Every finding on record at Community Hospital Inc.

Based on Medical Record (MR), agency policy and procedure, and interviews, it was determed the agency failed to ensure all identified risk factors were included in the plan of care. This deficient practice affected one of fourteen MRs reviewed including MR # 6 and had the potential to negatively affect all patients admitted to this hospice. Findings include: Agency Policy: Initial and Comprehensive Assessment Policy Number: None Date Revised: 5/4/23 ...The Comprehensive Assessment is ... a thorough evaluation of the patient's physical, psychosocial, emotional and spiritual status... The Initial Assessment includes an evaluation of the patient/family's immediate physical, spiritual and emotional needs... The Comprehensive Assessment includes the evaluation of: ...Complications and risk factors that affect care planning... Agency Policy: Suicide Risk Assessment and Intervention Policy Number: None Date Revised: 8/1/23 The Hospice IDT (Interdisciplanary Team) will take appropriate action to identify and reduce the risk of suicide for patients, families and caregivers in the hospice program. Patients and caregivers are initially screened for anticipatory grief indicators, which includes the risk of self harm, by the social worker as part of the Initial/Comprehensive Assessment... Warning Signs - observable or behavioral indicators that someone is considering suicide. Warning signs are more serious than risk factors and suggest that someone may be at acute risk or actively considering death by suicide... --- 1. MR # 6 was admitted on 4/3/24 with a terminal diagnosis of Malignant Neoplasm of Base of Tongue. Review of the Skilled Nurse (SN) Assessment dated 4/3/24 revealed the SN documented MR # 6's behavior was abnormal with a flat affect, withdrawn and appeared depressed. Review of the POC dated 4/3/24 revealed no documentation the identified problem of depression was addressed with a plan of care. Review of the IDT Meetings note dated 4/5/24 revealed no documentation the IDT discussed or addressed MR # 6's depression and included depression in the plan of care. Review of the SN Regular Visit note dated 4/8/24 revealed the nurse documented MR # 6 appeared to be depressed, and the caregiver reported MR # 6 just wanted to be left alone. Review of the IDT Meetings note dated 4/19/24 revealed no documentation the IDT updated the plan of care to include depression. An interview was conducted on 5/2/24 at 2:44 PM with Employee Identifier (EI) # 1, Director, who confirmed the staff had identified MR # 6 was depressed and failed to discuss the findings with the IDT and failed to add depression to the plan of care.

Based on Medical Record (MR) review, Interdisciplinary Team (IDT) sign-in sheets, IDT Meeting notes, agency policy, and interviews, it was determined the agency failed to ensure all core members of the IDT participated in the Plan of Care (POC) for each patient. This deficient practice affected six of fourteen MR reviewed including Home Visit (HV) # 1, MR # 1, MR # 9, MR # 8, MR # 3, and MR # 6, and had the potential to negatively affect all patients admitted to this hospice. Findings include: Agency Policy: Interdisciplinary Team Agency Policy Number: None Revised Date: 7/22/21 Policy The hospice interdisciplinary team is a group of trained hospice staff persons that...work together to meet the medical, psychosocial, emotion and spiritual needs of hospice patients/families as they face living and dying with a terminal illness... Members of the interdisciplinary team include: The hospice Medical Director and or physician designee. RN (Registered Nurse) Case Manager... Medical Social Worker Family and Spiritual Care Coordinator (Bereavement support). Chaplain... Responsibilities of the interdisciplinary team include: Participation in the development and evaluation of the POC for each patient... Participation in regularly scheduled team meetings where each patient's POC is reviewed, discussed and updated... --- Review of the IDT Meeting notes for HV # 1, MR # 1, MR # 9, MR # 8, MR # 3, and MR # 6 dated 4/20/23, 10/20/23, 2/9/24, 2/23/24, and 4/5/24 revealed no documentation all core members, including the Chaplain and Social Worker, were present at each meeting and participated in the planning of care for each patient. An interview was conducted on 5/2/24 at 2:33 PM with Employee Identifier (EI) # 1, Director, who confirmed all core members were not present at each IDT meeting.