Harbor Hospice of Baytown LP

“Observed in Record Review. In 5 of 16 patient records reviewed, During RR# 1, RRHV# 1, RRHV# 2, RRHV# 3 and RRHV# 4’s home observation and patient records review it was noted the organization had not ensured the staff followed the organization policy Ongoing Comprehensive Assessments, No. 2-031 that included the nurse would assess the patient on each visit for skin integrity, pain, bowel sounds, bowel elimination, breath sounds, appetite/diet, and nutritional status. For example: during RRHV# 4’s home observation the Registered Nurse did not complete a skin assessment. This was observed, discussed, and validated with the Director of Nursing. Review of RRHV# 4’s patient record revealed RRHV# 4’s start of care date was approximately four months prior to the surveyor review of the record. Review of the Skilled Nurse (SN) visit notes revealed no documentation of a skin assessment, and/or breath sounds, and/or bowel sounds with bowel elimination documented on three SN visit notes. Review of RRHV# 3’s patient record revealed RRHV# 3’s start of care date was approximately five months prior to the surveyor review of the record. Further review of RRHV# 3’s patient record revealed 10 Skilled Nurse visit notes with no documentation of bowel elimination. Review of RRHV# 2’s patient record revealed seven SN visit notes with no documentation of lung sounds or bowel sounds. Review of RRHV# 1’s patient record revealed eight SN visit notes with no documentation of lung sounds and/or bowel sounds. Review of RR# 1’s patient record revealed seven SN visit notes with no documentation of the last bowel movement, lung sounds, or bowel sounds. This was reviewed, discussed, and validated with the Director of Nursing.”

“Observed in Record Review. In 2 of 3 bereavement patient records reviewed, During RRBR# 1 and RRBR# 3’s patient record review it was noted the organization had not ensured it assessed and reassesses its patients survivor risk factors, such as the nature of the relationship with the patient, circumstances surrounding the death, behaviors before and after death, availability of coping mechanisms, and potential for pathological grief reactions per law and regulation and organization policy Bereavement Services, No. 2-010 that included a bereavement risk assessment would be completed on admission and after death. For example: review of RRBR# 1’s patient record revealed no documentation of a post death bereavement risk assessment. Review of RRBR# 3’s patient record revealed no documentation of a post death bereavement risk assessment. This was reviewed, discussed, and validated with the Bereavement Coordinator and Administrator.”

“Observed in Record Review. In 1 of 16 patient records reviewed, During RRHV# 3’s patient record review it was noted the organization had not ensured it maintained complete and accurate patient records. For example: review of RRHV# 3’s hospice aide written instructions revealed the task of documenting bowel movements. Review of the RRHV# 3’s hospice aide visit notes revealed no documentation of bowel movements. Review of RN hospice aide supervisory visit revealed documentation Yes under Aide following plan of care/assignment and documentation Yes under Aide documentation adequate. This was reviewed, discussed, and validated with the Director of Nursing.”

“Observed in Record Review. In 1 of 16 patient records reviewed, During RR# 8’s patient record review it was noted the organization had not ensured the plan of care included statement of the scope and frequency of services necessary to meet the specific patient and family needs. For example: review of RR# 8’s patient record revealed documentation that RR# 8 had a Volunteer visit for haircuts as needed. However, review of the plan of care revealed no documentation of Volunteer scope or frequency. This was reviewed, discussed, and validated with the Director of Nursing.”

“Observed in Patient Home. In 2 of 3 home visited conducted with Medication Reconciliation, During RRHV# 1 and RRHV# 4’s home observations it was noted the organization had not ensured the plan of care included all services needed for palliation and management of the terminal illness and related conditions. For example: during RRHV# 1’s medication reconciliation during the home observation the medication profile revealed the medication Imodium A-D 2mg tablet AS DIRECTED-LOOSE STOOLS with no other documentation to include the dose or frequency of the medication. During RRHV# 4’s medication reconciliation during the home observation the medication profile revealed “Haloperidol 1mg tablet take 1 tablet by mouth every 4 hours for agitation/restlessness” with no clear indication if the Haloperidol was scheduled or as needed. This was reviewed, discussed, and validated with the Registered Nurse and Director of Nursing.”

“Observed in Record Review. In 2 of 16 patient records reviewed, During RRHV# 2 and RRHV# 4’s home observation and patient records review it was noted the organization had not ensured the nurse followed the plan of care. For example: review of RRHV# 4’s plan of care revealed the intervention to assess the skin every visit. During RRHV# 4’s home observation the registered nurse did not complete a skin assessment. This was observed, discussed, and validated with the Director of Patient Care Services. Review of RRHV# 4’s patient record revealed RRHV# 4’s start of care date approximately four months prior to the surveyor review of the record. Review of RRHV# 4’s patient record revealed weekly Skilled Nurse visit notes with documentation skin assessment completed with no documentation of the skin assessment. Review of RRHV# 2’s plan of care revealed the intervention to assess patient use of oxygen and oxygen effectiveness. Review of RRHV# 2’s SN visit notes revealed no documentation of oxygen use or effectiveness. This was reviewed, discussed, and validated with the Director of Nursing. Observed in Record Review. In 1 of 3 bereavement patient records reviewed, During RRBR# 3’s patient record it was noted the organization had not ensured it provided care, treatment, or services according to the patient’s individualized plan of care. For example: review of RRBR# 3’s record revealed a bereavement care plan that included a bereavement letter to be sent one month after RRBR# 3’s death which was approximately 90 days prior to the surveyor review of the record. Further review of the RRBR# 3’s patient record revealed no documentation the one month bereavement letter was sent. This was reviewed, discussed, and validated with the Bereavement Coordinator and Administrator..”

