Beacon Hospice of Georgetown

“Observed in Patient Home. In 3 of 3 home visits conducted, During RRHV# 1, RRHV# 2, and RRHV# 3’s home observations and patient record review it was noted the organization had not ensured staff followed the organization’s Comprehensive Assessment policy no. 2-030.1 that included a physical assessment to include temperature, a skin and other relevant data related to pertinent physical findings and the patient’s terminal illness. For example: review of RRHV# 2’s plan of care revealed the terminal diagnosis of Heart Failure. Review of RRHV# 2’s patient record review revealed a start of care RN comprehensive assessment dated approximately 298 days prior to the surveyor review of the record. Review of RRHV# 2’s once a week SN visit notes revealed no documentation of skin, cardiovascular, respiratory, gastrointestinal, genital urinary, or neurological assessment. Further review of the weekly SN visit notes revealed documentation of vital signs, pain assessment, and medication compliance. During RRHV# 2’s home observation the RN did not physically assess RRHV# 2’s skin and did not assess RRHV# 2’s lung sounds. During RRHV# 1’s home observation RRHV# 1 was observed with a PEG tube with a drainage gauze during the Hospice Aide bed bath. Review of RRHV# 1’s start of care RN comprehensive assessment revealed no documentation of a PEG tube or the skin surrounding the area. In addition, review of RRHV# 1’s plan of care revealed no documentation of a PEG tube. Review of RRHV# 2’s plan of care revealed the terminal diagnosis of Heart Failure. During RRHV# 2’s home observation the RN did not physically assess RRHV# 2’s skin and did not assess lung sounds. Review of RRHV# 2’s patient record revealed SN visits weekly with no documentation of skin, cardiovascular, respiratory, gastrointestinal, genital urinary, or neurological assessment. Further review of the SN visit notes revealed vital signs, pain assessment, and medication compliance. During RRHV# 3’s home observation the Administrator/RN did not have a thermometer at the time of the visit and did not perform a temperature reading. This was reviewed, discussed, and validated with the Regional Director/DON and Administrator/RN.”

“Observed in Record Review. In 1 of 14 patient records reviewed, During RR# 2’s patient record review it was noted the organization had not ensured it maintained a complete and accurate patient record. For example: review of RR# 2’s paper medical record revealed and oxygen safety risk assessment completed at the start of care with documentation RR# 2 had an oxygen concentration and had an order for oxygen at 2L via nasal cannula and was signed by RR# 2 and the RN. This was discussed, and reviewed with the Administrator/RN that stated RR# 2 never had oxygen in the home and does not now have oxygen in the home.”

“Observed in Record Review. In 2 of 14 patient records reviewed, During RRHV# 1 and RRHV# 2’s patient records review it was noted the organization had not ensured the plan of care was based on the patient’s goals and the time frames, settings, and services required to meet those goals. For example: review of RRHV# 1’s start of care RN comprehensive assessment revealed documentation that RRHV# 1’s pain goal to be 0 on a scale of 0 to 10. Review of RRHV# 1’s plan of care revealed a pain goal of 4/10. During RRHV# 1’s home observation RRHV# 1 was observed with a PEG tube. Further review of RRHV# 1’s plan of care revealed no documentation of a PEG tube or goal. Review of RRHV# 2’s patient record revealed the terminal diagnosis of heart failure. Review of RRHV# 2’s SN visit notes revealed RRHV# 2 had pain at best mild and at worst moderate with documentation of pain as an active problem. However, review of the current recertification plan of care with revealed no goal for pain. In addition, the start of care comprehensive assessment revealed RRHV# 2 was a risk for falls and the recertification plan of care revealed no safety goal. This was reviewed, discussed, and validated with the Regional Director/DON.”

“Observed in Record Review. In 4 of 14 patient records reviewed, During RRHV# 1, RR# 1, RRHV# 3, RR# 2’s patient records review it was noted the organization had not ensured the patients’ plans of care included all the services needed for the palliation and management of the terminal diagnosis and related conditions. For example: during RRHV# 1’s home observation RRHV# 1 was observed with a PEG tube. RRHV# 1’s patient representative/Uncle shared all medications are administered via the PEG tube. Review of RRHV# 1’s plan of care revealed no interventions or safety measures related to the PEG tube. Review of RR# 1’s patient record revealed RR# 1’s start of care approximately 60 days prior to the surveyor review of the record. This was reviewed, discussed, and validated with the Administrator/RN and Regional Director/DON. Review of RRHV# 3’s plan of care revealed Hospice Aide interventions and goals. However, RRHV# 3 did not have Hospice Aide services. This was reviewed, discussed, and validated with the Administrator/RN and Regional Director/DON. Review of RR# 1’s plan of care revealed interventions and goals for the Hospice Aide that were in progress. However, further review of the plan of care revealed no Hospice Aide frequency. Further review of RR# 1’s patient record revealed no Hospice Aide visit notes. Review of RR# 2’s patient record revealed the terminal diagnosis of Multi-system degeneration of the autonomic nervous system. Review of RR# 2’s RN start of care comprehensive assessment revealed documentation that RR# 2 required a mechanical diet. However, review of RR# 2’s plan of care revealed no documentation of aspiration precautions. This was discussed with the Administrator/RN and Regional Director/DON that shared RR# 1 did not have Hospice Aide services.”

