Bridge Hospice

“Upon patient record review, 1 of 5 (Patient #5) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 5: The medical record contained nursing documentation upon admission identifying patient suffered a fall recent to admission and was a high risk for falls. There was no evidence of problems, goals, and interventions related to fall safety included in the initial plan of care.”

“Upon patient record review, 3 of 5 (Patients #2,#4,#5) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient 2: The medical record contained nursing documentation upon admission identifying patient use of an over the bed table, and an order for nebulized duoneb identifying use of a nebulizer. There was no evidence of orders for the table and nebulizer included in the plan of care. Corrected on site. Patient 4: The medical record contained an order for nebulized albuterol identifying patient use of a nebulizer. There was no evidence of an order for the nebulizer included in the plan of care. Corrected on site. Patient 5: The medical record contained nursing documentation upon admission identifying patient use of a wheelchair. There was no evidence of an order for the wheelchair included in the plan of care.”

“Upon patient record review, 3 of 19 (Patient #1,2,4) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: Patient 1:Medication profile contains Docusate Sodium, Dulcolax, Haldol, Percocet, lorazepam, loperamide however, the facility MAR did not have these meds. Corrected on site. Patient 2:Medication profile contains Acetaminophen 650 rectal, calcium carbonate, loperamide,Morphine, Prilosec, quetiapine however, the facility MAR did not have these orders. Corrected on site. Patient 4: The medication profile has Loratadine daily PRN, facility has ordered daily. Corrected on site.”

“Upon patient record review, 4 of 19 (Patient #3,4,10,14) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 3: Pt has a fall mat on her DME list on POC though no fall risk care plan initiated. Corrected on site. Patient 4: SN documented in initial assessment pt. has history of several falls. No fall care plan initiated. Corrected on site. Patient 10: The MD documented on initial CTI 2/22/24 pt. with dysphagia. There was no risk for aspiration care plan initiated. SN documented on initial assessment 2/22/24 pt. with “left sided paralysis, max assist with ADL’s. There was no fall risk care plan initiated. Pt is on Eliquis and there is no risk for bleeding care plan initiated. Corrected on site. Patient 14: SN documented uses a w/c on initial assessment. however, there is not fall risk care plan initiated.”

“Upon patient record review, 3 of 19 (Patient #3,4,9) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: Patient 3: The POC 5/21/24 contains nursing orders with 12 PRN nursing visits which is not a detailed statement of the scope and frequency to meet individual patient needs. Patient 4: The POC 5/21/24 contains nursing visit orders with 9 PRN visit orders which is not a detailed statement of the scope and frequency to meet individual patient needs. Patient 9: The medical record contains an order on 5/15/24 to add 6 PRN SN visits for symptom management which is not a detailed statement of the scope and frequency to meet individual patient needs.”

“Upon patient record review, 14 of 19 (Patient #1,2,3,4,5,6,8,9,10,11,12,16,17,18) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patients 1,3,5,6,8,9,10,11,12,17,18: Initial POC has orders to educate patients on how to use O2 safely and monitor effectiveness. There is no O2 ordered. Patients are not on O2. Corrected on site. Patient 1: POC 4/22/24 contains Docusate Sodium, Dulcolax, Haldol, Percocet, lorazepam, loperamide however, the facility MAR did not have these meds. Corrected on site. Patient 2: Pt has a Foley catheter inserted on 4/26/24 there is no evidence of order. Corrected on site. POC 6/9/24 Acetaminophen 650 rectal, calcium carbonate,loperamide,Morphine, Prilosec, quetiapine the facility MAR did not have these orders. Corrected on site. Patient 3: Order 5/20/24 “clean with NS pat dry apply triple ATB ointment & cover with foam”, no frequency or who to perform. 5/30/24 SN documented “Skin sensitive when TED hose removed”. No order for TED hose. Corrected on site. Patient 4: POC 5/21/24 with Loratadine daily PRN, facility has ordered daily, POC has Quetiapine daily the facility does not have this order. It was discontinued 5/9/24 per the medical record but remained on POC 5/21/24. Corrected on site. Patient 5: Foley orders 1/16/24 & 3/31/24 have Irrigation orders with no amount of NS and frequency to flush and change every 30 days and PRN no reason. Corrected on site. Patient 6: POC 1/25/24& 4/24/24 “May irrigate Foley with NS” no amount or frequency. Corrected on site Patient 16: Order 3/19/24 “Pleurex drain cleanse site & redress every time fluid is drained”. No cleansing agent, dressing ordered or frequency. Patient 17: POC 4/14/24 “Change catheter every 31 days and as needed with no reason”. Patient 18: Order 6/8/23 “Supplies-incontinent and skin care”. POC 6/4/23 Foley orders with “may irrigate with NS no amount and change every 30 days and PRN with no reason.”

“Upon patient record review, 4 of 19 (Patient #1,3,6,8) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient 1: The POC has Oxygen on the DME list. Pt does not have oxygen orders. Corrected on site. Patient 3: Upon home visit finding pt. has a lift chair. This was not ordered on the POC. Corrected on site. Patient 6: SN documented on 5/31/24 “pt. in w/c”. There is no order for a w/c. Corrected on site. Patient 8: SN documented on initial assess 1/24/24 “pt. following wife around house with walker”. There are no orders for a walker on the POC 1/24/24 or 4/9/24. Corrected on site.”

