Nathan Adelson Hospice

“Observed in Patient Home. In 1 of 6 home visits conducted, the organization failed to ensure pain assessments were completed in accordance with agency policy. The agency’s Pain Procedure states that patients who are able to self-report pain should be assessed using either a numeric pain scale or a verbal descriptor scale. During RRHV #3, the patient reported experiencing pain during the home visit; however, the nurse did not utilize a numeric or verbal pain scale as part of the pain assessment. These findings were reviewed and validated with the hospice leadership team.”

“Observed in Record Review. In 2 of 6 home visits conducted, the organization failed to ensure patient assessments accurately reflected the patients’ conditions and care needs. Review of RRHV #2 identified the patient was legally blind; however, the admission assessment documented no visual impairment. In addition, the patient had upper and lower dentures, yet the admission assessment documented the patient’s oral status as normal. Review of RRHV #4 identified the patient had a left lower quadrant PleurX drain; however, assessment documentation consistently identified the drain as being located in the right lower quadrant. These findings were reviewed and validated with the hospice leadership team, including the manager who participated in the home visit”

“Observed in Record Review. In 10 of 24 active patient records reviewed, the hospice failed to ensure that plans of care contained current, individualized goals reflective of patient assessments, identified needs, and changes in condition. Review of RRHV #2 identified the patient was receiving pain medication; however, the plan of care did not include goals addressing pain management. For RRHV #5, the plan of care had not been updated over multiple certification periods to reflect the patient’s current assessment findings, including goals related to pain relief and pain-management education. Review of RRHV #6 identified the plan of care did not reflect the patient’s current condition, with goals remaining unchanged since admission approximately five months earlier and continuing to include admission teaching goals that were no longer pertinent to the patient’s ongoing care needs. Review of RRNHV #3 identified assessment findings of dysphagia, difficulty swallowing, and weight loss; however, the plan of care did not contain goals specific to these identified problems. For RRNHV #1, RRNHV #5, RRNHV #6, RRNHV #8, and RRNHV #14, goals had not been updated for multiple months and continued to reflect admission teaching goals rather than current patient needs. Additionally, for RRNHV #5, documentation reflected an increase in the patient’s Seroquel dosage, yet the plan of care did not include goals related to monitoring, management, or education associated with this medication change. Review of RRNHV #6 identified multiple clinical notes documenting ongoing family issues within the home requiring protective services involvement; however, the plan of care did not include goals or interventions to address these psychosocial concerns. Review of RRNHV #11 identified assessment findings of dysphagia and aspiration risk; however, the plan of care did not contain goals specific to these identified problems. These findings were reviewed and validated with the hospice leadership team. Observed in Record Review. In 8 of 24 active patient records reviewed, the organization failed to ensure plans of care contained goals that were measurable and specific to the individual patient’s needs. Review of RRHV #3 identified the patient had a PleurX drain and the plan of care included a goal for patient/caregiver education regarding drain management; however, the goal did not include a measurable outcome or timeframe for completion. Review of RRHV #5 identified goals that were not specific to the patient’s condition, including risk of falls will be reduced during hospice admission and patient will eat and drink to their comfort during hospice admission. Review of RRHV #6 identified goals that were not measurable or specific, including patient/family will verbalize understanding of education provided throughout hospice stay and patient will receive needed amount of education of infection control throughout hospice stay. In addition, review of RRNHV #1, RRNHV #3, RRNHV #4, RRNHV #5, and RRNHV #14 identified goals that were not measurable or specific to the patient’s individual needs. Examples included patient will have needed amount of education and support throughout hospice stay, patient will eat and drink to their comfort, pain managed at a comfort level, and patient’s agitation will be controlled to patient’s comfort. These findings were reviewed and validated with the hospice leadership team.”

