Queen City Hospice

“Upon patient record review, 1 of 27 (Patient #4) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: Patient 4: The patient medication profile has orders for Tylenol 650 TID routine, orders for Tylenol 650mg TID prn and hydrocodone with acetaminophen 1 tab every 4 hours prn. There is no directive for maximum dosing. The facility MAR has Loperamide 2mg give 2 capsules every 8 hours prn with max dose of 16gm. The hospice medication profile does not have an order for a max dose. Corrected on site.”

“Upon patient record review, 1 of 27 (Patient #10) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family’s needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient 10: The patient has a documented colostomy upon initial comprehensive assessment by the RN. There is a period of between 6/26/24-9/10/24 that the RN did not assess the colostomy. The LPN assessed the colostomy site and stoma and output on 8/20/24. On 8/23/24 recert the RN documented under GI “patient incontinent” and no assessment of the colostomy site was performed. On the following visits the patient is assessed as “incontinent” and no assessment of the colostomy site/stoma was assessed by the RN. The LPN performed a colostomy assessment on 9/5/24 and then the RN performed a colostomy assessment on 9/10/24. This patient is in a facility and dependent for all care.”

“Upon patient record review, 5 of 27 (Patient #12,14,17,18,20) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 12: The RN identified pt as being a high fall risk upon initial assessment 5/14/24. There was no High risk for fall care plan initiated with goals and interventions. Corrected on site. Patient 14: The POC shows pt is taking Eliquis. There is no at risk for bleeding care plan with goals and interventions. Corrected on site. Patient 17: The POC contains evidence pt is on Aspirin daily and there is no risk for bleeding care plan with goals or interventions. Corrected on site. Patient 18: The NP documented on the Face to face 8/15/24 that pt has dysphagia. There was no at risk for aspiration care plan with goals or intervention. Corrected on site Patient 20: The nurse documented on 8/28/24 that pt is a max assist for transfers though did not implement a fall risk care plan with goals and interventions. Corrected on site.”

“Upon patient record review, 6 of 27 (Patient #4,8,10,15,16,17) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 4: The hospice nurse wrote an order at the facility to discontinue senna-time on 6/12/24. This medication remains on the facility MAR. The patient has orders on the POC for Tylenol 650 TID routine, orders for Tylenol 650mg TID prn and Hydrocodone with Acetaminophen 1 tab every 4 hours prn. There is no directive for maximum dosing. The facility MAR has Loperamide 2mg give 2 capsules every 8 hours prn with max dose of 16gm. The hospice POC does not have an order for a max dose. Corrected on site. Patient 8: The POC contains an order to cleanse wound with wound cleanser, pat dry, apply TAO and cover”. The order does not state what to cover the wound with. Corrected on site. Patient 10: The RN identifies pt has a colostomy on the initial assessment 6/12/24. There were no orders added to the POC for the care of the colostomy. Corrected on site. Patient 15: The medical record contains an order on 7/18/24 to cleanse the wound to the buttocks and apply calmoseptine. It does not indicate who is to perform the wound care and what to cleanse the wound with. Corrected on site. Patient 16:The POC 6/8/24 has wound care orders though does not state who will provide the wound care. Corrected on site. Patient 17: The POC contains treatment orders for administration of insulin. The patient is not on insulin. Corrected on site.”

“Upon patient record review, 4 of 27 (Patient #12,15,17,20) did not have evidence that a revised plan of care includes information from the patient’s updated comprehensive assessment and must note the patient’s progress towards outcome/goals from the plan of care. Patient 12: There is an order for a foley catheter on 6/18/24, the POC was never updated to include the foley. Corrected on site. Patient 15: The medical record contains an order for wound care to the buttocks on 7/18/24. The POC 8/13/24 was not updated. Patient 17: The medical record at the facility contained an order for PT eval and treat on 7/5/24. This order was not included on the POC or in the hospice record. Patient 20: The face to face on 7/31/24 the NP documents pt is on a honey thickened liquid and puree diet. The POC was not updated to include a diet order. Corrected on site.”

“Upon client record review, 2 of 27 (Patient #3, 5) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 3: The nurse documented “applied Mepilex to bilateral skin tears to right and left arms and a Mepilex to the left shin” on 8/29/24. There is no order for Mepilex for the shin or arms. Corrected on site. Patient 5: The nurse documented “wound no longer open, left OTA”. There is no order to discontinue the wound care or to leave the wound open to air. Corrected on site.”

“Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient 4: The nurse removed a small bag from the nursing bag, left the nursing bag in the common area at the AL facility on a counter without barrier underneath. The nurse placed the small bag which held the bp cuff, thermometer and pulse oximeter on the bedside table of the patient without a barrier. The nurse used the bp cuff, pulse ox and thermometer on the patient and then placed the items back in to the small bag without cleansing them. Per bag policy 6-013 “The bag will be placed on a clean,dry surface with a disposable moisture-resistant barrier or hung on a door handle”. “When assessment completed, reusable equipment will be cleaned using EPA appropriate solution, and placed on the clean side of barrier to air dry”.”

