Comfort and Peace Hospice

“Observed in Record Review. In 16 of 18 patient records reviewed, The patient POCs did not have measurable outcomes to assess progress toward accomplishing goals established for HV#1, HV#2, HV#4, HV#5, HV#6, and RR#1-RR#11. For example: During HV#1 record review it was noted the goals lacked individualized outcomes measures to assess progress: Caregivers/patients will verbalize strategies to manage pain and enhance patient comfort, facility staff/family will verbalize/express understanding of medication /treatment orders and side effects, Caregivers/Patient will verbalize ways to address emotional well-being and provide support for the patient`s emotional needs, Patient will have appropriate maintenance of mental and psychological function as long as possible and reversal of behaviors when possible, Patient/caregivers will demonstrate behaviors to address emotional distress and promote a sense of calm and well-being. During HV#2 record review the following goals lacked measurable time frames to assess progress toward accomplishing goals: Facility staff will express understanding of measures to prevent falls, Facility staff will verbalize having urinary elimination needs met at an acceptable level. Patient will have less frequent episodes of urinary tract infections and skin breakdown, caregiver will verbalize understanding of steps to take in case of skin problems related to urinary incontinence, caregiver will verbalize understanding of steps to take in case of skin problems related to fecal/urinary incontinence. Pt/pcg will verbalize/express understanding of medication /treatment orders and side effects, Patient will ingest appropriate nutritional requirements in accordance to their activity level and metabolic needs, Facility staff will verbalize strategies to manage pain and enhance patient comfort. HV#3 record review lacked measurable goals to assess if accomplished: Patient will demonstrate behaviors to minimize symptoms such as shortness of breath, fatigue, and edema, Facility staff will demonstrate understanding of medication/treatment orders, Facility staff will demonstrate understanding on how to care for bowel incontinence. During RR#1 it was noted multiple goals without measurable time frames to assess if goals accomplished, for example: Caregivers/patients will verbalize strategies to manage pain and enhance patient comfort. During RR#2 it was noted multiple goals without measurable time frames to assess if goals accomplished, for example Facility staff/Family will verbalize having elimination needs met at an acceptable level, Patient/caregivers will verbalize methods to ensure the patient’s comfort and maintain their preferred positioning, Caregivers/patients will verbalize strategies to manage pain and enhance patient comfort. During RR#3 it was noted multiple goals without measurable outcome time frames, for example: Facility staff/Family will verbalize having elimination needs met at an acceptable level, Pt will have adequate food and fluids as tolerated or desired, Caregivers/patients will verbalize strategies to manage pain and enhance patient comfort, Pt will have all needs met, Complete final arrangements. Pt/ Family/PCG will verbalize concerns or needs regarding desired spiritual support. This was discussed with the organization leadership.”

“Observed in Record Review. In 13 of 18 patient records reviewed, During RR#2 it was noted on the POC neurological deficits with goals however there were no interventions added to accomplish the goals. In addition there was a cardiac issue added to the POC however the RN initial assessment documented the cardiac status components as WNL. During RR#3 it was noted cardiac interventions were added to the POC however the initial RN assessment indicated no cardiac issues noted. During RR#4 it was noted cardiac, respiratory and infection interventions were added to the POC after the RN initial assessment, however the RN assessment for those body systems were as follows cardiac: regular rhythm, no edema, no implanted cardiac device, pulses intact, no jvd, respiratory: LCTA, even/unlabored breathing, no cough, no wheezes, 99% on RA, immunological/infection: no active infection at this time. During RR#5 it was noted the POC had interventions related to a risk for infection however the RN assessment documentation was: no current antibiotic resistant infection, no hx of antibiotic resistant infection and no current active infection. The patient had a hx of seizures with Dilantin and Phenobarbital ordered. The neurological/emotional issue on the POC lacked interventions on seizure activity and precautions. During RR#6 it was noted the patient was at a risk of aspiration documented on the initial RN assessment however interventions on aspiration precautions and instruction to the family was not added to the POC. During HV#4, HV#5, RR#8, RR#9 it was noted lack of interventions on the POC for the music therapist (MT). During RR#8 it was noted lack of interventions related to instruction on aspiration risk and precaution with a goal that the patient would not experience aspiration. During RR#9 it was noted a goal to minimize the risk of URI, without interventions on the POC. During RR#10 it was noted lack of fall preventions interventions related to the goal of fall prevention. In addition, the beginning of July 2025 the patient had a F/C inserted however there were no interventions added to the POC related to F/C care as the GU interventions were established for urinary incontinence during the RN initial assessment. During RR#11 it was noted the cardiac and respiratory systems were documented without deficits by the RN during the initial assessments however there were interventions added to the POC for cardiac and respiratory issues. During RR#12 it was noted a respiratory goal without interventions added to the POC. This was discussed with the organization leadership.”

“Observed in Record Review. In 2 of 18 patient records reviewed, During RR#6 it was noted an order for an oxygen concentrator on the RN initial assessment. The POC respiratory problem intervention stated Assess the patient’s oxygen needs and administer supplemental oxygen therapy as prescribed. The POC lacked an order for the oxygen liter flow if needed for dyspnea. During RR#5 it was noted an order for oxygen therapy at 2-5 L as needed for shortness of breath. The order lacked the titration parameters for the different liter flows. This was discussed with the organization leadership.”

“Observed in Record Review. In 2 of 18 patient records reviewed, It was noted the POC orders were not followed. During HV#3 record review it was noted a frequency of 4x/month for the volunteer starting in June 2025. The visits for June were 3 and for July there were 5 visits documented. During RR#7 it was noted the frequency of volunteer of 2x/month on the POC was not followed. The visits ranged from 4 to 5 visits/mo. In addition RR#7 POC order to assess the diabetic status was not followed by the SN. There was lack of documentation on SN visits that the diabetic status was assessed and the order for BS prior to breakfast each day was not recorded by the SN as reviewed. This was discussed with the organization leadership.”

“Observed in Record Review. In 2 of 18 patient records reviewed, During HV#1 record review it was noted the aide assignment form lacked, in the additional instruction section of the form, interventions to address the patient’s legally blind vision deficit. During HV#2 it was noted the hospice aide had compression hose for the patient to apply after the shower. Upon review of the patient medical record it was noted an order to d/c the compression stockings the beginning of July 2025. The aide assignment form was not updated to include this change. This was discussed with the organization leadership.”