Aultman Hospice

“Observed in Record Review. In 2 of 16 patient records reviewed, for active patients with oxygen, it was noted by the nurse surveyor that orders were not clear or complete. For HOSRRHV#2, the oxygen order read “Oxygen O2 device inhale 2-5 liters per minute via nasal canula continuous as needed for SOB (shortness of breath)”. The patient was using the oxygen at night only with no liter flow noted in the electronic medical record (EMR). For HOSRRNHV#9, the oxygen order read “Oxygen O2 device, inhale 2-5 liters per minute intermittent as needed for SOB.” The documentation in the EMR indicated that he was using oxygen continuously but did not note a liter flow. Findings were verified with the Director, Hospice & Palliative Care and the Assistant Nurse Manger, Hospice & Palliative Care.”

“Observed in Patient Home. In 2 of 6 home visits conducted, it was noted by the nurse surveyor that the staff failed to follow acceptable practice and agency policy when performing patient care. During HOSRRHV#5, the hospice aide went to wash her hands in the communal resident bathroom in the Memory Care Unit. She set her baggies with soap, paper towels and gloves on the vanity without a barrier and proceeded to wash her hands. She then picked up the baggies and put them back in her bag. She then hand sanitized, with hand sanitizer by putting some in her palms and rubbing her palms together, then before it was dry, reached into her bag for her gloves and put them on. Throughout the visit when changing gloves she did not properly hand sanitize. During HOSRRHV#6, the registered nurse did not hand sanitize when donning or doffing gloves throughout the visit. She performed wound care without changing gloves between taking off the old dressing and cleaning the wound. She did change gloves before putting on the clean dressing, but she did not hand sanitize before putting the clean gloves on. Findings were discussed with the Assistant Nurse Manager, Hospice and Palliative Care who was present during the visits.”

“Observed in Record Review. In 4 of 14 patient records reviewed, with the hospice aide, it was noted by the nurse surveyor that the hospice aide care plan did not contain all the necessary or current information. For HOSRRHV#2, and HOSRRNHV#7, the patient was on PRN oxygen, yet the care plan did not address what the aide should do regarding the oxygen should the patient be on it during the bath. Additionally, for HOSRRHV#3, HOSRRNHV#7, and HOSRRNHV#11, there were no instructions as to when the hospice aide should notify the nurse such as for change in condition or skin breakdown. Findings were verified with the Director, Hospice & Palliative Care and the Assistant Nurse Manger, Hospice & Palliative Care.”

“Observed in Building Tour. It was observed in the cross corridor there was an exit, however the exit sign did not have the proper chevron leading to the emergency egress door. This was verified by the Facilities 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. It was observed in the mezzanine level with multiple natural gas HVAC units, there was excessive combustible storage throughout the entire area, and a workstation set up. This was verified by the Facilities 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. It was observed in the main IT closet that was smoke detector protected had multiple gaps in the drop ceiling greater than 1/8. This was verified by the Facility 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. It was observed at the main separation the 3 hour rated fire doors did not close and latch properly when tested. This was verified by the Facilities 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. It was observed in the main hallway outside the IT room this was a rated 1 hour fire barrier per the life safety drawings and had a penetration that was not sealed properly, also in the clean linen room in the cross corridor there were multiple unsealed pipes in the rated fire barrier.. This was verified by the Facilities 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. It was observed per the life safety drawings the 1 hour rated fire barrier for the fire riser room was missing the fire rating label on the frame. This was verified by the Facilities 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:”