Silverado Hospice San Diego

“Observed in Record Review. In 1 of 16 patient records reviewed, the organization failed to reassess its patient’s. During record review for HOSRRHV#4, the Hospice Nurse Surveyor observed the patient had a wound and the staff were providing wound care but it had not been assessed since it was first noted with full assessment and measurements 24 days prior to survey. Per the org policy it should have been measured weekly and assessed minimally at the comprehensive assessment every 14 days. This was discussed and reviewed with the Hospice Leadership Team.”

“Observed in Record Review. In 1 of 16 patient records reviewed, the organization failed to maintain a complete and accurate record. During record review for HOSRRNHV#3, the Hospice Nurse Surveyor observed documentation at SOC of a wound and wound care which included goals on the POC. There was no documentation of the wound or wound care on subsequent visits. Upon discussion with the care manager, who did not admit the patient, it was discovered the patient never had a wound to the coccyx as documented. This was discussed and reviewed with the Hospice Leadership Team.”

“Observed in Record Review. In 2 of 16 patient records reviewed, the organization failed to plan the patient’s care. During record review for HOSRNHV#1 and HOSRRNHV#8, , the Hospice Nurse Surveyor observed the plan of care did not contain all needed elements. In HOSRRNHV#1, the patient had a wound that had healed but the wound orders and goals/ interventions were not discontinued. In HOSRRNHV#8, the patient had a wound that was healed 11 days after it was first entered per the nurses narrative notes but the goals/ interventions and orders were not discontinued until 9 days later. This was discussed and reviewed with the Hospice Leadership Team.”

“Observed in Record Review. In 1 of 16 patient records reviewed, the organization failed to provide care, treatment, or services in accordance with orders. During record review for HOSRRNHV#7, the Hospice Nurse Surveyor observed the patient had orders stating Cleanse with wound cleanser, pat dry, apply triple antibiotics, cover with non-adhesive dressing, and secure with gauze bandage x2 days a week and prn if soiled or dislodged. During a recent RN PRN visit the wound care was documented as cleansed with wound cleanser, DSD applied. This was discussed and reviewed with the Hospice Leadership Team.”

“Observed in Record Review. In 1 of 16 patient records reviewed, the organization failed to provide interdisciplinary, collaborative care, treatment, or services. During record review for HOSRRHV#3, the nurse surveyor observed there was a triage call for a patient fall without injury in a facility. The triage nurse assigned a PRN visit to the nurse on-call. The visit was listed as missed and a nurse went out the next day. Upon discussion with the Hospice Team, it was noted that the nurse had issues with a power outage that night and was unable to go. There was no documentation of a phone call or reach out to the facility or the triage nurse to discuss the inability to make the visit. This was discussed and reviewed with the Hospice Leadership Team.”

“Based on interview, and record review, the agency failed to complete a comprehensive wound assessment, per the agency’s wound care guidelines, for 1 of 2 sampled patients (1).As a result, Patient 1’s wound care and treatment were delayed. Findings:Patient 1 was admitted to the agency 1/26/21 with diagnoses which included heart disease, per the agency’s Patient Information Report.A review of Patient 1’s medical record was conducted. Per the Visit Note Report, the following event happened:On 2/19/21, Skilled Nurse (SN) 2 documented that Patient 1 developed stage III (open wounds that affected the top two layers of skin and fatty tissue) pressure ulcers to the right outer side of the foot and unstageable pressure ulcer to the left heel. On 2/25/21, SN 1 documented that Patient 1’s wounds were “...not assessed ...wound care not provided: Caregiver completed care ...”On 2/28/21, SN 2 documented Patient 1’s wounds had yellow-green drainage with a foul odor. There was no documented evidence that SN 2 measured Patient 1’s wounds. On 3/4/21, SN 1 documented Patient 1’s wounds had no change in status. However, there was no documented evidence SN 2 measured Patient 1’s wounds. On 3/10/21, SN 3 documented Patient 1’s wounds had no change in status. There was no documented evidence that SN 2 measured Patient 1’s wounds. On 3/18/21, SN 1 documented Patient 1’s left heel had no change in the status, and Patient 1’s right outer side of the foot had a foul odor. There was no documented evidence that the wounds were thoroughly assessed. On 3/21/21, SN 4 documented Patient 1’s left heel had a malodorous smell and an 80 % slough (dead tissues), and Patient 1’s right outer side of the foot had minimal to moderate weeping. There was no change in treatment provided. On 3/22/21, SN 1 documented Patient 1’s wounds had no change in status. A foul odor to the left lower extremities remains. There was no documented evidence that the wounds were measured. On 3/24/21, SN 1 documented Patient 1’s left leg had deep tissue injury with some drainage and foul odor. On 3/26/21, SN 1 documented Patient 1’s right foot was “unstageable.” On 3/29/21, SN 1 documented Patient 1’s weeping venous stasis ulcers. There was no request for a treatment order to be changed.On 4/2/21, SN 1 documented Patient 1’s left foot deterioration to the left heel, thick tan drainage, slough, and odor, pending a new order. There was no treatment order changed.Per the Hospital Record, dated 4/6/21, Patient 1 was sent to the Emergency Room for advanced wound care. Patient 1 was found to have maggots in her foot. On 6/22/21 at 9 A.M., an interview was conducted with SN 1. SN 1 stated she had difficulty assessing Patient 1’s wounds and never measured Patient 1’s wounds. On 6/22/21 at 10:08 A.M., an interview was conducted with the Patient Care Manager (PCM). The PCM stated registered nurses should complete the wound assessment every seven days and any change of condition should have been addressed. Per the agency’s Charting on a New Wound Guidelines, “...measure wound every 7 days...re-evaluate in 2 weeks or 14 days...Do a complete Skin assessment...”Per the agency’s Wound Care Guidelines, “ ...wounds should be assessed and evaluated by the Hospice RN at least weekly (complete a comprehensive wound assessment) ...All wound interventions should be attempted by the Hospice clinical team...Utilization of an of an outside vendor for wound care:...(1) Complicated and complex wounds...a.Stage 3+ wounds b. Unstable wounds c. Significant purulent drainage d. Gangrene e. Chronic and/or severe wound infections... “”