Every finding on record at Bethesda Hospital, Inc.

Observed in Record Review. During a review of 1 of 23 patient records, it was noted that the organization did not ensure the comprehensive assessment update included all required information. For example, a review of the medical record for RRHV#1, revealed that the comprehensive pain assessment for benefit period #12, did not include the following information location, character, frequency, duration, and exacerbating factors. This observation was reviewed with the leadership team. Observed in Record Review. In 1 of 23 patient records reviewed, the patient assessment did not include the patient's needs for care. In the chart for RRNHV#2, the initial comprehensive assessment did not include the presence of the patient's colostomy and the CPAP use. This was discussed with the Clinical Support Specialist.

Observed in Record Review. During a review of 3 of 23 patient records, it was noted that the organization did not ensure the comprehensive assessment update included all required information. For example, a review of the interdisciplinary group meeting notes for RRHV#1, RRHV#5, and RRNHV#10, revealed that the following information was not documented: progress toward all goals. This observation was reviewed with agency leadership.

Observed in Record Review. In 2 of 23 patient records reviewed, it was noted that the organization did not ensure the plan of care goals included outcome measures for specific care activities. For example, a review of the medical record for HosInpt#3, revealed that the patient’s terminal illness diagnosis was Alzheimer’s disease. The plan of care did not include a goal statement to evaluate the response to care, treatment, and services related to Alzheimer’s disease interventions. Example#2: A review of the medical record for RRHV#6, revealed that the patient's terminal illness diagnosis was Protein Calorie Malnutrition, unspecified severity. The plan of care did not include a goal statement to evaluate the response to care, treatment, and services related to Protein Calorie Malnutrition. This observation was reviewed with the leadership team.

Observed in Record Review. In 1 of 23 patient records reviewed, the plan of care did not include interventions to manage pain and symptoms. In the chart for RRNHV#3, the patient had respite stays, however the plan of care was not updated to reflect the change in level of care required. Additionally, the patient's oxygen order was non-specific and read 2-10 liters per minute without clarification about how to use the range. The oxygen order was not included on the plan of care. This was discussed with the Clinical Support Specialist. Observed in Record Review. In 1 of 23 patient records reviewed, the plan of care did not include interventions to manage pain and symptoms. In the chart for RRNHV#4, the patient had GIP and respite stays, however the plan of care was not updated to reflect the changes in level of care required. This was discussed with the Clinical Support Specialist. Observed in Record Review. In 2 of 23 patient's records reviewed, it was noted that plan of care did not include interventions based on the problems identified in the comprehensive assessment. For example, a review of the medical record for HosInpt#3, revealed that the patient’s terminal illness diagnosis was Alzheimer’s disease. The plan of care did not include interventions related to Alzheimer’s disease. This observation was reviewed with the leadership team.Example #2: A review of the medical record for RRHV#6, revealed that the patient’s terminal illness diagnosis was Protein Calorie Malnutrition. The plan of care did not include interventions related to Protein Calorie Malnutrition. This observation was reviewed with the leadership team.

