Bristol Hospice - East Bay

“Based on record review and interview the agency failed to provide nursing services follow as plan of care for three of 14 sample selected patients (Patient 1 and Patient 4). This failure in practice had a potential effect of Patient 1 and Patient 4s quality of care and lack of appropriate services as ordered by the physician. A review of Patient 1s “;Hospice Plan of Care” indicated, Patient 1 was admitted to the hospice agency with multiple diagnoses including stroke (a serious life-threatening medical condition that happens when the blood supply to part of the brain is cut off), and the visit frequency for nurses was 2W1 (2 times a week for 1 week), 2W13 (2 times a week for 13 weeks) + 3 visits PRN (as needed). A review of Patient 1s list of visits indicated one nursing visit was missed on the week of 6/19/23 and one nursing visit was missed on the week of 7/3/23 without any documentation. A review of Patient 4s “;Hospice Plan of Care” indicated Patient 4 was admitted to the agency with multiple diagnoses including dementia (the loss of cognitive functioning, thinking, remembering, and reasoning to such an extent that it interferes with a person’s daily life and activities) and the frequency for Hospice Care Assistant (HCA) was 5W9 (5 times a week for 9 weeks) + 1 PRN. A review of Patient 4s list of visits indicated one HCA visit was missed on the week of 5/29/24 without any documentation. During a concurrent record review and interview on 6/5/24 at 10:45 a.m. with the Regional Director of Clinical Operation (RDCO), RDCO confirmed the missed visits for Patient 1 and 4 and stated when the agency establishes a care plan and visit frequencies for the patients, they need to follow the plan. The missed visits should be reschedule for the same week and any missed visits should be documented for team communications. During an interview on 6/5/24 at 11:10 a.m. with the Hospice Aid (HA), HA stated its important to document the missed visits for the communication between the team. A review of the agencys policy and procedure “;Missed Visits,” dated 2003, indicated “;... 1. If a visit is missed for any reason, the clinician should attempt to rescheduled it for the same week so that the physician ordered frequency is maintained and would not be considered a missed visit. 2. If a visit is missed and not rescheduled the clinician will: A. Notify the IDG (Interdisciplinary Group) and director of patient care services/clinical supervisor of the missed visit and reason for missed visit...””

“Based on interview and record review the agency did ensure to provide bereavement services (Assessing strengths, bereavement risk, and concerns and needs related to grief and loss) for one of 14 sample selected patients (Patient 14), when Patient 14s family did not receive any bereavement services after Patient 14s death. This failure in practice had the potential for Patient 14s family to not have the needed emotional support during the grieving process. A review of Patient 14s “;Clinical Summary” indicated Patient 14 was admitted to the agency in June 2023 and passed away six days later. During a concurrent interview and record review on 6/6/24 at 11:50 a.m. with the Regional Director of Clinical Operation (RDCO), RDCO reviewed Patient 14s clinical record and did not find any documents that showed the agency provided bereavement services for Patient 14s family. RDCO stated she could not find any care plan for bereavement and no documents about bereavement services for Patient 14. RDCO stated bereavement services are for the family’s emotional support and if the agency doesnt provide bereavement services, it is a possibility for the family to do not go through the grieving correctly. A review of the agencys policy and procedure “;Bereavement Services,” dated 2023, indicated “;... The hospice will provide an organized bereavement program supervised by a qualified bereavement coordinator for up to (1) year following the death of the patient...””

“It is required that the hospice Interdisciplinary Group, in consultation with the individual’s attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure that the hospice interdisciplinary group (IDG) completed an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care. Clinical Record 8: The patient elected hospice care on 1/31/23. A review of the clinical record revealed no documented evidence of a Medical Social Worker (MSW) initial assessment. There was no evidence that MSW services were offered and refused by the patient/caregiver within the initial comprehensive five-day window. During an interview on 12/20/23, the Administrator/Alternate Director of Patient Care Services, Regional Vice President (VP) of Clinical Operations, Regional VP of Operations, and Director of Clinical Operations agreed that the MSW did not complete an initial comprehensive assessment or documentation that the MSW was offered and refused by the patient.”

“It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. The written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review, observation, and interview. In 1 of 14 (7%) clinical records reviewed of patients who received hospice aide services, the agency did not ensure the hospice aide received specific written instructions to meet the patient’s care needs. Clinical Record 2/Home Visit 4: The patient elected hospice care on 3/17/23. The plan of care dated 11/12/23 ordered “Wound # 5... 2. Gently pat dry and apply Calmoseptine ointment. ... 4. Repeat after each episode of incontinence.” During the home visit with the Hospice Aide [Personnel Record 2] on 12/19/23, the Hospice Aide stated that she applied Calmoseptine ointment to the patient’s buttocks during every visit. The hospice aide care plan dated 11/12/23 did not document a task with instructions on applying Calmoseptine ointment. During an interview on 12/20/23, the Administrator/Alternate Director of Patient Care Services, Regional Vice President (VP) of Clinical Operations, Regional VP of Operations, and the Director of Clinical Operations agreed that the agency did not ensure the hospice aide care plan included a task with appropriate instructions to meet the care needs of the patient.”

