Caritas Hospice Care

“Based on review of records, staff interviews, and policies and procedures, it was determined the hospice Registered Nurse (RN) AA failed to ensure that the initial assessment was completed within 48 hours after the election of hospice care for five patients (P) (P#1, P#2, P#3, P#4, P#5) of 19 patients sampled. The findings include: Review of the undated policy titled “;Comprehensive Assessment-Initial”, Policy Number: PC.C33, reveals the following: Policy: An initial assessment to determine the patients immediate care and support needs is conducted by a hospice RN within 48 hours of the patients election of hospice care. 1. Review of the document titled “;Nurse Progress Note Comprehensive Assessment” dated 10/21/2022 reveals P#1 was admitted on 10/21/2022. the initial skilled nurse assessment was signed on 10/26/22, five days after the election of hospice care. The clinical record lacked documentation regarding the staff’s delay in completing the assessments. 2. Review of the document titled “;Nurse Progress Note Initial Assessment” dated 10/25/2023 reveals P#2 was admitted on 10/25/2023. The initial skilled nursing assessment was signed on 10/31/23, six days after the election of hospice care. The clinical record lacked documentation regarding the staff’s delay in completing the assessments. 3. Review of the document titled “;Nurse Progress Note Initial Assessment” dated 3/22/2023 reveals P#3 was admitted on 3/22/2023. The initial skilled nursing assessment was signed on 3/27/23, five days after the election of hospice care. The clinical record lacked documentation regarding the staff’s delay in completing the assessments. 4. Review of the document titled “;Nurse Progress Note Initial Assessment” dated 1/26/2024 reveals P#4 was admitted on 1/26/2024. The initial skilled nursing assessment was signed on 1/29/2024, three days after the election of hospice care. The clinical record lacked documentation regarding the staff’s delay in completing the assessments. 5. Review of the document titled “;Nurse Progress Note Initial Assessment” dated 11/09/2023 reveals P#5 was admitted on 11/9/2023. The initial skilled nursing assessment was signed on 11/12/2023, three days after the election of hospice care. The clinical record lacked documentation regarding the staff’s delay in completing the assessments. On 2/6/24 at 1:09 p.m., an interview was conducted with Registered Nurse (RN) AA who said she did not know why she completed the initial assessment late. The other RN had resigned and left the hospice since last year. On 2/6/24 at 2:18 p.m., an interview was conducted with the Director of Nursing (DON), who said she did not know why theyre unable to complete the nursing admission assessment within five days. The DON also confirmed that all surveyors were given all available documentation for the patients records.”

“Based on review of records, staff interviews, and policies and procedures, it was determined the interdisciplinary group failed to ensure that the initial comprehensive assessment was completed within five days of admission for three patients (P) (P#2, P#3, P#4) of 19 patients sampled. The findings include: Review of the undated policy titled “;Comprehensive Assessment-Initial”, Policy Number: PC.C33, reveals the following: Procedures: 4. Based on the patient’s needs and findings from the initial assessment, the hospice RN coordinates and designates disciplines that must participate in the comprehensive assessment of the patient within 5 days of his or her election of hospice care. 1. Review of the document titled “;Combined Disciplinary Plan of Care” reveals P#2 was admitted on 10/25/2023. The initial spiritual assessment was completed on 11/3/23, nine days after the patient’s admission. The clinical record lacked documentation regarding the staff’s delay in completing the assessments. 2. Review of the document titled “;Combined Disciplinary Plan of Care” reveals P#3 was admitted on 3/22/2023. The initial spiritual assessment was completed on 3/29/23, seven days after the patient’s admission. The clinical record lacked documentation regarding the staff’s delay in completing the assessments. 3. Review of the document titled “;Combined Disciplinary Plan of Care” reveals P#4 was admitted on 1/26/2024. The initial spiritual assessment was completed on 2/2/24, seven days after the patient’s admission. The clinical record lacked documentation regarding the staff’s delay in completing the assessments. On 2/6/24 at 11:08 a.m., an interview was conducted with the Administrator who said they have two chaplains, and one of them was on leave, and he did not know why the other chaplain BB delayed the assessment. The Administrator also confirmed that the surveyor has been provided with all available documentation for the patients records. On 2/6/24 at 2:04 p.m., an interview was conducted with chaplain BB, who said that she was on vacation and knew nothing about the late admission assessment. On 2/6/24 at 2:56 p.m., an interview was conducted with chaplain CC, who said that the reason why he did the admission late was because the patient was moved to another location, but he forgot to document it.”