Whatcom Hospice

“Observed in Record Review. In 1 of 3 resident records reviewed, the Hospice Nurse Surveyor noted that not all patient assessments and treatments had been documented in the EMR. For example, in INPTRR3, the patient had a wound in the L Axilla that was being treated. The Surveyor had been unable to validate that an assessment of the wound had occurred as there had not been any documentation that included size, drainage, peri-wound skin, nor that the dressing had been changed. This was validated with the Leadership present during the record review. Observed in Record Review. In 1 of 23 patient records reviewed, the Hospice Nurse Surveyor noted the patient assessment did not include all required elements. For example, in RRNHV8, the patient had Necrotizing Fasciitis with multiple wounds receiving care. There had not been an assessment related to the size of the wounds (that included: length, width and depth), wound bed appearance, peri-wound skin, and drainage since the patient came onto Hospice service 3 months ago. This was validated with the Assistant Director assisting with record reviews.”

“Observed in Record Review. In 2 of 3 resident records reviewed, the Hospice Nurse Surveyor noted orders not present for all care provided to the patient. For example, in INPTRR1, there had been documentation that a condom catheter had been placed on the patient; however, there had not been orders to apply the device. In INPTRR2, the patient was receiving care to L axilla wound, but there had not been orders that included what to cleanse the wound with, the frequency of the care, nor who was to complete the wound care. This was validated with clinical leadership present during the review. Observed in Record Review. In 3 of 23 patient records reviewed, the Hospice Nurse Surveyor noted not all orders for patient care had been present in the EMR. For example, in RRHV3, the patient, residing in a skilled facility, had an indwelling suprapubic catheter; however, there had been no orders for the insertion or changing of the catheter. In RRHV5, the patient had wound care with the use of ‘Mepitel’ over the skin tear, but this had not been in the orders. In RRHV6, the patient had an Aspira drain in the right abdomen that had orders for dressing changes; however, the order had not included what the site was to be cleansed with nor the frequency. This was validated with the Leadership present during the record review.”

“Observed in Record Review. In 1 of 23 patient records reviewed, the Hospice Nurse Surveyor noted documentation of patient care had not occurred per HCO policy. In RRNHV8, the patient had multiple wounds related to Necrotizing Fasciitis. The clinicians providing care over the 3 months the patient had been on service had documented ‘wound dressing changed per orders’ and ‘complex wound dressing done this visit’ and had not included all elements of the wound care and assessment as required in their Wound Documentation policy. The policy required full wound assessment (including measurements, description of the wound bed and surrounding skin, and drainage) as well as the actual care provided. This was validated with the Assistant Director assisting with record reviews.”

“Observed in Record Review. In 4 of 23 patient records reviewed, In RRHV3, the patient had an indwelling urinary catheter. There had been no clear orders present for who was responsible for the care of the catheter, Hospice staff or SNF staff. In RRHV6, the patient had an Aspira drain in the right abdomen that had orders for dressing changes and to drain the abdominal fluid up to 1000ml; however, the order did not include who was responsible to provide the care, whether Hospice RN or SNF staff. RRNHV8, the patient had complex wounds with care orders for 3 times per week. Hospice had been seeing the patient 2 times per week. There had been no clear information about the SNF responsibility in providing care for the 3rd dressing of the week. In RRNHV11, the patient had an indwelling urinary catheter. There had been no clear orders present for who was responsible for the care of the catheter, Hospice staff or SNF staff. This was validated with the Assistant Manager present during the record reviews.”

“Observed in Record Review. In 9 of 27 patient records reviewed, Confirmed by the RN Program Manager. The hospice individualized plan of care goals had not been measurable and had not been reflective of the patient’s goal. . Example: During review of HOSv#2 the plan of care goal had documented that spiritual resources are identified to include beliefs and practices that support or impair hospice experience. The patient will be knowledgeable in the management of bleeding. HOSv#5 goal had stated that the pain level would remain at a 3/10, however during assessment the patient pain goal had been to remain 1/10. HOSrr#13 the plan of care pain goal had documented to remain at 4/10, however the patient goal on assessment had been 1/10. HOSv#4 goal had documented that patient will identify their beliefs that support or impair hospice experience. Observed in Record Review. In 5 of 27 patient records reviewed, Confirmed by the RN Program Manager. The Hospice had not developed a plan of care to reflect interventions based on the problems identified in the comprehensive assessments. Example: During review of HOSv#3 the plan of care had not documented care to a decubitus ulcer and swallowing difficulties. HOSrr#13 had not included the wound care and treatment .”

“Observed in Record Review. In 3 of 27 patient records reviewed, Confirmed by the RN Program Manager. The plan of care had not been updated to reflect changes to the care or treatments. Example: During review of HOSrr#12 the patient had a wound being treated . The change in treatment to include medi honey had not been updated in the plan of care. During review HOSv#2 nursing notes it had been documented that the patient had complained of dizziness and prednisone had been ordered. It had not been updated to the plan of care. HOSv#3 plan of care had not been updated with the changes in treatment being provided to the sacral wound.”

“Observed in Patient Home. In 1 of 6 hospice visits observed and confirmed by the RN Program Manager. Staff had not followed accepted standards of practice. Example: During observation of HOSv#5 the SN had changed gloves frequently without cleansing her hands between glove changes per CDC guidelines and organization policy, Observed in Patient Home. In 1 of 6 Hospice patient visits observed and confirmed by the RN Program Manager. Staff had not followed accepted standards of practice or organization policy. Example: During observation of HOSv#5 staff had not followed agency policy and had placed her bag on the floor . Policy had stated that the bag should not be placed on the floor unless it had been a rolling bag.”