Steward Hospice Care Inc.

“Observed in Record Review. In 2 of 5 active patient records reviewed, the organization failed to ensure the plan of care was updated based on the patient’s reassessment and progress toward goals. On RRNHV #1, it was documented in assessment and IDG notes that patient has a PEG tube for feedings but there is no goals on the POC related to the PEG tube. On RRNHV #2, the assessment noted that patient has poor oral intake, noted weight loss and food pocketing by no goals related to this issues is on the plan of care. This finding was reviewed and validated with the DCPS.”

“Observed in Record Review. In 4 of 5 active patient records reviewed, the plan of care was not individualized for each patient with measurable and specific goals. On RRNHV #1, it was noted goals were not measurable to the patient with example of Provide optimal comfort and dignity, ensuring absence of non verbal pain indicators. On RRNHV #3, it was noted on chart review that goals not measurable with example of “managing pain and symptoms, ensuring comfort during daily care and addressing discomfort promptly”. On RRNHV #4, it was noted that goals were not measurable and specific with the example of Maintaining comfort and dignity, ensuring proper pain management despite patients inability to specify location or severity” and Supporting nutritional and hydration needs given poor oral intake and reliance on ensure. On RRNHV #5 it was noted that goals were not measurable and specific with examples of “Family will maintain adequate psychosocial support systems and resources throughout the benefit period”. The findings were reviewed and validated with DCPS.”

“Observed in Record Review. In 4 of 10 patient records reviewed, The surveyor noted (RRHV#3) that the assessment was not complete. The continuous care notes indicated that the patient was experiencing agitation; however, there was no assessment of the severity of agitation and restlessness. In (RRNHV#4) there was no assess of the G-tube site, feeding tolerance or the patient’s sacral wound by the registered nurse. The nurse was receiving report from the wound specialist. In (RRNHV#6) there was no assessment of the severity of pain. In (RRNHV#9), there was no evidence that the wound was assessed by the registered nurse, after the initial assessment. The documentation indicated that the nurse was receiving report from the wound care specialist only for a period of 6 weeks. The policy required the registered nurse to complete a comprehensive assessment every 15 days. This was confirmed with the DPS.”

“Observed in Record Review. The surveyor noted (RRNHV#4) that the patient assessment and continuous care notes indicated that the patient had a gastrostomy tube; however there were no orders for site care or flushes. Also, two continuous care notes indicated that the patient was receiving oxygen at 5 lpm; however there was O2 2lpm. Also, a note indicated started on food as tolerated, although the order was for NPO. The order for Jevity 1.5 cal @50 ml/hr via GT did not include a duration. In (RRNHV#9), there were no orders for wound care to the coccyx. The orders included a referral to the wound centre in February, however, the orders received were never included in the plan of care. This was confirmed with the director of patient services. Observed in Individual Tracer. The surveyor noted (RRHV#2) that there was no order for Foley catheter care or changes. The surveyor observed the presence of a catheter and the visit notes indicated it was patent; however there was no instructions/interventions about who was changing and maintaining the indwelling male catheter. This was confirmed with the DPS. Observed in Individual Tracer. In 10 of 10 patient records reviewed, The surveyor noted (RRHV#1) that the patient was admitted on continuous care level of care; however, there was no assessment or plan of care documented in the medical record to identify the need for continuous care. The continuous care notes indicated that the patient was receiving IV infusions; however, there was no order for the IV hydration, flushes and IVP site care, in the plan of care, as documented by the continuous care nurse. Also, the patient was admitted on continuous care, but there was no order for continuous care. Also, there was no order for suctioning performed by the continuous care nurse. This was confirmed with the DPS.”

“Observed in Individual Tracer. In 4 of 10 patient records reviewed, The surveyor noted (RRHV#1) that the signed Election of Benefit form found in the patient’s home record did not include a date of election. The surveyor noted that the copy uploaded to the electronic medical record had the date filled in after the Election form was signed and there was no evidence that the patient/caregiver had made the entry. Also, in (RRHV#2) the election date was absent in the home record signed copy but was added to the copy in the medical record. This was also noted in (RRHV#3). In (RRNHV#6), the election date was left blank although the document was signed. This did not follow organizational policy for completion of the election statement. This was confirmed with the DPS.”

