Every finding on record at Angelino Hospice Care Inc

Observed in Individual Tracer. In 1 of 3 home visits conducted, the surveyor observed that the patient was in pain. The nurse during the visit did not complete a pain assessment before instructing the nurse at the facility to administer morphine. The agency had a scale for administering different doses of morphine depending on severity of pain. There was no further information given to the facility staff regarding dosage of morphine.

Observed in Individual Tracer. In 11 of 11 patient records reviewed, the plan of care did not reflect individualized time frames for achieving goals. All eleven records had time frames for goals that consistently reflected the end of certification period. This was verified by the Director of Nursing.

Observed in Individual Tracer. In 1 of 11 patient records reviewed, there was no evidence that information regarding the patient's change of condition was reported to the aide. During HV3 the surveyor was informed by the board and care staff that the patient had developed an open area on her coccyx. Through interview with the aide who was providing the shower the surveyor learned that the aide was unaware of this new problem and did not have instructions on how to care for the wound. In reviewing the record the nurse had made a visit the previous day and obtained orders for care, however, there was no documentation that information had been provided to the aide. This was verified by the Director of Nursing.