Optimal Hospice Care

“Observed in Record Review. In 3 of 16 patient records reviewed, During RRHV# 1, RRHV# 2, and RR# 4’s patient records review it was noted the organization had not ensured it assessed the patient’s pain per organization policy Pain Assessment No. 2-032 that included worst pain, least pain, and pain goal. For example: review of RRHV# 1’s patient record revealed the start of care RN comprehensive assessment with documentation that RRHV# 1 had a pain intensity of mild with current pain management was not acceptable to RRHV# 1. However, further review of the RN comprehensive assessment revealed no documentation of the worst level of pain, best level of pain or pain goal. Review of RRHV# 2’s patient record revealed documentation that RRHV# 2 verbalized pain on movement that was mild. However, further review of RRHV# 2’s patient record revealed no documentation of the worst level of pain, best level of pain or pain goal. Review of RR# 4’s patient record revealed documentation that RR# 4 had a pain intensity of mild. However, further review of RR# 4’s patient record revealed no documentation of worst level of pain, best level of pain or a pain goal. This was reviewed, discussed, and validated with the Clinical Manager,”

“Observed in Record Review. In 1 of 16 patient records reviewed, During RRDC# 1’s patient record review it was noted the organization had not ensured it maintained accurate patient records. For example: review of RRDC# 1’s patient record revealed Interdisciplinary Group (IDG) documentation that RRDC# 1 was no longer eligible for hospice due to extended prognosis and discharge planning to ensure a smooth transition back into the community. Further review of RRDC# 1’s patient record revealed documentation four days prior to discharge by the Medical Director stating patient is still appropriate for hospice. This was reviewed, discussed, and validated with the Clinical Manager.”

“Observed in Record Review. In 6 of 16 patient records reviewed, During RRHV# 1, RRHV# 2, RRHV# 4, RR# 4, RR#5, and RR# 6’s patient records review it was noted the organization had not ensured the patient’s plan of care was based on the individual patient’s goals and the time frames, setting, and services required to meet those goals. For example: review of RRHV# 1, RRHV# 2, RRHV# 3, RR# 4 and RR# 5’s patient plans of care revealed the pain goal “patient will be pain free or verbalize an acceptable pain level with current pain management”. Further review of RRHV# 1, RRHV# 2, and RR# 4’s patient records revealed no documentation of an acceptable pain level/goal. Further review of RRHV# 3’s patient record revealed RRHV# 3 was unable to verbalize pain. Further review of RR# 5’s patient record revealed documentation that RR# 5 had a pain goal of mild. Review of RRHV# 4’s patient record revealed RRHV# 4 had a wound to the left heel with interventions. However, further review of RRHV# 4’s plan of care revealed no documentation of a wound goal. Review of RR# 6’s patient record revealed RR# 6 had a volunteer with three documented volunteer visit notes. However, review of RR# 6’s plan of care revealed no goals for the volunteer. This was reviewed, discussed, and validated with the Clinical Manager.”

“Observed in Record Review. In 1 of 16 patient records reviewed, During RR# 6’s patient record review it was noted the organization had not ensured the patient’s plan of care included a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs. For example: review of RR# 6’s patient record revealed three volunteer visit notes. Review of RR# 6’s plan of care revealed no documentation of a volunteer or a frequency of visits. This was reviewed, discussed, and validated with the Clinical Manager.”

“Observed in Record Review. In 2 of 16 patient records reviewed, During RRHV# 3 and RR# 5’s patient records it was noted the organization had not ensured the patient’s plan of care included drugs and treatments necessary to meet the needs of the patient. For example: review of RRHV# 3’s medication profile revealed an order for Trazodone 50mg tablet take 1 and 1/2 tablet by month. However, there was no documentation of the dose of 75mg. Review of RR# 5’s plan of care RR# 5 had multiple wounds to include a Stage 4 pressure ulcer to the coccyx with wound care dressing changes to be completed by the Skilled Nursing Facility (SNF). However, further review of the plan of care revealed no documentation of what wound care was being done or how often the wound dressings were changed. This was reviewed, discussed, and validated with the Clinical Manager.”

“Observed in Record Review. In 4 of 14 patient records reviewed with hospice aide, During RRHV# 3, RRHV# 4, RR# 7, and RR# 9’s patient records review it was noted the organization had not ensured the registered nurse (RN) prepared complete written patient care instructions for the hospice aide. For example: review of RRHV# 3’s patient record revealed RRHV# 3 had a co-morbidity diagnosis of Seizures with an anticonvulsant medication. Review of RRHV# 3’s hospice aide patient written instructions revealed no documentation of seizure precautions. During RRHV# 4’s patient record review revealed RRHV# 4 had a wound to the left heel with a wound dressing. Review of the hospice aide patient written instructions revealed the task of a shower. Further review of the hospice aide patient written instructions revealed no documentation of a wound or instructions on what to do if the wound dressing was to get wet during a shower. Review of RR# 7’s patient record revealed RR# 7 was a risk for fall and had oxygen at 2lpm via nasal cannula intermittently. However, review of RR# 7’s hospice aide patient written instructions revealed no documentation of fall precautions or oxygen precautions. Review of RR# 9’s patient record revealed RR# 9 had oxygen at 2lpm via nasal cannula. However, review of RR# 9’s hospice aide patient written instructions revealed no documentation of oxygen precautions. This was reviewed, discussed, and validated with the Clinical Manager.”

“Observed in Patient Home. In 1 of 3 Home visits conducted with medication reconciliation, During RRHV# 1’s home observation it was noted the organization had not ensured the patient record contained information that reflected the patient’s treatment. For example: during RRHV# 1’s home observation the RN was observed completing a medication reconciliation that revealed RRHV# 1 had been taking Dulcolax stool softener daily for constipation and Voltaren topical cream to the right wrist as needed for pain for approximately two months prior to the home observation. In addition, review of the Assisted Living Facility’s (ALF) medication administration record revealed Ipratropium Bromide two sprays orally/INH three times a day dated approximately 10 weeks prior to the home observation. However, the hospice medication profile revealed Ipratropium nasal 42 mcg/INH spray, administer 2 spray(s) intranasally three times a day. This was discussed, and validated with the Clinical Manager.”

“Observed in Record Review. In 1 of 3 patient records reviewed with live discharge, During RRDC# 1’s patient record review it was noted the organization had not ensured it provided the physician with the discharge summary after a discharge to the community. For example: review of RRDC# 1’s patient record revealed RRDC# 1 was discharged from hospice due to extended prognosis approximately 35 days prior to the surveyor review of the record. Further review of RRDC# 1’s patient record revealed no documentation of a discharge summary. This was reviewed, discussed, and validated with the Clinical Manager.”