Observed in Record Review. In 1 of 23 patient records reviewed, the plan of care (POC) did not include all services needed for the palliation and management of the terminal illness and related conditions, including the following: A statement of the scope and frequency of the services necessary to meet the patient’s and family’s needs. In the chart for RRNHV#3, the POC included ranged visits for aide services such as 2-4 visits/7 days (for the remainder of the number of days in the benefit period) without any further clarification as to when visits were to be made at the lower or higher visit count and who was to make the decision about what the actual visit frequency should be. This was discussed with the Clinical Support Specialist. Observed in Record Review. In 2 of 23 patient records reviewed, the plan of care (POC) did not include all services needed for the palliation and management of the terminal illness and related conditions, including the following: A statement of the scope and frequency of the services necessary to meet the patient’s and family’s needs. In the chart for RRNHV#5 and RRNHV#6, the POC included ranged visits for aide services such as 2-4 visits/7 days (for the remainder of the number of days in the benefit period) without any further clarification as to when visits were to be made at the lower or higher visit count and who was to make the decision about what the actual visit frequency should be. This was discussed with the Clinical Support Specialist. Observed in Record Review. In 1 of 23 patient records reviewed, the plan of care (POC) did not include all services needed for the palliation and management of the terminal illness and related conditions, including the following: A statement of the scope and frequency of the services necessary to meet the patient’s and family’s needs. In the chart for RRNHV#7 the POC included ranged visits for aide services such as 1-3 visits/7 days (for the remainder of the number of days in the benefit period) without any further clarification as to when visits were to be made at the lower or higher visit count and who was to make the decision about what the actual visit frequency should be. This was discussed with the Clinical Support Specialist. Observed in Record Review. In 1 of 23 patient records reviewed, the plan of care (POC) did not include all services needed for the palliation and management of the terminal illness and related conditions, including the following: A statement of the scope and frequency of the services necessary to meet the patient’s and family’s needs. In the chart for RRNHV#2, the POC included ranged visits for aide services such as 2-4 visits/7 days (for the remainder of the number of days in the benefit period) without any further clarification as to when visits were to be made at the lower or higher visit count and who was to make the decision about what the actual visit frequency should be. This was discussed with the Clinical Support Specialist.

Observed in Record Review. In 1 of 23 patient records reviewed, the plan of care did not include all services necessary to meet the patient's needs. In the chart for RRNHV#1, the plan of care did not include the oxygen liter flow. This was discussed with the Clinical Support Specialist. Observed in Record Review. In 1 of 23 patient records reviewed, the plan of care did not include all treatments required by the patient. In the chart for RRNHV#5, there was no order for oxygen on the patient's plan of care. This was discussed with the Clinical Support Specialist. Observed in Record Review. In 1 of 23 patient records reviewed, the plan of care did not include all services needed for the palliation and management of the terminal illness and related conditions. In the chart for RRNHV#7, the Oxygen order was not on the POC. This was discussed with the Clinical Support Specialist. Observed in Record Review. In 1 of 23 patient records reviewed, the plan of care did not include all services needed for the palliation and management of the terminal illness and related conditions. In the chart for RRNHV#2, the plan of care did not include the order for the Foley catheter. There was no order to routinely change the catheter which the RN did complete during a home visit. This was discussed with the Clinical Support Specialist.

Observed in Record Review. In 1 of 23 patient records reviewed, the interdisciplinary group, in collaboration with the patient’s attending physician, if any, reviews and revises the plan of care as frequently as the patient’s condition requires, but no less frequently than every 15 calendar days. In the chart for RRNHV#3, the patient chose an attending physician other than a hospice physician. There was no documentation in the record that the attending physician had reviewed or revised the plan of care. All orders and reviews were documented by the hospice physicians. This was discussed with the Clinical Support Specialist. Observed in Record Review. In 1 of 23 patient records reviewed, the interdisciplinary group, in collaboration with the patient’s attending physician, if any, reviews and revises the plan of care as frequently as the patient’s condition requires, but no less frequently than every 15 calendar days. In the chart for RRNHV#1, the patient chose an attending physician other than a hospice physician. There was no documentation in the record that the attending physician had reviewed or revised the plan of care. All orders and reviews were documented by the hospice physicians. This was discussed with the Clinical Support Specialist. Observed in Record Review. In 1 of 23 patient records reviewed, the interdisciplinary group, in collaboration with the patient’s attending physician, if any, reviews and revises the plan of care as frequently as the patient’s condition requires, but no less frequently than every 15 calendar days. In the chart for RRNHV#2, the patient chose an attending physician other than a hospice physician. There was no documentation in the record that the attending physician had reviewed or revised the plan of care. All orders and reviews were documented by the hospice physicians. This was discussed with the Clinical Support Specialist.

