Every finding on record at Carilion Franklin Memorial Hospital

Observed in Record Review. In 3 of 14 active Hospice patient records reviewed, the organization failed to assess potential medication related problems. On HSRRHV #4, the plan of care had duplicate PRN medications of Milk of Magnesia and Dulcolax and did not address how to handle the duplicate therapy. On review of HSRRNHV #2, the plan of care had duplicate PRN constipation medications of Senna-Docusate and Bisacodyl with no indication when to use the duplicate medications. ON HSRRNHV #5, the plan of care had duplicate PRN constipation medications of senna-Docusate, Milk of Magnesia and Dulcolax supp with no indication when to use the duplicate medications.This finding was reviewed with agency leaders.

Observed in Record Review. In 7 of 14 active Hospice patient records reviewed, the plan of care had not updated and individualized the plan of care to reflect the patient's condition. On HSRRHV #1, the patient had goals for teaching family methods to prevent weight loss since admit 5 months ago on a patient in the declining stages of the disease process that is expected that weight loss will occur. In addition, care plan not updated to reflect care and teaching to the family/caregiver how to care for wound in a home where the caregivers were actively caring for the wound for several months. On HSRRHV #2, the care plan had not been updated to reflect the current condition of the patient with teaching goals for management of dysphagia, aspiration management that were on the care plan for months, but caregivers were competent with the cares. On HSRRHV #4, the plan of care had not been updated to reflect the care needs of the patient including teaching of medications that had not been on the care plan since admission over a year ago. In addition, on review of HSRRNHV #1, HSRRNHV #3, HSRRNHV #7 and HSRRNHV #9 the care plan had not had goals updated on the plan of care to reflect the changes in patient with examples of patient on oxygen with no goals for the oxygen, newly started medications with no goals to reflect and teaching remaining on the care plan when education was provided months ago. This finding was reviewed and validated with agency leaders.

Observed in Patient Home. In 1 of 1 home visits conducted with a Hospice CNA, the aide failed to provide care and treatment according to the aide plan of care. In HSRRHV #4, it was observed that plan of care was to provide oral care and to change bed linens every visit and this was not done during the visit. In addition, the aide applied lotion that was not ordered on the care plan. This was reviewed and validated with agency leaders.

Observed in Patient Home. In 1 of 4 Hospice home visits conducted, the patient's individualized emergency management plan was not present in the home. During HSRRHV #3, it was noted that their was not an individualized emergency plan for the patient in the home. This finding was discussed and validated with agency leadership.

Observed in Tracer Activities. During contract review, the surveyor noted that the contract for pharmacy services did not include all of the required elements. This was evidenced by the lack of a stipulation that the contracted pharmacy would complete a criminal background check on contracted employees who provide direct patient care of have access to patient records. This observation was discussed with the hospice director at the time of discovery.

Observed in Record Review. In 7 of 13 patient records reviewed, the organization did not conduct a patient-specific comprehensive assessment. In HSP HV #1, the surveyor noted the nurse identified the patient had a stage 2 pressure ulcer on admission; however, there was no reassessment on the wound since admission. This was confirmed with the hospice supervisor. In HSP HV #2, the surveyor noted the patient-specific comprehensive assessment did not include a spiritual assessment by a chaplain or a psychosocial assessment by a medical socials worker. There was no documentation of declination of service. This was confirmed with the hospice supervisor. In HSP HV #3, the surveyor noted there was a secondary diagnosis of stage 2 pressure ulcer; however, there was no assessment of the ulcer on admission except the location and no reassessment of the wound since start of care. This was confirmed with the hospice supervisor. In HSP RR #1, the surveyor noted the nurse failed to reassess the rash to the forearm on subsequent visits. This was confirmed with the hospice supervisor. In HSP RR #2, the surveyor noted the nurse documented the second month of service the patient developed a burn/blister on middle finger of left hand, left wound open to air; however, there was no reassessment of the wound performed. In HSP RR #6, the surveyor noted the patient was taking metformin; however, the nurse failed to perform an endocrine assessment as part of the comprehensive assessment. This was confirmed with the hospice supervisor. In HSP RR #7, the surveyor noted the daughter requested chaplain services for the patient; however, the skilled nursing facility had COVID restrictions which prevented visit; however, there was no documentation of attempt to contact by phone or notify daughter that unable to meet the need due to COVID restrictions. This was confirmed with the hospice supervisor.

