Every finding on record at Ambassadore Hospice Care, Inc.

Observed in Record Review. In 6 of 6 patient records reviewed, the plan of care did not include measurable outcomes or goals. Upon review of the plan of care for all records, not all outcomes and goals were measurable. Examples included the following: Patient will have optimum level of oxygen; pain will remain in comfortable level during care; optimal blood sugar management for patient comfort. These stated goals do not contain specific information that can be accurately measured to assist organizational staff in determining whether the patient is progressing towards achieving their goals. This was reviewed and validated with the Director of Patient Care Services.

Observed in Patient Home. In 2 of 3 home visits conducted, standard precautions were not used to reduce the risk of infection. According to organizational policy Hand Hygiene No.9-009, hand hygiene will be performed after glove removal. During HV#1 and HV#2, the RN was observed removing gloves on several occasions without performing hand hygiene after glove removal. This was discussed with the RN/Director of Patient Care Services following the visits.

Observed in Record Review. In 2 of 3 patient records reviewed with aide services, complete written patient care instructions were not prepared by the RN. On review of the record for HV#1 and RR#4, it was noted the patients were on anticoagulant therapy. On review of the aide plan of care, there were no specific instructions provided to the aide regarding bleeding precautions. This was reviewed and validated with the Director of Patient Care Services.

Observed in Record Review. In 1 of 6 patient records reviewed, the medication list in the record was inaccurate. Upon review of RR#4, it was noted physician documentation indicated per the patient's daughter, the patient was taking Cannabis gummies. On review of the medication profile in the record, Cannabis was not listed. This was reviewed and validated with the Director of Patient Care Services. Observed in Record Review. In 1 of 3 home visits conducted in which medications were reviewed, the medication list in the record was inaccurate. Upon review of the medication profile for HV#3, it was noted the patient had an order for Humulin N 5 units daily; however, in discussion with the spouse he checks her blood sugar daily and if it is greater than 150 he will give 10 units, if it is less than 150 but greater than 90 he will give 5 units and if it is less than 90 he will hold the dosage. This was discussed with the Director of Patient Care Services following the visit.

Observed in Record Review. In 2 of 6 patient records reviewed, the record contained inaccurate information. Upon review of HV#1 it was noted the aide care plan indicated the patient had a foley catheter in place; however, on review of nursing assessment documentation, the patient did not have a catheter and wore briefs for incontinence. Upon review of RR#6, it was noted physician documentation indicated the patient wishes to be a DNR and admission paperwork indicated this as well; however, on review of the patient's POLST form, she is listed as a Full Code. This was reviewed and validated with the Director of Patient Care Services.