Observed in Record Review. In 1 of 23 patient records reviewed, the organization had not provided the patient with care according to the patient's individualized plan of care. In the chart for RRNHV#3, the aide did not follow the visit frequency on the plan of care and had documented 4 missed visits without any documentation that the IDT had been informed. This was discussed with the Clinical Support Specialist. Observed in Record Review. In 2 of 23 patient records reviewed, the organization had not provided the patient with care according to the patient's individualized plan of care. In the chart for RRNHV#5, the aide did not follow the visit frequency on the plan of care. Aide visits were ordered on the plan of care as 2-4 visits/7 days; 3x/week in the aide assignment, yet in the first 7 days, 2 visits were documented; in the second 7 days, 1 visit was documented. No missed visits were documented. In the chart for RRNHV#6, there were no aide visits provided in weeks 1, 2 and 3 of the benefit period. Visits were to be provided 2-4 times per week. This was discussed with the Clinical Support Specialist.

Observed in Record Review. In 1 of 23 patient records reviewed, the patient assessment did not include the patient's needs for care. In the chart for RRNHV#8, the initial comprehensive assessment did not include an assessment of the patient's and family's spiritual needs. There was no spiritual care assessment documented. This was discussed with the Clinical Support Specialist. Observed in Record Review. In 1 of 23 patient records reviewed, the patient assessment did not include the patient's needs for care. In the chart for RRNHV#2, the initial comprehensive assessment did not include an assessment of the patient's and family's spiritual needs. There was no spiritual care assessment documented. This was discussed with the Clinical Support Specialist.

Observed in Record Review. In 1 of 5 patient records reviewed, for whom aide services were ordered. a registered nurse had not prepared written patient care instructions for the hospice aide. In the chart for RRNHV#5, there was no aide care plan. The aide had seen the patient weekly. This was discussed with the Clinical Support Specialist.

Observed in Record Review. In 1 of 5 patient records reviewed, for which aide services were ordered, the aide had not provided services in accordance with the plan of care. In the chart for RRNHV#6, the aide failed to perform multiple assigned tasks on multiple visits, yet there was no indication in the record to indicate why the assignment had not been completed as ordered. This was discussed with the Clinical Support Specialist.

Observed in Record Review. In 2 of 5 patient records reviewed, for whom aide services were ordered, the organization had not effectively supervised the aide to ensure that services meet the patient's needs. In the chart for RRNHV#5, the RN documented supervisory visits at the required frequency, however failed to recognize that the aide had not provided the visits at the frequency ordered. In the chart for RRNHV#6, Aide services were not provided in weeks 1,2,3. The RN documented aide supervision including that the aide was following the plan of care, yet failed to recognize that the aide had not provided the visits as ordered, nor that multiple interventions had not been provided on multiple visits. This was discussed with the Clinical Support Specialist.

Observed in Record Review. In 1 of 3 applicable individual tracers, it was noted that the organization did not ensure the medication list included accurate information. For example, individual tracer activities for RRHV#1, revealed that the plan of care did not include an accurate description of the medication’s the patient was currently taking. The medication list included the following information: 1) Eliquis 2.5mg take 1 tablet by mouth 2 times daily; 2) Metformin 500mg take 1 tablet by mouth daily; 3) Ferrous Sulfate 325mg take 1 tablet by mouth at bedtime; 4) Florastor 250mg take 1 capsule by mouth every morning. The patient was currently taking Eliquis 5mg 1 tablet by mouth 2 times daily; and Metformin 500mg 1 tablet by mouth 2 times per day. The patient was no longer taking Ferrous Sulfate and Florastor. This observation was reviewed with the leadership team. Observed in Record Review. In 1 of 23 patient records reviewed, the patient record did not contain the following clinical information: Any medications administered, including dose. In the chart for RRNHV#4, the nurse documented Haldol given at this time, however did not document the dose or route. This was discussed with the Clinical Support Specialist.

