Four Seasons the Care You Trust

“Observed in Record Review. In 4 of 8 patient records reviewed, for active patients in home hospice, it was noted by the nurse surveyor that the comprehensive assessment was not completed within five calendar days of the election of hospice care. For RRNHV#11, the chaplain completed his initial assessment 10 days late. There was no documentation to explain the delay. For RRNHV#12, the chaplain documented an initial phone call to the patient 13 days after the election of hospice care at which time the patient refused spiritual care. For RRNHV#13, the chaplain called the patient on day 2 after admission and left a message. There was no other documentation in the record until the spiritual assessment was documented 2 months later. For RRNHV#14, the chaplain’s initial assessment was completed on day 6 after the election of the benefit. There was no documentation as to why the visit was delayed. Findings were verified by the Team Leader assisting with record review. Observed in Record Review. In 2 of 12 patient records reviewed, The hospice’s interdisciplinary group, in consultation with the patient’s attending physician, if any, did not complete the comprehensive assessment no later than five calendar after the election of hospice care. During review of the record associated with hospice home visit 6 and hospice record 3, it was noted that the social worker did not make a visit within five days of the admission in record 3 and the chaplain did not make a visit with in five days in the record associated with hone visit 6. This was confirmed by the Team Lead.”

“Observed in Record Review. The written plan of care was not based on the patient’s goals and the time frames, settings, and services required to meet those goals. During review of the record associated with hospice home visit 5 it was noted that goals were not in place for findings in the comprehensive assessment. For example, the patient had an arm wound documented at admission but there were no goals or interventions related to wound in the initial plan of care, and the patient had decreased nutritional intake and nausea and vomiting assessed but there were no nutritional goals or interventions in the initial plan of care. This was confirmed by the team leader. Observed in Record Review. In 2 of 12 patient records reviewed, The written plan of care was not based on the patient’s goals and the time frames, settings, and services required to meet those goals. During review of the record associated with hospice home visit 5 and hospice record associated with home visit 6 it was noted that goals related to pain were not appropriate. In the record associated with home visit 5 the patient reported a pain level of 8 at admission with a patient goal of a pain level five. The only goal related to pain for the initial assessment stated that the patient will continue to report that her pain is well controlled with a date of two weeks hence. There was no documentation that the patient had reported her pain to be well controlled and the patient’s pain was still at an 8 on the second visit two days later. In the record associated with home visit 6 the patient’s pain was rated at a 6 on admission, and the goal stated that the patient’s pain would be at the patient’s goal of 4 in 15 days. This was confirmed by the team leader.”

“Observed in Record Review. In 4 of 12 patient records reviewed, The plan of care includes all services needed for the palliation and management of the terminal illness and related conditions, including the following:
interventions to manage pain and symptoms.

During review of the record associated with hospice home visit 5 it was noted that although the patient consistently reported moderate to severe pain, the only intervention in the care plan stated assess for pain and initiate pain interventions as needed. There were no specific interventions as to pharmacological or non pharmacological approaches. In the record associated with home visit 6 it was noted that although the patient had a new PEG tube requiring dressing changes, there were no interventions or goals in the care plan related to the tube. In record 1 the patient was noted to have oral thrush and was on Diflucan at admission but there was nothing in the plan of care relating to oral thrush management. In record 5 it was noted that the patient had a diagnosis of ALS and had dyspnea at 3 on admission but there was nothing in the plan of care for dyspnea until one month after admission. This was confirmed by the team leader. Observed in Record Review. In 2 of 12 resident records reviewed, The organization did not implement interventions to reduce falls based on the patient’s assessed risk. In the records associated with records 2 and 3 there were no interventions related to falls based on falls risk assessment. For example, in record 3 the fall risk was scored at 7, but there was no fall care plan for 28 days after admission, and in record 2 the fall risk was scored at 8, but there was no fall care plan until 2 and 1/2 months after admission. This was confirmed by the team lead. Observed in Record Review. In 2 of 3 patient records reviewed, for patients located in the inpatient hospice house, it was noted by the nurse surveyor that for RRIPU#2, the patient was admitted to the hospice house GIP for pain and agitation. Agitation was not included in the care plan, but the patient was receiving pharmacological interventions. Additionally, a foley catheter was inserted but not added to the care plan. For RRIPU#3, the patient had a foley inserted and her breast tumor erupted and became an open area requiring dressing changes. Both were being addressed and cared for but had not been added to the plan of care. Findings were verified by the Team Leader assisting with record review.”

