Cross Timbers Hospice, Inc.

“Observed in Record Review. In 3 of 17 patient records reviewed, the bereavement assessment was not completed by the social worker, as required by policy. The hospice surveyor observed in HOSRRNHV #10 the social worker did not complete a bereavement assessment on the patient’s brother. In HOSRRBRV #1 the social worker did not complete a bereavement assessment on the two adult sons in the home and the cousin who is also the caregiver. In HOSRRBRV #2 the social worker did not complete a bereavement assessment on the patient’s father. The social worker documented in November and December that the patient was at the father’s home. Per the organizational policy Bereavement Services 2-009 the program will provide bereavement services to the family and caregiver of hospice patients. This was reviewed and validated with the Bereavement Coordinator.”

“Observed in Record Review. In 8 of 14 patient records reviewed, the hospice surveyor observed where the nursing, MSW, and chaplain care plans are not individualized and specific to the patient needs. In HOSRRHV #1 and HOSRRNHV #1, HOSRRNHV #8 the nursing care plan stated, Patient safety needs AEB changes are made as needed to assure safety needs are met. It is not clear what the safety needs are and how they will be met. In HOSRRHV #1 the Chaplain care plan stated, Pt to express a sense of acceptance and peace regarding changing circumstances. It is not clear what sense of peace would be for the patient. In HOSRRNHV #1 the nursing care plan stated, Care needs met AEB patient voices care needs met. It is not clear what specific care needs the patient has. In HOSRRNHV #2, HOSRRNHV #7 and HOSRRNHV #10 the MSW care plan stated, Patient will adjust to changes and changing physical conditions and will express feelings of being supportive. It is not clear what the conditions are that the MSW is going to help the patients and families address. In HOSRRNHV #3 the chaplain care plan stated, Patient and family utilize chaplain to provide spiritual support. It is not clear what spiritual support the patient or family may need. In HOSRRNHV #9 the MSW care plan stated, Patient and family will express feeling emotionally supported by SW as they cope with the psychosocial aspect of disease process. It is not clear what psychosocial aspects of the disease process the MSW will assist the patient with. The Chaplain care plan stated, Chaplain services to provide spiritual and emotional support, not specific what type of emotional support he will be providing. This was reviewed and validated with the Patient Care Coordinator. Observed in Record Review. In 5 of 14 patient records reviewed, the organization failed to plan the patient’s care. The hospice surveyor observed in HOSRRNHV #1 where the patient had an acceptable level of pain as 0 and the RN entered a care plan that stated Patient will experience pain relief and control AEB patient rates pain at 4 or less. In HOSRRNHV #2 the patient was assessed for an acceptable level of pain and it was 0 and the nurse entered the care plan, Patient will experience pain relief and control AEB patient rates pain at 3 or less. In HOSRRNHV #3 the patient’s acceptable level of pain control was not assessed and the care plan for pain states, Patient will experience pain relief and control AEB patient denies pain and rates 3 or less. In HOSRRNHV #5 the nurse used a verbal tool to assess the patient’s pain but the nurse documented using the Edmonton Symptom assessment System in the care plan. He documented the wrong scale in the care plan for pain, In HOSRRNHV #7 the nurse used the PAINAD scale as the patient has a diagnosis of Alzheimer’s. In the care plan for pain the nurse documented that the FACES scale was used. These care plans do not align with the patient’s pain goal. This was reviewed and validated with the Patient Care Coordinator.”

“Observed in Record Review. In 5 of 14 patient records reviewed, the organization failed to plan the patient’s care. The hospice surveyor observed in HOSRRHV #4 where the RN documented in IDT notes that the patient had a fungal rash underneath her left breast and that it would be treated with antifungal powder daily. No care plan was entered for this problem. In HOSNHV#3 the patient had Nystatin powder on the medication list for chaffing under both breasts. The care plans did not include this as a problem or goal. In HOSRRNHV #5 the patient had a diagnosis of respiratory failure but no care plan was entered. In HOSRRNHV #7 the patient was on ASA and Plavix and there was no care plan for bleeding precautions. In HOSRRNHV #10 the patient was on 4 different medications for constipation and there was no care plan entered for constipation.. This was reviewed and validated with the Patient Care Coordinator.”

