Every finding on record at Community Health Center of Southeast Kansas Inc

It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including medical supplies and appliances necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review, interview, and observation. In 1 of 8 (12%) clinical records reviewed revealed that the agency did not ensure that all medical supplies and appliances were included in the plan of care. Clinical Record 2/Home Visit 2: During the home visit (HV2) observation with the registered nurse (Personnel Record 3) on 03/19/2024 it was observed that the patient had a bed alarm in place. The initial plan of care dated 11/10/2023-02/07/2024 and current plan of care dated 02/08/2024-04/07/2024 did not include a bed alarm in the patient supplies. In an interview on 03/20/2024, the Clinical Manager stated, "I did not realize that the bed alarm should be included since the patient had it prior to admission.".

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes physician orders. This standard was not met as evidenced by clinical record review, interview, and observation. In 3 of 8 (38%) clinical records reviewed revealed that the agency did not ensure that all physician's orders were included in the patient's records. Clinical Record 2: During the home visit (HV2) observation with the registered nurse (Personnel Record 3) on 03/19/2024 it was observed that the patient had a bed alarm in place. The clinical record lacked evidence of physician's orders for the bed alarm. Clinical Record 7: The nursing visit note dated 01/14/2024 read in part "patient has redness to the coccyx so an optifoam dressing was applied.". The record lacked physician's orders the optifoam dressing to the coccyx. Clinical Record 8: The clinical record included a Physician's orders dated 02/14/2024 for a wound on the left knee that read "Apply skin prep to the wound on left knee and place a pillow between the patient's knees.". The nursing visit note dated 02/16/2024 read in part "bordered gauze applied to patient's left knee". The record lacked specific physician's orders for a bordered gauze dressing to the left knee. In an interview on 03/20/2024, the Clinical Manager reviewed the records and stated, "I do not see any orders for the bed alarm or the wound care that was documented".