Every finding on record at Baptist Healthcare of Oklahoma, LLC

Based on record review and interviews the Agency failed to conduct and document patient-specific initial comprehensive assessment that included a review of all medications patients were taking and a bereavement assessment of the patient's family and others. --- Based on record review and interviews the Agency failed to conduct a review of all medications patients were taking as part of the initial comprehensive assessment to identify potential side effects, drug interactions, duplicate drug therapy and drugs associated with laboratory testing which could affect the patient's drug therapy. See L530. Based on record review and interviews the Agency failed to conduct a bereavement assessment of the patient's family and others as part of the initial comprehensive assessment focusing on factors that may impact their ability to cope with the patient's death. See L531.

Based on record reviews and interviews, the Agency failed to conduct a drug regimen review during the initial comprehensive assessment for fourteen (#1-#14) of fourteen (#1 -#14) records reviewed. --- Clinical record reviews failed to provide evidence the Agency conducted a drug regimen review during the initial comprehensive assessment for fourteen (#1-#14) of fourteen (#1 -#14) records reviewed. During an interview on 03/28/23 at 2:00 PM, Clinical RN1 stated the Quality RN conducted drug regimen reviews for the hospice records. During an interview on 03/29/23 at 12:45 PM, Quality RN1 stated her reviews were conducted at the time of re-certification and she did not conduct initial drug regimen reviews as part of the initial comprehensive assessment. Further review of Agency Titled "Initial and Comprehensive Assessment" stated at "Procedure: Item 2...The initial assessment needs to include the following information:" ..."Drug Profile..." During an interview on 03/29/23 at 2:50 PM, Clinical RN1 and Quality RN1 stated no process was in place to conduct the drug regimen review as part of the initial comprehensive assessment and stated records #1 - #14 had no initial drug regimen review conducted as part of the initial comprehensive assessment as required.

Based on record reviews and interviews, the Agency failed to conduct a bereavement assessment during the initial comprehensive assessment for two (#9 and #12) of fourteen (#1 -#14) records reviewed. --- Patient #9 Review of record #9 with a SOC date of 01/31/23 for certification period 01/31/23 to 04/30/23 revealed a primary diagnosis of hypertensive heart and renal disease with congestive heart failure. Further review of the clinical record failed to provide evidence of a bereavement assessment. During an interview on 03/28/23 at 1:30 PM, Clinical RN1 stated the bereavement assessment was completed by the Social Worker and if she was not available, the Chaplain or RN would complete the bereavement assessment. Patient # 12 Review of record #12 with a SOC date of 02/21/23 for certification period 02/21/23 to 04/23/23 revealed a primary diagnosis of parotid gland cancer. Further review of the clinical record failed to provide evidence of a bereavement assessment. During an interview on 03/29/23 at 12:20 PM, Social Worker1 stated she conducts bereavement assessments and confirmed the Chaplain or RN would complete the assessment if she was not available. Further review of Agency Titled "Initial and Comprehensive Assessment" stated at "Procedure: Item 2...The initial assessment needs to include the following information:" ..."Bereavement..." During an interview on 03/29/23 at 2:40 PM, Clinical RN1 stated no bereavement assessment was completed as required for Patients #9 and #12.

Based on record review and interviews the RN failed to conduct on site supervision of the Hospice Aide every 14 days as required for one (#13) of eleven (#1, #3-#11 and #13) records reviewed with orders for Hospice Aide services. --- Patient #13 Review of clinical record #13 for certification period 09/30/22 - 11/28/22 revealed a primary diagnosis of Congestive Heart Failure and orders for Hospice Aide services two times a week for eight weeks. Review of documentation by the RN on Skilled Nurse Visit Notes for the weeks of 10/03/22 to 11/21/22 failed to provide evidence the RN conducted any supervisory visits of the Hospice Aide during this time period. During an interview on 03/29/23 at 2:45 PM, Clinical RN1 stated the RN failed to conduct supervisory hospice aide visits as required for Patient #13.