Harbor Hospice

“Observed in Record Review. In 2 of 3 patient records reviewed, it was noted that stated goals were not measurable or specific. For example, in IPU record review #1 a goal was stated as follows: Pain to be managed to satisfaction through end of life. Anxiety will be managed to patient satisfaction. In IPU record review #2 a goal was stated as follows: Pt will achieve and maintain optimal physical comfort. This was discussed with the IPU director. Observed in Record Review. In 7 of 20 patient records reviewed, it was noted that the stated goals on the plan of care were not specific or measurable. For example, in record review for home visit #6 the goals were stated as follows: Pt will report satisfaction with pain control and verbalize satisfaction with pain level. In record review #1 there was a goal stated as , Pt will have optimal breathing pattern through end of life and will be free of complications related to aspiration. In record review #3 goals were stated as Pt will have optimal breathing pattern and optimal urinary pattern. In record review #3 there were goals stated as Pt will have adequate cardiac function and verbalize acceptable comfort of respiratory status. In record review #5 the goals were stated as Pt will have optimal skin integrity maintained and Pain issues will be met to patient satisfaction. In record review #7 a goal was stated as pt will verbalize satisfaction of treatment for nausea and pt will verbalize satisfaction with nutrition and hydration and control of blood sugars through end of life. In record review #9 a goal was stated as pt will have optimal sleep. This was confirmed by the Director of Clinical Services.”

“Observed in Record Review. In 2 of 20 patient records reviewed, it was noted that in review of record for home visit #3 there were no wound care orders on the plan of care for a patient with three wounds. Review of five skilled nurse visit notes indicated that the nurse was cleansing the wound with wound cleanser and applying xeroform gauze twice weekly. There was only an order to cleanse wound #1 with wound cleanser and the dressing was To be determined based on wound healing with no frequency for changing the dressing. In another example for record review #2 there were no orders for wound care in which the nurse documented providing wound care with xeroform dressing. This was confirmed by the Director of Clinical Services. Observed in Record Review. In 2 of 2 patient records reviewed, for patients who were discharged it was noted that there were no discharge orders. This was noted in discharge record review #1 who revoked care and for discharge record #2 who elected to transfer to another hospice. This was confirmed by the Director of Clinical Services.”

“Observed in Record Review. In 3 of 20 patient records reviewed, It was noted that in review of record for home visit #3 there was no documentation during the IDT meetings for the last two months that included revisions in the plan of care for a patient with three wounds which deteriorated to include purulent drainage and foul odor. In another example, it was noted in review of record for home visit #5 the plan of care was not updated to include a new development of cellulitis in bilateral lower legs for which an antibiotic was prescribed. In another example, in record review for home visit #6 it was noted that the plan of care was not updated to include sleeping issues for which sleep medication was increased. This was confirmed by the Director of Clinical Services.”

“Observed in Record Review. In 1 of 12 patient records reviewed, where hospice aide services were provided it was noted that the supervising nurse did not assess if assigned tasks were being completed. For example, in review of record for home visit #2 and in discussion with the patient it was noted that none of the hands on care activities had been completed in review of notes for the past two months. For example, bathing, skin care, peri-care were assigned tasks however the aide documented that the patient refused these care tasks on every visit. This was discussed with the Director of Quality and Director of Patient Care.”

“Observed in Record Review. In 4 of 20 patient records reviewed, it was noted that in record review for home visit #4, record review #2, record review #4 and record review #5 the hospice aide documented in multiple visit notes that all of the bath types were completed to include bed bath, partial bath, shower, etc. This was confirmed by the Director of Clinical Services. Observed in Record Review. In 1 of 20 patient records reviewed, It was noted that in review of record for home visit #3 there had been no documentation of wound measurements since the start of care two months ago for a patient with three wounds, with one that was documented as having tunneling. Agency policy is to document wound measurements monthly and as needed. This was confirmed by the Director of Clinical Services.”

“Observed in Document Review. The Annual Fire Alarm Inspection and Test documentation from April 2025 and May 2024 did NOT include an INVENTORY of notification appliances (speakers, horns, chimes, and strobes). The report only included a statement that all horn/strobes passed. This was verified by the Residence Manager and Quality Director. Observed in Document Review. The Quarterly test of the dry fire sprinkler low-air supervisory was NOT completed the 2nd and 3rd Quarter of 2024, or the 1st Quarter of 2025. This was verified by the Residence Manager and Quality Director.”