Observed in Record Review. In 1 of 23 patient records reviewed, the patient record was not accurately documented. In the chart for RRNHV#3, the admission plan of care (POC) indicated the start date was effective 6 days after the admission of the patient. It was confirmed by the Hospice Surveyor with the Clinical Support Specialist that this was a data entry error by the clinician who created and/or edited the POC and should have started on the day of admission. Additionally, the plan of care included interventions and goals for OT and PT, however there were no OT nor PT visits or interventions ordered. This also was a documentation error as confirmed with the Clinical Support Specialist. Observed in Record Review. In 1 of 23 patient records reviewed, the patient record was not accurately documented. In the chart for RRNHV#7, the admission plan of care (POC) indicated the start date was effective 7 days after the admission of the patient. It was confirmed by the Hospice Surveyor with the Clinical Support Specialist that this was a data entry error by the clinician who created and/or edited the POC and should have started on the day of admission. Additionally, the plan of care included interventions and goals for OT and PT, however there were no OT nor PT visits or interventions ordered. This also was a documentation error as confirmed with the Clinical Support Specialist.

Observed in Building Tour. There was spray on fire proofing missing from the structural beam in the Main Fire Alarm Control Panel Room. This was confirmed by the Maintenance Technician & Facility Manager. The surveyor discussed the Life Safety deficiency with the organization, and it was determined that the following ILSMs will be implemented until the deficiency has been resolved and according to the organization's ILSM policy: Observed in Building Tour. During the building tour, two (2) penetrations were found above the acoustical ceiling tile (ACT) in the one (1) hour fire barriers at the following stairwells. The locations were:*Communications Stairwell near the elevator & cafe'. Hole measure approximately four (4) inches by four (4) inches around & thru the 3/4 metal conduit*Stairwell near the Chapel around the & thru the 3/4 conduit & MC CablingThis was confirmed by the Maintenance Technician. This finding was observed during survey activity, but corrected onsite prior to the surveyor's departure. The corrective action taken needs to be included in the organization's Evidence of Standards Compliance submission. Observed in Building Tour. Penetrations were noted in the smoke barrier wall in the conference room that also served as a corridor wall. Room was protected with a smoke detector & sprinkler protection. Penetrations were also sealed with various fire caulks. This was confirmed by the Facilities Manager. This finding was observed during survey activity, but corrected onsite prior to the surveyor's departure. The corrective action taken needs to be included in the organization's Evidence of Standards Compliance submission.

Observed in Document Review. During the document review session t was noted that EP 3 (Duct / Heat / Smoke / Manual Fire Alarm Boxes) & EP 4 (Notification Devices (audible & visual) & door-releasing devices) did not state what year & sections the items were inspected too. This was confirmed by the Maintenance Technician. Observed in Document Review. During the document review session t was noted that EP 16 (Portable Fire Extinguishers Maintained Annually) did not state what year & sections the item was inspected too. This was confirmed by the Maintenance Technician.

Observed in Record Review. In 3 of 20 patient records reviewed, The hospice nurse surveyor noted (HV#3) that there was no evidence in the record that indicated the severity of the patient's symptoms and factors that alleviate or exacerbate physical symptoms of constipation, nausea and vomiting were assessed. The patient was dis-impacted one week after admission. Also, in (HV#4) there was no evaluation of the severity of the patient's nausea and vomiting. Also, in (DRR#2), there was no assessment of the severity of the patient's dysphagia. This was confirmed with the documentation specialist.

Observed in Patient Home. During the home visit for HV2, the surveyor observed that the nurse did not follow the organization's Medication Management policy. During the visit the nurse counted the narcotic medications and set up the medication planner. It was also noted that medications were kept in various rooms of the house. Medications in the home were not reconciled against the current medication profile. Policy required medication reconciliation to occur with each nursing visit. This was discussed with hospice leadership.