“Observed in Record Review. In 4 of 24 active patient records reviewed, the organization failed to ensure medication orders were clear, complete, and included sufficient direction for administration. Review of RRHV #5 and RRHV #6 identified physician orders for both bisacodyl and senna on an as-needed (PRN) basis for constipation; however, the orders did not provide direction on how the duplicate therapy should be managed. Review of RRNHV #5 identified physician orders for both milk of magnesia and bisacodyl PRN for constipation without guidance regarding use of the duplicate therapies. In addition, the patient had PRN orders for both morphine and oxycodone for pain management without direction indicating when each medication should be used. Review of RRNHV #8 identified PRN orders for both morphine and hydromorphone for pain; however, the orders did not provide guidance regarding administration of the duplicate therapies. These findings were reviewed and validated with the hospice leadership team. Observed in Record Review. In 3 of 24 active patient records reviewed, the organization did not have an accurate and complete medication list. On RRHV #2, it was noted on discussion with the caregiver that patient has been taking diclofenac sodium topical gel for arm pain but this medication was not reflected on the plan of care. On RRHV #1, it was noted that patient had orders for Mucinex PRN but there was no indication for use, agency policy is that PRN medications will have an indication for use. On RRNHV #12 it was noted that patient had PRN orders for morphine, midodrine and Megestrol Acetate with no indication for use. This finding was reviewed with agency leadership. Observed in Record Review. In 3 of 24 active patient records reviewed, the organization failed to ensure the plans of care included all drugs and treatment necessary to meet the patient’s needs. Review of RRHV #3 identified the patient was receiving oxygen at 3 liters per minute; however, the plan of care contained an order for oxygen at 2 liters per minute. In addition, orders related to management of the patient’s PleurX drain did not specify the frequency for drainage. Review of RRHV #4 identified that during the home visit, the nurse performed a dressing change to the drain site and obtained an INR test; however, the plan of care did not contain orders for these services. Review of RRNHV #7 identified nursing documentation reflecting wound care was provided to a wound on the patient’s elbow; however, the plan of care did not contain orders for this service. These findings were reviewed and validated with the hospice leadership team.”

“Observed in Patient Home. In 1 of 6 home visits conducted, the organization failed to ensure medical equipment was cleaned in accordance with manufacturer instructions. During review of RRHV #4, the nurse performed a PT/INR test and subsequently cleaned the testing device using Clorox wipes. Review of the manufacturer’s instructions identified the device was to be cleaned using either 70% alcohol or a 10% sodium hypochlorite solution prepared fresh every 24 hours. The cleaning agent used was not consistent with the manufacturer’s recommended cleaning procedures. These findings were reviewed and validated with the hospice manager who participated in the home visit and with the hospice leadership team.”

“Observed in Record Review. In 3 of 14 patient records reviewed that included hospice aide services, the organization failed to ensure aide plans of care contained specific instructions necessary to meet the patients’ individual care needs. Review of RRHV #1 identified the patient was bedbound and had bilateral lower-extremity edema and wounds; however, the aide plan of care instructed the aide to ambulate the patient and did not include care instructions specific to the patient’s current condition. Review of RRHV #2 identified the patient wore dentures; however, the aide plan of care did not include instructions regarding denture care. In addition, the patient was documented as bedbound, yet the plan of care instructed transfer to a wheelchair without specifying the level of assistance required to safely complete the transfer. Review of RRHV #5 identified the aide plan of care instructed the aide to ambulate the patient; however, it did not specify the type or level of assistance required for ambulation. These findings were reviewed and validated with the hospice leadership team.”

“Observed in Patient Home. 1 of 6 home visits conducted, the organization failed to ensure care and services were provided within a timeframe necessary to meet the needs of the patient and family. During RRHV #6, the assisted facility nurse identified concerns regarding delays in obtaining medications. Review of agency triage documentation, pharmacy orders, and the medical record identified that the assisted facility contacted the hospice requesting medication for the patient; however, the medication was not ordered until 7 days after the initial request. Review of the organization’s medication ordering process identified established medication-ordering timelines that required medications to be ordered within 1 day of the request. The delay was not consistent with the organization’s established process and did not ensure timely access to needed medications. These findings were reviewed and validated with the hospice manager who participated in the home visit and with the hospice leadership team.”

“Observed in Record Review. In 2 of 4 bereavement records review, the bereavement coordinator confirmed that the organization did not have complete medical records as evidenced by: Bereavement records were missing entries that had been documented in a messaging application outside of the medical record. In RRBR4, the medical record was missing documentation of a bereaved calling the hospice to set up counseling and the phone call the bereavement coordinator made to schedule the counseling session. In RRBR1, the medical record was missing documentation of a bereaved calling the hospice to request counseling and two phone calls made by the bereavement counselor to set up counseling sessions.”

