Ogeechee Area Hospice, Inc.

“Observed in Record Review. In 1 of 10 patient records reviewed, The hospice nurse surveyor noted (ARR#1) that there was no evidence in the patient record to confirm that education and training was tailored to the patient’s needs related to medication use, dosing and frequency for pain management. The surveyor noted that the call log indicated that the patient’s caregiver called on day five (5) to report that they had given the wrong dose of Methadone. Upon review of the two previous encounter notes, there was no evidence that the caregivers were provided instruction about dosing and administering the appropriate medications. The patient had three pain medications ordered including Morphine ER routine dosing, Methadone routine dosing and oxycodone prn. This was confirmed with the nurse educator.”

“Observed in Record Review. In 1 of 10 patient records reviewed, The hospice nurse surveyor noted (ARR#1) that there were no nursing frequency orders obtained for a patient admitted with severe pain. The surveyor noted that the patient has an assessed pain score of 10/10; however, because there were no frequency orders, a visit was not completed to reassess the patient until the family called to report that they had given the wrong medication (five days later). A prn routine tuck in call the day after admission did not include a pain assessment. When the nurse assessed the patient’s pain on the next visit (five days later), it was still 9/10 with movement. Also, the family reported that the patient had not had a bowel movement since before admission; however, there was no plan to visit to evaluate either the pain or constipation. This was confirmed with the Director of Nursing.”

“Observed in Individual Tracer. In 11 of 17 patient records reviewed, The hospice nurse surveyor noted (HOSHVRR#1) that there was no evidence in the record that an assessment of the patients drain insertion sites (2) were assessed. In (HOSHVRR#2), there was no evidence that the patient’s PEG tube insertion site was assessed. Also, there was no indication that an assessment of the patient’s risk for aspiration was completed, and it was unclear if the patient was receiving enteral feedings or an oral diet or if there were any dietary restrictions. In (HOSHVRR#3) there was no evidence in the medical record that there was an assessment of the severity of the patient’s symptoms of pain that included the best and worst pain levels. also, there was no assessment of the patient’s chronic diarrhea. The surveyor noted that there was no assessment of the adequacy of the environment and safety risks. The surveyor noted that there was a large dog, several trip hazards, two toddlers living in the home and lengthy oxygen tubing; however, these risks were not documented. Also, in (HOSHV#4), there was no assessment of the severity of agitation identified as a problem in August. In (ARR#5), the wound assessment was incomplete and did not include measurements. Also, there was no assessment of the severity of agitated, identified as a problem. In (ARR#5), there were no wound measurement included in the wound assessment, as required by policy. In (ARR#6), the patient was admitted on Levofloxacin; however, there was no evidence of an infection assessment of the patient’s cellulitis. In (ARR#7), there was no assessment of the severity of dysphagia, the PEG tube insertion site, the patients dietary restrictions or dietary needs or the Stage Two buttocks wound. In (ARR#9), there was no assessment of the patient’s buttocks wound. In (ARR#11), there was no assessment of the severity of the patients agitation or environment and safety risks. In (ARR#12), there was no assessment of the patient’s risk for aspiration. In (ARR#13), there was no assessment of the patient’s aspiration risk, stage two wound, seizure risk and agitation. In (ARR#14), there was no environmental safety risk assessment, severity of the patient’s dyspnea or oxygen use and safety. This was confirmed with the nurse educator.”

“Observed in Individual Tracer. In 10 of 17 patient records reviewed, The hospice nurse surveyor noted (HOSHVRR#1) that the medication orders were incomplete, not specific-Dulcolax supp. 1 rectal as needed constipation-no frequency, Haldol 1-2 tablets every four hours as needed agitation/restlessness, Hycosamine 0.125 mg 1-2 tab q 6 prn, Lorezapam 1 mg. 1-2 tablets q 4 as needed anxiety/agitation, Morphine Sulfate 0.25 -0.5 ml every 2 hours as needed SOB/pain, Senna 1-2 tablets 2 times a day, Tramadol 50 mg. 1 tablet every 4 hourd as needed for pain. The surveyor noted that the organization was utilizing standing orders; however the orders were not transcribed onto the medication profile with defined parameters for dosing the medications. Also, there was no verbal order to institute the standing orders as selected or the elements of the Comfort kit. The surveyor noted that every patient record included standing orders and all three home visit records (HOSHV#1, HOSHV#3 and HOSHV#4) of medications had orders that did not include parameters for dosing. The surveyor noted that all the home care patient records (ARR#5, #6, #8, #10, 11, #12) had orders that included ranges without parameters for dosing. The surveyor also noted I (IPURR#1), that the order for the patient receiving routine care in the residence included parameters that were not on the standing orders. For example, the order for Ativan was written 0.5 mg. 1-4 tabs every 4 hours as needed for agitation instead of Ativan 0.5 mg, start dose at 0.5 mg and may increase by 0.5 mg increments until symptoms subside, not to exceed a maximum dose of 2 mg. There was no evidence that they had received a verbal order for the changes. This was confirmed with the Director of Nursing.”

