Superior Hospice

“Observed in Record Review. In 12 of 12 patient records reviewed, the Hospice Organization failed to ensure that the POC goals had time frames for achieving goals. For example, duringthe RRHV#1, RRHV#2 and RRHV#3 the Hospice Surveyor identified that several of the goals did not include a time frame for achieving the goal. Examples include: RRHV#3: Patient’/Caregiver understands need to report changes in pain level to hospice staff. Pain is managed at a level acceptable to the patient. RRHV#2 : Patient’/Family will seek help from care team as appropriate/when destress.Patient’/Family will demonstrate effective coping skills. RRHV#1:Pain is managed at a level acceptable to the patient. Patient/family are supported during withdrawal of life support. These findings were review, confirmed and discussed with the Director of Nursing.”

“Observed in Record Review. the Hospice Agency did not ensure the completion of physician orders. For example; during the RRHV#1 the Hospice Surveyor noted incomplete physician orders: Lateral right upper buttock Stage III wound: Cleanse with wound cleanser, pat dry, apply saline-soaked collagen dressing to the wound bed, cover with 4x4 gauze, and apply a bordered foam dressing daily and as needed if saturated, until healed; however, the SN visit frequency was scheduled of twice weekly. The order did not identify who was responsible for performing the wound care when the Hospice SN was unavailable, such as a family member or caregiver. This finding was review and confirmed with the Director of Nursing. Observed in Regulatory Review. In 6 of 12 patient records reviewed, the patient receiving duplicative therapy without clear indication for use. For example, in RRNHV #3 the patient medication profile indicates that there were two PRN medications order for pain; however, no perimeters for when the patient should take which was given. For example: Tylenol 8 hour 650mg Extended Release 1 tab every 8 hours PRN PEG TUBE Pain and Morphine Concentrate 100 mg/5ML (20 MG/ML oral solution every 2 hours/PRN Pain. This finding was reviewed and discussed with the Director of Nursing. Observed in Record Review. the Hospice organization failed to ensure complete provider order to the Plan of Care. For example, during the HV#2 the patient’s daughter stated that the patient is giving Isosource 1.5 cal unflavored via PEG Tube three time daily. No order for this intervention in the current plan of care. This finding was reviewed and discussed with the Director of Nursing. Observed in Record Review. In 6 of 12 , the HCO failed to ensure physician’s order for medications, treatments, and/or procedures. For example, during the RRHV#3, the Hospice Surveyor noted that there was no order for changing the patient’s Suprapubic Catheter and/or who or when it is to be changed. This finding was review and discussed with the Director of Nursing.”

“Observed in Patient Home. In 1 of 3 home visits conducted, the organization failed to provide the patient with care, treatment, or services according to the patient’s individualized plan of care. For example: during the HVRR #1 the Hospice Surveyor identified that physician’s order for wound care was as follows: Lateral right upper buttock Stage III wound: Cleanse with wound cleanser, pat dry, apply saline-soaked collagen dressing to the wound bed, cover with 4x4 gauze, and apply a bordered foam dressing daily and as needed if saturated, until healed. However, during the HV#1 the Hospice Surveyor observed that the SN did not apply saline-soaked collagen dressing to the wound bed, but rather the collagen was applied dry to the wound bed. This finding was discussed and reviewed with the Director of Nursing.”

“Observed in Pharmacy. In 1 of 3 home visits conducted, the SN did not perform hand hygiene between glove changes. For example; Prior to initiating wound care, the SN donned two pairs of gloves. The SN removed the patient’s soiled dressing and then removed one pair of gloves before cleansing the wound with wound cleanser and 4x4 gauze pads. After cleansing the wound, the nurse discarded the used gauze and immediately applied the new wound dressing.Following the dressing application, the SN placed the unused wound care supplies back into the supply/storage box while wearing the same gloves that had been used while cleansing the wound and the subsequence application of the new wound dressings.The SN then removed the gloves before removing the disposable bed pad from the patient’s bed and underneath the patient prior to the start of the wound care.These findings were reviewed and discussed with the Director of Nursing.”

“Observed in Record Review. In 1 of 12 patient records reviewed, the patient record was inaccurate or contains errors (i.e. conflicts with other documentation). For example, in a visit note completed the last week in August, there was documentation that the patient had no pain in the narrative section; but in another section for the same visit note, it was documented that the patient reported pain, indicating a pain level of 3. Additionally, the it was also documented in the same note that, based on information provided by the caregiver, that the patient’s pain was relieved by rest and prescription pain medication. Review of the medication profile revealed that Morphine was the only medication ordered for pain management. However, during this Hospice Surveyor’s home visit, the patient’s caregiver stated that the patient was not receiving any medication for pain. These findings were reviewed and discussed with the Director of Nursing.”

