Hospice and Homecare of Reno County

“Observed in Record Review. In 1 of 18 patient records reviewed, During HOSRRHV# 1’s patient record review it was noted the organization had not ensured it maintained accurate patient records. For example: review of HOSRRHV# 1’s patient record revealed documentation of a fall with increase in pain/injury. However, review of the Interdisciplinary Group/update to Plan of Care revealed documentation of a fall with noninjury with no documentation of HOSRRHV# 1 needing an increase in as needed pain medication due to the fall. This was reviewed, discussed, and validated with the Administrator. Observed in Record Review. In 1 of 4 home visits conducted, During HOSRRHV# 4’s home observation it was noted the organization had not ensured the organization maintained a complete and accurate record. For example: during HOSRRHV# 4’s home observation this surveyor observed an oxygen concentrator and a portable oxygen tank in HOSRRHV# 4’s room. Review of HOSRRHV# 4’s patient record revealed at start of care approximately 16 months prior to the home observation with no documentation of oxygen. This was reviewed and discussed with the Administrator that shared the oxygen equipment was owned by the patient and had been in use prior to the admission to hospice.”

“Observed in Record Review. In 1 of 18 patient records reviewed, During HOSRRHV# 2’s patient record review it was noted the organization had not ensured the plan of care included all the services needed for the palliation and management of the terminal illness and related conditions. For example: review of HOSRRHV# 2’s patient’s Interdisciplinary Group/Update to Plan of Care revealed a goal and interventions for a Volunteer. Review of HOSRRHV# 2’s patient record revealed documentation of two Volunteer Visit Notes. Further review of the Interdisciplinary Group/Update to Plan of care revealed no documentation of a Volunteer frequency or that the Volunteer had provided services. This was reviewed, discussed, and validated with the Administrator.”

“Observed in Record Review. In 1 of 2 patient records reviewed with injury with fall, During HOSRRHV# 1’s patient record review it was noted the organization had not ensured the physician was notified per organization policy A210 Fall Risk Assessment and Prevention Plan that included notifying the physician after a fall with significant clinical indications such as a fall with increase in pain. For example: review of HOSRRHV# 1’s patient record revealed a Comprehensive Assessment visit note with documentation that the caregiver reported a fall with a need for four tablets of hydrocodone in 24 hours in stead of the usual 2 tablets as needed Hydrocodone related to stiffness from the fall. Further review of HOSRRHV# 1’s patient record revealed no documentation the physician was notified of the fall with increase in pain. This was reviewed, discussed, and validated with the Administrator.”

“Observed in Record Review. In 2 of 2 patient records reviewed with a Fall, During HOSRRHV# 1 and HOSRRNHV# 2’s patient records review it was noted the organization had not ensured it implemented the organization process for monitoring, internally reporting, investigating, and documenting incidents per the organization policy “A210, Fall Risk Assessment and Prevention Plan” that included completing an fall incident report for all patient falls by the staff member notified of the fall. For example: review of HOSRRHV# 1’s patient record revealed documentation HOSRRHV# 1 had five falls during the first certification period that included two falls with increase in pain/injury. However, further review of HOSRRHV# 1’s patient record revealed no documentation of an incident report for any of the documented falls. Review of HOSRRNHV# 2’s patient record revealed HOSRRNHV# 2 had a fall with injury. However, review of HOSRRNHV# 2’s patient record revealed no documentation of a fall incident report. This was reviewed, discussed, and validated with the Administrator.”

“Observed in Record Review. In 3 of 14 patient records reviewed with Hospice aide, During HOSRRNHV# 3, HOSRRNHV# 4, AND HOSRRNHV# 8’s patient records review it was noted the organization had not ensured the RN prepared complete written patient care instructions for the hospice aide. For example: review of HOSRRNHV# 3’s patient record revealed HOSRRNHV# 3 had two wound dressings and a foley catheter. However, further review of the written patient care instruction for the hospice aide revealed no documentation of HOSRRNHV# 3 with wound dressings or instructions on what to do the dressings got wet during the bed bath or foley catheter instructions. In addition, HOSRRNHV# 3’s written patient care instructions include assisting HOSRRNHV# 3 with meals and thick it to thicken liquids. Review of HOSRRNHV# 3’s patient record revealed no documentation on what consistency of thickened liquids HOSRRNHV# 3 needed. Review of HOSRRNHV# 4’s patient record revealed HOSRRNHV# 4 had a wound to the coccyx with a dressing. However, review of HOSRRNHV# 4’s written patient care instructions for the hospice aide revealed no documentation of a wound dressing or instructions on what to do if the wound dressing became wet. Review of HOSRRNHV# 8’s patient record revealed HOSRRNHV# 8 had a foley catheter inserted. However, review of HOSRRNHV# 8’s written patient care instructions revealed no documentation regarding foley catheter care. This was reviewed, discussed, and validated with the Administrator.”

“Observed in Patient Home. In 2 of 3 home visits conducted with medication reconciliation, During HOSRRHV# 2 and HOSRRHV# 3’s home observations it was noted the organization had not ensured the patient record contained information that reflected the patient’s care, treatment, or services. For example: during HOSRRHV# 2’s medication reconciliation it was noted the Assisted Living Facility (ALF) medication profile had documentation of Tylenol 650 mg, take two 325mg tablets every four hours as needed for pain or temp above 101, Bisacodyl 10mg suppository once a day as needed for constipation, and Mintox maximum strength 400mg-400mg every 8 hours as needed for heartburn. However, review of the organization’s medication profile revealed no documentation of the medications. During HOSRRHV# 3’S medication reconciliation it was noted the ALF’s medication profile had Trazodone 50 mg once a day at bedtime. However, review of the organization’s medication profile revealed Trazodone 100 mg once a day at bedtime. In addition, the ALF’s medication profile had documentation of Trospium Chloride 20 mg in the afternoon daily. Review of the organization’s medication profile revealed no documentation of Trospium Chloride. This was observed with the Intake Coordinator, discussed with the Administrator and validated.”

“Observed in Record Review. In 1 of 5 patient records reviewed residing in a SNF, During HOSRRNHV# 3’s patient record review it was noted the organization had not ensured the hospice plan of care identified the care and services that are needed and identified which provider is responsible for performing the functions that have been agreed upon and included in the plan of care. For example: review of HOSRRNHV# 3’s patient record revealed HOSRRNHV# 3 resided in a skilled nursing facility. Review of HOSRRNHV# 3’s plan of care revealed a pressure ulcer to the coccyx with wound care orders to change the dressing two times a week and as needed. Further review of the plan of care revealed a pressure ulcer to the right lower shin with wound care orders to change the dressing three times a week and as needed. However, further review of the plan of care revealed no documentation regarding the provider responsible for performing the wound dressing change. This was reviewed, discussed, and validated with the Administrator.”