Global Hospice and Pallative Care, Inc.

“Observed in Patient Home. In 1 out 4 home visits conducted, the organization failed to maintain complete and accurate patient records. For example, in the home visit conducted for RRHV#2, the patient’s plan of care included orders and equipment for oxygen therapy. It was documented that the patient had oxygen in use at 2 LPM via nasal cannula as needed for symptom management; however, there was no oxygen equipment in the home. Upon further observation, the visiting nurse confirmed with the patient that they have never had oxygen equipment in the home. This was reviewed, discussed, and validated with the DPCS and Administrator. Observed in Record Review. In 4 out of 14 active records reviewed, the organization failed to maintain complete and accurate patient records. For example, in record review for RRNHV#1, the initial comprehensive assessment documented that the patient was on continuous oxygen at 4 LPM via nasal cannula; however, the treatment and medication list documented that the patient was on oxygen at 2 LPM via nasal cannula continuously. All follow-up documentation notes that the patient is on oxygen at 4 LPM continuously via nasal cannula. In record review for RRNHV#3, it was documented in the comprehensive assessment that the patient was on oxygen at 3 LPM as needed for shortness of breath; however, the treatment list documented that the patient was on 2 LPM as needed. In record review for RRNHV#5, the registered nurse (RN) documented in the initial comprehensive assessment that the patient was on oxygen at 2 LPM via nasal cannula continuously; however, the treatment list and plan of care indicated that it was only used as needed. In record review of RRNHV#8, the recertification assessment documented continuous oxygen use at 4 LPM; however, the plan of care notes oxygen at 2 LPM continuously. This was reviewed, discussed, and validated with the DPCS and Administrator.”

“Observed in Record Review. In 19 out of 19 records reviewed, the organization failed to ensure that the written plan of care is based on the patient’s goals and the timeframes, settings, and services required to meet those goals. For example, in all records reviewed, the plan of care did not include measurable goals. All goals were vague, not individualized, and did not include a realistic or appropriate timeframe for completion. Examples include, Patient will achieve optimal level of sleep, The patient will be free of injuries to maintain safety within the certification period, The patient will have adequate foods and fluids to maintain comfort, and The patient will have pain controlled at an optimal level. This was reviewed, discussed, and validated with the DPCS and Administrator.”

“Observed in Record Review. In 4 out of 14 records reviewed, the organization failed to plan the patient’s care. For example, in record review of RRNHV#2, the patient had a documented wound to the right heel as a result of a ruptured blister; however, there were no wound care orders or interventions listed on the plan of care. In record review for RRNHV#6, the patient had a documented stage II pressure injury to the coccyx, a right heel deep tissue injury (DTI), and a left ankle DTI; however, there were no wound care or treatment orders listed on the plan of care. In record review of RRNHV#8, the patient had a documented stage II pressure injury to the sacrum; however, there were no interventions or treatment orders included in the plan of care. In record review for RRHV#4, the patient had a documented skin tear to the right forearm, and multiple open abrasions to the right lower leg; however, there were no wound care or treatment interventions included in the plan of care. This was reviewed, discussed, and validated with the DPCS and Administrator.”

“Observed in Patient Home. In 1 out of 4 home visits conducted, the organization failed to implement activities for the prevention and control of infections and communicable diseases. For example, during the home visit conducted for RRHV#3, the Registered Nurse (RN) was observed entering her nursing bag on three separate occasions with gloved hands, and two occasions with ungloved hands. Each time the RN entered the bag on these occasions, she failed to perform hand hygiene. According to organizational policy [Policy# 9-014.1], hand hygiene must be performed prior to entering or re-entering the nursing bag. This was reviewed, discussed, and validated with the DPCS and Administrator.”

“Observed in Record Review. In 8 out of 14 active records reviewed, the organization failed to plan the patient’s care. For example, in record review for RRNHV#1 and RRNHV#9, the patient’s were documented to be on continuous oxygen at 4 LPM via nasal cannula; however, the aide care plan’s did not include instructions detailing if the oxygen could be removed during the bed bath. For RRNHV#5, the patient was documented to be on oxygen at 2 LPM via nasal cannula continuously; however, the aide care plan did not indicate if the oxygen could be removed during the bed bath. For RRHV#1, RRHV#4, RRNHV#3, RRNHV#8, and RRNHV#10, the patient’s were documented to be on oxygen at 2 LPM via nasal cannula as needed; however, the aide care plan’s did not include instructions for what to do if oxygen was in use during aide visits. This was reviewed, discussed, and validated with the DPCS and Administrator.”

“Observed in Patient Home. In 2 out of 3 home visits conducted with an observed medication reconciliation, the organization failed to ensure the patient record contains information that reflects the patient’s care, treatment, or services. For example, in the home visit conducted for RRHV#3, the patient was noted to be taking Tylenol ES 500 mg one tablet every four hours as needed for mild pain; however, this medication was not listed on the medication profile in the home or medical record. In the home visit conducted for RRHV#4, the patient was noted to be taking Lorazepam 0.5 mg every four hours as needed; however, this was not listed on the medication profile in the home or medical record. Upon further review, the medication profile included Miconazole nitrate powder to be applied topically three times a day for 14 days; however, this medication was not present in the home and had been discarded eight months prior. It was also noted that the medication profile included Imodium A-D 2 mg caplet to be taken once daily as needed; however, this medication was not present in the home. This was reviewed, discussed, and validated with the DPCS and Administrator.”