Friends of Caroline Hospice of Beaufort, Inc.

“Observed in Record Review. In 3 of 6 patient records reviewed, the organization failed to ensure the written plan of are was based on goals that were specific, measurable, and time-bound. On review of RRNHV#1 there was a goal that was not measurable in it read edema will decrease. In RRNHV#3 an example of a goal that was not measurable was patient will be safe in home environment as evidenced by decreased number of falls. In RRNHV#6 an example was patient will have adequate care of catheter within 2 weeks.. These observations were reviewed with the Compliance officer and the Clinical Leader.”

“Observed in Record Review. In 6 of 6 patient records reviewed, the organization failed to ensure the plan of care include all services needed for the palliation and management of the terminal illness and related conditions. For example: on review of RRHV#1 the documentation noted the patient was a high fall risk and was treated for a UTI yet the issues were not reflected on the plan of care. In RRNHV#2 the patient was on antibiotics for a UTI, and had documentation of difficulty swallowing but no care plans to guide the care. In RRNHV#3 the patient had a primary diagnosis of Pulmonary Fibrosis yet no care plan for respiratory. In RRNHV#4 there was a foley catheter and Peg tube but no related care plans to guide the care. In RRNHV#5 there was documentation of an infection and issues with vaginal bleeding yet the issues were not reflected in the plan of care. In RRNHV#6 the patient had pain issues with oxycodone ordered but no care plan for pain. There was documentation of a UTI but no care plan related to the infection open. These observations were reviewed with the Compliance Officer and Clinical Leader.”

“Observed in Record Review. In 2 of 6 patient records reviewed, the organization failed to ensure the plan of care include all services needed for the palliation and management of the terminal illness and related conditions to include drugs and treatments necessary to meet the needs of the patient. On review of RRNHV#1 there were as needed (PRN) medications as part of the plan of care that failed to include an indication as required. Example: Cephalexin 250 mg take one capsule once daily only if symptomatic yet the order failed to specify what symptoms. The orders for dicyclomine and MiraLAX did not have an indication for PRN use. In RRNHV#4 The documentation showed the patient had a foley and later a PureWick yet there were no related physician orders noted on the record. The patient also had tube feeds via peg tube but no orders for the tube feeds noted. These observations were reviewed with the Compliance Officer and Clinical Leader.”

“Observed in Record Review. In 9 of 21 patient records reviewed, the plan of care did not include all services needed for the palliation and management of the terminal illness and related conditions. In the chart for RRHV#1, the patient was assessed to be at high risk for falls. There were no patient specific interventions on the plan of care that addressed this risk. Additionally, the plan of care had not been updated as the patient had been admitted more than 6 months prior to the survey, yet the goal of Patient will be safe within one week remained on the current plan of care. In the chart for RRHV#2, there were no individualized fall reduction interventions on the POC. During the visit, the primary caregiver stated she uses multiple interventions including bilateral bed rales, a baby monitor, motion detector lights in bedroom, etc. In the charts for RRHV#3 and RRNHV#5, there were no interventions on the plan of care related to the safe use of oxygen. In the chart for RRHV#3, the current plan of care (POC) included 2 different, inaccurate medication list which included numerous duplicate medications including Oxycodone, Hyoscyamine, Ativan, Tylenol, Bisacodyl, etc. In the chart for RRHV#4, the medication orders were incomplete and did not include the reason for administration of prn medications including Dulcolax suppository, Haldol, Morphine, etc. which is required per organizational policy for medication orders. Additionally, prn visits were on the plan of care for all disciplines, however did not include an indication for when a prn visit would be made nor a number of prn visits allowed. In the chart for RRNHV#8, the order for Novolog was incomplete and stated - see sliding scale - as needed without inclusion of the sliding scale. Additionally, the assessment included information that the caregiver was using Zinc and Allevyn to the patient’s sacral decub. There was no order found on the POC. In the chart for RRNHV#9, the order for oxygen was not obtained and included on the plan of care until at least one day after the documentation indicated the patient was using oxygen in the IPU. In the chart for RRIPU#2, the patient developed a skin tear after a fall. The RN washed and dressed wound with Tegaderm and absorbent gauze. The POC was not updated with orders for this care. This was confirmed with the Compliance Officer assisting with record review.”

