Sheridan Memorial Hospital Hospice

“Observed in Record Review. In 1 of 2 live discharged patient records reviewed, During HOSRRDC# 1’s patient record review it was noted the organization had not ensured it provided interdisciplinary, collaborative care, treatment, or services. For example: review of HOSRRDC# 1’s patient record revealed HOSRRDC# 1 revealed a terminal diagnosis of metastatic breast cancer. Review of a Skilled Nurse visit note revealed documentation that HOSRRDC# 1 had fallen and had a bruise to the right elbow with no other injuries. Review of the Skilled Nurse visit note completed one day after the fall revealed HOSRRDC# 1 was complaining of weakness and having trouble transferring. Review of the Skilled Nurse visit note dated two days after the fall revealed documentation that HOSRRDC# 1 was no longer able to walk to the bathroom and required a bedside commode and continued to have declined in the ability to transfer. Review of an On-Call phone call dated three days after the fall revealed documentation that HOSRRDC# 1 had declined and the family was no longer able to transfer her or care for her. Further review of the On-Call phone call revealed documentation that the family was informed the patient could go to the emergency department and revoke hospice services. Review of HOSRRDC# 1’s patient record revealed no documentation that the physician was notified of the fall or the subsequent decline over the following three days. Further review of HOSRRDC# 1 patient record revealed HOSRRDC# 1 was diagnosed with a closed fracture of the right humerus with pneumonia. This was reviewed, discussed, and validated with the Hospice Manager.”

“Observed in Record Review. In 1 of 1 patient records reviewed with hospice aide services, During HOSRRHV# 3’s patient record review it was noted the organization had not ensured the RN completed supervisory assessments of the hospice aide’s services no less frequently than every 14 days. For example: review of HOSRRHV# 3’s patient record revealed the hospice aide provided hospice aide services two visits a week since approximately two months prior to the surveyor review of the record. Further review of the patient record revealed no documented RN supervisory assessments of the hospice aide services. This was reviewed, discussed, and validated with the Hospice Manager.”

“Observed in Record Review. In 1 of 2 discharged patient records reviewed, During HOSRRDC# 1’s patient record review it was noted the organization had not planned the patient’s care. For example: review of HOSRRDC# 1’s patient record revealed HOSRRDC# 1 revealed a terminal diagnosis of metastatic breast cancer. Review of a Skilled Nurse visit note revealed documentation that HOSRRDC# 1 had fallen and had a bruise to the right elbow with no other injuries. Review of the Skilled Nurse visit note completed one day after the fall revealed HOSRRDC# 1 was complaining of weakness and having trouble transferring with no update to the plan of care. Review of the Skilled Nurse visit note dated two days after the fall revealed documentation that HOSRRDC# 1 was no longer able to walk to the bathroom and required a bedside commode and continued to have declined in the ability to transfer with no update to the plan of care. Review of an On-Call phone call dated three days after the fall revealed documentation that HOSRRDC# 1 had declined and the family was no longer able to transfer her or care for her. Further review of the On-Call phone call revealed documentation that the family was informed the patient could go to the emergency department and revoke hospice services. Review of HOSRRDC# 1’s patient record revealed no documentation that the physician was notified of the fall or the subsequent decline over the following three days or the plan of care was updated. Further review of HOSRRDC# 1 patient record revealed HOSRRDC# 1 was diagnosed with a closed fracture of the right humerus with pneumonia. This was reviewed, discussed, and validated with the Hospice Manager.”

