Cheyenne Regional Davis Hospice Center

“Observed in Record Review. In 2 of 14 patient records reviewed, where the patients were active, the organization did not conduct and document a patient-specific comprehensive assessment related to severity of symptoms. Identified during the record review for HOSRRHV#3 and HOSRRNHV#10, there was no documentation to support that the Skilled Nurses inquired about the patients’ blood sugar readings, and necessary/subsequent insulin doses administered during assessments despite both patients having sliding scale insulin orders three times daily. Additionally during the home visit conducted for HOSRRHV#3, the Hospice Surveyor noted that the Skilled Nurse did not assess the patient’s recent blood sugar readings or need for insulin. This was validated with the Hospice Clinical Manager who was present during the record review session.”

“Observed in Patient Home. In 2 of 2 home visits conducted, where Hospice Registered Nurses (RNs) were observed, the organization did not assess potential medication-related problems including duplicate drug therapy. Observed during the home visits conducted for HOSRRHV#3, the RN only inquired about refills of medication needed, and in HOSRRHV#4, the RN looked at only a few of the medications listed on the medication profile. Neither RN conducted a thorough medication reconciliation according to the process described by the Hospice Clinical Manager and Administrator prior to the home visit observations which should have included the patients’ home medication list, and the medication profile in the medical record being compared to the actual medication in the patients’ homes during routine home visits. This was validated with the Clinical Manager and the Administrator who were present during the home visits.”

“Observed in Record Review. In 5 of 14 patient records reviewed, who were actively receiving Home Hospice Services, the organization had not included all services needed in the management of the terminal illness and related conditions including interventions to manage symptoms. Identified during the record review for HOSRRNHV#3, HOSRRNHV#10, and HOSRRHV#3, there were no care plans/interventions developed to manage Diabetes despite each patient’s medication profile listing active Insulin orders. In HOSRRNHV#7, HOSRRNHV#8, and HOSRRNHV#9, there were no care plans/interventions developed to manage Dysphagia despite each patient’s history and admission assessment identifying Dysphagia as an active problem. This was validated with the Hospice Clinical Manager who was present during the record review session.”

“Observed in Record Review. In 4 of 14 patient records reviewed, where the patients were actively receiving Home Hospice Services, the organization had not included all medications and treatment necessary to meet the patient’s needs in accordance with the organizational policy #08.02.01, #4: All medication orders must contain: g. the specific instructions for use, when applicable. For example during the record review for HOSRRHV#3 Hospice Surveyor identified that the patient’s medication profile listed Acetaminophen ES, 1000 mg every 6 hours as needed for pain or fever, and Hydrocodone 10-325 mg. every 4 hours as needed for pain, with no indication of which medication should be used to treat a specific pain level or in which order. Additionally, there was no precaution listed for the recommended maximum daily dose of Acetaminophen. Identified during the record review for HOSRRHV#4, the patient’s medication profile listed Acetaminophen 325 mg. every 4 hours as needed for pain/fever, and Tramadol 50 mg every 6 hours as needed for pain, without indication of which medication to be used first for pain management or for what level of pain being experienced. In HOSRRNHV#1 the medication profile listed Tramadol 50 mg., 1/2 tablet every 4 hours as needed for pain, and Hydrocodone 5/325 every 6 hours as needed for pain without indicated the level of pain or order of use. In HOSRRNHV#3, the medication profile listed Ibuprofen 2mg every 4 hours as needed for pain, and Hydrocodone 5/325 every 4 hours as needed for pain without indication of level of pain or type of pain being experienced. This was discussed with the Hospice Administrator and the Hospice Clinical Manager.”

“Observed in Patient Home. In 2 of 4 home visits conducted, the hospice had not ensured that the patient and/or caregivers received instruction on the safe use of durable medical equipment. For example, during home visits conducted for HOSRRHV#2 and HOSRRHV#4, the Hospice Surveyor observed that the patients were in hospital beds with full side rails. Upon review of the patient admission booklet, it was identified that there was no safety education included regarding durable medical equipment, and upon review of the patients’ records, there was no documentation to support that the organization had provided education on the potential safety risks associated with full bed rails in accordance with organizational policy #06.02.01, pg. 12-13.. This was discussed with the Hospice Administrator and Hospice Clinical Manager.”

“Observed in Tracer Activities. During discussion with the Hospice Administrator and the Hospice Clinical Manager, the Hospice Surveyor identified that there had been no education and training provided to the clinical staff members at the contracted Skilled Nursing Facility in providing care to hospice patients in accordance with the Contract Agreement, pg. 7 - 3.7 Hospice Orientation and Training: Hospice will provide educational resources to the Facility for purposes of orientation, teaching and continuing education regarding Hospice care, including in-services, written materials and multi-media presentation as appropriate or requested. This was discussed with the Administrator and Clinical Manager.”

“Observed in Document Review. In August of 2024 the Fire and smoke damper testing identified 7 failed dampers. All but one was repaired as of July of 2026. The organization could not provide evidence that the Interim Life Safety Measures Mitigation (ILSM) that was identified by the Interim Life Safety Measure Risk assessment required. The last unit is in the process of being repaired. This was confirmed by the Facilities management team. 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:”