Observed in Individual Tracer. In 20 of 20 patient records reviewed, The hospice nurse surveyor noted (HV#3) that the plan of care did not include goals and interventions to manage the patient's dyspnea and the goal for management of pain and constipation, did not include any outcome measures and the time frames were all for the end of the certification period. For example, the goal for pain was stated as pain level will remain comfortable for patient even though the patient's pain level was assessed as six (6) on a scale of 1-10. In (HV#4) the goals for pain and nausea and vomiting did not include outcome measures or time frames for symptom management. The patient's pain was assessed as six (6) on a scale of 1-10. In .(HV#5) the goal for dyspnea was trouble breathing will be lessened and did not include outcome measures or time frames. In (HV#6), the surveyor noted that there was no measurable outcome or time frame for managing the patient's dyspnea and safety related to oxygen use. The surveyor noted that there were no measurable outcomes and time frames for managing symptoms for (DRR#1), (DRR#2), (DRR#3), (DRR#4), (DRR#5) and (DRR#6). This is a repeat finding from the previous survey. This was confirmed with the documentation specialist. Observed in Record Review. The surveyor found that the organization had not developed an individualized written plan of care for the patient. For example, in review of the medical record for HV1 the surveyor found the goal was not measurable (Patient will demonstrate adequate sleep/rest pattern) and/or not patient focused (Patient/family is receiving emotional support as evidenced by SW visit with patient for socialization.....) In review of the medical record for HV2, the goals were all to be completed by the end of certification period. These goals included the following: Patient's pain physical comfort to stated goal, verbalization understanding of pain management plan, trouble breathing will be at an acceptable level of comfort AEB patient reporting, verbalize pressure relief interventions, diet to promote healing, implement strategies to reduce fall risk within (?) AEB no reports of falls. In review of the medical record for ARR1, ARR2, ARR3, and ARR5, each had goals that did not include a targeted completion date. In ARR5, ARR6 and ARR8, the emotional support goal was not patient focused. This was discussed with the Epic Documentation Specialist assisting with record review.

Observed in Record Review. In 6 of 20 patient records reviewed, the surveyor found that the plan of care did not include all interventions to manage pain and symptoms. For example, in review of the medical record for HV2, the plan of care did not contain an order for the oxygen that was in use. In review of the medical record for ARR1, the plan of care did not contain an order for the oxygen in use or the foley catheter. In ARR2, the patient was identified as being at risk for falls and had a goal, but there were no individualized interventions to address this risk. In ARR5, the patient was on Warfarin but this was not addressed in the plan of care. In ARR7, the patient was admitted with glioblastoma and had orders for Keppra. The plan of care did not address the potential for seizures or any precautions. This same patient had an order for the urinary catheter that was in place. The order did not include that it was a coude, the size of the catheter or the size of the balloon. In ARR8, the plan of care did not contain an order for the oxygen that was in use. This was discussed with the Epic Documentation Specialist assisting with record review.

Observed in Record Review. In 1 of 20 patient records reviewed, the surveyor found that the plan of care did not identify the frequency of service for Holistic therapy. This was discussed with the Epic Documentation Specialist assisting with record review.

Observed in Individual Tracer. In 8 of 20 patient records reviewed, The hospice nurse surveyor noted (HV#3) that the patient was on oxygen 2 LPM via NC; however there was no oxygen order on file. Also, a nurse visit note indicated that the nurse administered an enema; however, there was no order in the record. In (HV#4), the surveyor noted that the patient had three different ant-emetics ordered as needed: Phenergan, Zofran and Reglan; however there was no information about the order or reason to give which medication. In (HV#5) the surveyor noted that there were three incomplete medication orders for prn dosing; however, there was no indication for use for Tramadol, Clobetasol and Albuterol. Also, the patient was observed to be on continuous oxygen and indicated that she wore it at all times; however there was no order on file. In (HV#6), the surveyor noted that there were no orders or care plan updates when the patient changed level of care eight times between routine care and respite care, provided in the inpatient unit. This was confirmed with the documentation specialist. Observed in Record Review. The surveyor found that the plan of care did not specify the unique medications and/or treatments necessary to meet the patient's needs. For example, in review of the medical record for HV2, the surveyor found that the patient had acetaminophen with hydrocodone and morphine ordered as needed for pain without further defining when to give each medication. In review of the medical record for ARR1, the patient had an order for albuterol nebulizer treatments as needed but did not specify an indication. In review of the medical record for ARR4, the patient had albuterol nebulizer treatments and an albuterol inhaler ordered as needed for shortness of breath without further defining when to give each medication. This was discussed with the Epic Documentation Specialist assisting with record review.