“Observed in Record Review. In 4 of 10 patient records reviewed, The surveyor noted (RRHV#3) that the plan of care had not been updated since the initial plan of care was developed last January and the IDT notes did not reflect any progress toward goals including pain, agitation, and dyspnea management. The plan of care was not updated when there was a change in level of care from continuous care to routine care. In (RRNHV#4) the plan of care was not updated since October and when the patient developed a sacral wound. The IDT notes did not include an update about the patient’s nutritional status on enteral feeds, or wound healing status. In (RRNHV#5) the care plan was not updated since August and the IDT did not reflect progress toward goals or the status of the patient’s wound healing. in (RRNHV#8), the IDT and care plan did not reflect progress toward goals or the progress of the patient’s wound healing. This was confirmed with the leadership team.”

“Observed in Individual Tracer. In 10 of 10 patient records reviewed, The surveyor noted (RRHV#1) that the plan of care did not include outcome measures or time frames for achieving the goals. For example, the patient was admitted on continuous care for symptom management of pain and dyspnea; however, the goal was stated following and administering pharmacological regimen safely and with a target date of the end of the certification period. The same goal remained for the next recertification period and the target dates changed to the end of each episode since February. In (RRHV#2) the goal for pain following and administering pharmacological regimen safely was not measurable and the target dates were for the end of each certification period since November. In (RRNHV#3) the pain goal was also stated following and administering pharmacological regimen safely . In (RRNHV#4), the goal for alteration in nutrition did not include measurable outcomes perform G/NG site care to prevent infection and the severe dyspnea outcome was participating in breathing treatment regimen. In all records reviewed, all goals included a target date for the end of the certification periods and moved each certification period to the end of the next period. This was confirmed with the director of patient services. Observed in Record Review. In 4 of 10 patient records reviewed, The surveyor noted in several records that the plan of care was not individualized for each patient. For example, in (RRNHV#5) the patient was admitted to continuous care for pain and dyspnea management and was experiencing restlessness and agitation; however, there were no goals or interventions to manage the symptoms on the initial plan of care. (RRNHV#6) that the assessment indicated that the patient was experiencing pain, constipation and falls; however, there were no goals or interventions on the initial plan of care to address the issues. In (RRNHV#8) the patient was assessed to have a wound to the knee in June. The wound care was being provided by a wound care specialist; however, there was no care plan for wound care that indicated what treatments were to be provided and who was assessing and/or managing the wound care. In (RRNHV#9) the patient was assessed to have a coccyx wound that was being managed by a wound care specialist; however, there was no plan of care that identified the need for wound care, the interventions and treatment and who was assessing the wound and who was performing the wound care. skilled nursing visits were done by both RN and LVN and there was no direction provided about the wound. This was confirmed with the leadership team.”

“Observed in Individual Tracer. In 4 of 10 patient records reviewed, The surveyor noted (RRHV#1) that the home health aide supervisions were not conducted every 14 days. There was no record of a supervision from through late January through February for a period of 28 days and for a period of 28 days in April to May. Also, in (RRHV#3), there were no documented supervisions from the beginning of May through mid July (70 days). In (RRNHV#4) there was no evidence of a supervision for 28 days from June to July. In (RRNHV#6) there were no documented supervisions from March to April (35 days). This was confirmed with the DPS.”

“Observed in Individual Tracer. In 3 of 10 patient records reviewed, The surveyor noted (RRHV#1) that the patient record indicated that the patient was receiving continuous care for the first three days on hospice; however, there was no documentation of the medication administered by the nursing staff or any indication that the medications were administered by anyone else. In (RRNHV#4) the patient was receiving continuous care; however, the nursing notes indicated that the medications were crushed and given via G-tube, however it did not indicate what medications and doses were given. Also in (RRNHV#5), the continuous care notes did not indicate what medications and doses were administered and was documented as evening meds as ordered and morning meds as ordered. There was no evidence of a medication administration record in any of the records. The policy indicated that the continuous care flow sheet was to be used for documenting medications and treatments; however, this flow sheet was not part of the medical record. This was confirmed with the DPS.”