Every finding on record at Cadence Healthcare LLC

Observed in Record Review. In 1 of 12 patient records reviewed, During RRHV# 1's patient record review it was noted the organization had not ensured Fall Risk Assessments were completed per organization policy Safety Program that included completing a Fall Risk Assessment at start of care and recertification. For example: review of RRHV# 2's start of care registered nurse (RN) comprehensive assessment and recertification RN comprehensive assessment revealed no documentation of a Fall Risk Assessment. This was reviewed, discussed, and validated with the Administrator.

Observed in Record Review. In 12 of 12 patient records reviewed, During RRHV# 1, RRHV# 2, RRHV# 3, POSSIBLY RR# 1, RR# 2, RR# 3, RR# 4, RR# 5, RR# 6, AND RR# 7, D/C# 1, and D/C# 2's patient records review it was noted the organization had not ensured the written plan of care was based on the patient's goals and the time frames, setting and services required to meet those goals. During review of 12/12 patient records revealed Medical Social Worker and/or Chaplain services with the same goals that included either establishing a plan of care when patients had been on service from two years to two months; and/or the goals Patient/Caregiver will have decreased fear/anxiety regarding death and dying process with no indication how to measure “decreased”; and/or patient will experience an increased sense of closure and peacefulness at the end of life, with no indication how to measure “increased”. In addition, RRHV# 1 and RRHV# 2 both had dysphagia with altered diets and thickened liquids. However, review of both RRHV# 1 and RRHV# 2’s plans of care revealed no goals related to the risk of aspiration. Further review of RRHV# 1, RRHV# 2, and RR# 5’s plans of care revealed the same pain goal that included patient pain would be managed at a level acceptable to the patient. However, there was no indication what pain level was acceptable. Review of RRHV# 3's plan of care revealed the pain goal Patient/Caregiver will verbalize/demonstrate appropriate management. However, there was no indication what appropriate management was. This was reviewed, discussed, and validated with the Administrator.

Observed in Record Review. In 6 of 12 patient records reviewed, During RRHV# 1, RRHV# 2, RRHV# 3, RR# 3, RR#4, and RR# 5's patient records review it was noted the organization had not ensured treatments necessary to meet the patient's needs was included in the plan of care. For example: During RRHV# 1s home observation it was noted RRHV# 1 was on thickened liquids due to risk of aspiration and history of aspiration pneumonia. Review of RRHV# 1's plan of care revealed no documentation of thickened liquids or what consistency the thickened liquids should be. The Board and Care staff shared I put 4 scoops of the thick it in a 16 oz cup. Further review of the plan of care revealed no aspiration precautions. In addition, during RRHV# 1's home observation oxygen was noted at the beside and the registered nurse shared it was RRHV# 1's oxygen concentrator and portable oxygen tank. However, review of the plan of care revealed no documentation of oxygen. This was observed, discussed, and validated with the RN at the home observation and validated with the Administrator during record review. During RRHV# 2's home observation it was noted RRHV # 2 was on thickened liquids due to risk of aspiration and history of aspiration pneumonia. However, review of RRHV# 2's plan of care revealed thickened liquids with no indication as to what consistency. The Assisted Living Staff shared they put one large scoop for every cup of liquids. Further review RRHV# 2's plan of care revealed no documentation of aspiration precautions. This was observed, reviewed, and discussed during the home observation with the Licensed Vocational Nurse and validated with the Administrator during record review. Review of RRHV# 3’s patient record revealed RRHV# 3 was taking an anticoagulant medication. However, review of RRHV# 3’s plan of care revealed no bleeding precautions. Review of RR# 3’s patient record revealed documentation that RR# 3 had oxygen as needed. However, review of RR# 3’s plan of care revealed no documentation/order for oxygen. Review of RR# 4’s patient record revealed RR# 4 was dependent on 4 lpm of continuous oxygen. However, review of RR# 4’s plan of care revealed no documentation/order for oxygen. Review of RR# 5’s patient record revealed RR# 5 was on continuous oxygen at 3lpm. However, review of RR# 5’s plan of care revealed no documentation/order for oxygen. This was reviewed, discussed, and validated with the Administrator.

Observed in Patient Home. In 1 of 2 home visits conducted with vital sign equipment, During RRHV# 2's home observation it was noted the organization had not ensured it reduced risks of infection associated with medical equipment to include following Clorox Bleach wipes manufacturers recommendations to have four minutes of contact time/wet time. For example: during RRHV# 2's home observation the Licensed Vocational Nurse (LVN) was observed cleaning the stethoscope, B/P cuff, thermometer, and pulse oximetry with a Clorox Bleach wipe and placing each piece of equipment immediately into a plastic bag. This was discussed and validated with the LVN during the home observation and discussed and validated with the Administrator during record review. Observed in Patient Home. In 2 of 3 home visits conducted, During RRHV# 1's home observation it was noted the organization had not ensured staff followed the organization's policy Hand Hygiene that included performing hand hygiene after removing gloves, prior to putting on gloves, and after touching items in the environment. For example: during RRHV# 1's home observation the registered nurse was observed removing gloves and putting on new gloves with no hand hygiene performed after removing gloves. In addition, the RN was observed with gloves on and cleaned a the B/P equipment with Clorox bleach wipes and with the same gloves performed vital sign assessments to include temperature, pulse oximetry, and listening to RRHV# 1's heart, lungs, and abdomen. During HV# 2's home observation the Licensed Vocation Nurse (LVN) was observed washing hands with no clean paper towels to dry the hands and used the toilet paper from the toilet paper roll in the Assisted Living (ALF) shared bathroom on two occasions and letting the hands drip dry on two more occasions. This was discussed with the LVN and validated and was discussed and validated with the Administrator.

