Hospice of the Chesapeake, Inc.

“Observed in Record Review. it was noted by the nurse surveyor that the IDG meeting notes did not reflect progress toward goals nor updates to the plan of care. For RRHV#2, the patient had multiple falls, one of which resulted in the patient receiving staples in the back of his head. Nothing was noted in the IDG notes regarding the occurrences. For RRHV#3, the patient had an arterial ankle wound. There was nothing reflected in the IDG notes regarding the condition of the wound or that the patient also developed cellulitis and was put on an Antibiotic. Findings were verified by the Director of Operations. Observed in Record Review. In 22 of 22 patient records reviewed, where the interdisciplinary group met two or more times the organization failed to update the comprehensive assessment to reflect changes that occurred since the initial assessment. For example, in records RRNHV#1 through RRNHV#14 the interdisciplinary group did not consistently document patient decline, progress towards goals, and plans for the next two weeks. For example, in record RRNHV#3 clinical documentation identified that the patient fell twice in three days. In record RRNHV#5 the patient was started on an antibiotic for a dental infection and had also had a fall. In record RRNHV#6 a nurse documented that the husband was exhausted, and caregivers were threatening to leave. In record RRNHV#11 a nurse documented that the patient returned from hospital after having a nasogastric tube placed. The plans of care were not revised, nor were these identified problems addressed in interdisciplinary group notes. This RFI was reviewed and verified with the Director of Support Services and QAPI Coordinator.”

“Observed in Record Review. In 22 of 22 active patient records reviewed, the organization failed to ensure that plan of care goals identified requirements for completion. For example: patient will maintain optimal mobility; patient will remain safe in environment; desired nutrition/hydration needs will be met; oral comfort/hygiene will be maintained; patient/caregiver will verbalize/demonstrate effective adjustment techniques and support network; In addition, most goals that were written when the patient was admitted as long ago as six months were not resolved because the completion target was consistently changed to the date of the next interdisciplinary meeting two weeks later. the organization failed to assess patient needs and provide education and training on the storage handling, and access to medical gases. This RFI was reviewed and verified with the Director of Support Services and QAPI Coordinator. Observed in Record Review. the nurse surveyor noted that the goals were not consistently measurable. For RRHHV#1, RRHH#2, RRHV#3, RRHV#4, RRHV#5, and RRHV#6 goals were not measurable with time frames all at the end of the certification period. For example, there were no goals for wound care progression. Findings were discussed with the Director of Operations”

“Observed in Record Review. , it was noted by the nurse surveyor that medication orders were not clear or complete. For RRHV#1, the order for a Fentanyl Patch100mg/hr, one patch every 3 days, said to remove old patch before applying new patch but did not contain any further instructions regarding the patch application. Additionally, the patient had orders for Morphine concentrate, Acetaminophen, and oxycodone with no indication of when to take which medication. For RRHV#2, the order read Donepezil 10mg tab, 20mg every evening, with no instruction to take 2 tablets. The order for Polyethylene glycol 3350 17 gm/dose oral powder did not include instructions to mix in liquid. For RRHV#3, the oxygen order was for Oxygen 2 – 4 liters by nasal canula continuously. Findings were verified by the Director of Operations
 Observed in Record Review. In 7 of 22 active patient records reviewed, the plan of care did not include all services needed for the palliation and management of the terminal illness and related conditions, including medications and treatment necessary to meet the patient’s needs. For example, in record of RRNHV#5 the medication list included Clindamycin 300 mg four times a day for 10 days. The order was not provided by the hospice medical director. Rather, it was written by a nurse practitioner at the skilled nursing facility. In record RRNHV#6 an order was written for Nystatin 100,000 units/gram topical powder, apply twice a day to rash, but did not specify a location. Five days later the same order was written with new directions to apply under the breast. In record RRNHV#11 a nurse documented that the patient returned from hospital with a nasogastric tube and was receiving Pediasure 150 mls at 9.6 mls/hour by pump. There were no orders for the tube, pump, or enteral feeding. And in record RRNHV#14 a nurse documented in the initial comprehensive assessment that the patient had a large tumor on the lip that made eating difficult. There were no orders for nutritional support. This RFI was reviewed and verified with the Director of Support Services and QAPI Coordinator.”

