Ambercity Hospice, Inc.

“Observed in Patient Home. In 5 of 6 records reviewed with Aide services, it was noted that that aide care plan did not have specific instructions for the aide. On RRHV #1, it was noted that the patient had a gaping open wound to the head with a dressing but there was not instructions on the aide care plan to reflect this wound and how to handle dressing with shower, hair shampoo and combing which was ordered but impacted by this wound. Delegation also notes PRN oxygen but no detail on when it should by on patient. On RRHV #2, it was noted that the care plan stated to ambulate ad lib on a patient that is bedbound and requires 2 person assist for transfer to wheelchair. In addition, orders for PRN oxygen on the aide delegation with no instruction on when it should be on patient and patient is currently not even using oxygen. On RRHV #3, the assigned tasks did not include specific instructions for care. Examples include, orders for PRN oxygen on the delegation, patient using a bath bench for shower that was noted on the care plan, and care plan listing adult diapers when patient was continent and wearing underwear. On RRNHV #6, the care had orders for PRN oxygen on the delegation but no instruction on when to use. On RRNHV #7 oxygen 2L was on care plan with no indication if it was continuous or PRN use and if patient needed it during shower. This finding was reviewed and validated with agency leadership.”

“Observed in Patient Home. In 1 of 1 home visits conducted with the aide, it was noted that the aide did not provide care per the orders. On RRHV #3, it was noted that the aide checked blood pressure, saturation and temperature on the patient and those tasks were not delegated to the aide. Additionally, the orders were to perform teeth brush every visit, passive ROM every visit, apply deodorant every visit, and apply lotion every visit, the aide did not perform those tasks during the visit and the patient was not asked to even gain a refusal for the ordered care. This finding was reviewed and validated with agency leadership.”

“Observed in Record Review. In 1 of 10 active patient records reviewed, the medical record was not complete and accurate. On RRHV #3, it was noted during the home visit that patient was walking with a cane and on arrival to the visit was outside sitting yet the last comprehensive assessment states patient is non ambulatory and that the DME used is a walker. In addition, the documented states patient is maximum dependence for ADLs but the patient removed clothing for his shower and dressed after shower with minimal assist. Patient was also observed on home visit with minimal assist to no assist with transfer and only the assist of a cane for walking, but the assessment stated maximum assist. This finding was reviewed with agency leadership.”

“Observed in Record Review. On 3 of 10 active patient records reviewed the organization failed to complete initial assessment per agency policy. Agency psychosocial assessment policy states the MSW will make contact within 2 days of admission and complete assessment. On RRHV #1, it was noted that the MSW did not complete the initial assessment or contact within two days of admission per agency policy. The MSW did have a contact note on day five that calls had been attempted but this was outside the contact requirement of within 2 days. On RRHV #2 and RRNHV #7, it was noted that the MSW failed to complete an initial assessments within two days after admission and documentation of a call attempt to patient was not documented in the communication notes. This finding was reviewed with the DON. 
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“Observed in Record Review. In 3 out of 10 active patient records reviewed, the medication assessment but failed to identify issues with medication. The organization’s Medication policy states, the nurse will assess for duplicative medications and adverse reactions on medications. In RRHV #1, the nurse surveyor noted during the home visit that their were discrepancies between the medical record and the home patient list. There was duplicate therapies of Ondansetron and Compazine that were PRN with no indication of which drug to use when. There were missing medications in the patient’s medication bin at the board and care that could not be found, and medication changes that had not been updated on the record. On RRHV #2, it was noted on medication review patient had duplicate PRN therapy medications for nauseas and vomiting (Ondansetron and Compazine) and for agitation restlessness (Ativan 0.5mg 1 tab every 4 hours as needed and Ativan 0.5mg 1 tab twice daily as needed) with no instructions for when to use each duplicate order. In addition the patient had 3 different prescription doses in the board and care facility of Acetaminophen 325 mg and 500 mg PO and Acetaminophen suppository in the medication box and there was no instructions on maximum dosing per day of Acetaminophen. On RRHV #3, it was noted that there was duplicate PRN medications for nauseas and vomiting (Ondansetron and Compazine) and for agitation restlessness (Ativan 0.5mg 1 tab every 4 hours as needed and Ativan 0.5mg 1 tab twice daily as needed) with no instructions for when to use each duplicate order. This finding was reviewed with Agency Leadership.”

“Observed in Record Review. In 2 of 10 active patient records reviewed, the organization failed to ensure the patient’s primary caregiver received education and training as appropriate for new medications ordered. On review of RR HV #3, patient started on Robitussin and azithromycin earlier in the month and no teaching documented that board and care caregiver taught on the new medication. On review of RRNHV #5, it was noted that new orders for Zofran PRN for nausea was started but there was no documented teaching with the caregiver when to use medication. This observation was reviewed with the agency leadership.”

