Grand Terrace Hospice

“Observed in Record Review. In 2 of 6 patient records reviewed, the organization failed to ensure the care, treatment, and services were provided according to the patient’s individualized plan of care. On review of RRNHV#5 the hospice aide was ordered a frequency per the plan of care of 3 times a week yet on the 1st week of July there were only 2 visits documented. There was no documentation of why the visit was missed. On RRNHV#6 the plan of care order for Skilled nursing was for 1 time a week. On the 2nd week of June there was no skilled nurse visit documented. There was a missed visit noted documented for the Tuesday of that week that stated Clinical stated patient was not available to be visited. There was no documentation that there was any attempt to make-up or reschedule the visit later in the week to maintain the services per the plan of care. On the 4th week of June there were 2 skilled nursing visits documented when the order was for 1 time a week. These observations were reviewed with the DPCS and Staff RN.”

“Observed in Patient Home. In 1 of 3 home visits conducted, the Skilled Nurse failed to perform a medication reconciliation. For example, in RRHV #2 the Skilled Nurse did not perform a medication reconciliation as per the organization policy #3-002.1 which states, as part of our mission to provide quality of care to all patient, every licensed nurse required to check all patient prescription and over the counter medications, creams, ointments, drops, and supplements that currently take on each visit. This was validated and reviewed with the Director of Patient Care Services and the Administrator.”

“Observed in Record Review. In 1 of 3 patient records reviewed, the organization failed to provide education/teaching towards the goal. For example, in RRHV #1, the goals for benefit period 11 and 12 are as follows, Constipation: in 3-4 weeks pt/family/PCG will verbalize satisfaction of adequate bowel care resulting to normalize of bowel elimination pattern and increased comfort. There is no documentation to support that the SN provided teaching on the goal. There are similar findings in RRNHV #1, 3, 4, 5, 6, and 7. This was validated and reviewed with the Director of Patient Care Services and the Administrator.”

“Observed in Record Review. In 1 of 3 patient records reviewed, the organization failed to update the plan of care. For example, in RRHV #3, the Skilled Nurse (SN) visit frequencies in benefit period #5 were one times a week times 60 days. The SN made two additional PRN visits throughout the benefit period and did not obtain an order nor document any supporting evidence that the Doctor was made aware. There was also no IDG discussion as to the additional needed frequencies. This was validated and reviewed with the Director of Patient Care Services.”

“Observed in Patient Home. In 1 of 3 home visits conducted, the organization failed to discontinue medications on the plan of care in the patient’s home. For example, in RRHV #2, medihoney 1 application topical three times a week, Bisacodyl 5 mg 1 tablet two times a day, Senna 8.6 mg twice a day, Morphine Sulfate 100 mg/20 mg sublingual every two hours as needed, Amlodipine 5 mg 1 tablet once a day, Ativan 2mg/0.25 ml sublingual every 4 hours as needed, docusate sodium 100 mg 1 capsule twice a day, DuoNeb 2.5 mg 1 each inhalation every 4 hours as needed, along with 11 other medications and 2 wound care orders were not discontinued on the plan of care and in the patient’s home. This was validated and reviewed with the Director of Patient Care Services.”

“Observed in Record Review. In 1 of 3 patient records reviewed, the organization failed to document the progress towards the goals. For example, in RRHV #1, the goals for benefit period 11 and 12 are as follows, Constipation: in 3-4 weeks pt/family/PCG will verbalize satisfaction of adequate bowel care resulting to normalize of bowel elimination pattern and increased comfort. There is no documentation to support in either benefit period there was progress towards the goals. There is also no documentation to support a discussion with the Physician as to the patient not being able to obtain the goal within the 3-4 weeks and no documentation to support the goals were discussed in IDG. There were similar findings in RRNHV #1, 3, 4, 5, 6, and 7. This was validated and reviewed with the Director of Patient Care Services.”

“Observed in Record Review. In 2 of 3 patient records reviewed, the Certified Home Health Aide failed to follow the plan of care. For example, in RRHV #3 in benefit period #5, the CHHA had two missed visits. There is no documentation to support the organization being made aware of the missed visits. This was validated and reviewed with the Director of Patient Services. Observed in Record Review. In 2 of 3 patient records reviewed, the Certified Home Health Aide (CHHA) failed to follow the plan of care. For example, in RRHV #1, benefit period #11, the plan of care visit frequencies indicates three times a week visits. During the first week the CHHA only provide twice a week visits. There is no missed visit notification note. This was validated with the Director of Patient Care Services.”

“Observed in Patient Home. In 2 of 3 home visits conducted, the Certified Home Health Aide (CHHA) failed to follow the plan of care. For example, in RRHV #1 the plan of care included providing nail care. The CHHA did not perform nail care during the visit and also stated nail care has never been performed. The plan of care given to the Surveyor included the task. Another example, in benefit period #12, the CHHA indicated a shower was provided to the patient in the summary note but checked no shower on the note. The CHHA also indicated the patient was not shampooed, was not provided oral hygiene, the hair was not combed, or shaved in the notes although the SN aide care plan stated these task should be completed at every visit. The CCHA had a similar issue in RRNHV #5. The care plan indicated the patient should be shampooed each visit. The CHHA indicated the task was not completed and did not give a reason nor notify the organization. This was validated and reviewed with the Director of Patient Care Services.”

“Observed in Record Review. In 2 of 14 patient records reviewed, the Physician failed to include all elements required on the CTI such as the current subjective and objective medical findings, current medication and treatment orders, information about the medical management of the patient’s condition. For example, in RRNHV #1 in benefit period 2 , the Physician documented, elderly male admitted to hospice services with the diagnosis of CVA. He has resulting left sided hemiplegia and needs assistance with ADLs. Patient to continue hospice services as per family wishes and in benefit period #3, the Physician documented, elderly male who is admitted to hospice services with the diagnosis of CVA. Patient has residual hemiplegia after the stroke. He uses a cane for ambulation. He needs assistance with ADLs as he is hemiplegic on the left side. He will continue hospice care services as per family wishes. In RRNHV #3 in benefit period #2, the Physician documented. elderly female admitted to hospice services with the diagnosis of cerebral infarction. Patient had a CVA last year resulting in left sided hemiplegia. She is wheelchair bound and required assistance with ADLs. Given the patient’s overall condition and resulting hemiplegia both patient and family have agreed to continue hospice services. In benefit period #3 the Physician documented, elderly female admitted to hospice services with the dx of CVA. She has suffered a stroke leaving her with hemiplegia on the left side. Patient is wheelchair bound and needs assistance with ADLs and day to day activities. Given the patients overall condition she will be admitted to hospice services as per family wishes. This was validated and reviewed with the Director of Patient Care Services.”