Observed in Record Review. In 10 of 12 patient records reviewed with Hospice Aide, During RRHV# 1, RRHV# 3, D/C# 2, RR# 1, RR# 2, RR# 3, RR# 4, RR# 5, RR# 6, and RR# 7's patient records review it was noted the organization had not ensured the registered nurse prepared a complete written patient care instructions for the hospice aide. For example: during RRHV# 1's patient record review it was noted RRHV# 1 had oxygen at the bedside. However, review of RRHV# 1's hospice aide written patient care instructions revealed no documentation of oxygen or oxygen precautions. Review of RR# 4’s patient record revealed RR# 4 was on continuous oxygen at 4lpm via nasal cannula. However, review of RR# 4’s hospice aide written patient instructions revealed no documentation RR# 4 had oxygen or if the oxygen could be removed during bathing and there were no oxygen precautions on the written instructions. Review of RR# 5’s patient record revealed RR# 5 was on continuous oxygen at 3lpm via nasal cannula. However, review of RR# 5’s hospice aide written patient instructions revealed no documentation of oxygen or if oxygen could be removed during bathing and no oxygen precautions. Review of RR# 6’s patient record revealed RR# 6 had oxygen as needed and was a fall risk. However, review of RR# 6’s hospice aide written patient care instructions revealed no documentation of oxygen precautions or fall precautions. Review of RR# 7’s patient record revealed RR# 7 had oxygen as needed. However, review of RR# 7’s hospice aide written patient care instructions revealed no documentation of oxygen or oxygen precautions. Review of RRHV# 3's patient record revealed RRHV# 3 had oxygen as needed and fall precautions. However, review of RRHV# 3's hospice aide written patient care instructions revealed no documentation of oxygen precautions or fall precautions. Review of D/C# 2's patient record revealed fall risk. However, review of D/C# 2's hospice aide written patient care instructions revealed no documentation of fall precautions. Review of RR# 1's patient record revealed RR# 1 has oxygen as needed. However, review of RR# 1’s hospice aide written patient care instructions revealed no documentation of oxygen precautions. Review of RR# 2’s patient record revealed RR# 2 had oxygen as needed and was a fall risk. However, review of RR# 2’s hospice aide written patient care instructions revealed no documentation of oxygen precautions or fall precautions. Review of RR# 3’s patient record revealed RR# 3 had oxygen as needed and was a fall risk. However, review of RR# 3’s hospice aide written patient care instructions revealed no documentation of oxygen precautions or fall precautions. This was reviewed, discussed, and validated with the Administrator.

Observed in Patient Home. In 1 of 3 home visits conducted, During RRHV# 1's home observation it was noted the organization had not ensured it respected, protected, and promoted patients' rights. For example: during RRHV# 1's home observation RRHV# 1 was in a shared room with a roommate present in the bed approximately 5 feet from RRHV# 1's bed. During the home observation the registered nurse completed a full skin assessment to include the peri-anal area with no privacy curtain. This was discussed with the Administrator and validated.

Observed in Patient Home. In 2 of 2 home visits conducted with medication reconciliation, During RRHV# 1 and RRHV# 2's home observations it was noted the organization had not ensured the patient record reflected the patient's care, treatment, or services. For example: review of RRHV# 1's medication profile revealed Macrobid 100mg capsule take 0.5 capsule and the Board and Care medication administration record (MAR) had Macrobid 50mg take one capsule. Further review of RRHV# 1's medication profile revealed Melatonin 3mg as needed for sleep. However, review of the Board and Care MAR revealed Melatonin had been discontinued prior to the beginning of the month. Staff at Board and Care shared RRHV# 1 had not taken Melatonin in a really long time. During RRHV# 2's home observation the licensed Vocational Nurse (LVN) and the Assisted Living Facility (ALF) staff were observed completing a medication reconciliation. Review of RRHV# 2's medication profile revealed Macrobid 100mg capsule take 0.5 capsule. However, the ALF MAR revealed Macrobid 50 mg capsule. Further review of RRHV# 2's medication profile revealed Morphine Immediate release 15mg tablet as needed for pain that was started approximately two years prior to the home observation. However, review of the ALF MAR for the current month revealed no documentation of Morphine immediate release 15mg tablet and the ALF did not have the medication. In addition, during RRHV# 2’s medication reconciliation it was noted that several medications had expired to include: Dulcolax Suppositories expired approximately four months prior to the home observation, and both Zyrtec 10mg and Levsin 0.125 mg had expired approximately two months prior to the home observation This was reviewed, discussed, and validated with the nurses during the home observations, and discussed and validated with the Administrator during record review.