Observed in Individual Tracer. In 3 of 6 home visits conducted, The hospice nurse surveyor noted (HV#3) that the aide failed to sanitize hands when entering the home and before moving the patient items from a side table. The aide then washed her hands at sink and used the patient's cloth towel to dry her hands instead of paper towels, as required by policy. This was confirmed with the nurse manager. Observed in Patient Home. The surveyor observed that the staff member did not follow accepted standards of practice for hand hygiene. For example, during the home visit for HV2, the staff member touched objects in the patients environment and then donned gloves without performing hand hygiene. During this same visit, the staff member washed his hands at the patient's sink and then used the patient's cloth towel hanging on a towel rack to dry his hands. This observation was discussed with leadership.

Observed in Record Review. Where the patient had hospice aide services ordered, the surveyor found that the registered nurse had not provided the aide with information on safety precautions to implement or when to notify the nurse. For example, in review of the medical record for HV1, the patient had Clopidogrel ordered. The plan of care for the hospice aide did not specify the unique safety precautions or notification requirements related to this finding. In review of the medical record for HV2, the surveyor noted that the patient had oxygen ordered and was at high risk for falls. The plan of care for the hospice aide did not specify the unique safety precautions or notification requirements related to these findings. In review of the medical record for ARR3, the patient had Eliquis ordered. The plan of care for the hospice aide did not specify the unique safety precautions or notification requirements related to this finding. In review of the medical record for ARR7, the patient had orders for Keppra (glioblastoma) and was at risk for falls. The plan of care for the hospice aide did not specify the unique safety precautions or notification requirements related to these findings. This was discussed with the Epic Documentation Specialist assisting with record review. Observed in Individual Tracer. In 2 of 10 aide care plans, The hospice nurse surveyor noted (HV#3) that the aide care plan did not include instructions about the use of oxygen. The surveyor noted that the aide removed the cannula when washing the patient's face. Also, the care plan indicated that the aide was to provide a bed bath every visit and a shower prn ; however, there were no instruction for when the aide was to provide a shower. Also, the care plan did not include the patient's code status. This was confirmed with the documentation specialist.

Observed in Tracer Activities. Leadership and the governing body should have reasonably known about non-compliance with the Condition of Participation (418.100 and 418.56).

Observed in Building Tour. In 3 of 4 inpatient unit building tours, The hospice nurse surveyor noted (IPU1) that there were three large penetrations (greater than 6 inches) in a wall in the mechanical closet that penetrated to the patient area. The penetrations were repaired and corrected on site. This finding was observed during survey activity, but corrected onsite prior to the surveyor's departure. The corrective action taken needs to be included in the organization's Evidence of Standards Compliance submission. Observed in Building Tour. The hospice surveyor found that the organization had not ensured that all penetrations in the firewall were protected with an approved fire-rated material. For example, during the tour of IPU3, there was one penetration in the fire rated wall in the electrical room and one penetration in the fire rated wall of the elevator shaft. During the tour of IPU4, there was one penetration in the fire rated wall of the soiled utility room. These findings were also observed by the maintenance mechanic assisting with the building tour. This finding was observed during survey activity, but corrected onsite prior to the surveyor's departure. The corrective action taken needs to be included in the organization's Evidence of Standards Compliance submission.

Observed in Record Review. The hospice nurse surveyor noted in (DRR#2) that the plan of care did not identify the care and services that were needed and identify which provider was responsible for performing the functions that have been agreed upon and did not indicate who was performing skin care, administering medications, and feeding the patient with swallowing difficulties. Also, in (DRR#4) the plan of care did not include information about who was administration medications and providing nephrostomy tube care. This was confirmed with the documentation specialist. Observed in Record Review. In 5 of 5 patient records reviewed, where the patient resided in a skilled facility, the surveyor found that the plan of care did not identify which provider was responsible for performing the functions that had been agreed upon and included in the plan of care. This identification of responsibility was not found for the plan of care for HV1, ARR1 and for ARR5. This was discussed with the Epic Documentation Specialist assisting with record review.