Traditions Health of Oklahoma City

“Observed in Record Review. In 10 of 10 active patient records reviewed, During RRHV# 1, RRHV# 2, RRHV# 3, RR# 1, RR# 2, RR# 3, RR# 4, RR# 5, RR# 6, and RR# 7’s patient record review it was noted the organization had not ensured the written plan of care was based on the patient’s goals and the time frames, settings, and services required to meet those goals. For example: review of RRHV# 3’s initial plan of car and subsequent two recertification plans of care revealed no patient specific Chaplain goals. During RRHV# 2’s patient record review revealed an initial plan of care with all goals with the same timeframe of “2 weeks” that included “Nursing plan of care will be established by 2 weeks”, “Medical Social Worker plan of care will be established by two weeks”, “Chaplain plan of care will be established by 2 weeks”, “Patient/caregiver will verbalize/demonstrate understanding of management of ALS. Facility staff is knowledgeable and involved in hospice plan of care for patient by 2 weeks”. Further review of RRHV# 2’s initial and subsequent plans of care revealed no patient specific Chaplain goals. During RRHV# 1’s patient record review revealed an initial plan of care with Updates/Add-Ons to the initial plan of care to included goals “MSW will establish a plan of care by [10 days after soc]”, “Decreased fear/anxiety regarding death and dying process” with no time frame and “patient will express an increased sense of closure and peacefulness at the end of life” with no time frames. Review of RR# 5’s plan of care revealed the goal: Pain will be managed at a level acceptable to the patient. However, this was no measurable pain level documented in the plan of care. Review of RR# 1, RR# 2, RR# 3, RR# 4, RR# 5, RR# 6, and RR# 7’s plans of care revealed Chaplain frequency of visits with no documented Chaplain goals of care and all the MSW patient goals did not have time frames. This was reviewed, discussed, and validated with the Branch Director.”

“Observed in Record Review. In 2 of 10 active patient records reviewed, During RRHV# 2 and RRHV# 3’s patient records review it was noted the organization had not ensured it planned the patient’s care to include interventions to manage symptoms. For example: review of RRHV# 3’s patient record revealed RRHV# 3 was taking Eliquis at the time of the start of care. Review of RRHV# 3’s initial plan of care and two subsequent recertification plans of care revealed no bleeding precautions. Review of RRHV# 2’s patient record revealed RRHV# 2 was taking Eliquis at the time of the start of care. Review of RRHV# 2’s initial plan of care and two subsequent recertification plans of care revealed no bleeding precautions. This was reviewed, discussed, and validated with the Branch Director.”

“Observed in Record Review. In 5 of 10 active patient records reviewed, During RRHV# 2, RRHV# 3, RR# 5, RR# 6, RR# 7’s patient records review it was noted the organization had not ensured the plan of care revisions were based on information from updates to the patient’s comprehensive assessment and address the patient’s progress toward goals and outcomes. For example: review of RRHV# 3’s patient record revealed an initial plan of care with all the goals with the timeframe of five days after the start of care that included Nursing plan of care will be established [soc date], Patient/caregiver will verbalize/demonstrate understanding of care required secondary to bowel incontinence [soc date], Patient/caregiver will verbalize knowledge of preventative measure responding to the event of hemorrhage bleeding and recognized early management [soc date}, Medical Social Worker will establish a plan of care [soc date]. Review of RRHV# 3’s subsequent recertification plan of care 90 days later revealed the same goals with the same timeframe date. Further review of RRHV# 3’s subsequent recertification 180 days after the start of care revealed the same goals with the same timeframe. During RRHV# 2’s patient record review revealed an initial plan of care with all goals with the same timeframe of “2 weeks” that included “Nursing plan of care will be established by 2 weeks”, “Medical Social Worker plan of care will be established by two weeks”, “Chaplain plan of care will be established by 2 weeks”, “Patient/caregiver will verbalize/demonstrate understanding of management of ALS. Facility staff is knowledgeable and involved in hospice plan of care for patient by 2 weeks”. Review of RRHV# 2’s subsequent recertification 90 days later revealed the same goals with the same timeframe. Further review of RRHV# 2’s subsequent recertification 180 days after the initial plan of care revealed the same goals and timeframes. During review of RR# 7’s initial plan of care revealed goals with time frames dated 2 to 15 days after the of the start of care. Review of RR# 7’s four subsequent recertification plans of care revealed the exact same goals with the same timeframes. Review of RR# 6’s initial plan of care revealed all goals dated 5 days after the start of care. Review of two subsequent recertification plans of care revealed the exact same goals with the same time frames. Review of RRE 5’s recertification plan of care revealed the same goals and time frames as the initial plan of care. This was reviewed, discussed, and validated with the Branch Director.”

“Observed in Record Review. In 1 of 2 bereavement records reviewed, During BR# 1’s bereavement plan of care review it was noted, the organization did not plan the patient s care by developing a bereavement plan of care. For example: review of BR# 1’s bereavement plan of care included documentation IDG to discuss; Risk of 19; Contact has a history of mental health and extreme dependency. Chaplain will consult with IDG after death call and possible visit. Chaplain also reaching out to family friend and also MSW regarding possible aps referral. However, further review of the bereavement plan of care revealed no timeframes for any of these interventions. This was reviewed, discussed, and validated with the Bereavement Coordinator and Branch Director.”

“Observed in Record Review. In 3 of 10 active patient records reviewed, During RRHV# 1, RRHV# 2, and RRHV# 3’s patient records it was noted the organization had not ensured registered nurse (RN) responsible for hospice aide supervision prepared complete written patient care instruction for the hospice aide. For example: review of RRHV# 1’s patient record revealed RRHV# 1 transferred to the hospice approximately 60 days prior to the surveyor review of the record. Review of RRHV# 1’s hospice aide written patient care instructions revealed the task of bathing in the “tub”. Further review of RRHV# 1’s hospice aide visit notes beginning two days after the transfer to hospice revealed narrative documentation by the hospice aide that a “shower” was completed. During the home observation a shower was noted in RRHV# 1’s bathroom. However, the hospice aide written patient care instructions had not been updated to reflect the task of “Shower”. Review of RRHV# 2’s patient record revealed RRHV# 2 had aspiration precautions and was takin Eliquis. Review of RRHV# 2’s hospice aide written patient instructions revealed the task of “shaving” and “assisting with meals”. However, review of RRHV# 2’s hospice aide written patient care instructions revealed no documentation of what equipment to use when shaving, bleeding precautions, or aspiration precautions. Review of RRHV# 3’s patient record revealed RRHV# 3 was taking Eliquis. Review of RRHV# 3’s hospice aide written patient care instructions revealed the task of shaving. However, further review of RRHV# 3’s hospice aide written patient care instructions revealed no documentation on what equipment to use when shaving or bleeding precautions. This was reviewed, discussed, and validated with the Branch Director.”

“Observed in Patient Home. In 1 of 2 home visits conducted with medication reconciliation, During RRHV# 1’s home observation it was noted the organization had not ensured the medication list included all of the over the counter medications. For example: during RRHV# 1’s home observation the surveyor observed the registered nurse (RN) complete a medication reconciliation with RRHV# 1’s daughter present. RRHV# 1’s daughter reviewed the medications and shared RRHV# 1 had been taking Vitamin D for over a year. However, review of the medication list revealed no Vitamin D listed. This was observed, discussed, and validated with the Branch Director.”