Sutter Auburn Faith VNA & Hospice-Hospice

“Observed in Record Review. In 7 of 14 patient records reviewed, it was noted that an initial bereavement assessment was not completed. For example in HOSRRHV#2 the ‘initial bereavement assessment’ was documented by the MSW on day 25 of care and in HOSRRNHV#10 it was documented on day 33 of care. In HOSRRHV#4 and HOSRRNHV#1 there was no initial bereavement assessment documented. In HOSRRNHV#6 the initial Bereavement assessment was documented on day 58, HOSRRNHV#5 it was documented on day 77 and HOSRRNHV#4 it was documented on day 24. This was confirmed with the Clinical Manager and Case Manager present.”

“Observed in Record Review. In 10 of 14 patient records reviewed, the written plan of care was not based on the patient’s goals and the time frames, setting and services required to meet the goals. For example, in HOSRRHV#2 the record included documentation of visits by the spiritual counselor and volunteer however there was no documented POC for these disciplines, no goals and no interventions. Also in the same record the patient had a foley catheter and there was no documentation of urinary or catheter related goals and interventions. In records HOSRRNHV#2, HOSRRHV#3 and #4 the spiritual counselor was seeing the patient, but there was no POC documented, no goal or interventions for this discipline. Also in record HOSRRHV#3 the documentation indicated that the patient had a wound with dressings ordered, however there were no POC goals or interventions related to the wound or wound care. In record HOSRRNHV#4 the goals were not individualized and did not have time frames such as Patient’s pain will be reduced to the level of the stated goal. Record HOSRRNHV#7 goals were not individualized and did not have time frames such as; Spiritual distress identified and decreased with visit. In record HOSRRNHV#9 the respiratory goals time frame was within 2 weeks from admission and has remained unchanged or not updated after 4 months. In record HOSRRNHV#10 on admission there was documentation of wound related goals and interventions with a time frame of within 2 weeks and currently at 6 weeks the goal has remained unchanged or updated. This was confirmed with the Clinical Manager and RN Case Manager present.”

“Observed in Record Review. In 14 of 14 patient records reviewed, it was noted that the organization had not obtained orders for care, treatment, or services. For example, in record HOSRRHV#2 there was documentation of the patient receiving volunteer and spiritual counselor visits, however there was no documented frequency for volunteer or spiritual counselor on the IDG, POC, or supplemental order. This patient also had a foley catheter and there was no documentation of an order for foley catheter care. For example, records HOSRRHV#1, #2, #3 and #4 and HOSRRNHV#1 through #10 included 4 nurse visits as needed or PRN and were not accompanied by a description of the patient’s medical signs and symptoms that would occasion a visit. This was confirmed and discussed with the Clinical Manager and RN Case Manager present.”

“Observed in Record Review. In 2 of 14 patient records reviewed, it was noted that the plan of care had not been revised. For example, in record HOSRRNHV#9 the respiratory goals time frame was within 2 weeks from admission and has remained unchanged or not updated after 4 months. In record HOSRRNHV#10 on admission there was documentation of wound related goals and interventions with a time frame of within 2 weeks and currently at 6 weeks the goal has remained unchanged or updated. This was confirmed with the Clinical Manager and RN Case Manager present.”

“Observed in Record Review. In 2 of 14 patient records reviewed, it was noted that care was not provided according to the plan of care. For example in record HOSRRNHV#4 the plan of care included MSW visits 2 visits every 2 weeks and for 3 weeks there were no visits documented and no missed visit or refused visit notes. In record HOSRRNHV#10 the plan of care included aide visits twice a week and for 2 weeks in May only 1 visit was completed with no missed visit or patient refused notes. This was confirmed with the nurse Case Manager present.”

“Observed in Patient Home. In 1 of 2 home visits conducted, that included oxygen therapy in the home it was noted that the staff did not provide education on the safe storage of oxygen cylinders in the home. For example, during home visit HOSRRHV#1 at the end of the visit upon questioning by the surveyor the board and care staff showed the nurse and surveyor that the E tank was stored in a closed closet. The nurse did not educate/re-educate about safe storage of oxygen. This was confirmed with the Clinical Manager present.”