St. Croix Hospice

“It is required that the documented comprehensive assessment includes a drug profile that contains the patient’s current: prescription and over-the-counter (OTC) drugs. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #2-004, “Medication Profile” (last reviewed 03/13/2023), stated in part, “The medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications.” In 1 of 14 (7%) clinical records reviewed, the agency did not ensure that the drug profile was updated to include all prescription and over-the-counter medications the patient was taking. Clinical Record 9: The patient elected hospice care on 01/22/2024 with a diagnosis of Atherosclerotic Heart Disease. The Registered Nurse (RN) visit note dated 03/12/2024 documented “Niece reported that she administered dose of Imodium over weekend and that it slightly helped.” The agency’s drug profile, effective 01/22/2024 through 03/14/2024 (date of record review), did not document Imodium. During an interview on 03/14/2024, the Administrator/Regional Director of Clinical Operations (RDCO) confirmed that the drug profile did not include Imodium, stating, “The RN that made the visit confirmed that she had not yet entered the medication, but it has been added now.””

“It is required that each patient’s individualized written plan of care: identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed, the agency did not ensure the plan of care contained interventions based on problems identified during the comprehensive assessments. Clinical Record 5: The patient elected hospice care on 02/14/2024. The initial nursing assessment dated 02/14/2024 documented that the patient had an Aspira drain, covered with a dressing at insertion site, in both the right and left lung areas. On 03/11/2024, the Registered Nurse (RN) documented that 600 ml (milliliters) of amber-colored fluid was drained from the right side.” The plan of care, effective 02/14/2024 to present, did not document problems, goals, or interventions related to the Aspira drains. During an interview on 03/13/2024, the Administrator/Regional Director of Clinical Operations (RDCO) confirmed the plan of care did not include problems, goals, or interventions related to the Aspira drains and stated, “There was so much being done with those drains, I am not sure how we missed them on the care plan.””

“It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 3 of 11 (27%) clinical records reviewed of patients receiving Hospice Aide (HA) services, the agency did not ensure the Hospice Aide care plan included specific written patient care instructions for the Hospice Aide. Clinical Record 5: The patient elected hospice care on 02/14/2024. The initial nursing assessment dated 02/14/2024 documented that the patient had an Aspira drain, covered with a dressing at insertion site, in both the right lung and left lung areas. On 03/11/2024, the Registered Nurse (RN) documented that 600 ml (milliliters) of amber-colored fluid was drained from the right side.” The aide care plan, effective from 02/14/2024 to the present, assigned the HA the following relevant tasks: bathing (bed), dressing, and skin care (apply full body lotion). The aide care plan did not include documentation of precautions the HA needed to follow regarding the Aspira drains, nor did it specify what the HA should do if the dressings became wet, soiled, or dislodged. Clinical Record 6: The patient elected hospice care on 01/04/2024. The initial nursing assessment dated 01/04/2024 documented an unstageable wound to the coccyx area. The wound care orders included covering with a dressing. The skilled nursing (SN) visit note dated 03/07/2024 documented that the patient still had the wound with the dressing intact. The aide care plan, effective from 01/05/2024 to the present, assigned the HA the following relevant tasks: bathing (bed), dressing, and incontinent care. The aide care plan did not alert the HA that the patient had a wound dressing in place or provide instructions on what to do if the dressing was soiled, wet, or dislodged. Clinical Record 10: The patient had a coccyx wound, stage 2, with an onset date of 02/26/2024. The wound care orders include covering the area with a foam dressing. The most recent SN visit note dated 03/11/2024 documented that the wound with the dressing was still present. The aide care plan, effective 11/06/2023 to the present, assigned the HA the relevant task: to provide a shower with every visit. The aide care plan did not alert the HA that the patient had a wound dressing in place or provide instructions on what to do if the dressing was soiled, wet, or dislodged. During an interview on 03/14/2024, the Administrator/Regional Director of Clinical Operations (RDCO) confirmed the findings. The Administrator/RDCO reported that the aide care plans should have included this information and that education had already been provided to the RN case managers.”

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. Each patient’s record includes, at a minimum: physician orders. This standard was not met as evidenced by clinical record review, document review, and interview. In 1 of 14 (7%) clinical records reviewed, the agency did not ensure the patient clinical records contained physician orders for all medications. Clinical Record 9: The patient elected the hospice benefit on 01/22/2024 with a diagnosis of heart disease. The Registered Nurse (RN) visit note dated 03/12/2024 documented, “Niece reported that she administered a dose of Imodium over weekend and that it slightly helped.” The clinical record did not include documentation of a physician order for Imodium. During an interview on 03/14/2024, the Administrator/Regional Director of Clinical Services (RDCO) reported that the RN obtained an order for the Imodium on 03/12/2024 but had not yet entered it into the record. The Administrator/RDCO agreed that the order should have been entered into the record upon receipt and said, “It has been entered now.””