Advantage Health Systems

“Observed in Record Review. In 3 of 16 patient records reviewed, the initial bereavement assessment not completed per organizational policy. In the Bereavement Policy 2-010.1 it states that bereavement services will be provided to the family and caregivers of hospice patient at the time of admission. In HOSRRNHV #2 the nephew and niece did not have a bereavement assessment completed. In HOSRRNHV #4 the bereavement assessment was not completed on the daughter and stepdaughter. In HOSRRNHV #6 the son in law that lives with the patent was not assessed for bereavement. This was reviewed and validated with the DPCS.”

“Observed in Patient Home. In 3 of 4 home visits conducted, the organization failed to maintain accurate Plan of Care. The hospice surveyor observed in HOSRRHV #1 the care plan states to provide wound care to the patient’s right ingrown thumb. The skin assessment shows that the wound care is being provided to the right ingrown large toe. In HOSRRHV #2 the patient had Propranolol HCL 40 mg ordered with a parameter for dosing documented as below HR of 160. When the RN was questioned on this she stated this was a typographical error and that it should read HR below 60. In HOSRRHV #2 the patient was using a Miconazole antifungal powder to the groin area daily and this was not documented on the medication list. In HOSRRHV #3 the following medications were on the medication list but missing from the assisted living, Acetaminophen 650 mg suppository 1 every 6 hours for mild pain, Ativan .05 mg 1 tab every 4 hours as needed for anxiety and agitation, Bisacodyl 10 mg rectal suppository prn for constipation, and Imodium A-D 2 mg 2 tablets as needed for loose stools. This was reviewed and validated with the DPCS. Observed in Record Review. In 2 of 16 patient records reviewed, the organization failed to maintain complete and accurate patient records. In HOSRRNHV #3 5 days prior to the record review the RN documented that the patient had a foley in place and on a visit done one month ago the nurse documented that a Coude tipped catheter was used. This is a female patient and does not have any type of indwelling catheter per the DCPS. In HOSRRNHV #3 there is a care plan for aspiration but there is no documentation in the assessment that the patient has dysphagia or has aspiration issues. In HOSRRDC #2 Oxygen in care plan states 3-4 liters and the Respiratory section in the admission assessment states patient is on 2 Liters. The flow rate in the RN assessment is inaccurate. The DPCS states that at this time the oxygen was not placed on the medication list it was added to the care plan. This was reviewed and validated with the DCPS.”

“Observed in Record Review. In 6 of 14 patient records reviewed, the hospice surveyor noted that the agency had not ensured that the goals established on the plans of care included measurable outcomes and individualized as required by regulation. For example in HOSRRHV #1 the pain goals states that the patient will have an acceptable pain level of 3/10 in 8 weeks. An observational pain tool was used and moaning and grimacing were the how the patient showed her pain there is no way to measure a verbal pain level. Per the organizational policy on Pain Assessment 2-032.1 if the patient is unable to communicate pain using the rating scale, is cognitively impaired, the clinician will assess behavioral factors that signal pain or discomfort and include this information in the assessment. In HOSRRNHV #2 the pain goal states to maintain a level of pain that is acceptable. There is no definition of what the patient considers an acceptable level of pain control. A verbal descriptor tool was used to assess pain but a pain goal was not assessed for this patient per agency policy Pain Assessment 2-032.2 that when using a verbal descriptor and pain is assessed the patient’s pain goal needs to be documented. In HOSRRHV #2 the patient had a pain goal that at every visit the nurse would assess pain using a standardized pain scale (numeric) within 8 weeks. The patient’s pain goal had not been assessed and the patient is currently taking Hydrocodone every 4 hours for pain and Roxanol 5 mg for breakthrough pain. In HOSRRHV #4 the nurse used a verbal descriptor to assess for pain but did not enter a pain goal for the patient. In HOSRRNHV #4 the patient had a pain score of 3 and no pain goal was assessed. The care plan states that the patient will verbalize relief from pain from 3/10 to 1/10. This is not the patient’s goal as it was not assessed. Per the Pain Assessment policy an observational goal should have been used. In HOSRRNHV #7 the RN created a care plan for pain to the patient’s lower extremities. The RN did not assess the patient specific pain goal in her assessment. The pain goal states the pain in the lower extremities will be managed and the goal of 4/10 will be met. This was not a patient specific pain goal. This was reviewed and validated with the DPCS. Observed in Record Review. In 1 of 14 patient records reviewed, the organization failed to individualize time frames to meet the care plan goals. In HOSRRHV #1 all of the goal timeframes ended in 8 weeks, this included care plans for pain, anxiety, and nutrition. The nurse surveyor noted during the home visit where the patient was combative and anxious when the HHA was giving her a bath and brushing her teeth. Pain and anxiety had not been addressed as a priority. The patient was also ordered a pureed liquid diet due to aspiration risk during the home visit the spouse stated that he had fed her cake just a few days earlier. This was reviewed and validated with the DPCS.”

“Observed in Record Review. In 1 of 16 patient records reviewed, wound care orders changed and the organization failed to update the most recent orders. In HOSRRNHV #6 the patient had a stage 3 pressure injury on his sacrum and there were no orders for the dressing change for 3 visits in July. The dressing change provided was to cleanse the area with wound cleanser, pat dry, apply medi honey to the area and cover with a bordered gauze. There was no documentation of a signed order for the three visits. This was reviewed and validated with the DPCS. Observed in Record Review. In 1 of 16 patient records reviewed, the organization failed to plan the patient’s care. In HOSRRNHV #1 the patient was on Aspirin 81 mg per day and the RN did not create a care plan addressing the bleeding risk. This was reviewed and validated with the DPCS. Observed in Record Review. In 1 of 16 patient records reviewed, the surveyor noted that duplicate medications had been ordered and the instructions for use were not clear. In HOSRRNHV #1 the patient had Acetaminophen 325mg 2 tab q 6 hrs. as needed for mild pain, Acetaminophen rectal suppository 650 mg every 4 hours as needed for mild pain/fever, Hydrocodone Acetaminophen 5-325 mg 2 tab every 6 hours as needed for severe pain, Hydrocodone Acetaminophen 5-325 mg 1 tab every 6 hrs. as needed for moderate pain, IBU 800 mg 1 every 6 hours for pain, Roxanol 20 mg every 2 hrs. SL as needed for severe pain and SOB, Roxanol 10 mg every 2 hours SL as needed for mod pain and SOB, Roxanol 5 mg every 2 hrs. SL as needed for mild pain/SOB, Tramadol HCL 50 mg 1 tab 3 times per day as needed for pain, and Tylenol extra strength 500 mg 1 tablet every 6 hours as needed for pain. It is not clear when to take one over the others in for the varying levels of pain. This was reviewed and validated with the DPCS.”

“Observed in Record Review. In 3 of 16 patient records reviewed, wound care not documented per organizational policy law and regulation. In HOSRRNHV #4 two times in July the RN did not document the wound care provided to the patient to the right elbow skin tear and the Left heel stage 3 pressure injury. In HOSRRNHV #6 there was no documentation in the record for wound care documentation on three separate visits in July. The organizational policy states wound care will be provided per the intervention with each visit. In HOSRRNHV #8 in IDT in June the record showed that the providers ordered Midodrine 5 mg po every day due to low BP the medication was not added to medication list. This was reviewed and validated with the DPCS.”