“Observed in Record Review. In 6 of 14 patient records reviewed, the hospice surveyor observed in HOSRRHV #1 the patient had duplicate medications for anxiety. The patient had Lorazepam 0.5 mg QHS, Lorazepam 0.5 mg every six hours as needed for anxiety, and Lorazepam 0.25 ml buccal every 6 hours and as needed. It is not clear which of the medications the patient should take for anxiety. This patient also had duplicate medications to treat constipation. There were orders and the bottle stated, for a stool softener 100 mg twice a day, Dulcolax 5 mg daily and as needed, and Senna one tab twice a day and as needed. It is not clear which of the medications the patient should take for constipation. In HOSRRHV #2 the patient had Norco 5-325 mg 1 tablet by mouth every 6 hours and as needed for break through pain, and Roxidone 15 mg every 4 hours and as needed for breakthrough pain. It is not clear which one should be taken for breakthrough pain. This patient also had orders for Phenergan 25 mg every 6 hours and as needed for nausea and Zofran 4 mg every 4-6 hours and as needed for nausea. In HOSRRNHV #4 the patient was on Colace 20 ml by peg tube twice a day, Senna 8.6 mg twice a day in am and pm, Senna Plus 8.6 mg one dime a day and adjust to 1-4 times as needed, and Dulcolax 10 mg rectal suppository every 72 hours and prn. There are no parameters for when one should be taken over the other. This patient also had duplicate orders for Tramadol 50 mg two times a day oral for severe pain and Tramadol 50 mg 1/2 tablet by mouth every 6 hours and prn for severe pain. For anxiety this patient had Atarax 25 mg 2 pills orally as needed and Ativan 0.5 mg orally every 3 hours prn. In HOSRRNHV #5 the patient was on Methadone 2.5 mg by mouth twice a day for severe pain and Advil 200 mg every 4 to 6 hours and as needed for severe pain. It is not clear which one should be taken for severe pain. n HOSRRNHV #6 the patient was on Phenergan 25 mg every 6 hours for nausea and Zofran 4 mg 2 tablets every 4 hours for nausea. It is not clear wen the patient should take one of the medications over the other. In HOSRRNHV #10 the patient was on MiraLAX 17 gm in 8 ounces of fluid one time a day and prn, MOM 30 mg daily and as needed, Bisacodyl suppository daily as needed for constipation. There were no clear parameters of when to take one over the other. This was reviewed and validated with the Patient Care Coordinator. Observed in Patient Home. In 6 of 14 patient records reviewed, the organization failed to accurately document medications. In HOSRRHV #1 and HOSRRNHV #1 the patient had an order for Oxygen 2-4 liters continuous via nasal cannula. The RN failed to document when the patient should use 2, 3, or 4 liters. In HOSRRNHV #5 the patient had an order for Oxygen 4-5 liters. The RN failed to document when the patient should use 4 or 5 liters. In HOSRRNHV #8 the patient had an order for Oxygen 6-10 liters. The RN failed to document when the patient should use 6, 7, 8, 9, or 10 liters. In HOSRRNHV #9 and HOSRRNHV #10 the patient had an order for Oxygen 1-5 liters. The RN failed to document when the patient should use 1, 2, 3, 4, or 5 liters. This was reviewed and validated with the Patient Care Coordinator.”

“Observed in Patient Home. In 7 of 14 patient records reviewed, the home health aide failed to provide care, treatment or services for the patient. In HOSRRHV #1, HOSRRNHV #1, HOSRRNHV #5, HOSRRNHV #8, HOSRRNHV #9, and HOSRRNHV #10 the patients were on continuous Oxygen and there were no instructions for the aide in the aide flowsheet plan as to what she should do with the oxygen when bathing the patient. These patients also had a range for liter flows and the aide flowsheet did not contain the appropriate liter flow for the patient. Additionally, all of these patients had barrier cream in the flowsheet to be applied but there were no directions as to the location where it should be applied. The nurse surveyor observed during the home visit in HOSRRHV #4 where the aide flowsheet plan stated that the aide would provide the patient oral care, nail care, skin/back care, and barrier cream with each visit. The aide did not offer or provide any of these services and the barrier cream did not have a location as to where it should be applied. The hospice surveyor asked the home health aide about the barrier cream and she was unaware of what it was for. This patient also had a wound to her left breast and a fungal infection underneath her left breast. There were no instructions in the aide flowsheet plan as to what she should do with the site during the shower. After the shower the aide sprinkled antifungal powder underneath the left breast. This was reviewed and validated with the Patient Care Coordinator. Observed in Record Review. In 10 of 14 patient records reviewed, the organization failed to individualize the patient’s care. The hospice surveyor observed in HOSRRHV #1, HOSRRHV #2, HOSRRHV #4, HOSRRNHV #3, HOSRRNHV #5, HOSRRNHV #7, HOSRRNHV #8, HOSRRNHV #9, HOSRRNHV #10, where under Observations Reported to the Nurse there is templated language for the aide to report difficulty swallowing or eating and seizures and none of these patients had a diagnosis or issues. This language was found in all of the aide assignment sheets. This was reviewed and validated with the Patient Care Coordinator.”

“Observed in Patient Home. In 1 of 4 HR files reviewed, the home health aide failed to follow the plan of care. In HOSRRHV #4 the hospice surveyor observed that the home health aide did not perform peri care per the aide flowsheet. She gave the patient a hand towel with soap and the patient cleaned herself in the front only. This patient is incontinent of bladder and when the aide was assisting her to put on her diaper she gave the patient an incontinent pad to place in the diaper and then she assisted the patient with placing toilet paper on top of the incontinent pad. Applying the toilet paper was not in the aide flowsheet that was developed by the RN. This was reviewed and validated with the Patient Care Coordinator.”

“Observed in Patient Home. In 3 of 4 home visits conducted, the hospice surveyor observed that the medication list in the home was inaccurate. In HOSRRHV #2 the medication list stated that the patient was taking Losartan 50 mg one time per day. On the medication bottle it states that the patient is to take the medication twice a day. The patient had timolol maleate 1 drop per eye on the medication list but the medication box states that the medication is Dorzolamide HCL Timolol maleate. In HOSRRHV #3 the medication list states Hydrochlorothiazide 25 mg per day but the medication bottle states 12.5 mg per day. The Pantoprazole on the medication list states 40 mg one time a day but the medication bottle states 20 mg per day. This patient also was taking Docusate Sodium 100 mg QHS which was not on the medication list. Per the patient’s daughter the patient has been on these medications for months. In HOSRRHV #4 the patient states that she is using asper cream topical ointment for her arthritis to her left heel. This was not included in the medication list. This was reviewed and validated with the Patient Care Coordinator.”