Every finding on record at Community Hospital of the Monterey Peninsula

Observed in Record Review. On 1 of 3 bereaved records reviewed, the organization did not complete and initial bereavement risk. Agency policy is that an initial will be done within 5 days of admission. On RRBR #2, it was noted that an initial bereavement assessment was not completed and the only risk assessment done was 3 months after the patient passed away. This finding was reviewed with Hospice leaders.

Observed in Record Review. In 5 of 14 active patient records reviewed, the organization failed to update the plan of care. On RRHV #1, it was noted that there has been changes to the patient’s wounds but the plan of care had not been updated to reflect the progress of the wounds and changes to the wound orders. On RRHV #4, it was noted that the patient has been assessed itching and increased confusion and the care plan has not been updated to reflect these changes based on assessment. On RRNHV #2, it was noted that patients had been started on nightly Ativan dose due to patient’s anxiety but those changes in patient condition were not reflected on the plan of care. On RRNHV #4, it was noted that goals had not been updated to reflect changes, patient had symptoms of cough and congestion that was being treated with cough syrup that were not on the plan of care. On RRNHV #8, it was noted that teaching goals for safe environment had not been updated since admission 3 months ago. This finding was reviewed with Hospice Leadership.

Observed in Patient Home. In 1 of 4 home visits conducted, the organization did not provide care or treatment according to the patient's individualized plan of care. On RRHV #1, it was observed during the home visit that the nurse did not follow the orders for wound care and applied Calcium Alginate to the wound and it was not ordered on the plan of care. This finding was reviewed with Hospice Leadership.

Observed in Data Session. The organizations quality assessment and performance improvement program (QAPI) did not include indicators that are related to improved palliative outcomes. This finding was discussed with the QAPI leaders present at the time of the survey.

Observed in Record Review. In 3 out of 14 active records reviewed, the organization failed to ensure the medical record contained information to accurately reflect the patient's care, treatment, and services. Agency policy is that medications will be updated each visit as needed to reflect current medications and discontinue medications no longer ordered. During the home observation for RRHV#2 the medication list in the home had not been updated to reflect new medications that had been added since admission a month ago. In addition, the home list had written that the patient may take melatonin as needed but the medical record did not reflect Melatonin. On interview with the paid caregiver, she stated the night caregiver would give Melatonin and showed me the bottle that was with patient's other medications. During RRHV#4 there was no evidence in the home of the medication list and on interview with the daughter she stated they talk medications but there was no list in her book, and she didn’t remember one given. On RRNHV #2, it was noted in nursing notes that the physician gave an order for nightly Ativan, but this had not been updated on the medication profile. These observations were reviewed with the hospice leadership.

Observed in Tracer Activities. upon review of the organization's admission packet, it was noted that the organization failed to ensure that the hospice inform and distribute written information to the patient concerning its policies on advance directives, including a description of applicable state law. When reviewing with the Director and Assistant Director it was noted that the hospice has a packet of information that can be distributed to patient on advance directives but is not included in the admission packet and patient handbook for all patients.

Observed in Record Review. In 10 of 13 patient records reviewed, the organization failed to ensure the hospice interdisciplinary group complete the comprehensive assessment no later than 5 calendar days after the election of hospice care. For example: in review of HV#2 and RR#4 the MSW and Chaplain initial assessment was not completed until the month after admission. Phone calls were documented to the patient yet the assessment was not complete until the following month. In HV#3 the MSW assessment was not completed until day 8. In RR#5 the MSW and Chaplain were unable to access the facility the week of admission, however the Chaplain was able to access and complete the assessment on day 12 yet the MSW assessment was not completed until 56 days after admission. Similar observations of the MSW and/or Chaplain assessment not occurring within the first 5 days after admission were noted in HV#1, RR#7, RR#8, RR#9, RR#10, and RR#11 These observations were reviewed with the Director and the Assistant Director.