“Upon patient record review, 1 of 27 (Patient #14) did not have evidence the hospice medical director, physician employees, and contracted physician(s) of the hospice, in conjunction with the patient’s attending physician, are responsible for the palliation and management of the terminal illness and conditions related to the terminal illness. This is demonstrated by any of the following: 1. All physician employees and those under contract must function under the supervision of the hospice medical director. 2. All physician employees and those under contract shall meet this requirement by either providing the services directly or through coordinating patient care with the attending physician. 3. If the attending physician is unavailable, the medical director, contracted physician, and/or hospice physician employee is responsible for meeting the medical needs of the patient. Patient 14: The nurse documented on 8/30/24 at 10:27 am that the patient was having increased GI/constipation symptoms. There is no evidence the nurse called the elected attending for orders. The nurse called the hospice NP to obtain orders for a KUB. There is no evidence the attending physician was updated regarding the change in pt condition. Corrected on site by nurse added a late entry to document that the attending physician of record was called and notified of the KUB order and pt sent to the hospital.”

“Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. The Queen City office in 2023 year end was 1.8%. Quarter 3 2023 was 2% and Quarter 4, 1.7%. Fayetteville year end was 0.9%, Quarter 3 0.8%, Quarter 4 was 2.3%, Capitol year end 2023 0.7%, Quarter 3 0.8%, Quarter 4 1.0%, Dayton 1.4% year end, Quarter 3 1.2%, Quarter 4 0.5%.”

“Upon patient client record review, 7 of 27 (Patient #2,5,8,9,12,15,17) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient 2: The aide documented that nail care, shaving and skin care were not performed at the visit with a reason of “SV”. This is not an approved abbreviation. Patient 5: The nurse documented wound care on 2/27/24, 5/6/24,4/29/24 by restating the order. The care was not in past tense indicating the wound care was performed. On 5/2/24 the nurse documented “wound care as ordered”. There is no evidence the nurse followed the POC. Patient 8: The nurse documented on 8/20 “Cleansed with wound wash, pat dry, applied TAO and covered”. The nurse did not document what the wound was covered with. Patient 9: The nurse documented “T/O” on 9/3/24 this is not an approved abbreviation. Patient 12: The nurse documented wound care on 9/9/24 by restating the order, it is unclear if they followed the POC. On 8/23/23 the nurse documented “wound care provided as ordered”. It is unclear whether they followed the POC. Patient 15: The nurse documented on 9/6/24 “applied calmoseptine per order, covered”. There is not evidence they followed the POC. On 8/30/24 the nurse documented “wound care provided and documentation in wound record”. There was no documentation in the wound record. Patient 17:The nurse documented obtaining a verbal order for an xray at 6:25pm on 8/25/24. The signed physician order in the medical record has verbal order obtained 9/2/24.”

“Upon client record review, 4 of 5 (Patient #1,2,3,5) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 1: The SN documented on 1/24/24 the following notes: “This RN made a new schedule to administer oxycodone every 8 hours with Tylenol doses in between”. There is no evidence of an order for these medications. On 1/25/24 the SN documented giving pt Morphine 5mg at 12:20pm and there was an order at 0904 on 1/25/24 for morphine to be given 10mg every 1 hour prn. Patient 2: The SN documented on 3/13/24 “Patient exhibiting discomfort moaning, facial grimacing, medication administered following POC”. There is no evidence that the SN followed the POC. The SN documented giving Morphine 15mg at 1600. There is no order to continue giving the morphine at 15mg the orders for 15mg morphine was a one time dose. Patient 3: The SN documented at 0900 on 1/29/24 “Morphine given” There is no evidence the orders were followed. Patient 5: The SN documented on 3/12/24 “Inserted Foley”. There is no evidence the nurse followed the POC. On 3/13/24 the SN documented in the narrative EMR “1933 FSN administered morphine and Ativan for pain.” The paper documentation has documented the Morphine and Ativan were given at 1937.”

“Upon patient client record review, 4 of 5 (Patient #1,2,3,5) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient 1: The SN documented 1/22/24 “DTR”. This is not an approved abbreviation. Patient 2: The SN documented 2/22/24 “NOJ distended” “FSN”. These are not approved abbreviations. Patient 3: The SN documented on 3/2/24 and 3/10/24 pt is incontinent and wears briefs. Per the POC and previous nursing notes pt has a Foley. There is evidence of the Foley catheter remaining in place prior to and after these visits. Patient 5: The SN documented on 3/12/24 at 1700 “received order for Morphine 10mg every 1 hour prn”. There is no evidence of an order for 10mg. The order was put in the POC/medication profile at morphine 5mg every 1 hour prn. This appears to be a typo. The pt was not given the 10mg dose. SN documents on 3/14/24 “FSN and NH” These are not approved abbreviations.”