River City Hospice of Texas, L.L.C.

“Observed in Record Review. In 1 of 10 patient records reviewed, The organization failed to conduct and document a patient-specific comprehensive assessment and reassessment that identifies the patient’s need for hospice care and services. For example: on review of RRHV#1 there were physicians orders for wound care to the Rt Heel (unstageable) and Lt Heel (stage 3) yet in the nursing documentation there was only documentation of assessment of the Left Heel weekly as required. There was documentation of assessment of the Rt Heel noted in the record twice in October, once in November and again in December where it was documented as healed. This observation was reviewed with the Alt. Director of Nursing.”

“Observed in Record Review. In 1 of 10 patient records reviewed, the organization failed to ensure a complete and accurate patient record. On review of RRHV#1, the most recent wound care documentation specified the assessment of a Lt Heel wound yet the documentation of the dressing change performed was noted to be for the Rt. Heel. There was no documentation noted for the right heel to clarify why it was conflicting. This conflicting documentation was also noted on multiple additional notes in the latest benefit period. This observation was reviewed with the Administrator and Alt. DON.”

“Observed in Record Review. In 10 of 10 patient records reviewed, The organization failed to ensure the plan of care was based on the patient’s individualized goals that were specific, measurable, and time-bound. Throughout all active records reviewed there was a lack of the plan of care goals being specific, measurable and time-bound. For example: in RRHV#1 a goal read Pain will be managed at a level acceptable to the patient per certification period and Patient/caregiver will verbalize/demonstrate appropriate pain management per certification period. In RRHV#2 an example was Patient will follow an effective bowel program to prevent/relieve constipation throughout cert. In RRHV#3 a goal was Patient will have safety needs met while on hospice services. In RRNHV#5 a goal read Changes in neurologic status will be addressed appropriately per certification period. Further examples can be seen in all active records RRNHV#4,RRNHV#6, RRNHV#7, RRNHV#8, RRNHV#9 and RRNHV#10. These observations were reviewed with the Administrator, and Alt. Director of Nursing.”

“Observed in Record Review. In 7 of 10 patient records reviewed, the organization failed to ensure the plan of care included all services needed for the palliation and management of the terminal illness and related conditions. On review of RRHV#2 there was documentation of a urinary tract infection with antibiotics ordered yet the issue was not reflected on the plan of care. In RRHV#3 during the home observation the patient noted issues with nausea, vomiting and the inability to eat as desired. She noted antiemetics has been ordered yet there was no care plan to guide the care. Further there was documentation of growing lesions/masses to the patient’s chest yet the issue was not reflected in the care planning process. In RRNHV#4 documentation noted a skin infection to the elbow yet no care plan to guide its care. In RRNHV#6 there was documentation of an eye infection but no care plan to guide the care. In RRNHV#7 the patient was noted to have skin cancer wound/lesions, issues with gout that required colchicine, and was taking insulin for diabetes yet the care plan did not reflect the issues documented in the record. In RRNHV#8 there was documentation of an APS referral for issues noted in the home but no care plan guiding the care. In RRNHV#10 there was documentation of lab draws for CBC, CMP, and UA C&S and medication for BPH was increased for symptom control, yet the issues were not reflected in the care plans. These observations were reviewed with the Administrator, and Alt Director of Nursing.”

“Observed in Record Review. In 2 of 10 patient records reviewed, The organization failed to ensure the plan of care included all services needed for the palliation and management of the terminal illness and related conditions to include drugs and treatments necessary to meet the patients needs. On review of RRNHV#7 there were oxygen orders that noted a range of O2 2-10 liters per nasal cannula continuous yet there were no specific instructions to guide the patient to know when to use what liter flow. In RRNHV#10 there were multiple as needed pain medications of Tramadol 50mg and Hydrocodone 5/325 mg every 6 hours as needed and Morphine 0.25 ml sublingual every 2 hours as needed yet there were no specific instructions to guide the patient/caregiver to know which medication to choose for which situation. Further the oxygen order had a range of 5-10 liters per minute but no specific instruction to guide the user in liter flow selection. These observations were reviewed with the Administrator, and Als Director of Nursing.”

“Observed in Patient Home. In 1 of 3 home visits conducted, the organization failed to implement the infection prevention and control activities it had planned. For example: on home observation for RRHV#1 the RN missed multiple opportunities to perform hand hygiene per the organization policy and current guidelines. The RN performed the patient assessment with gloves and then without doffing gloves and performing hand hygiene was noted to access the nursing bag multiple times, document on computer, and cleanse equipment. Further, the RN while performing wound care removed the existing dressing, cleansed the wound, replaced the dressing, and went back to performing patient care all without removing gloves and performing hand hygiene. These observations were reviewed with the RN, the Administrator, and Alt. DON.”

“Observed in Record Review. In 3 of 6 patient records reviewed, The organization failed to ensure the Registered Nurse provided written patient care instructions for the hospice aide. For example: on review of RRHV#1 the documentation showed the patient with bilateral heel wounds with wound care dressings, however there were no written care instruction for the hospice aide on how to handle the dressings while providing care. In RRHV#3 there was documentation that the patient had growing cancerous lesions/masses to the chest, yet there were no instruction to guide the Aide on bathing or providing care around the area of the lesions/masses In RRNHV#10 the patient had Oxygen in the home yet the Aide assignment did not include oxygen precautions. These observations were reviewed with the Alt Director of Nursing.”

“Observed in Patient Home. In 2 of 3 home visits conducted, the organization failed to ensure the patient record contain information that reflected the patient’s care, treatment, and services. On home observation for RHV#1 during the RN’s medication reconciliation, it was noted that the Lorazepam in the home was oral liquid concentrate and the caregiver noted that the liquid concentrate was what was being given yet the medication profile had listed Lorazepam pills. In RRHV#2 during medication reconciliation the bottle for Trazadone in the home was for 50 mg and the wife confirmed she was giving 50mg yet the medication profile reflected 100mg tabs to be given. This observation was reviewed with the Administrator, and Alt DON.”