Observed in Record Review. In 3 of 13 patient records reviewed, the assessment did not include the severity of symptoms. In HSP RR #2, the surveyor noted the nurse did not assess the severity of the patient's symptoms for dyspnea, seizures, depression or anxiety. This was confirmed with the hospice supervisor. In HSP RR #4, the surveyor noted the nurse did not assess the severity of the patient's symptoms for nausea and vomiting. This was confirmed with the hospice supervisor. In HSP RR #6, the surveyor noted the nurse did not assess the severity of the patient's symptoms for nausea, vomiting and anxiety. This was confirmed with the hospice supervisor.

Observed in Record Review. In 6 of 13 patient records reviewed, an initial bereavement assessment was not performed as part of the initial comprehensive assessment. In HSP RR #1, HSP RR #2, HSP RR #3, HSP RR #8, HSP HV #1 and HSP HV #2, the surveyor noted the hospice did not perform a bereavement risk assessment as part of the comprehensive assessment on admission. This was confirmed with the Hospice Supervisor.

Observed in Record Review. In 5 of 13 patient records reviewed, the written plan of care was not based on the patient's goals and the time frames, settings and services required to meet those goals. In HSP RR #5, HSP HV #1 and HSP HV #2, the surveyor noted the skin breakdown goal on the plan of care did not include a time frame. This was confirmed with the Hospice Supervisor. In HSP HV #2, the surveyor noted the plan of care included the following non-measurable spiritual goal: Patient will receive identified spiritual or religious resources by the chaplain resources are prayer, scripture reading, and singing. This was confirmed with the hospice supervisor. In HSP RR #1, the surveyor noted the plan of care included the following non-measurable goal: patient/caregiver will demonstrate/report reduction in anxiety to a manageable level during dyspnea episode by 2 visits. This was confirmed with the hospice supervisor. In HSP RR #5, the surveyor noted the plan of care included the following non-measurable goal without a timeframe: Husband and step-daughter Sandra will address psychosocial concerns and work to alleviate feelings of stress, depression, anxiety and negativity. This was confirmed with the hospice supervisor. In HSP RR #4, the surveyor noted the plan of care included an intervention to address need for community resources; however, there was no goal identified. This was confirmed with the hospice supervisor.

Observed in Record Review. In 11 of 13 patient records reviewed, the plan of care did not include interventions to manage pain and symptoms. In HSP HV #1, the surveyor noted the patient was identified as having edema and constipation; however, the plan of care did not include interventions to address these identified needs. In addition, the patient was identified as being at risk for falls; however, the plan of care did not include interventions to address this risk. In HSP HV #2, the surveyor noted the patient was identified as having shortness of breath and cough; however, the plan of care did not include interventions to address these identified needs. This was confirmed with the hospice supervisor. In HSP HV #3, the surveyor noted the patient was identified as being at risk for falls; however, the plan of care did not include interventions to address this identified risk. In addition, the plan of care was not updated to resolve the hospice orientation interventions and the plan of care included the same goals for communication and maintaining independence; however, still did not have interventions at the time of recertification. Also, at the time of recertification the patient was identified as having constipation; however, the plan of care was not revised to included interventions for this identified need. This was confirmed with the hospice supervisor. In HSP RR #1, the surveyor noted the patient was identified at risk for falls and had edema; however, the plan of care did not include interventions to address these identified needs. This was confirmed with the hospice supervisor. In HSP RR #2, the surveyor noted the plan of care included goals for depression, pain, and fall risk; however, the plan of care did not include interventions to reach these goals except assess depression, pain and safety. Also, the patient was identified as having seizures; however, the plan of care did not include interventions to address this identified need. This was confirmed with the hospice supervisor. In HSP RR #3, the surveyor noted the plan of care included goals for fall risk and pain; however, the plan of care did not include interventions to reach these goals except assess safety and pain. This was confirmed with the hospice supervisor. In HSP RR #4, the surveyor noted the patient was identified as having nausea/vomiting and edema on admission; however, the plan of care did not include interventions to address this identified need. This was confirmed with the hospice supervisor. In HSP RR #5, the surveyor noted the plan of care did not include interventions for the patient's terminal diagnosis of dysphagia. In addition, the patient was identified as having constipation; however, the plan of care did not include interventions to address this identified need. This was confirmed with the hospice supervisor. In HSP RR #6, the surveyor noted the patient was identified as having nausea/vomiting, diarrhea, ascites and anxiety; however, the plan of care did not include interventions to address these identified needs. This was confirmed with hospice supervisor. In HSP RR #7, the surveyor noted the patient was identified at risk for falls and skin breakdown; however, the plan of care did not include interventions to address these risks. This was confirmed with the hospice supervisor. In HSP RR #8, the surveyor noted the patient was identified at risk for falls; however, the plan of care did not include interventions to address this risk. This was confirmed with the hospice supervisor. In HSP RR #9, the surveyor noted the patient was identified as having pain; however, the plan of care did not include interventions to address this identified need except to assess pain. This was confirmed with the hospice supervisor.

