Pacific Sun Hospice

“Observed in Record Review. In 1 of 10 patient records reviewed, the agency did not provide treatment or services according to the plan of care. For example: RRNHV#3, the patient had a problem identified as type 2 diabetes mellitus requiring blood glucose monitoring and insulin therapy. Interventions include Monitor blood glucose twice daily, Administer insulin per sliding scale and Metformin as ordered and Notify physician for blood glucose below 70 mg/dl or above 250 mg/dl. The skilled nurse did not assess or document blood glucose readings during routine/comprehensive nursing visits since admission for a total of four weeks. This was discussed with the DPCS and the Alternate DPCS.”

“Observed in Record Review. In 5 of 5 patient records reviewed, During RR#1 it was noted multiple goals that were not individualized and not measurable. Multiple goals were to be accomplished within 2 weeks. For example: Pt will maintain optimum peripheral circulation as manifested by absence of non-verbal signs of pain or discomfort within these two weeks, Pt/Family/PCG will verbalize having urinary elimination needs met at an acceptable level and prevent UTI within these two weeks, Pain will remain in comfortable level during care. During RR#2 it was noted that many goals were not measurable. For example: SBP to be within range of 90-160 mmHg and DBP to be within range of 60-80 mmhg within __, (no measure, left blank in the EMR), Prevent hospitalization related to hypothyroidism within these two weeks. Patient/cg to report 3-4x/week BM without discomfort within two weeks,(no evidence of constipation assessed, patient assessed to have bowel incontinence), The patient will safely participate in physical activities as tolerated within 2 weeks (patient assessed as bedridden with max assist with ADLs), Pt needs will be met on a day to day basis as communicated within these two weeks. During RR#3 it was noted many goals were not individualized and not measurable. For example: Patient will have a behavioral manifestation of decreased/absent episodes of anxiety/agitation within 2 weeks. Patient will not inflict any harm to self or others within 2 weeks (In discussion with the Administrator, there is lack of documentation in the medical record that the patient inflicted self harm or harm to others), Pt needs will be met on a day to day basis as communicated. During RR#4 it was noted many goals were the same as the other medical records reviewed. Goals not individualized with end dates within 2 weeks. For example:Pt will maintain optimum peripheral circulation during these two weeks, Patient will not inflict any harm to self or others within 2 weeks (In discussion with the Administrator, there is lack of documentation in the medical record that the patient inflicted self harm or harm to others. This goal is taken from a list within the EMR). During RR#5 it was noted many goals were the same as other medical records reviewed with end dates of within 2 weeks. For example: Pt will maintain optimum peripheral circulation, Patient will have a behavioral manifestation of absent /controlled anxiety within 2 weeks. Patient will not inflict any harm to self or others within 2 weeks. ( In discussion with the Administrator the goal was chosen from a list in the EMR. There was no documentation of self harm or harm to others). In addition RR#3 and #4 lacked goals for visits established by the spiritual counselor. This was discussed with the Administrator and DPCS.
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“Observed in Record Review. In 2 of 5 patient records reviewed, During RR#3 and RR#4 it was noted the spiritual counselor visit frequency was once a month. The POCs lacked interventions established for spiritual care. This was discussed with the Administrator and DPCS. Observed in Record Review. In 1 of 5 patient records reviewed, During RR#2 it was noted an order to cleanse Perineal area and vagina and apply triple antibiotic. The order lacked who would perform the treatment and the frequency of the treatment. This was verified and discussed by the Administrator and DPCS.”

“Observed in Record Review. In 1 of 5 patient records reviewed, During RR#1 it as noted an order for G-tube feedings of Jevity 237mL Enteral Suspension, 1 can each meal given bolus via gravity. The order lacked the flushing protocol before or after the bolus feeding. This was discussed with the Administrator and DPCS. Observed in Record Review. In 2 of 5 patient records reviewed, During RR#1 it was noted multiple medication orders with directions to be crushed and administered via a G tube. The orders lacked the flushing protocol before or after the medication administration. During RR#2 it was noted on the medication profile an order for Acetaminophen and Norco for pain. The order lacked pain scale parameters of when to administer each medication. This was discussed with the Administrator and DPCS.”