“Observed in Record Review. In 7 of 10 active patient records reviewed, the plan of care did not reflect the care and treatment needs of the patient. On RRHV #1, assessment notes for the spiritual counselor state concern for afterlife, loss of independence, powerlessness, lonely, grieving and this was not reflected in the goals for care of the patient. On RRHV #2, there were not goals related to they nystatin being used on buttock due to patient’s incontinence. No goals related to the Respiratory infection that was treated with antibiotics. On RRHV #3 it was noted in the MSW record that the patient had financial issues and that paperwork for financial help was being sent to fill out but this was reflected in the plan of care. In addition, the spiritual counselor notes state patient is hopeless, lonely, grieving and with fear and this was not reflected in the goals for care of the patient. On RRNHV #1 the MSW and Spiritual goals did not reflect the assessed needs of the patient nor were they measurable or specific. The nursing goals did not focus on the teaching needs that were assessed for ambulation and the use of a walker and cane to reduce fall risk. On RRNHV #3, the goals for care refer to the management of diabetes with insulin yet the patient has no orders for insulin and diabetes is managed with oral medications. MSW and spiritual goals are not specific to the care needs that were identified on assessment such as need for a Power of Attorney, grief and anxiety. On review of RNHV #5 it was noted that MSW and chaplain goals were not measurable and specific to the assessed needs of the patient such as needing meals on wheels, loss of independence and powerlessness. On RRNHV #7, it was noted that chaplain goals were not measurable and specific to the assessed needs of the patient such as with loneliness, family conflict, powerlessness, and anxiety. This finding was reviewed with agency leadership.”

“Observed in Record Review. In 4 of 6 patient records reviewed with a recertification, the plan of care was not revised based on the patient’s and/or caregiver’s needs. On review of RRHV #1 it was noted that the patient had a large open wound from a tumor with foul drainage and the goals were not measurable and specific to the wound, they were written as the intervention. On review of RRHV #2, it was noted that the care plan had not been updated to reflect that patient was having hypotension and that hypertensive medications were being held, in fact the most recent IDG not stated patient was hypertensive when the assessed BP on visits were low. Patient also started on Nystatin to buttock and a course of antibiotics for an upper respiratory infection and there was not discussion our updates to the plan of care for those changes. On review of RRHV #3 it was noted that the care plan had not been revised to reflect the patients needs of example teaching goals from admission still on POC and not updated to reflect current needs of patient 6 months later. Goal for walker safety when during home visit it was noted patient was only using a cane for ambulation. Goals for adequate oxygen use when patient only has order for PRN oxygen that is not even being used by patient. On review of RRNHV #5, it was noted that Zofran was started for nausea but there was no goals or interventions for the management of nausea. This was reviewed with agency leadership.”

“Observed in Patient Home. In 2 of 3 home visits conducted, the nurse surveyor observed that the agency did not implement measures to reduce the risk of infection associated with medical equipment. Agency Bag Technique policy (7-014.1) states that equipment will be cleaned with alcohol and/or soap and water. On RRHV #2, the nurse did not follow agency policy, she cleaned her vital sign equipment with Clorox and immediately returned to bag without following manufacture wet time of 3 minutes. On RRHV #3, the aide cleaned her vital sign equipment with Purel hand sanitizer and used her bare hands to rub the sanitizer on the equipment. This finding was reviewed with agency leadership. 
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“Observed in Record Review. In 4 out of 10 active patient records reviewed, the medication orders were not clear and accurate. The organization’s Medication policy states, drug review will be done on admission and ongoing and will address duplicate therapy and be used for care planning teaching with the patient/caregiver. In RRHV # 1, the surveyor noted, that the medication record did not contain accurate information for medication because the medication list in the home did not match the medication list in the medical record. Examples include, triple antibiotic on the home list but not in the medical record list and hydrogel 20% in the medication list in the medical record but not on the home list. Also, duplicate PRN medications for nauseas and vomiting (Ondansetron and Compazine) with no instructions for which duplicate medication to use when. In RRHV #2, the nurse surveyor noted that medication list was not clear and accurate, during medication review the patient had a prescription bottle of Acetaminophen 325 mg for PRN use and a pill card for Acetaminophen 500 mg for PRN pain use however, there were only orders in the medical record for the 500mg dosing. In addition, physician orders were for Seroquel 50 mg tabs to give 3 tabs at bedtime but on review of the medication record in then board and care the medication record there had to take 1 tab in morning and 1 tab at noon and then an additional order for 1 tab at bedtime. It was also noted that the pill bottle had writing on the bottle that stated am-1, pm -1, bedtime-3. In RRHV #3, it was noted that there was duplicate PRN medications for nauseas and vomiting (Ondansetron and Compazine) and for agitation restlessness (Ativan 0.5mg 1 tab every 4 hours as needed and Ativan 0.5mg 1 tab twice daily as needed) with no instructions for when to use each duplicate order. On RRNHV #3, it was noted that there was duplicate PRN medications for nauseas and vomiting (Ondansetron and Compazine) and for wheezing/SOB (Albuterol 90mcg and Albuterol 0.083%) with no instructions for when to use each duplicate order. This finding was reviewed with Agency Leadership. Observed in Record Review. In 2 of 10 active patient records reviewed, the medical record reflects the patients care and services for medical equipment provided to patient. On RRHV #2, it was noted that during the home visit the patient had a overlay mattress on her bed, however, the documentation on the medical record does not reflect that patient has this DME. On RRHV #3, it was noted that the patient was using a cane for ambulation and the cane was delegated on the plan of care for the aide. However, the most recent nursing assessment documents a walker and no cane. This finding was reviewed with agency leadership.”

“Observed in Record Review. In 2 of 2 discharged patient records reviewed where patient discharged from service, a discharge summary for care and treatment was not sent to the provider or a notification given that it was available. On RRDC #1, the discharge summary indicated the patient revoked, a summary was written but it was not sent to physician and/or notification of it’s availability was not completed. On RRDC #2, the discharge summary was created by the nurse, however it was not sent to physician and/or notification of it’s availability was not completed. This was reviewed and validated with DCPS Designee who stated they did not have a process in place for the step of notifying and was giving the patient the summary to take to the PCP. 
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