“Upon patient record review, 2 of 19 (Patient #1,2) did not have evidence that a revised plan of care includes information from the patient’s updated comprehensive assessment and must note the patient’s progress towards outcome/goals from the plan of care. Patient 1: The SN documented 4/9/24 recertification assessment that pt. is a high fall risk. There is no fall care plan initiated. Corrected on site. Patient 2: Upon home visit finding, pt. has a Foley. Per SN documentation the Foley was place 4/26 however, there are no problems/goals/interventions related to new need.”

“Upon client record review, 7 of 19 (Patient #2,3,5,6,10,14,16) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 2: The SN documented inserting a Foley catheter on 4/26/24, did not document technique used and there is no order for a Foley. On 5/23/24 the SN documented irrigating the Foley with 60cc NS with no order to irrigate. Corrected on site. Patient 3: 5/21/24 SN documented “Skin tears to BUE, band aid applied to LUE and steri strip to RUE”. There is no order. Patient 5: On 6/14/24 SN documented Foley catheter changed inserted 18fr 8cc balloon. Pt did not tolerate 10cc’s. Order is for 18fr 10ml balloon. There is no evidence of a new order obtained for the smaller balloon size. Patient 6: POC orders to change catheter every 30 days and PRN. There is evidence the pt. had the Foley upon admission 1/25/24. The SN did not change the Foley until 3/14/24 and nurse documented “writer did take out old catheter and inserted new 16fr catheter”. The order is for a 20fr 10cc balloon catheter. The next change of the Foley is documented 4/21/24 which is greater than 30 days. The nurse documented 6/11/24 “catheter cloudy with sediment”. Then made another PRN visit 6/11/24 for the Foley becoming dislodged. SN documented “F/C reinserted 20fr draining clear yellow”. There is no evidence of an order to keep Foley in place greater than 30 days. Patient 10: SN documented 6/17/24 “Application of barrier cream” There is no order for barrier cream. Corrected on site. 6/7/24 SN documented “pt. was evaluated by SNF ST and diet changed from puree to mechanical soft, chopped diet and nectar thickened fluids”. There is not order for the ST eval or diet change in the record. Corrected on site diet order. Patient 14: The SN documented on initial assessment 3/10/23 “oxygen initiated” There was no order at that time for oxygen. There was not order for oxygen until 10/31/23. Patient 16: On 3/21/24 “Writer drained 1000cc from Pleurex drain” there is no evidence the SN completed cleansing of site,a dressing change each time the fluid was drained as ordered. There is no description of the fluid drained.”

“Upon patient record review 1 of 19 (Patient #19) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Patient 19: The SN documented 6/16/23 “Grand daughter giving morphine every 3 hours and Ativan every 6 hours, reports being exhausted. Offered MS to f/u with VA for possible long term placement. Declines at this time. Educated on caregiver expectations” There is no evidence that a respite stay was offered to meet the needs of the patient/family.”

“Upon personnel record review, 1 of 13 (Personnel #5) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) Personnel 5: The aide did not have evidence of performing a competency for the following tasks upon hire or annually: ·Reading and recording temperature, pulse, and respiration ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(A) Bed bath ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed ·(D) Nail and skin care ·(E) Oral hygiene ·(F) Toileting and elimination”

“Upon patient client record review, 8 of 19 (Patient #1,2,4,5,6,9,11,16) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient 1: The SN documented on 6/13/24 Oxygen in home is safely stored and pt understands use. Pt is not on oxygen. 6/11/24 SN documented “DD/T” this is not an approved abbreviation. The SN documented wound care on 6/3/24 “Cleanse with NS and apply dry dressing, wound care to be provided by facility staff every 3 days and prn for soiling, wound care performed”. The care needs to be in past tense indicating what the nurse performed. Patient 2: SN documented 6/11/24 “Tx done by RNCM per MD order” which does not contain details of treatment performed. Patient 4: SN documented “RP aware”. This is not an approve abbreviation. 6/13/24 SN documented “wound care to great toe provided per doctors orders” which does not contain details of wound care completed. Patient 5: SN documented 6/15/24 “foley flushed and working properly”. 5/14/24 SN documented “Inserted 18fr 10cc balloon foley catheter per agency protocol” which does not contain details of how nurse provided care. Patient 6: RN documented 2/21/24 “Catheter bag changed and catheter flushed” which does not say what it was flushed with. Patient 9: SN documented 6/13/24 “collaborated with HMD”. This is not an approved abbreviation. Patient 11: SN documented on 6/5/24 “PRN visit due to COC”. This is not an approved abbreviation. Patient 16: The SN documented on 3/17/24 “Removed 1000cc of fluid and placed dressing over insertion site”. Does not state type of dressing applied or the cleansing of the site.”

“Upon patient record review, 2 of 19 (Patient #1,2) did not have evidence that the hospice provided the following information: Patients 1,2: The facility hospice chart did not contain evidence of: The most recent hospice plan of care specific to each patient, Hospice election form and any Advance Directives specific to each patient, Physician certification and recertification of the terminal illness specific to each patient, Names and contact information for hospice personnel involved in hospice care of each patient, Hospice medication information specific to each patient, Hospice physician and attending physician (if any) orders specific to each patient.”