“It is required that a hospice aide provides services included in the plan of care. This standard was not met as evidenced by clinical record review, observation, and interview. In 4 of 13 (31%) clinical records reviewed of patients that received hospice aide services, the agency did not ensure the hospice aide provided services included in the plan of care (POC). Clinical Record 1/Home Visit 1: The patient elected hospice care on 7/6/23. The hospice aide care plan dated 12/1/23 assigned the hospice aide the task: “Partial/Complete Bath: Shower Bath.” The registered nurse (RN) [Personnel Record 1] interviewed during the home visit on 12/19/23 stated that the hospice aide provided a “bed bath” for the patient every visit. A review of the hospice aide visit notes dated 12/1/23 through 12/18/23 documented the hospice aide performed a “Shower Bath” during each visit. Clinical Record 2/Home Visit 4: The patient elected hospice care on 3/17/23. The plan of care dated 11/12/23 ordered “Wound # 5... 2. Gently pat dry and apply Calmoseptine ointment. ... 4. Repeat after each episode of incontinence.” During the home visit with the Hospice Aide [Personnel Record 2] on 12/19/23, the Hospice Aide stated that she applied Calmoseptine ointment to the patient’s buttocks during every visit. The hospice aide care plan dated 11/12/23 did not document a task for applying Calmoseptine ointment. Clinical Record 3/Home Visit 2: The patient elected hospice care on 9/7/23. The hospice aide care plan dated 9/7/23 assigned the hospice aide the task: “Bathing: Shower Bath.” During the home visit with the social worker (SW) [Personnel Record 3] on 12/19/23, the hospice aide was observed performing a “bed bath.” Clinical Record 17: The patient elected hospice care on 8/30/22. The hospice aide care plan dated 11/21/23 assigned the hospice aide the task: “... Bed Bath 2x per week.” For the week of 12/3/23, the hospice aide documented that a bed bath was performed three times: 12/4/23, 12/6/23, and 12/8/23. For the week of 12/10/23, the hospice aide documented that a bed bath was performed three times: 12/11/23, 12/13/23, and 12/15/23. During an interview on 12/20/23, the Administrator/Alternate Director of Patient Care Services, Regional Vice President (VP) of Clinical Operations, Regional VP of Operations, and Director of Clinical Operations (DCO) agreed the hospice aide did not provide tasks assigned in the hospice aide care plan.”

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. Each patient’s record includes, at a minimum, physician orders. This standard was not met as evidenced by clinical record review, observation, and interview. In 4 of 19 (21%) clinical records reviewed and home visits observed, the agency did not ensure the clinical record included a physician order for services provided. Clinical Record 1/Home Visit 1: The patient elected hospice care on 9/2/23 and resided in a skilled nursing facility (SNF). The plans of care (POC) dated 9/2/23 and 12/1/23 ordered Humalog insulin to be given three times a day with sliding scale dosing based on fingerstick blood sugar (FSBS) results. During the home visit with the registered nurse (RN) [Personnel Record 1) on 12/19/23, The RN stated that the SNF was performing FSBS on the patient. A clinical record review revealed no documented evidence of a physician order for FSBS. Clinical Record 3/Home Visit 2: The patient elected hospice care on 9/7/23. The POC dated 12/6/23 ordered “Aspirations Precautions.” During the home visit on 12/17/23, bedside suction was observed at the patient’s bedside. A clinical record review revealed no evidence of a physician’s order for the bedside suction and its use in patient care. Clinical Record 17: The patient elected hospice care on 8/30/22. The initial nursing assessment dated 8/30/22 documented the patient’s diet as “nothing by mouth” (NPO) except mouth care and Jevity feedings through a “G-tube” (gastrostomy tube). The POC dated 8/30/22 documented “Nasogastric (NG) Tube.” A clinical record review revealed no evidence of a physician’s order for the NPO diet and the use of the G-tube. The agency reported the Electronic Medical Record (EMR) provided the drop-down option of “NG Tube” only. Clinical Record 18: The patient elected hospice care on 10/12/23. The nursing assessment completed on 12/13/23 documented, “Arm protection sleeves provided to patient...” A physician order dated 12/19/23 provided orders for the following supplies: Neosporin and sterile 4x4 gauze. A clinical record review revealed no evidence of a physician order for the arm protection sleeves and no specific instructions for using the Neosporin and sterile 4x4 gauze. During an interview, the Administrator/Alternate Director of Patient Care Services, the Regional Vice President (VP) of Clinical Operations, the Regional VP of Operations, and the Director of Clinical Operations in an interview on 12/20/23 agreed that the agency did not ensure a physician order was written for services provided.”