Every finding on record at Angels Grace Hospice LLC

Observed in Record Review. in 1 of 14 active patient records reviewed, the Hospice Nurse Surveyor noted that patient education was not provided to the patient. On review RRNHV #2, it was noted that the patient had started Albuterol nebs and a new medication of Robitussin for cough but there was not education documented after starting those two medications. This finding was reviewed with agency leaders.

Observed in Record Review. In 14 of 14 patient records reviewed, Hospice surveyor noted goals in patient records were not measurable and specific to the care needs for the patient. On RRNHV #1, it was noted on assessment that speech was Non sensical and unable to respond to questions but the patient had goal to verbalize an acceptable pain level. On RRNHV #2, goals were not measurable with examples of Patient's symptoms will be consistent with stage of disease process and problems managed as well as disease process will allow and Patient's nutritional needs will be met as patient's condition /comfort allows.. On RRHV #1, RRHV #2, RRHV #3, RRHV #4, RRNHV #3, RRNHV # 4, RRNHV #5, RRNHV #6, RRNHV #7, RRNHV #8, RRNHV #9 and RRNHV #10 goals were not measurable or specific with examples that include: Consult with FN for any changes regarding insulin therapy, Patient will remain comfortable, Skin integrity will be maintained and problems managed as disease process, Anxiety/agitation controlled through course of care, Patient's nutritional needs will be met as patient's condition /comfort allows, Patient will be pain free or verbalize an acceptable pain level with current pain management regimen and breathing at optimal level within disease parameters and optimum bowel functioning consistent with food intake and stage of disease process. This finding was reviewed with agency leadership.

Observed in Record Review. In 1 of 14 patient records reviewed, the Hospice nurse surveyor noted that care was not provided according to the hospice plan on treatment. On review of RRNHV #2, it was noted that the nurse had removed ear wax from the patients ear with a curette and there was no orders for that treatment. This finding was reviewed with agency leadership.

Observed in Record Review. In 6 of 14 active patient records reviewed, the Hospice Nurse Surveyor noted medications ordered were not specific to patient needs. On RRHV #2 and RRNHV #8, it was noted that he patient has duplicate PRN orders for constipation of bisacodyl and Milk of Magnesia with no indication of when to use each duplicate therapy. On RRHV #3, it was noted that the patient has duplicate PRN orders for constipation of Biscodyl and Senokot with indication for when to use each duplicate therapy. On review of RRNHV #1, it was noted that patient had PRN orders for Senna and Biscodyl but no clear instruction on when to use each duplicate therapy. On RRNHV #2 , it was noted that the patient has duplicate PRN orders for constipation of MiraLAX and bisacodyl with no indication of when to use each duplicate therapy. On RRNHV #4, Bisacodyl and saline enema for constipation PRN ordered with no indication when to use each duplicate therapy. This finding was reviewed with agency leadership.

Observed in Record Review. In 2 of 3 bereavement records reviewed, the organization did not follow the bereavement plan of care. On review of RRBR #2 and RRBR #3, it was noted that the 6 month phone call has not been completed and was due a week ago. This finding was reviewed with agency leaders.

Observed in Patient Home. In 1 of 4 home visits conducted, the patient's individualized emergency management plan was not completed. During RRHV #1 it was noted that patient patient’s individualized emergency plan in the home packet was blank. This was reviewed with the clinical director who was present for the visit.

Observed in Record Review. In 1 of 2 live discharge records reviewed, the organization did not send discharge summary timely. Agency Discharge Summary Policy (2-072.1) states that the organization will send the discharge summary within 72 hours of discharge. On RRDC #1, it was noted that the organization sent the discharge summary 10 days after discharge.

Observed in Patient Home. In 1 of 4 home visits, the surveyor noted that there was no documentation provided to the patient regarding their policy on controlled substance disposal. Agency Home Use and Disposal of Controlled Substance Policy (3.005.1) states admitting nurse will provide written copy of the policy on controlled substance. The admission booklet states that the nurse will review the policy on control substance disposal but no policy is in the admission binder. This was reviewed and confirmed with Clinical administrator who was present for the visit.