“Observed in Patient Home. In 2 of 3 home visits conducted, During RRHV# 2 and RRHV# 3’s home observations it was noted the organization had not ensured staff followed organization policy Hand Hygiene that included performing hand hygiene with an organization-approved alcohol-based hand rub and performing hand hygiene after removing gloves. For example: during RRHV# 2’s home observation the RN was observed removing gloves and putting on new gloves approximately 3 times without performing hand hygiene after removing gloves. During RRHV# 3’s home observation the Administrator/RN was observed cleaning hands with a Hand Wipe with Benzalkonium Chloride 0.11% and no alcohol. In addition, the Administrator/RN used the hand wipe at the beginning of the wound dressing change and patient assessment and did not perform hand hygiene again until after the wound dressing change and patient assessment was completed and included multiple glove changes. This was discussed and validated with the Regional Director/DON and Administrator. Observed in Patient Home. In 2 of 2 home visits conducted with vital sign equipment, During RRHV# 2 and RRHV# 3’s home observation it was noted the organization had not ensured staff followed organization policy Bag Technique that included cleaning the reusable equipment with alcohol and/or soap and water prior to returning to the supply bag and performing hand hygiene prior to entering the supply bag. For example: during RRHV# 2’s home observation the RN was observed placing the bag on the floor with a barrier and cleaning the stethoscope, pulse oximetry, and automatic wrist B/P cuff with a Clorox Bleach wipe and placing each piece of the equipment immediately into the supply bag with no contact time/wet time and no hand hygiene performed. During RRHV# 3’s home observation the Administrator/RN was observed completing the patient assessment and placing the vital sign equipment immediately into the supply bag without cleaning the equipment and no hand hygiene performed. This was discussed and validated with the Regional Director/DON and Administrator/RN.”

“Observed in Record Review. In 1 of 2 patient records reviewed with Hospice Aide services, During RRHV# 1’s home observation it was noted the organization had not ensured the RN prepared complete written patient care instructions for the Hospice Aide. For example: during RRHV# 1’s home observation RRHV# 1 was noted to have a PEG tube with a gauze drainage in place. Review of RRHV# 1’s Hospice Aide patient written instructions revealed no documentation regarding the PEG tube or safety measures related to the PEG tube. This was reviewed, discussed, and validated with the Administrator and Regional Director.”

“Observed in Record Review. In 1 of 2 patient records reviewed with Hospice Aide, During RRHV# 1’s patient record review it was noted the organization had not ensured the hospice aide provided care, treatment, or services per hospice aide care plan that included documenting the date of the last bowel movement. For example: review of RRHV# 1’s hospice aide visit notes revealed documentation done under Elimination: Document bowel movements; report to RN if no BM in 3 days with no further documentation of what date or how many days since last bowel movement. This was reviewed, discussed, and validated with the Administrator.”

“Observed in Patient Home. In 3 of 3 home visits conducted, During RRHV# 1, RRHV# 2, and RRHV# 3’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: review of RRHV# 1’s medication profile revealed 10 medications to be administered by mouth and one medication with no documented route. Further review of the medication profile revealed five medications to be administered via PEG tube. During RRHV# 1’s home observation RRHV# 1’s patient representative/Uncle shared there was no medication list in the home and all medications were administered via RRHV# 1’s PEG tube. During RRHV# 2’s home observation it was noted the medication profile had promethazine 25 mg that had been discontinued six month prior to the home observation. In addition, RRHV# 2 was currently taking Tylenol 500mg 2 tablets once a day as needed for neck pain, Docusate Sodium 100mg every other day, Docusate Sodium with Sennoside every other day, and Latanoprost eye drops every night for more than nine months prior to the home observation and none of the medications were not present on the medication profile. During RRHV# 3’s home observation the medication reconciliation revealed RRHV# 3 had been taking Dicyclomine 20 mg three times daily and Cephalexin 500 mg at bed time for approximately 30 days prior to the start of care; was taking aspirin 81mg daily and Centrum Silver twice a day. However, Review RRHV# 3’s medication profile revealed no documentation of those medications. This was reviewed, discussed, and validated with the Regional Director/DON and Administrator/RN.”