Every finding on record at Bristol Hospice - Utah, LLC

Based on interview and medical record review, it was determined the hospice did not ensure the clinical record contained current and correct clinical information for 1 of 13 medical records reviewed. Findings include: Patient 1 was admitted to the hospice on 9/9/2021 with a diagnosis of Amyotrophic Lateral Sclerosis (ALS). Patient 1 medical record review was completed on 12/29/2021 and revealed the following: On 9/9/2021, it was documented on the admission assessment completed by the skilled nurse (SN) that patient 1's wound status was active; the date identified was documented as 09/09/2021. It was documented that the wound location was at the posterior right buttock and was a stage II pressure ulcer. Wound type was documented as a, "Pressure Injury." On 9/10/2021, the following was documented by a different skilled nurse, "Skin is CDI (clean, dry, and intact), pt (patient) reports he has never had a pressure sore." On the interdisciplinary team (IDT) note dated 9/14/2021, the following was documented by the SN who completed patient 1's admission, "Pt. has PU (pressure ulcer) on coccyx stg (stage) II and calmoseptine used Q (every) change to protect area." The IDT note was electronically signed by the admission nurse, the physician, and the nurse that visited patient 1 on 9/10/2021 who documented that patient 1 had never had a pressure sore. On the IDT note dated 9/28/2021, the following was documented by the SN who completed the visit note on 9/10/2021, "No pressure sores present." The plan of care and updated plans of care had a diagnosis of pressure ulcer of right buttock, stage 2 with a date of 9/9/2021. At the time of survey on 12/29/2021, the diagnosis had not been removed or updated to correct the error in the PU diagnosis. On 12/28/2021 at 4:55 PM, via email, the administrator was asked to provide additional information and help clarify the conflicting documentation identified in patient 1's medical record regarding the wound. On 12/29/2021 at 10:35 AM the administrator responded, "In summary, there was actually no wound, and the Admit RN (registered nurse) documented those details in error. There was no lotion used for (patient's name). Our Admit RN is adding an addendum to document the error. The IDT note includes the incorrect documentation from the admit RN. It also includes the RNCM (case manager) report/finding that there was no wound. When the RNCM attended the day two visit, she documents that there was no wound. On 9/28/21 The RNCM notes that the skin condition is clean, dry and intact..." On 12/29/2021 at 10:48 AM the administrator was asked to confirm that the SN admission assessment of the wound, and the diagnosis of stage II pressure ulcer, were documented or assessed in error. On 12/29/2021 at 11:18 AM, the administrator responded, "Yes, documented in error. In speaking with the RNCM, she recalls how upset the family was that the RNCM was asking to see pt's buttock to see a wound that they said didn't exist. Pt did lean over for RNCM to observe wound and there wasn't one. So she documented no wound. Admit RN can't recall where she got that information. We have reviewed every chart that the Admit RN admitted that week, and can't find a patient that that matches."

Based on interview and medical record review, it was determined the clinical records did not contain physicians orders for wound care that was provided for 2 of 3 patients with documented wounds. Findings include: Patient 12 was admitted to the hospice on 7/7/2021 with a diagnosis of Heart Failure. Patient 12's medical record review was completed on 12/28/2021 and revealed the following: Skilled nurse (SN) visits notes from 10/10/2021 through 12/11/2021 were reviewed. The SN completed eighteen visits to patient 12 during that time. Sixteen of the eighteen visit notes mention some form of wound care being provided to patient 12 for various wounds. There was no documented evidence that a physician had ordered any of the wound care. The hospice administrator (ADM) was asked about physician wound care orders. The ADM responded on 12/27/2021 at 4:39 PM via email stating, "...it looks like the RNCM (registered nurse case manager) for (patient 12) did not know how to use the system to generate an order for would care. She only has it mentioned in the narrative notes." Note: The RNCM for patient 12 had been employed with the hospice for approximately 8 months. Patient 10 was admitted to the hospice on 11/17/2021 with a diagnosis of hypertensive heart disease with heart failure. Patient 10 medical record review was completed on 12/29/2021 and revealed the following: On 11/17/2021, it was documented on the admission assessment completed by the SN that patient 10 had "Scattered venous stasis wounds on his BLE (bilateral lower extremities). He has a stage 2 pressure sore on his buttocks due to increased bowel incontinence and increased time sitting." SN visits notes from 11/17/2021 through 12/24/2021 were reviewed. The SN completed fourteen visits to patient 10 during that time. Six of the fourteen visit notes mention some form of wound care being provided to patient 12 for various wounds. There was no documented evidence that a physician had ordered any of the wound care. On 12/29/2021 at 10:00 AM, the ADM was interviewed. She was asked about the lack of wound care orders and documentation. She stated they have identified that their wound care charting is not "intuitive" and the nurses were not documenting appropriately in the wound care section. She stated, "we need to do more education with our nurses."