Every finding on record at Carepartners Rehabilitation Hospital,LLLP

Observed in Record Review. In 1 of 14 patient records reviewed, for active patients, it was noted by the nurse surveyor the nurse conducted a medication assessment but failed to follow up on a pending medication change. For HOSRRNHV#1, there was a new medication order on admission for Dexamethasone tablets twice a day and for Dexamethasone liquid twice day to be discontinued once the tablets are available. Two weeks after admission, both medication orders are on the medication profile and documentation in the nursing notes does not specify which one the patient is taking. Findings were discussed and verified with the RN Clinical Team Manager, the Accreditation Readiness Specialist, the Hospice Educator, and the Hospice Director.

Observed in Record Review. In 1 of 14 patient records reviewed, it was noted by the nurse surveyor that orders were not clear or complete. For HOSRRHV#1, there was an order to increase the registered nurse visit frequency, however the order did not include the reason that the frequency was being increased. Findings were discussed and verified with the RN Clinical Manager, Home Health and Hospice Clinical Practice Director, Hospice Program Director, and the Division Director of Accreditation and Regulatory.

Observed in Record Review. In 4 of 14 patient records reviewed, it was noted by the nurse surveyor that orders were unclear. For HOSRRHV#4, medication orders included standing orders for Morphine, plus an order for a prn Morphine. The prn order did not have any parameters to indicate when it should be taken. HOSRRNHV#3, Wound care orders did not identify where the wound dressing was to be applied and who was responsible for cleaning and dressing the wound. HOSRRNHV#5, medication orders were unclear as to when patient was to take Tylenol versus Morphine for pain. Additionally, patient was on a standing order for an Albuterol nebulizer treatment every six hours with prn treatments every two hours without specific indications on when to use the prn order along with a prn order for an Albuterol inhaler without specific use instructions. HOSRRNHV#10, the patient had orders for two pain medications, Acetaminophen and Oxycodone without clear indications on when to use which medication. Findings were discussed and verified with the RN Clinical Manager, Home Health and Hospice Clinical Practice Director, Hospice Program Director, and the Division Director of Accreditation and Regulatory.

Observed in Record Review. In 3 of 5 patient records reviewed, for patients with a hospice aide, it was noted by the nurse surveyor that the hospice aide care plans did not include the information necessary for the hospice aide to effectively care for the patients. For HOSRRHV#1, the patient had on heel protector boots, there were no instructions to the hospice aide as to what she should do in regards with the boots (remove or not remove) during the bath. For HOSRRNHV#3, there were no instructions to notify the nurse for a change in the patient’s condition. For HOSRRNHV#5, the patient was on continuous oxygen and there were no instructions as to what to do with the oxygen during the patient’s shower. Additionally, there were no instructions to notify the nurse for a change in the patient’s condition. Findings were discussed and verified with the RN Clinical Manager, Home Health and Hospice Clinical Practice Director, Hospice Program Director, and the Division Director of Accreditation and Regulatory.

Observed in Record Review. In 1 of 14 patient records reviewed, for active patients, it was noted by the nurse surveyor that the medication profile was inaccurate. For HOSRRNHV#3, there was an order to apply Medi Honey to a patient’s wound, however, it was not on the medication profile. Findings were discussed and verified with the RN Clinical Team Manager, the Accreditation Readiness.

Observed in Record Review. In 2 of 2 patient records reviewed, for live discharge, the organization failed to provide the patient's attending physician with a copy of the hospice discharge summary. In review of HosRRDC#1 and HosRRDC#2 there was no documentation that the discharge summary was provided to the patient's attending physician as required. This observation was reviewed with the Hospice Clinical Manager and Hospice program Director.

Observed in Building Tour. In 1 of 4 1-hr fire barrier door latching inspections, On building tour it was observed that 1 hour fire barrier cross corridor doors by room 1042 were equipped with required latching hardware but did not positive latch when tested. This area is protected throughout with fire suppression and smoke detection. This was confirmed by the Facility 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 Individual Tracer. In 5 of 5 patient records reviewed, During HOS RR Visits 1-5, the Hospice nurse surveyor noted that the goals were not measurable. The goals included phrases such as manage cardiopulmonary issues; manage Neurological systems; and manage medications as evidenced by steady symptom control without defining the symptoms. This was validated in a discussion with and observation by the Hospice Manager and Accreditation director.

Observed in Individual Tracer. During HOS HV 3, the Hospice nurse surveyor noted that the aide failed to change the bathwater after peri care and moving to the back. This was validated in a discussion with and observation by the Hospice Manager.

Observed in Tracer Activities. Upon review of three bereavement records, the care plans did not reflect the needs and goals of the bereaved, including specific, individualized interventions.

Observed in Tracer Activities. The organization had not defined competency criteria for all of the volunteers, as evidenced by the lack of competency for the volunteer grief counselor. This observation was confirmed with the volunteer coordinator and the clinical manager.

Based on clinical record review and staff interview the agency failed to notify the physician of a deep tissue injury for 1 of 1 patients with a wound (#1). Findings included: --- Patient #1 was admitted on 02/19/21 with diagnoses of lennox gastaut syndrome (severe form of seizures), and intractable w/o status epilepticus (seizures). The plan of care update for 12/11/22 to 02/08/23 had orders for skilled nursing 1 time a week for 1 week, and 1 time a week for 7 weeks. Review of the skilled nursing visit on 01/03/23 had documentation of current integumentary (skin) status- DTI (deep tissue injury) right hip. No documentation was in the record of the physician being notified of the wound. An interview with the agency director on 02/21/23 at 11:48 a.m. revealed ";cant find physician note for the date of 1/3/23 where he documented that he was notified of the wound or looked at it".