“Observed in Patient Home. In 2 of 3 home visits conducted with vital sign equipment, During RRHV# 1 and RRHV# 2’s home observations the organization had not ensured staff followed the manufacturer’s guidelines and organization policy Bag Technique that included cleaning the thermometer with alcohol and cleaning the B/P cuff per manufacturer’s guidelines. For example: during RRHV# 1 and RRHV# 2’s home observation the Registered Nurse was observed cleaning the thermometer with B/P cuff with a Clorox wipe. Review of the B/P cuff’s manufacturer’s guidelines revealed the B/P cuff was to be cleaned with a dry cloth only and unable to be disinfected for multiple patient use. This was reviewed, discussed, and validated with the Director of Nursing.”

“Observed in Record Review. In 2 of 3 bereavement patient records reviewed, During RRBR# 1 and RRBR# 2’s patient records revealed the organization had not ensured it developed an individual bereavement plan of care. For example: review of RRBR# 1’s patient record revealed an initial bereavement risk assessment that indicated a bereavement risk of moderate. However, review of the RRBR# 1’s bereavement care plan revealed no documentation of a 2 month call that would be included in a moderate risk level. During RRBR# 2’s patient record revealed a Post Death Bereavement Risk Assessment that indicated a bereavement risk of low. However, review of RRBR# 2’s bereavement care plan revealed documentation of moderate risk level interventions. This was reviewed, discussed, and validated with the Bereavement Coordinator and Administrator.”

“Observed in Record Review. In 7 of 11 patient records reviewed with hospice aide, During RRHV# 1, RRHV# 2, RRHV# 3, RR# 1, RR# 4, RR# 6 and RR# 7’s patient records review it was noted the organization had not ensured the hospice aide followed the written patient care instructions that included documenting the last bowel movement. For example: review of RRHV# 3’s hospice aide written patient care instructions revealed the task of document bowel movements. Review of the hospice aide visit notes revealed documentation Done under document bowel movements. Further review of RRHV# 3’s patient record revealed RRHV# 3’s start of care was approximately five months prior to the surveyor review of the record and the hospice aide frequency was five times a week. Review of RRHV# 1’s patient record revealed RRHV# 1’s state of care date was approximately five months prior to the surveyor review of the record. Review of RRHV# 1’s hospice aide written patient care instructions revealed the task of document bowel movements. Review of the hospice aide visit notes revealed documentation “Done” with no documented date of last bowel movement. Review of RRHV# 2’s patient record revealed RRHV# 2’s start of care was approximately a year prior to the surveyor review of the record. Review of RRHV# 2’s hospice aide written patient care instructions revealed the task of notifying the RN if no BM [bowel movement]. Review of the hospice aide visit notes revealed no documentation of a BM. Review of RR# 1’s patient record revealed RR# 1’s start of care was approximately four months prior to the surveyor review of the record. Review of RR# 1’s hospice aide written patient care instructions revealed the task of document bowel movements. Review of RR# 1’s hospice aide visit notes revealed no documentation of the date of the last BM. Review of RR# 4, RR# 6 and RR# 7’s patient records revealed hospice aide written patient care instructions with the task “document bowel movements”. However, review of RR# 4, RR# 6 and RR# 7’s hospice aide visit notes revealed no documentation of bowel movement. This was reviewed, discussed and validated with the Director of Nursing.”

“Observed in Record Review. In 4 of 11 patient records reviewed with hospice aide services, During RRHV# 1, RRHV# 2, RRHV# 3, and RR# 1’s patient records review it was noted the organization had not ensured the hospice aide was supervised by the registered nurse during on-site visit to the patient’s home no less frequently than every 14 days. For example: review of RRHV# 1’s patient record revealed RRHV# 1 with hospice aide visits two visits a week. Further review of RRHV# 1’s patient record revealed no documentation of a RN supervisory visit for approximately the last 60 days. Review of RRHV# 2’s patient record revealed hospice aide visits five visits each week. Further review of RRHV# 2’s patient record revealed no documentation of a RN supervisory visit for approximately 60 days. Review of RRHV# 3’s patient record revealed no documentation of a RN supervisory visit for 21 days when the hospice aide services were initiated. Review of RR# 1’s patient record revealed hospice aide visits two visits a week. Further review of RR# 1’s patient record revealed no documentation of a RN supervisory visit for approximately 40 days. This was reviewed, discussed and validated with the Director of Nursing.”

“Observed in Patient Home. In 2 of 3 home visits conducted with Medication Reconciliation, During RRHV# 1 and RRHV# 4’s home observations it was noted the organization had not ensured the patient record contained information that reflected the patient’s care, treatment, or services. For example: during RRHV# 1’s medication reconciliation during the home observation the medication profile revealed documentation of Imodium A-D 2mg tablet AS DIRECTED-LOOSE STOOLS. However, RRHV# 1’s spouse shared she had tried the Imodium tablet for diarrhea approximately 38 days prior to the home observation and RRHV# 1 was unable to swallow the tablet, so she bought pediatric Imodium (1mg/75cc) and gave one dose to RRHV# 1 and that was all the RRHV# 1 needed. During RRHV# 4’s medication reconciliation during the home observation the Assisted Living Facility (ALF) medication administration record (MAR) revealed “Hydroxyzine HCL 10 mg tablet every morning and at bedtime for anxiety” dated approximately 70 days prior to the home observation. Review of the Hospice medication profile revealed no documentation of Hydroxyzine HCl. This was reviewed, discussed, and validated with the Registered Nurse and the Director of Nursing.”