“Observed in Individual Tracer. In 10 of 14 patient records reviewed, The hospice nurse surveyor noted (HOSHVRR#1) that there was no evidence in the patient record to confirm that education and training was tailored to the patients needs related to falls risks or that falls intervention, strategies and education were provided. The surveyor confirmed that a falls risk assessment method was not available or documented. Also, in (HOSHV#3), (HOSHVRR#4), (ARR#5, #6, #8, #10, #11, #12, and #14) there was no documentation of education and training provided to reduce risk for falls. This was confirmed with the nurse educator.”

“Observed in Individual Tracer. In 14 of 14 patient records reviewed, The hospice nurse surveyor noted (HOSHVRR#1) that the plan of care did not include measurable outcomes or times frames for achieving goals. For example the goals were written as patient will achieve and maintain optimal physical comfort, facilitate the normal grief process, surgical drains will remain patent while under hospice care, patient will achieve and maintain optimal skin integrity and optimal urinary elimination patterns and comfort. The plan of care did not include complete orders, for example, the Foley catheter 14 fr order did not include a balloon size. Also, in (HOSHVRR#2) the patient had a PEG tube and the goal read patient will maintain optimal nutrition and hydration In (HOSHVRR#3), the patient was on oxygen and the goal was patient will achieve optimal breathing patterns, airway patency and comfort The goals was not measurable and the plan did not include any interventions or outcomes for managing oxygen safety risks. The surveyor noted in 14 of 14 records reveiwed that none of the goals listed included measurable outcomes or time frames for achieving goals. This was confirmed with the nurse manager.”

“Observed in Individual Tracer. In 4 of 14 patient records reviewed, The hospice nurse surveyor noted on (HOSHVRR#2), that there were no orders for wound care to two drain insertion sites or PEG tube site care on the plan of care. On (HOSHVRR#3), there were no goals/outcomes or interventions to managing back and leg pain and chronic diarrhea. On, (HOSHVRR#4) there were no measurable outcomes or time frames for managing agitation identified as a problem. In (ARR#5) the comprehensive assessment identified problems with dyspnea and weeping leg wounds; however, there were no care plan goals or interventions to manage the symptoms. This was confirmed with the nurse educator.”

“Observed in Record Review. In 1 of 3 patient records reviewed, The hospice nurse surveyor noted (IPURR#1), that the medication administration record indicated that the patient was medicated with Ativan 1 mg. as requested by the patient to help him rest. The surveyor noted that Ativan was not indicated in the orders for sleep or rest but for agitation. Also, the dosing order was to begin at 0.5 mg. The surveyor noted that that was the first dose given. There was no indication that the order was clarified with the physician before it was given for other than the symptom indicated or at the higher dose. This was confirmed with the nurse educator.”

“Observed in Document Review. In 2 of 2 years, The hospice nurse surveyor noted that there was no documentation available to confirm that the organization had completed annual inspection and testing of fire door assemblies by individuals who could demonstrate knowledge and understanding of the operating components of the door being tested and insure that the testing begins with a pre-test visual inspection; testing includes both sides of the opening. This was confirmed with the facilities manager. Observed in Building Tour. In 1 of 2 hallways, The hospice nurse surveyor noted that the hallway egress was blocked with three portable computer tables on one side and a housekeeping cart and mop bucket on the opposite wall. This was confirmed with the facilities manager. This finding was observed during survey activity, but corrected onsite prior to the surveyor’s departure. The corrective action taken needs to be included in the organization’s Evidence of Standards Compliance submission. Observed in Building Tour. The hospice nurse surveyor noted that there was a missing escutcheon for a sprinkler head in the riser room and there was a brown staining around a sprinkler head in the soiled utility room. This was confirmed with the facilities manager. This finding was observed during survey activity, but corrected onsite prior to the surveyor’s departure. The corrective action taken needs to be included in the organization’s Evidence of Standards Compliance submission. Observed in Building Tour. In 1 of 4 porches, The hospice nurse surveyor noted that there was no sign reading NO EXIT posted on the door of the Sunrise Room patio that is neither an exit nor an access to an exit but may be mistaken for an exit. This was confirmed with the facilities manager. This finding was observed during survey activity, but corrected onsite prior to the surveyor’s departure. The corrective action taken needs to be included in the organization’s Evidence of Standards Compliance submission.”