“Observed in Record Review. In 2 of 21 patient records reviewed, the hospice’s interdisciplinary group, in consultation with the patient’s attending physician, if any, had not completed the comprehensive assessment no later than five calendar days after the election of hospice care. In the chart for RRHV#2, the initial spiritual assessment was not conducted until 12 days post the date of election. In the chart for RRNHV#8, neither the social worker nor the chaplain completed the initial assessment within the 5 day window. This was confirmed with the Director of Compliance.”

“Observed in Record Review. In 8 of 21 patient records reviewed, the written plan of care was not based on the patient’s goals and the time frames, settings, and services required to meet those goals. In the chart for RRHV#1, there were no goals related to the patient’s high risk of falls as assessed at the time of admission. In the chart for RRNHV#5, the goal of patient will be safe in the home environment did not include a timeframe; there was no goal on the plan of care related to oxygen safety. In the chart for RRHV#2, there was a non-specific safety goal on the plan of care which did not specifically address the oxygen use and fall risk. In the chart for RRHV#3, there was no goal related to safe use of oxygen nor fall risks. In the chart for RRHV#4, the POC was updated with Seroquel for hallucinations and anxiety, yet the POC was not updated with a goal related to this change in treatment. In the chart for RRNHV#7, there is no actual goal on the POC for anxiety, yet the goal was to be met within 2 weeks; there was no goal related to the patient’s risk of falls. In the chart for RRNHV#11 reflexology treatments every 2 weeks for relaxation and increased circulation were added. The POC was not updated with a goal related to this problem and new intervention. In the chart for RRIPU#1, the POC was not updated with a goal for pain management with new pain post fall with rib fractures and the addition of a Fentanyl patch. This was confirmed with the Compliance Officer assisting with record review.”

“Observed in Record Review. In 2 of 21 patient records reviewed, the plan of care (POC) did not include interventions to manage pain and symptoms. In the chart for RRHV#3, the POC did not include any interventions related to pain management other than medications. The patient, per the SN report during the home visit, has chosen not to get out of the hospital bed, nor elevate the head of the bed more than approximately 10 degrees as these interventions are what is managing his pain. In the chart for RRIPU#1, the POC was not updated when the patient developed new pain post fall with rib fractures and the addition of a Fentanyl patch and prn pain medications. This was discussed with the Director of Compliance.”

“Observed in Record Review. In 3 of 21 patient records reviewed, the organization had not provided the patient with care, treatment, or services according to the patient’s individualized plan of care. In the chart for RRNHV#14, SN was ordered weekly. In at least the 2nd and 3rd weeks of the cert period, only one visit weekly made by nursing. In the chart for RRNHV#9, spiritual care was ordered monthly yet no visits had been documented since the initial eval more than 6 months prior to the survey. In the chart for RRHV#1, spiritual care visits were ordered monthly on the plan of care. No spiritual care visits had been provided for more than 3 months as confirmed with the Compliance Officer assisting with record review.”

“Observed in Record Review. In 1 of 21 patient records reviewed, all disciplines that provide care, treatment or services to the patient had not collaborated in the care of the patient and coordinated their efforts to support the goals outlined in the plan of care. In the chart for RRNHV#9, the patient was started on oxygen during a respite stay in the IPU. There was no order for oxygen, and there was no indication that the physician was made aware of the change in the patient’s condition. This was discussed with the Compliance Director.”

“Observed in Building Tour. It was observed that the fire doors in Administration did not latch when tested. This was verified by the Facility Manager. 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 gas fired dryer room that the dryer vent penetrated the suspended ceiling and was not properly sealed with smoke detection present. This was verified by the Facility Manager. 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 oxygen tank manifold room that the fire damper wall penetration was not properly sealed. This was verified by the Facility Manager. 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:”