“Observed in Patient Home. In 1 of 6 home visits conducted, it was observed by the nurse surveyor that the nurse did not clean her equipment per agency policy. For RRHV#2 the cleaned her equipment (BP cuff, stethoscope, pulse oximeter) with alcohol wipes and immediately dropped them into her bag without allowing them to dry per the recommended product dry time of one minute. For RRHV#3, The skilled nurse after using her wrist BP cuff on the patient put it in her pocket without cleaning and after use put her stethoscope around her neck. Finding was verified by the Director of Operations who was present during the home visit. 


 Observed in Pharmacy. In 2 of 6 home visits conducted, it was observed by the Nurse Surveyor that the organization did not implement the infection prevention and control activities it had planned. For example, during RRHV#2 the registered nurse took the patient’s vital signs, assessed his lungs, abdomen and feet, then donned gloves to check the healing of his head wound all without hand sanitizing. Additionally, she went in and out of her nursing bag several times without sanitizing her hands during the patient visit. During RRHV#3, the skilled nurse did not hand sanitize before or after the patient assessment or at any time during the visit after touching items in the room such as the oxygen concentrator or furniture. Findings were verified by the Director of Operations who was present on the home visits.”

“Observed in Patient Home. In 3 of 5 patients receiving hospice aide services, it was noted by the nurse surveyor that hospice aide care plans were not complete or updated. For RRHV#2 the hospice aide care plan did not give instructions regarding when to notify the nurse, the patient was reportedly having problems with constipation. Additionally, the hospice aide care plan was not updated to reflect a patient fall that resulted in patient getting 7 staples to the back of his head. The hospice aide was to shampoo the patient every visit. For RRHV#3, the hospice aide care plan was not updated to reflect what to do regarding a dressing on the patient’s ankle. For RRHV#6, the hospice aide care did not give instructions regarding when to notify the nurse. Additionally, the patient was on continuous oxygen and there were not any instructions of what the aide was to do with the oxygen while giving the patient a bed bath. All findings were verified by the Director of Operations”

“Observed in Record Review. the organization failed to assess patient needs and provide education and training on the storage handling, and access to medical gases. In records RRHV#1, RRHV#3, RRHV#4, and RRHV#6 where oxygen was present, the safety assessment documented in the initial comprehensive assessment did not include whether there were smoking materials, other fire safety risks in the home, or risks to neighboring residences and buildings. As a result, there was no documentation of oxygen safety education having been provided to the patient, family, or caregiver. Finding was verified by the Director of Operations Observed in Patient Home. In 2 of 6 home visits conducted, it was noted by the nurse surveyor that for RRHV#1 there were two backup E-tanks that were standing up in the middle of the back bedroom, unsecured. They were laid down flat on the floor by the Social Worker prior to leaving the patient’s home. For RRHV#3, the oxygen concentrator in the patient’s skilled facility room was partially covered with the room’s dividing curtain and shoved under the overbed table, and the plug was half hanging out of the outlet. Additionally, the plug for the oxygen concentrator was not plugged into a red plug (in case of power failure). The skilled nurse did push the plug securely into the wall and did move the curtain and pull out the oxygen concentrator. Findings were verified by the Director of Operations who was present during the home visit. Observed in Record Review. In 8 of 22 active patient records reviewed, the organization failed to assess patient needs and provide education and training on the storage handling, and access to medical gases. In records RRNHV#2, RRNHV#6, RRNHV#7, RRNHV#13 where oxygen was present, the safety assessment documented in the initial comprehensive assessment did not include whether there were smoking materials, other fire safety risks in the home, or risks to neighboring residences and buildings. As a result, there was no documentation of oxygen safety education having been provided to the patient, family, or caregiver. This RFI was reviewed and verified with the Director of Support Services and QAPI Coordinator.”

“Observed in Building Tour. During the building tour, the maintenance manager and IPU manager confirmed penetrations in the ceiling as follows: two penetrations in the IT room and three in the mechanical control room. 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. During the building tour, the maintenance manager and IPU manager confirmed that the magnetic releasing device was missing from on the fire-rated doors into the south wing. It had been propped open using cardboard. 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. During the building tour, the maintenance manager and IPU manager confirmed that the escutcheon plate on the sprinkler head in the bathroom of room 10 had fallen below ceiling level. 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.”