Blue Star Hospice, Inc.

“Observed in Record Review. In 14 of 14 patient records reviewed, the Hospice Nurse Surveyor had been unable to validate that volunteer services had been offered to the patient and family. In records RRNHV #5, RRNHV #6, RRNHV #7, RRNHV #9, RRNHV #12, RRNHV #13 and RRNHV #14 there had been no documentation in the patient record identifying volunteer services as provided. In records RRHV #1, RRHV #2, RRHV #3, RRHV #4 and RRHV #11 there had been documentation that volunteer services had been explained; however there had been no documentation related to patient accepting or declining the service. This was validated with the DPCS and Clinical supervisor.”

“Observed in Record Review. In 14 of 14 patient records reviewed, the Hospice Nurse Surveyor noted patient care goals on the Plan of Care that had been generic, not measurable and without a specific time frame for achievement. For example, in RRHV #1, for diabetes-Pt will achieve and maintain blood glucose levels within acceptable range. For decline in ADL’s: Support resident who has declined in order to lessen the likelihood of complications (i.e., pressure ulcers and contractures). RRHV #2 for pain the goal was Patient will report that pain is reduced to the level personally desired: on a scale of 1-10 and Patient’s quality of life will be at an optimal level. RRHV #3, the goal for Skin Integrity was Patient will be free of skin breakdown maintaining skin integrity during hospice length of stay and Patient will experience no discomfort from skin breakdown during hospice length of stay. Of note this patient had stage 3 and 4 pressure wounds and had been experiencing significant pain. This had been evident in all records reviewed. This was validated with the DPCS and the Clinical Supervisor. 
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“Observed in Record Review. In 10 of 14 patient records reviewed, the Hospice Nurse Surveyor observed that not all patient clinical needs identified during patient assessments had been addressed on the patient plan of care (POC). For example, in RRHV #1 the patient had a high risk for pressure injuries; however, the POC had been missing skin care and pressure injury prevention. RRHV #2 had orders to flush the patients port a cath but this care had not been included on the POC. This same patient had an implanted pain pump, but this had not been referenced on the POC. RRHV #3 the patient had two urinary tract infections (UTI) documented in the last month; however, the UTI and methods to mitigate had not been added to the POC. This same patient had multiple wounds that had become infected, but this was not added to the POC. RRHV #4, the patient had chronic hypoxia, was Oxygen dependent and had bouts of pneumonia; however, this had not been included on the POC. RRNHV #6, the patient had identified problems with dysphagia and UTI’s but neither had been included on the POC. RRNHV #7 the patient had an upper respiratory infection and started on antibiotics but this had not been added to the POC. The patient also had issues with dysphagia, pain and falls that had not been included on the POC. In RRNHV #8, the patient had issues with agitation/anxiety and dysphagia problems that had not been on the POC. RRNHV #12, the patient had a wound that had been treated and a recent upper respiratory infection and neither of these had been on the POC. In RRNHV #13, the patient had a wound that had been treated but integumentary status had not been included on the POC, and in RRNHV #14, the patient had been an aspiration risk and high risk for skin breakdown, yet these had not been on the poc. This was validated with the DPCS and Clinical Supervisor. Observed in Record Review. In 5 of 14 patient records reviewed, the Hospice Nurse Surveyor noted patient medication or treatment orders to be incomplete. For example, in RRHV #1, the patient had ketoconazole 0.02 MG/MG Topical Gel 2%thin layer Topical Gel Topical as needed without a identifying a specific area of application. The Same patient had orders for wound care that had been missing the frequency of the care and who was to complete. In RRHV #2, the patient had and order that stated: “Ok to flush Port-A-Cath per protocol” without the specific protocol attached to the patient record, who was to complete and the frequency of the flushing. In RRHV #3, the patient had Morphine Sulfate ordered every 6 hours as needed for pain and Norco every 4 hours as needed for pain without specific clinical indications for administration. In RRHV #4, the patient had Tramadol 50 mg every 6 hours as needed pain and acetaminophen 3 times per day as needed pain/fever, and morphine 30 mg every 12 hours prn pain without specific indications for which to use. In RRNHV #11 the patient had hydrocortisone acetate 0.01 MG/MG Topical Ointment ordered to apply a thin layer as needed without specifying the area of application. This was validated with the Clinical Supervisor.”

“Observed in Record Review. In 5 of 5 patient records reviewed, where the patient had a wound, the Hospice Nurse Surveyor noted documentation of the treatments performed such as dressing change had not been fully described in the clinical notes. For example in RRHV #2, the patient had an order to ‘flush Port-A-Cath per protocol’; however, there had been no protocol in the patient record and the Surveyor had not been able to validate that the Port had ever been flushed. In RRHV #3, RRNHV #12, RRNHV #13 and RRNHV #14, the RN documented that wound care had been done per orders. This was validated with the DPCS. 

 Observed in Patient Home. In 2 of 4 patient records reviewed, the Hospice Nurse Surveyor noted the medication list in the electronic medical record (EMR) had been inaccurate, missing either the correct dosage or frequency of the medication. For example, in RRHV #2 the patient had a bottle of Night Time Sleep Aide (Diphenhydramine 50mg) that he had been taking for a while that had not been included on the medication list as well as an incorrect Zofran dose. The EMR said 8 mg but the patient had 4 mg in the home. In RRHV #3, the patient had been taking the medication docusate sodium 50 MG / sennosides, USP 8.6 MG Oral Tablet 2 times per day, but the EMR reflected the patient taking daily. This was validated with the Clinical Supervisor present during the home visits.”

“Observed in Record Review. In 4 of 14 patient records reviewed, the Hospice Nurse Surveyor noted the Hospice Aide (HA) had not followed the HA Plan of Care (POC) per the documentation. For example, in RRNHV #5, the HA had orders to perform a shower, shampoo, and inspect the mouth 5 times per week; however, the HA had not documented that all of these had been completed as ordered and there had been no documentation to support the reason for not following the POC nor communication documented that the primary nurse had been communicated with. In RRNHV #7 the HA had orders to inspect the patient’s mouth, bath feet and apply lotion and complete the skin sheet 3 times per week; however, there had been multiple visits where this had not been documented as completed. This had been observed in RRNHV #8, RRNHV #9 , This was validated with the DPCS and the Clinical Supervisor”