Dhr Health Hospice

“Observed in Record Review. In 1 of 17 patient records reviewed, it was noted that the organization did not ensure that patient specific comprehensive assessments included all required information. For example, during a review of the medical record for RRNHV#8, the clinician documented the following information: Wound care to site as follows: using aseptic technique, cleanse site with wound cleanser, pat dry, apply gentamicin ointment, cover with gauze BID”. A subsequent review of the plan of care orders revealed the location of the wound was the right side of the patient’s neck. During a review of the initial comprehensive assessment, it was noted that a description of the patient’s wound at the right side of the neck was not documented. This observation was reviewed with agency leadership.”

“Observed in Record Review. In 4 of 17 patient records, it was noted that the organization did not ensure goals were individualized to the patient’s needs and condition. During a review of the medical record for HosInpt#2, the following goal statements were noted: “Patient free of any signs/symptoms of infection” and “Complete healing of wound without complication”. The goal statement(s) did not include a method to measure the effectiveness of problem interventions. The stated timeframe of six weeks was not a realistic measurement to assess the implementation of problem interventions related to infection and wound care. Example #2: During a review of the medical record for HosInpt#3, the following information was noted: The comprehensive assessment documented that the patient’s level of consciousness was unresponsive. The FLACC scale was used for pain assessment. The goal for the pain problem was: “Patient will be free or verbalize an acceptable pain level with current pain management regimen”. This goal statement was not specific to the patient’s needs and did not include a method to measure “acceptable pain level”. In addition, the plan of care included the following goal statement: “Maintenance of respiratory baselines as evidenced by breathing at optimal level within disease parameters”. This goal statement did not include a method to measure “breathing at optimal level”. Example #3: During a review of the medical record for RRHV#2, the following goal statement was noted: “Anxiety/agitation controlled through course of care”. This goal statement did not include a method to measure “controlled”. In addition, the timeframe of “through course of care” is not a realistic time frame to address symptoms of anxiety and agitation. Example #4: A review of the medical record for RRNHV#3, revealed that during the 2nd week of services the patient experienced a fall. The plan of care was not updated with a goal statement to evaluate interventions related to fall prevention. This observation was reviewed with agency leadership.”

“Observed in Record Review. In 3 of 17 patient’s records, it was noted that the plan of care did not include interventions based on the problems identified in the comprehensive assessment. For example, during a review of the plan of care for RRHV#1, the following goal statement(s) were noted: Patient/Caregiver can describe measures to reduce/prevent fatigue and Family/Caregiver will demonstrate the ability to cope with limitations. The plan of care did not include interventions to educate the patient and caregiver on measures to reduce/prevent fatigue; and the plan of care did not include interventions to educate the patient and caregiver on measures to address coping limitations. Example #2: A review of the medical record for RRHV#2, revealed that the patient had a goal statement titled “Anxiety/agitation controlled through course of care”. The plan of care did not include interventions to manage symptoms related to anxiety/agitation; the plan of care did not include interventions to provide education for the patient’s caregiver related to the care and coping strategies of anxiety/agitation symptoms. In addition, the plan of care had a goal statement related to bowel elimination problems. The Plan of Care did not include interventions related to the management of bowel incontinence; and the plan of care did not include interventions related to providing education to the patient’s caregiver for the care of the patient’s skin related to bowel incontinence. Example #3: A review of the medical record for RRNHV#3, revealed that the patient had a plan of care problem titled Impaired Skin Integrity. The plan of care did not include interventions for the management and treatment of a stage 2 ulcer at 2nd toe of left foot. The plan of care did not include interventions to provide education related to the wound care, and strategies to protect the patient’s skin integrity. In addition, the patient experienced a fall during the 2nd week of services. The plan of care was not updated with interventions to maintain patient safety, and strategies to prevent injury. This observation was reviewed with agency leadership.”

“Observed in Individual Tracer. In 4 of 4 Individual Tracers, the organization did not ensure that a copy of its written policies and procedures on the management of controlled medications was provided to the patient or the patient’s representative and family. For example, during survey activities for RRHV#1, RRHV#2, RRHV#3, and RRHV#4, it was noted that a copy of the organizations written policies and procedures related to the management of controlled medications was not present in the patient and family handbook. An additional review of the medical records for the identified patient’s revealed no documented evidence that staff documented that this policy was provided and discussed. This observation was reviewed with agency leadership.”

“Observed in Record Review. In 1 of 17 patient records reviewed, it was noted that the organization did not ensure that an evaluation of patient education and training was provided when required. For example, during a review of the medical record for RRNHV#3, it was noted that during the 2nd skilled nurse visit, a clinician documented the following information: “Patient’s daughter [name omitted] performed wound care as ordered prior to SN visit”. However, there was no documented evidence that an evaluation of the patient’s caregiver competence to perform the wound care treatment was performed. This observation was reviewed with agency leadership. Observed in Record Review. In 1 of 17 patient records reviewed, it was noted that the organization did not ensure patient education and training was provided based on the patient’s assessed needs. For example, during a review of the medical record for RRNHV#3, it was noted that during the 2nd skilled nurse visit, a clinician documented the following information: “Patient’s daughter [name omitted] performed wound care as ordered prior to SN visit”. However, there was no documented evidence that the patient’s caregiver received education and training related to wound care treatment. This observation was reviewed with agency leadership.”

“Observed in Building Tour. It was observed that the lobby sliding doors which were the marked egress path had thumb latches on the doors which required two steps to open the doors in an emergency. 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 fire alarm panel room that there was a magnetic lock on the door. The push to exit had to be used to exit the room because there was no proximity sensor to release the door in the path of egress. 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 that there was a ceiling wire to the suspended ceiling wrapped around the fire sprinkler piping. 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:”