Vitas Healthcare of Texas L P

“It is required that the comprehensive assessment includes consideration of the following factors: the nature and condition causing admission, including the presence, or lack of, objective data and subjective complaints. This standard was not met as evidenced by clinical record review and interview. In 1 of 4 (25%) clinical records reviewed in which the patient was provided GIP (General Inpatient Care) either at a facility or the agency’s facility, the agency did not ensure that the initial comprehensive assessment documented all objective data, particularly IV lines that would impact the care of the patient. Clinical Record 13: The patient was admitted to GIP (General In-Patient Care) at a local hospital on 04/30/2024. The hospital discharge instructions to hospice included orders for Dilaudid (pain medication) 2 mg 0.25 ml IV every hour for pain, Robinal (secretion control) 0.2 IV every 4 hours as needed for secretions, and Haldol (medication for restlessness) 0.2 ml (1 mg) intravenous every 4 hours as needed for aggression. The hospital paperwork documented a 20 gauge right radial angiocatheter in place, a 22 gauge angiocatheter in the left forearm, and a triple lumen central venous catheter. The admission assessment documented on 04/30/2024 did not include documentation of the angiocatheter in the right or left arm or the central line. The hospice did continue the intravenous medication orders that were given through this catheters during the stay at the hospital GIP setting. The intravenous lines were discontinued during the late afternoon of 04/30/2023 when the family decided to take the patient home to die. The patient died peacefully at home late that night. During the interview, the Patient Care Manager and Quality Manager stated that the infusion devices should have been documented on the initial comprehensive assessment.”

“It is required that each patient’s individualized written plan of care: identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 1 of 4 (25%) clinical records in which the patient was admitted for GIP (General inpatient care) and receiving intravenous medications, the agency did not ensure that all interventions for the patient’s care were documented on the care plan. Clinical Record 20: During the home visit with the Registered Nurse (RN) on 05/02/2024, a review of the medication profile and physician order revealed that Dilaudid could be administered IV (intravenous) or SQ (subcutaneous). The nurse administered the Dilaudid through the accessed port. During an interview after the medication delivery, the nurse stated that the port access and dressing change were not documented on the plan of care. The nurse stated the correct procedure but agreed they were unsure of the Huber needle size or length. The dressing over the Huber needle was labeled with a 22 gauge Huber needle and the date of the port access. The nurse stated that they would add the interventions to the plan of care. During an interview, the Patient Care Manager and the In-Patient Unit Manager stated that the nurse did follow the interventions documented in the policy but agreed that it was not documented on the plan of care. The Quality Manager developed a venous access care plan to implement.”

“It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by clinical record review and interview. In 1 of 13 (8%) clinical records reviewed in which a Hospice Aide (HA) was accepted, the agency did not ensure documentation that the nurse was notified of the care not provided for the patient. Clinical Record 3: The HA care plan assigned the HA the relevant tasks: sponge bath and applying protective cream each visit. The plan of care ordered HA services three (3) times a week. The HA visit dated 03/14/2024 documented that the tasks applying protective cream and giving a sponge bath were “not performed/declined.” The HA documented the report to the nurse as “not answered.’ The HA visit dated 02/08/2024 documented that the task applying protective cream was “not performed/declined.” The HA documented the report to the nurse as “not answered.’ The “not answered” did not indicate if the nurse was notified of the care not delivered. During an interview, the Patient Care Manager, the General Manager, and the Quality Manager stated that the “no answer” documented did not reflect the call the aide made and likely left a voice mail.”

“It is required that hospice inpatient facilities provide a sanitary environment by following current standards of practice, including nationally recognized infection control precautions, and avoiding sources and transmission of infections and communicable diseases. This standard was not met as evidenced by interview and observation. Observed during the facility tour on 05/02/2024. In the supply room that stored supplies for patient care was a container of Clorox antibacterial wipes, partially full, it expired on May 17, 2022. The General Manager and the In-Patient Unit Manager agreed that the container had expired and were unclear as to how the container ended up with the patient supplies with the other Clorox wipes. Observed during facility tour on 05/02/2024. In the supply room that stored supplies for patient care was a container of Clorox antibacterial wipes, partially full, it expired on May 17, 2022. The general Manager and the In-Patient Unit manager agreed that the container had expired and were unclear how the container ended up with the patient supplies with the other Clorox wipes.”