Staten Island University Hospital Univ Hospice

“Observed in Individual Tracer. In 9 of 16 patient records reviewed, The surveyor noted (RRHV#1) that the spiritual assessment was not completed by the chaplain within 5 days as required by policy PC-26. The assessment was attempted by telephone call; however, a home visit was not completed and there was no indication that the patient/CG refused. Also, in (RRHV#2) no chaplain visited to complete the spiritual assessment and an telephone call was not placed until day five with no visit /assessment completed. Also, the psycho-social assessment was not completed by the social worker, in person, as required, and the telephone call to the caregiver, did not include an assessment of the patients needs. In (RRHV#3) there were no chaplain visits or spiritual assessment telephone contact until two weeks after election, and there was no evidence that the patient refused or delayed the visit. In (RRHV#4) there was no documentation that the psychosocial and spiritual assessments were completed, and the bereavement risk assessment was not documented until seven days after election. In (RRIPU#21), the bereavement risk assessment was not completed until two weeks after election. In (RRNHV#5) the spiritual assessment was not completed until day eleven, In (RRNHV#6) the psycho-social assessment/ MSW visit was not completed until day seven. In (RRNHV#8), the spiritual assessment was not completed until day nineteen. In (RRNHV#9) the spiritual assessment was not completed and the chaplain was not declined. In (RRNHV#11), the spiritual assessment was not completed until thirty days after election. The initial assessment policy required that all assessment be completed in the first five days of election of the hospice benefit. This was confirmed with the leadership team.”

“Observed in Record Review. The surveyor noted that (RRNHV#8) the pre-bereavement risk assessment indicated that the caregiver was at moderate risk for complicated grief; however, there were no interventions identified in the plan of care to meet the caregiver needs. Also, the nursing assessment indicated that the patient had dysphagia and was hard of hearing; however, it was not addressed in the plan of care. In (RRNHV#9) there were no interventions to address dysphagia and risk for falls. as identified in the assessment. In (RRNHV#11) there were no interventions to manage dyspnea. The assessment indicated that the patient was on CPAP, oxygen and used prn nebulizers. In (RRNHV#12) the plan of care interventions were not updated when the patient’s level of care changed from routine level of care to general inpatient level of care including visit frequencies and medications prescribed in the inpatient unit. In (RRNHV#14) the patient was assessed to have a gastrostomy tube and was prescribed enteral feedings; however, there were no gastrostomy site care or enteral feeding orders/interventions on the plan of care from January through June. Also, there were no interventions for vascular access midline dressing changes. This was confirmed with the leadership team. Observed in Individual Tracer. The surveyor noted (RRHV#4) that the patient record included several visit notes by physical therapy; however, there were no visit orders or a plan of care for physical therapy. This was confirmed with the leadership team.”

“Observed in Record Review. In 7 of 16 patient records reviewed, The surveyor noted that the (RR#20IPU) orders were incomplete for oxygen. The order for O2 2lpm did not indicate if the oxygen was to be administered continuously or as needed. Also, the parameters for holding Metoprolol were unclear and simply stated systolic BP 100, pulse 60. In discussion with the nurse the order was to hold for systolic BP less than 100 and a pulse less than 60. There were no instruction as to when to notify the physician. This was confirmed with leadership team.”

“Observed in Individual Tracer. In 4 of 14 patient records reviewed, The surveyor noted (RRHV#2) that the plan of care frequency orders were not followed. The Chaplain was ordered 2xm for 4 months and the MSW was ordered 2x a month for 4 months; however, no home visits were performed by the chaplain or social worker for the first month and there was no indication that the patient had refused or that the physician was notified. Also, in (RRHV#3) the HHA was ordered 5x week; however, it was only provided 3 x week in May and June. In (RRHV#4), the chaplain did not visit as ordered 1-2 x month and the social worker did not visit 1-2 x month as ordered. There was no indication that the patient refused or that the physician was notified. In (RRNHV#7) the aide was ordered 5 x a week; however aide services were not provided. This was confirmed with the leadership team.”

“Observed in Record Review. In 1 of 16 patient records reviewed, The surveyor noted that (RRHV#3) the election form was altered after it was signed by the patient representative and the date of election changed to the following day by the nurse. There was no evidence that the representative was aware of the change or had agreed to the change. This was confirmed with the leadership team as not following organizational policy. Observed in Medication Management Tracer. In 1 of 1 tracers conducted, The surveyor noted that the (RRIPU#1) narcotic count sheet was altered with scribbles of the count number for three consecutive days, noted in the hospice residence narcotic count log. It was unclear as to the actual count recorded and who had made the entries. The policy required that entries be corrected by drawing a line through the error, initialing it and rewriting the entry. This was confirmed with the director.”

“Observed in Record Review. In 2 of 3 SNF patient records, The surveyor noted (RRNHV#10) that the hospice plan of care for this patient in a skilled nurse facility, did not specify who was administering medications and treatments and who was managing the patient’s symptoms of pain and dyspnea. Also, (RRNHV#14) did not indicate whether or not the hospice was assessing the wound and how often, including the wound measurements; who was assessing the gastrostomy tube, who was providing site care and who was managing the vascular access midline site care. This was confirmed with the leadership team.”