Observed in Record Review. In 7 of 13 patient records reviewed, the plan of care did not include a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs. In HSP HV #1, HSP RR #1, HSP RR #2 and HSP RR #3, the surveyor noted the plan of care included a medical social worker visit frequency of one visit as needed; however, there was no indication given for the prn visit. This was confirmed with the hospice supervisor. In HSP HV #2, the surveyor noted the plan of care indicated a skilled nursing visit frequency that included 1 prn visit for NCD letter delivery; however, this was not an as needed visit but a planned visit as the patient requested the addendum of non-covered items. This was confirmed with the hospice supervisor. In HSP RR #4, the surveyor noted the medical social worker visit frequency included 2 prn visits with an indication deliver lockbox and install the life line; however, these were planned interventions that could have been met with a planned visit frequency. This was confirmed with the hospice supervisor. In HSP RR #5, the surveyor noted the plan of care included a skilled nursing visit frequency of one time per week with two prn visits; however, the first three week of service 2 additional visits were made each week either extra visits or prn visits as the patient was agitated and becoming physical with husband with frequent medication changed. The interdisciplinary group did not increase the skilled nursing visit frequency to meet the patient and family needs or consider increasing the medical social worker visit frequency. This was confirmed with the hospice supervisor.

Observed in Record Review. In 9 of 13 patient records reviewed, the plan of care did not include all drugs and treatment necessary to meet the needs of the patient. In HSP HV #1, the surveyor noted the patient was identified as having a stage 2 pressure ulcer on the admission assessment; however, the plan of care did not include interventions to address this identified need. This was confirmed with the hospice supervisor. In HSP HV #2, the surveyor noted the patient was identified as having a urostomy on admission; however, the plan of care did not include interventions to address this identified need. This was confirmed with the hospice supervisor. In HSP HV #3, the surveyor noted the plan of care indicated aleve 220 mg twice daily with meals; however, the actual frequency was twice daily prn per the daughter. In addition, the plan of care included the goals patient to remain as independent as possible and remains safe in their environment' and patient will effectively communicate symptoms needs and concerns;; however, there were no interventions identified to reach these goals. In addition, the patient was identified as having a stage 2 pressure ulcer to the sacral area; however, the plan of care did not include interventions to address this identified need. Also, the plan of care included massage therapy; however, the intervention did not include the location, frequency, or duration of massage. This was confirmed with the hospice supervisor. In HSP RR #1, the surveyor noted the plan of care medication order for Nystatin indicated twice daily as needed to sacral wound; however, there was no indication given for the prn order. This was confirmed with the hospice supervisor. In HSP RR #2, the surveyor noted the plan of care included medication orders for an albuterol inhaler and an albuterol nebulizer prn for shortness of breath; however, the order did not include specific instructions as to which device to use when. In addition, the plan of care included a morphine range order of 0.25 ml - 1 ml prn pain; however, the order did not include specific instructions as when to take what dose. Also, the patient developed a skin tear to th eleft wrist; however, the plan of care was not updated to address this identified need. This was confirmed with the hospice supervisor. In HSP RR #3, the surveyor noted the nurse applied calazime cream and mepilex to the left gluteus stage 3 pressure ulcer; however, there was no order obtained for the calazime and mepilex. This was confirmed with the hospice supervisor. In HSP RR #5, the surveyor noted the plan of care included an order for silvadene apply topical; however, the order did not specify the location of application. This was confirmed with the hospice supervisor. In HSP RR #7, the surveyor noted the facility inserted a foley catheter and the plan of care was not updated to include goals and interventions to address this identified need. This was confirmed with the hospice supervisor. In HSP RR #9, the surveyor noted the skilled nurse inserted a foley catheter; however, the plan of care was not updated to include goals and interventions to address this identified need. This was confirmed with the hospice supervisor.

Observed in Record Review. In 2 of 13 patient records reviewed, the organization did not ensure that the care and services were provided in accordance with the plan of care. In HSP HV #1, the surveyor noted the plan of care included interventions to provide instruction on prevention of skin breakdown; however, there was no documentation of instruction on prevention of skin breakdown provided since the start of care eight weeks ago. This was confirmed with the hospice supervisor. In HSP RR #7, the surveyor noted the plan of care included an order to assess the wound every visit. The patient resided in a skilled nursing facility and the facility nurse was performing wound care. The wound measurements did not change from week 1 through week 5 in the documentation which indicated 5 cm x 3 cm; however, on week 5 the wound measurements dropped to 2.5 cm x 0.5 cm and then three weeks later the wound documentation indicated healed. The wound assessment indicated the dressing was dry and intact on a 2 visit notes. There was no documentation of the periwound, wound bed documented. This was confirmed with the hospice supervisor.

