOA. Administrator reports that the agency expectations would be that the aide have facility staff sign for authentication of these visits.”