“Observed in Record Review. In 2 of 24 active patient records reviewed, the organization failed to ensure the medical record was complete and contained all information pertinent to the patient’s care. Review of RRHV #1 and RRHV #6 identified that calls to the triage team had occurred; however, documentation related to those communications was maintained outside of the medical record and was not incorporated into the patient record making the record incomplete. These findings were reviewed and validated with the hospice manager who participated in the home visit and with the hospice leadership team.”

“Observed in Tracer Activities. In both inpatient units (IPUs), the organization failed to ensure the destruction of controlled substances was conducted in accordance with applicable laws and regulations. FDA regulation 1317.95 requires that controlled substances be destroyed in a manner that renders them non-retrievable and that two employees witness the handling and destruction process until the substance is rendered non-retrievable. During observation of medication administration in the Tenaya IPU, a clinician withdrew a dose from a single-use vial of a controlled substance, leaving a remaining amount of medication in the vial. The partially used vial was then placed into a large metal collection container that was not secured and could be overturned to gain access to its contents. Staff stated the organization’s process was to allow the container to fill and then add a cement filler to render the contents non-retrievable. As a result, partially used vials containing controlled substances remained in a non-destroyed state for an unwitnessed period of time prior to final destruction. Observation of the medication room at the main IPU campus identified that, while the controlled-substance collection container was locked, the deposit opening was large enough to allow a hand to reach into the container. Review identified that partially used vials containing controlled substances were deposited into the container without first being rendered non-retrievable, resulting in controlled substances remaining accessible in a non-destroyed state prior to final destruction. These findings were reviewed and validated with the hospice leadership team.”

“Observed in Patient Home. In 1 of 6 home visits conducted, the organization failed to ensure environmental safety hazards were identified and addressed. During RRHV #3, observation identified two oxygen cylinders stored in an upright position without being secured in a stand or other stabilizing device. Organization staff present during the visit did not identify or address the unsafe storage condition. The oxygen cylinders remained unsecured until the conclusion of the visit, when the surveyor requested that the cylinders be secured prior to departure. These findings were reviewed and validated with the hospice manager who participated in the home visit.”

“Observed in Building Tour. In 2 of 5 above ceiling checks, Above the ceiling at the one hour rated fire barrier across from room A8 the fire sprinkler pipe was found to be supporting the air handler ductwork.Above the ceiling at the one hour rated fire barrier across from room A1 the fire sprinkler pipe was found to be supporting the air handler ductwork.This was confirmed by the Facilities Management team. The surveyor discussed the Life Safety deficiency with the organization, and it was determined that the following ILSMs will be implemented until the deficiency has been resolved and according to the organization’s ILSM policy: Observed in Building Tour. In the ATS room with fire sprinkler and smoke detection had a penetration identified in the ceiling membrane by an approximate half inch conduit going through the ceiling and the fire stopping material has fallen down and causing a hole not protected. This was confirmed by the Facilities Management team. The surveyor discussed the Life Safety deficiency with the organization, and it was determined that the following ILSMs will be implemented until the deficiency has been resolved and according to the organization’s ILSM policy: Observed in Building Tour. In 2 of 30 fire sprinklers checked, Fire sprinklers outside the exit doors at the E quad exit and outside by the PBX entry doors were found to be covered with debris. This was confirmed by the Facilities Management team. 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. In 1 of 25 fire sprinklers checked at this location, The stairwell by room A1 was found to have a sprinkler that was missing the required escutcheon ring. This was confirmed by the Facilities Management team. The surveyor discussed the Life Safety deficiency with the organization, and it was determined that the following ILSMs will be implemented until the deficiency has been resolved and according to the organization’s ILSM policy: Observed in Building Tour. Across from room B8, the IT room which has smoke detection and fire sprinkler protection was found to have penetrations in the ceiling membrane. This was confirmed by the Facilities Management team. The surveyor discussed the Life Safety deficiency with the organization, and it was determined that the following ILSMs will be implemented until the deficiency has been resolved and according to the organization’s ILSM policy: Observed in Building Tour. In 1 of 5 Fire barrier checks, The two hour rated occupancy separation fire barrier at the main doors above the ceiling was found to have a penetration without any fire stopping material. This was confirmed by the Facilities Management team. The surveyor discussed the Life Safety deficiency with the organization, and it was determined that the following ILSMs will be implemented until the deficiency has been resolved and according to the organization’s ILSM policy:”