“Observed in Record Review. In 2 of 12 patient records reviewed, The organization did not provide the patient with care, treatment, or services according to the patient’s individualized plan of care. During review of records 4 and 6 it was noted that visits were not provided according to orders. In record 4 nursing visits were ordered for 1x week but no visits were provided in the first week after the admission visit. In record 6 nursing was ordered once per week but no visits were provided in a one week period. this was confirmed by the team lead.”

“Observed in Patient Home. In 1 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 per policy “Hand Hygiene Policy During RRHV#2 the Social Worker did not hand sanitize upon entry into the patient’s room or before and after assisting the patient with sending an email on the patient’s own tablet. Finding was verified by the Spiritual Care Team Leader who was present on the home visit. Observed in Individual Tracer. The organization did not implement the infection prevention and control activities it has planned. During hospice home visit 5 it was observed that the nurse did not cleanse her hands before entering the nursing bag per policy. This was confirmed by the team leader. Observed in Individual Tracer. The organization did not implement the infection prevention and control activities it has planned. During hospice home visit 5 it was observed that the nurse did not cleanse her hands after doffing gloves per policy. This was confirmed by the team leader. Observed in Individual Tracer. The organization did not implement the infection prevention and control activities it has planned. During hospice home visit 5 it was observed that the nurse cleansed her hands, then grasped the would solution bottle that was kept in the patient’s home before donning gloves on two occasions. This did not follow organizational policy. This was confirmed by the team leader. Observed in Individual Tracer. The organization did not reduce the risk of infections associated with medical equipment, devices, and supplies. During hospice home visit 5 it was observed that the nurse her notebook computer directly on the patient’s table. She then placed patient pill bottles on the computer during the pill box fill. The nurse did not cleanse the computer per policy upon leaving the patient’s home. This was confirmed by the team leader. Observed in Individual Tracer. The organization did not implement infection prevention and control activities when doing the following: Cleaning and performing disinfection of medical supplies and devices. During hospice home visit 5 it was observed that sani-wipe disinfecting wipes were used to clean equipment used to take vital signs. The nurse removed one sani-wipe from its package and used it to clean equipment prior to use. The wipe was left open during the visit was then used to clean equipment after use. The wipe was no longer wetting the equipment. This was confirmed by the team leader.”

“Observed in Record Review. In 1 of 8 patient records reviewed, for active patients, It was noted by the surveyor that for RRNHV#13, one Hospice Aide Supervisory visit was completed 15 days apart, not the required 14 days. Finding was verified by the Team Leader assisting with record review. Observed in Record Review. In 2 of 12 patient records reviewed, The registered nurse did not supervise the hospice aide during an on-site visit to the patient’s home no less frequently than every 14 days. During review of records 4 and 6 it was noted that aide supervision was not documented every 14 days or less. For example in record 4 there was no supervisory visit documented for 4 1/2 weeks and in record 6 there was no supervision documented for 8 1/2 weeks. This was confirmed by the team lead.
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“Observed in Patient Home. In 1 of 6 home visits conducted, it was noted by the nurse surveyor that for RRHV#1, the patient did not have a completed individualized emergency plan in her home folder. There was some general information related to emergency planning but nothing regarding what to do if care, treatment, or services are disrupted by a natural disaster or emergency. Finding was verified by the Director of Hospice Clinical Services who was present during the home visit. Observed in Individual Tracer. The organization did not document procedures to follow if care, treatment, or services are disrupted by a natural disaster or an emergency. During hospice home visits 5 and 6 it was observed that there was no emergency plan in place at the patient’s home or in the patient record. This was confirmed by the Team Leader.”