Treasure Coast Hospice of Martin

“Observed in Record Review. In 6 of 20 patient records reviewed, it was noted the organization failed to ensure that the hospice plan of care plan includes all services needed for the palliation and management of the terminal illness and related conditions, including medications necessary to meet the patient’s needs. For example in HOSRRHV#1, Hydromorphone 1mg/ml PRN for pain and Acetaminophen 650 mg supp PRN, the orders did not include specific indications to differentiate the use of each medication, such as mild, moderate, or severe pain. HOSRRHV#2, Xanax Tablet 0.5 mg 2 tablets Oral at bedtime to take 2 tablets PO at bedtime and 1/2 tablet (0.25 mg) 1 tablet by mouth every 4 hours as needed, however, the orders did not include specific indication for use. HOSRRHV#5- Acetaminophen 650 mg supp. PRN for mild pain and Hydromorphone HCl 1 mg PRN for pain/sob, however, the orders did not include specific indication for use. HOSRRHV#6 -Acetaminophen 650 mg supp. PRN for mild pain and Hydromorphone HCl 1 mg PRN for pain/sob, however, the orders did not include specific indication for use.HOSRRNHV#7, multiple PRN pain medications i.e., Acetaminophen 650 mg suppository PRN for pain; Hydromorphone 1 mg PRN for pain, and Oxycodone-Acetaminophen 10-325 mg PRN for pain, were ordered for pain management; however, the orders did not include specific indications to differentiate the use of each medication, such as mild, moderate, or severe pain. HOSRRNHV#18 - Acetaminophen 650 mg supp. PRN for mild pain and Hydromorphone HCl 1 mg for pain/sob, however, the orders did not include specific indication for use. This finding was discussed and validated by the Director of Compliance and Director of Education.”

“Observed in Record Review. In 6 of 10 active patient records with hospice aide services, it was noted the organization had failed to ensure that the written patient care instructions for a hospice aide must be prepared by a registered nurse who is responsible for the supervision of a hospice aide. For example, in HOSRRHV#5, the aide care plan did not contain instructions related to oxygen safety precautions for a patient receiving oxygen therapy, nor did it include guidance for reporting signs and symptoms of bleeding associated with antiplatelet medication such as Aspirin. HOSRRHV#6, the aide care plan did not contain instructions related to oxygen safety precautions for a patient receiving oxygen therapy. HOSRRNVH#7, the aide care plan did not contain instructions related to oxygen safety precautions for a patient receiving oxygen therapy, nor did it include guidance for reporting signs and symptoms of bleeding associated with anti-coagulant/antiplatelet medications, including Aspirin and Plavix. HOSRRNHV#8, the aide care plan did not contain instructions related to bleeding precautions as it did not include guidance for reporting signs and symptoms of bleeding associated with antiplatelet medications, such as Aspirin. HOSRRNHV#11, the aide care plan did not contain instructions related to oxygen safety precautions for a patient receiving oxygen therapy, nor did it include guidance for reporting signs and symptoms of bleeding associated with antiplatelet medications, Aspirin. HOSRRNHV#15, the aide care plan did not contain instructions related to bleeding precautions as it did not include guidance for reporting signs and symptoms of bleeding associated with antiplatelet medications, such as Aspirin. This finding was discussed and validated by the Director of Compliance and Director of Education.”

“Observed in Record Review. In 3 of 23 patient records reviewed, In the In-Patient Unit (IPU), the Certified Nursing Assistant (CNA) was ordered to obtain vital signs measurements. Review of three (3) shift notes contained no documentation that vital signs were obtained, and one (1) note contained incomplete vital sign documentation with temperature and pulse rate measurement missing. During an interview, the IPU Nurse Manager stated that CNAs document vital signs on a paper record rather than in the electronic medical record. However, the Nurse Manager was unable to provide the paper documentation (VS log) for review, explaining that the vital sign logs were not uploaded in the EMR and had already been shredded. Therefore, there was no evidence available to verify that the vital signs were obtained and documented as required. This finding was discussed and validated by the Inpatient unit Manager.”

“Observed in Record Review. In 2 of 23 patient records reviewed, it was noted that the organization failed to ensure that all documentation entries were appropriately authenticated and dated. For example in HOSRRDC#1, reviewed of the paper-document DC Instructions revealed that the document was signed and dated; however, the signature did not include a professional credentials. Also noted in record HOSIn-patient#1, review of the IPU clinical record revealed that a CNA clinical note remained unsigned for four days after the care was provided. During an interview , the IPU nurse Manager stated that the CNA clinical notes are expected to be completed and electronically signed before the end of each shift. This finding was discussed and validated by the Director of Compliance, Director of Education, and IPU Nurse Manager.”

“Observed in Record Review. In 7 of 20 patient records reviewed, the organization failed to evaluate the patient’s understanding of the education and training provided. For example, HOSRRHV#1, the hospice nurse documented teaching related to pain management, however, the patient’s/caregiver’s response to the education was not documented. There was no evidence that understanding of the instructions was assessed or validated. HOSRRHV#2, the hospice nurse documented teaching related to dietary modification to manage bowel function and pain relief measures, however, the patient’s/caregiver’s response to the education was not documented. HOSRRHV#4, the hospice nurse documented teaching related to hydration and maintain proper fluid intake; causes and management of nausea, however, the patient’s/caregiver’s response to the education was not documented HOSRRNHV#8, the hospice nurse documented teaching the patient/family regarding oxygen safety; however, the record lacked documentation of the patient’s or caregiver’s response to the education, including understandin, comprehension, or need for reinforcement. HOSRRNHV#9, the hospice nurse documented teaching related to maintaining a safe environment; however, the patient’s or caregiver’s response to education was not documented. HOSRRNHV#10, the hospice nurse documented educating the patient/caregiver’ on pressure relief measures to prevent further skin breakdown; however, the patient’s or caregiver’s response to the teaching was not documented. HOSRRNHV#11, the hospice nurse documented educating the patient/caregiver’ on pain management, however, the patient’s or caregiver’s response to the teaching was not documented. This finding was discussed and validated by the Director of Compliance and Director of Education & Quality..”