Every finding on record at Ascension Seton

Observed in Patient Home. In 1 of 2 home visits conducted, the organization failed to complete medication reconciliation. At home visit RRHV#1 a registered nurse did not compare bottle labels to the medication list in the home as required by the Medication Reconciliation policy. This RFI was reviewed with the Administrator, the Administrator designee, the Supervising Nurse, and the Supervising Nurse designee.

Observed in Record Review. In 10 of 10 active patient records reviewed, the organization documented the date that goals were created in the plan of care but did not identify target dates for completion. This RFI was reviewed with the Administrator, the Administrator designee, the Supervising Nurse, and the Supervising Nurse designee.

Observed in Record Review. In 9 of 10 active patient records reviewed, care, treatments, services, orders and interdisciplinary meeting notes were documented in the paper medical records, however associated plans of care for patients admitted as long as 22 months prior to this survey date had not been updated in all but record RRNHV#7. This RFI was reviewed with the Administrator, the Administrator designee, the Supervising Nurse, and the Supervising Nurse designee.

Observed in Competency Session. In 1 of 7 HR files reviewed, the chaplain did not have a competency assessment documented every three years as required by policy in personnel file HR#6 SC. This RFI was reviewed with the Administrator, the Administrator designee, the Supervising Nurse, and the Supervising Nurse designee.

Observed in Tracer Activities. The organization failed to document efforts to recruit and retain volunteers for the last three years. This RFI was reviewed with the Administrator, the Administrator designee, the Supervising Nurse, and the Supervising Nurse designee.

Observed in Record Review. In 1 of 10 active records reviewed, there was no documentation that the medical director reviewed the patient's clinical information. In record RRHV#3 the recertification documentation for benefit periods 4 through 8 there were not CTIs. This RFI was reviewed with the Administrator, the Administrator designee, the Supervising Nurse, and the Supervising Nurse designee.

Observed in Patient Home. In 2 of 2 home visits conducted where oxygen was present, cylinders were not stored safely. At home visit RRHV#1 there were three oxygen cylinders stored in a closed closet. As well, only one M-24 tank was secured in a holder. Another M-24 cylinder and M-15 cylinder were standing upright and unsecured. At home visit RRHV#3 two M-9 cylinders were stored in a closed closet. This RFI was reviewed with the Administrator, the Administrator designee, the Supervising Nurse, and the Supervising Nurse designee.

Observed in Individual Tracer. In 2 of 3 home visits conducted, the surveyor observed that, the hospice nurse did not follow accepted standards of practice to prevent the transmission of infections and communicable diseases. In HV#1, it was observed that RN Case Manager inspected the peg tube site without wearing gloves. In HV#2, RN Case Manager only brought 1 pair of gloves to do wound care. It was observed that RN Case Manager removed dressing without wearing gloves. After cleaning the wound, RN Case Manager did not have another pair of gloves to apply clean dressing. These observations were discussed with Administrator/Nursing Supervisor.

Observed in Patient Home. In 2 of 3 home visits conducted, the surveyor observed the medication list did not include a list of nonprescription medications, herbal products, and home remedies that relate to the patient's care, treatment, or services. In HV#1, it was observed that the Calcium/Vitamin D was not listed on the medication list. In HV#3, it was observed that the following medications were not listed on the medication list: Zarbees Cough Syrup, Children's Tylenol, Ondansetron, and Albuterol. These observation were discussed with the Administrator/Nursing Supervisor.

Observed in Record Review. In 1 of 8 patient records reviewed, the surveyor observed that the organization did not protect health information against unintentional alterations. In RR#1, it was observed that that the election of hospice benefit date had been written over which does not follow agency policy# 9643989, which states, amendments and corrections will be made by making a single line through the entry along with the initials of the person making the correction and the date and time the amendment or correction was made. Upon discussion with the leadership team, they stated that this had been identified during a mock survey and addressed; however, they were unable to provide documentation of the education provided to the clinical staff.