“Observed in Record Review. In 1 of 2 discharged patient records reviewed, During HOSRRDC# 1’s patient record review it was noted the organization had not ensured the plan of care was updated to reflect the patient’s deterioration. For example: review of HOSRRDC# 1’s patient record revealed HOSRRDC# 1 revealed a terminal diagnosis of metastatic breast cancer. Review of a Skilled Nurse visit note revealed documentation that HOSRRDC# 1 had fallen and had a bruise to the right elbow with no other injuries. Review of the Skilled Nurse visit note completed one day after the fall revealed HOSRRDC# 1 was complaining of weakness and having trouble transferring with no update to the plan of care. Review of the Skilled Nurse visit note dated two days after the fall revealed documentation that HOSRRDC# 1 was no longer able to walk to the bathroom and required a bedside commode and continued to have declined in the ability to transfer with no update to the plan of care. Review of an On-Call phone call dated three days after the fall revealed documentation that HOSRRDC# 1 had declined and the family was no longer able to transfer her or care for her. Further review of the On-Call phone call revealed documentation that the family was informed the patient could go to the emergency department and revoke hospice services. Review of HOSRRDC# 1’s patient record revealed no documentation that the physician was notified of the fall or the subsequent decline over the following three days or the plan of care was updated. Further review of HOSRRDC# 1 patient record revealed HOSRRDC# 1 was diagnosed with a closed fracture of the right humerus with pneumonia. This was reviewed, discussed, and validated with the Hospice Manager. Observed in Record Review. During the Medical Director interview and patient records review it was noted the organization had not ensured it provided interdisciplinary care, treatment, or services. For example: during the Medical Director interview it was noted the Medical Director did not have a back up physician to attend the Interdisciplinary Group (IDG) when the Medical Director was not able to attend/participate. The Medical Director shared that when unable to attend/participate in the IDG, the Medical Director would follow up with the Hospice Manager for updates. The Hospice Manager shared if the Medical Director had not signed the IDG then the Medical Director did not attend. Review of the IDG’s dated approximately 58 days prior to the surveyor review of the record revealed no signature of the Medical Director. During IDG and patient record review it was noted the organization had not had a Spiritual Coordinator for approximately the last two months. This was reviewed, discussed, and validated with the Hospice Manager.”

“Observed in Record Review. During the IDG observation and interviews with the Director of Nursing and Hospice Manager it was noted the organization had not ensured Spiritual Coordinator was available to the patient ad family to assist the patient and family in minimizing the stress and problems that arise from the terminal illness, related conditions, and the dying process. For example: the organization’s Spiritual Coordinator resigned approximately two months prior to the survey and the BSW was being utilized for this role. However, review of the Spiritual Caregiver job description revealed the BSW did not meet the educational requirements of a Bachelor’s Degree from a CHEA in a content area relevant to chaplaincy. This was discussed and validated with the Hospice Manager.”

“Observed in Record Review. In 2 of 2 bereavement records reviewed, During HOSRRBR# 1 and HOSRRBR# 2’s bereavement records review it was noted the organization had not ensured it developed a bereavement plan of care that specified the types of bereavement services to be offered and the frequency of delivery. For example review of HOSRRBR# 1 and HOSRRBR# 2’s bereavement records revealed a bereavement care plan with no documentation of services to be offered or a frequency of service delivery. Further review of the bereavement care plans revealed documentation after the services were completed. This was reviewed, discussed, and validated with the Hospice Manager.”

“Observed in HR File Review. In 1 of 1 HR files reviewed with Hospice Aide services, During HR files review it was noted the organization had note ensured the RN completed an annual on-site visit to the location where the patient is receiving care in order to observe and assess each aide while the aide is providing care. For example: review of HOSHR# 4/Hospice Aide HR file revealed HOSHR# 4 date of hire was over 12 months from the day of the surveyor review of the HR file. Further review of the HOSHR# 4’s HR file revealed no documentation of a RN an annual on-site supervisory visit. This was reviewed, discussed, and validated with the Hospice Manager.”

“Observed in HR File Review. In 1 of 1 Volunteer HR files reviewed, During HR files review it was noted the organization had not ensured it assessed the skills and competence of all volunteers. For example: review of the Volunteer Program orientation/education revealed a session with the Physical therapist for transfer training. The Volunteer Coordinator shared that Volunteers do transfer patients in the home. Review of HOSHV# 12/volunteer’s HR file revealed no documentation of a competency for transfers. This was reviewed, discussed, and validated with the Volunteer Coordinator and the Hospice Manager.”

“Observed in Patient Home. In 2 of 2 home visits conducted with Skilled Nurse, During HOSRRHV# 1HOSRRHV# 2’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 HOSRRHV# 2’s medication profile revealed Lorazepam PRN. However, when reviewing HOSRRHV# 2’s medications with HOSRRHV# 2’s spouse it was noted HOSRRHV# 2 had not been taking Lorazepam for several months prior to the home observation and HOSRRHV# 2’s spouse had removed the medication to a cabinet away from the active medications. Further review of the medications in the home revealed HOSRRHV# 2 was taking Trazodone at bedtime as needed for sleep and had taken one the night prior to the home observation. Review of the medication profile revealed no documentation of Trazadone. During HOSRVHV# 1’s home observation the RN was observed putting Senna into HOSRRHV# 1’s medication minder from pm to am. However, review of the medication profile revealed no documentation of Senna. This was reviewed, discussed, and validated with the RN and Hospice Manager.”