Observed in Record Review. In 3 of 13 patient records reviewed, all disciplines that provided care, treatment or services to the patient did not collaborate in the care of the patient and coordinate their efforts to support the goals outlined in the plan of care. In HSP RR #1, the surveyor noted the patient developed a rash to the forearm; however, there was no documentation the physician was notified of the rash. This was confirmed with the hospice supervisor. In HSP RR #3, the surveyor noted the patient developed an unstageable pressure ulcer to the left foot and a skin tear on the second skilled nursing visit and a right upper arm skin tear one month ago; however, there was no documentation of MD notification. This was confirmed with the hospice supervisor. In HSP RR #6, the surveyor noted the patient's blood pressure on two skilled nursing sequential visits were 88/65 and 80/45; however, there was no documentation the physician was notified. This was confirmed with the hospice supervisor.

Observed in Individual Tracer. In 2 of 3 home visits conducted, the organization did not use standard precautions to reduce the risk of infection. In HSP HV #1, the surveyor noted the aide cleaned the perineal area and then with the same gloved hands applied lotion. In addition, the aide cleaned the rectal area and with the same gloved hands put on the patient's shirt. This was discussed with the Hospice Manager. In HSP HV #2, the surveyor noted the skilled nurse doffed gloves after touching the patient and then donned new gloves without performing hand hygiene. This was discussed with the Hospice Manager.

Observed in Record Review. In 6 of 13 patient records reviewed, the registered nurse did not prepare written patient care instructions for the hospice aide. In HSP HV #1, the surveyor noted the aide plan of care initially indicated personal care of a bed bath to be provided until the third week of service, when the aide plan of care no longer indicated personal care. In the eighth week of service, yesterday, the surveyor noted that personal care was added again to the plan of care to include shower. In discussion with the hospice aide during the home visit, the patient had been receiving a shower. This was confirmed with the hospice supervisor. In HSP HV #2, the surveyor noted the aide plan of care did not include fall precautions or instructions related to the oxygen. This was confirmed with the hospice supervisor. In HSP RR #3, the surveyor noted the nurse documented the aide was applying miracle cream to the patient's pressure ulcer on buttocks; however, this was not included in the aide plan of care. In addition, the aide plan of care did not include fall precautions. This was confirmed with the hospice supervisor. In HSP RR #5, the surveyor noted the aide plan of care did not include fall precautions or aspiration precautions. This was confirmed with the hospice supervisor. In HSP RR #7 and HSP RR #8, the surveyor the aide plan of care did not include fall precautions. This was confirmed with the hospice supervisor.

Observed in Record Review. In 1 of 13 patient records reviewed, the hospice aide did not provide services that were in the plan of care. In HSP RR #5, the surveyor noted the aide plan of care indicated shower; however, the aide performed a bed bath. There was no documentation of RN notification. This was confirmed with the hospice supervisor.

Observed in Tracer Activities. The governing body/leadership did not ensure that the following Conditions of Participation were met as determined through observations, documentation, and staff interviews:  - §418.100 and 418.54, 418.56.

Observed in Record Review. In 4 of 13 patient records reviewed, the patient record did not contain all clinical information. In HSP HV #1, the surveyor noted the hospice aide failed to document the personal care provided for six weeks. This was confirmed with the hospice supervisor. In HSP RR #1, the surveyor noted the interdisciplinary group meeting discussion was not documented from 9 days ago. In addition, the surveyor noted the nurse failed to document the results of the wound assessment on the second visit. In addition, the wound assessment documentation did not specify the location of the pressure ulcer and only indicated other. This was confirmed with the hospice supervisor. In HSP RR #2, the surveyor noted the skilled nurse indicated they assessed for depression at last week's visit as required by the plan of care; however, the nurse failed to document the results of the assessment. This was confirmed with the hospice supervisor. In HSP RR #4, the surveyor noted there was an order to discontinue Ativan 10 days ago and to start Xanax; however, on the medication profile the Ativan was not discontinued. This was confirmed with the hospice supervisor.

Observed in Record Review. In 1 of 2 discharge records reviewed where the patient was discharged alive, the hospice did not create a discharge summary. In HSP RR #7, the surveyor noted the hospice patient was discharged due to extended prognosis; however, the hospice did not create a discharge summary to include a summary of the patient's stay, including treatments, symptoms and pain management, the patient's current plan of care and latest physician orders, and other documentation that would assist in post discharge continuity of care. This was confirmed with the hospice supervisor.