“Observed in Record Review. In 1 of 12 patient records reviewed, the Hospice failed to ensure that the current medication profile was accurate. For example, during the medication reconciliation section of HV#1, the Hospice Surveyor identified that the following medications were listed on the medication list provided to this surveyor; however, they were not present in the home at the time of the visit and/or the patient’s daughter stated that they had been discontinued by the patient’s physician:a. Amitriptyline 25 mg, one tablet by mouth at bedtimeb. Atorvastatin 20 mg, one tablet by mouth dailyc. Eliquis 5 mg, by mouth twice dailyd. Ferrous Sulfate 324 mg (65 mg elemental iron), delayed-release tablet, one tablet by mouth three times weeklye. Levothyroxine 125 mcg, one capsule by mouth dailyf. Metformin 1,000 mg, one tablet by mouth twice dailyg. MiraLAX 17 grams, by mouth dailyh. Tramadol 50 mg, one tablet by mouth every 8 hoursi. Vitamin C 500 mg, one tablet by mouth dailyj. Zinc Gluconate 50 mg, one tablet by mouth dailyAdditionally, according to the patient’s daughter, the patient was taking the following medication, which was not included on the medication profile:a. Vitamin D: The patient’s daughter was unable to provide the dosage but stated that she administers the medication to the patient once weekly.These findings were reviewed and discussed with the Director of Nursing.”

“Observed in Record Review. In 2 of 10 patient records reviewed, The hospice nurse surveyor noted (ARR#3) that the nursing assessment indicated that the patient was receiving G-tube feedings; however, there was no evidence that the G-tube insertion site had been assessed. In (ARR#7), the nursing assessment indicated that the patient had a wound; however, there was no indication that the wound was assessed by a hospice nurse when admitted or since (24 days ago). The only information was that the facility staff had reported the wound. This was confirmed with director of nursing.”

“Observed in Record Review. In 4 of 10 patient records reviewed, The hospice nurse surveyor noted (ARR#1) that the medication orders included Acetaminophen, Norco and Morphine as needed for pain and did not indicate the order in which the medications were to be given or for what level of pain the medications were to be used. In (ARR#4), (ARR#6) and (DRR#2) both Tylenol and Morphine were ordered as needed for pain and did not indicate the type of pain or the order to use the medication. This was confirmed with the director of nursing. Observed in Record Review. In 10 of 10 patient records reviewed, The hospice nurse surveyor noted in ten of ten records reviewed that the plan of care and physician orders did not include oral diet orders for all 10 patients. In (ARR#3) the surveyor noted that the patient assessment indicated that the patient was NPO and receiving Jevity via G-tube. The plan of care did not include the NPO order. Also, the surveyor noted in (DRR#1), (DRR#2), (DRR#3), (ARR#6) and (ARR#7), the patient’s were at risk for aspiration; however, the plan of care did not include orders for pureed or thickened liquids were indicated. The surveyor noted that the EMR did not include a locator for diets. This was confirmed with the director of nursing. Observed in Record Review. In 6 of 10 patient records reviewed, The hospice nurse surveyor noted (ARR#3) that the nursing assessment indicated that the patient had a G-Tube; however, there were no orders or interventions on the plan of care for site care. In (ARR#4) the orders for wound care for wounds # 2, #3, and #4, did not indicate how often the wound care was to be done or who would perform the care when the nurse did not visit. In (DRR#2), the assessment indicated that the patient had a wound; however, there were no goals, interventions or wound care orders and the plan of care did not indicate who was to assess and/or perform the care of the wound for this patient in a SNF. I (DRR#3) there were no goals, interventions or wound care orders for a wound to the left toe and the plan of care did not indicate who was to perform wound care for this patient in a SNF. In (ARR#6), the surveyor noted that the plan of care and physician orders did not include goals or interventions for managing a non-stageable tunneling wound of the sacrum and there were no orders for the care of the wound. In (ARR#7) there were no goals, interventions or orders for wound care to a stage 2 wound to her thigh and it did not indicate who was responsible to perform the care for this patient in a skilled. This was confirmed with the director of nursing.”