Nurses Touch Hospice, Inc.

“Observed in Record Review. In 3 out of 7 active patient records reviewed, the organization failed to complete a comprehensive spiritual assessment on admission. Hospice Bereavement assessment policy (2-037.1) states that on admission the MSW or RN will complete a bereavement risk assessment to include survivor needs, services to be provided and grief risk factors. On HSPRRHV #1, it was noted that a bereavement risk assessment was not completed on admission. On HSPRRHV #2, it was noted that the MSW made a visit and identified the bereaved but did not assess survivor needs or grief risk factors. On HSPRRNHV #1, it was noted that the initial bereavement assessment has not been completed and the patient was admitted 1 month ago. This finding was reviewed with hospice leadership.”

“Observed in Record Review. In 5 of 7 active patient records reviewed, the organization failed to plan the patient’s care with goals that were measurable and time specific. On HSPRRHV #1, goals were not measurable and specific with examples of “Hydration status will be maintained or optimized for comfort”, “Patient will maintain adequate urinary output appropriate to condition”, “Patient will maintain a comfortable and restful sleep pattern appropriate to condition”. On HSPRRHV #2, patient has orders for multiple pain medications but the goals is not measurable and specific to the patient with the goal as “Pain will remain in comfortable level during care.”. On HSPRRHV #3, the goals are not measurable and specific with examples of “verbalize having urinary elimination needs met at an acceptable level” and “Blood sugar management for pt. comfort”. In addition, goals were not measurable or specific on records HSPRRNHV #2 and HSPRRNHV #3 with examples of: “AchievIn 6 of 7 active patient records reviewed, the organization failed to plan the patient’s care with goals that were measurable and time specific. On HSPRRHV #1, goals were not measurable and specific with examples of “Hydration status will be maintained or optimized for comfort”, “Patient will maintain adequate urinary output appropriate to condition”, “Patient will maintain a comfortable and restful sleep pattern appropriate to condition”. On HSPRRHV #2, patient has orders for multiple pain medications but the goals is not measurable and specific to the patient with the goal as “Pain will remain in comfortable level during care.”. On HSPRRHV #3, the goals are not measurable and specific with examples of “verbalize having urinary elimination needs met at an acceptable level” and “Blood sugar management for pt. comfort”. In addition, goals were not measurable or specific on records HSPRRNHV #2, HSPRRNHV #3 and HSPRRNHV #4 with examples of: “Achieve and maintain peripheral circulation for Pt comfort”, “promote regular bowel movement”, “Patient will maintain adequate nutritional intake” “Patient will maintain adequate circulation, and “Blood pressure will remain patient-specific acceptable range” This finding was discussed and reviewed with the Hospice leadership team.e and maintain peripheral circulation for Pt comfort”, “promote regular bowel movement”, “Patient will maintain adequate nutritional intake” “Patient will maintain adequate circulation, and “Blood pressure will remain patient-specific acceptable range”. This finding was discussed and reviewed with the Hospice leadership team.”

“Observed in Record Review. In 3 of 7 active patient records reviewed, the hospice nurse surveyor noted medication orders were not clear and accurate. On HSPRRHV # 1, the physician’s orders in the plan of care documented Tylenol extra strength oral tablets” and “acetaminophen suppository both to be used PRN for pain with no indication how to handle the duplicate therapy. On HSPRRHV #3 and HSPRRNHV #2, the physician’s orders in the plan of care documented Tylenol oral tablets” and “acetaminophen suppository both to be used PRN for pain with no indication how to handle the duplicate therapy or max dosing per day for acetaminophen use. This was discussed with the hospice team.”

“Observed in Record Review. In 1 out of 1 patient records reviewed with aide services, the organization failed to plan the patient’s care. During record review for HSPRRHV#3, the Hospice Nurse Surveyor observed the aide care plan had not been updated to reflect the care needs of the patient who is a full assist transfer from a wheelchair to the bed. The care plan did not delegate or provide instructions on the use of the wheelchair or the transfer from wheelchair to bed for the bath. This was discussed and reviewed with the Hospice Leadership Team.”

“Observed in Record Review. In 2 of 3 bereaved records reviewed, the organization failed to ensure the medical record contained information that reflected the patient’s care, treatment or services. Agency death policy (2-065.1) states that the nurse will notify the attending physician of death and document in the medical record all interventions and any significant information in the medical record. In HSPRRBR #1 and HSPRRBR #2, the patient passed away while on service but there is no documentation regarding the passing of the patient or that the physician was notified. This finding was reviewed with Hospice Leadership. Observed in Record Review. In 5 out of 7 active patient records reviewed, the organization failed to ensure the medical record contained information to accurately reflect the patient’s care, treatment, and services. On HSPRRHV #1, the plan of care had not been updated for the last 21 days as evidenced by blank and unsigned IDG forms. On home observation for HSPRRHV #2 the registered nurse noted that the patient’s medication profile listed at the assisted living facility contained Senna that has been signed by the assisted living facility staff as giving one time per day over the last month, but the Hospice medication list did not reflect orders for the Senna. In addition the documentation for IDG lacked showing the attendance of the social worker and chaplain attending the IDG meetings over the last month and lack of IDG documentation for the last 21 days.. On HSPRRHV #3, it was noted that all members of the IDG group had not been documenting their attendance and participation in IDG meetings. On HSPRRNHV #1 and HSPRRNHV #2, it was noted that the chaplain had not been documenting attendance to the IDG meeting. This finding was reviewed with Hospice leadership.On 2 of 14 patient records reviewed, the organization did not review the plan of care at least every 15 days. On HSPRRHV #2, the plan of care had not been updated for the last 35 days as evidenced by blank and unsigned IDG forms. This finding was reviewed with Hospice leadership.”

“Observed in Record Review. In 2 of 4 patient records reviewed that were live discharges, the organization did not provide a discharge summary the informed the receiving provider with a summary of the patient’s care and progress towards goas while they were on hospice services. On HSPRRDC #2, it was noted that the discharge summary was completed but it only stated patient was discharged due to prolonged prognosis with no detail of the patient’s care received or progress toward goals. On HSPRRDC #3, the discharge summary was created but only stated patient discharged to the hospital with no detail on the care received by the hospice. This finding was reviewed with Hospice Leadership.”