Observed in Record Review. In 3 of 13 patient records reviewed, the organization failed to define the assessment and reassessment criteria as related to the severity of symptoms. For example: upon review of RR#7, RR#8 and RR#11 the patient's had active pain upon admission, yet the organization policy for comprehensive assessment related to pain noted assessment of pain including the intensity, quality, character, frequency, location, and duration as appropriate to the patient's age and clinical condition, but the policy failed to specify assessment of the patient pain goal or tolerable level of pain to assist in achieving patient comfort goals. This observation was reviewed with the Assistant Director.

Observed in Record Review. In 13 of 13 patient records reviewed, the organization failed to ensure that the written plan of care reflect patient and family goals and interventions based on the problems identified in the initial, comprehensive and updated comprehensive assessments. Upon review of the clinical records in was noted that the goals established do not reflect the problems identified in the assessments. For example: in HV#1 and HV#2 the patient's care plan related to skin integrity goal noted demonstrate knowledge on how to do wound care yet the goals does not address the outcomes desired as a result of the treatments performed. IN HV#3 the goal for bowel elimination stated will express strategies for successful bowel elimination yet the intervention of administer enema and suppository do not address measures to achieve the set goal, nor does the goal address the desired outcomes for bowel elimination. Goals that did not address the patient and family desired outcomes from problems identified in the comprehensive assessments were noted throughout the records reviewed as most goals established were such as patient will express strategies or patient will verbalize understanding of. These observations were reviewed with the Director and Assistant Director. Observed in Record Review. In 6 of 13 patient records reviewed, the organization did not ensure the hospice plan of care reflected the patient and family goals and interventions based on the problems identified in the comprehensive assessments. For example: In review of HV#2 the patient record noted the patient was diabetic taking an oral glycemic agent yet this was not reflected on the care plan. In RR#5 and RR#6 the patient was treated for a suspected UTI with antibiotics yet there were no goals and interventions related to urinary system on the care plan. In RR#6 the documentation noted the patient with multiple medication changes related to over sedation, however the status was not reflected on the plan of care as there were no goals and interventions to address the issue. In RR#7 and RR#11 the patient was noted to have pain as an active problem yet there were no goals and interventions to address pain. In RR#10 the SN documentation noted issues with edema and constipation yet there were no goals and interventions to address the issues. These observations were reviewed with the Director and Assistant Director.

Observed in Patient Home. In 3 of 13 patient records reviewed, the organization failed to ensure that the plan of care accurately reflected all drugs and treatments necessary to meet the needs of the patient. For example: during the medication reconciliation for HV#1 there were noted discrepancies as the medication profile for the hospice stated citalopram 20mg tabs, however the pill pack and instructions in the patient home noted citalopram 10 mg tabs. The simvastatin on the medication profile was 40 mg take 0.5 tab, yet the pill pack in the patient home was 40 mg take 1 tab. Example 2: On review of RR#7 the patient was on continuous Bipap but the order in the record only states continuous Bipap and does not indicate the Bipap settings. Further the order for O2 indicated 2-5 liters per nasal cannula titrate as need, however there were no parameters or instructions to indicate when and how to adjust the liter flow. Example 3: in RR#8 the patient had orders for two different strengths of morphine liquid 20mg/1ml and 10mg/5ml, but no indication on when to use the 10mg/5 ml. In RR#7 the medication profile had lorazepam 0.5 mg tab and 1mg tab PRN with parameters for mild, moderate, and severe anxiety, but no indication on which order to use first. These observations were reviewed with the Director, Assistant Director, and the RN.

Observed in Record Review. In 13 of 13 patient records reviewed, the organization failed to ensure that the plan of care was revised to include information from the patient's updated comprehensive assessment and note the patient's progress toward outcomes and goals. For example: upon review of HV#1 the goal for wound care established stated demonstrate knowledge on how to do wound care. The goal was established on admission and remains in place with no documented progress toward the goal currently 9 months since admission. In RR#4 the goal specified that the pt/cg would verbalize 2 methods of UTI prevention and signs and symptoms of UTI by next visit. The goal was established on admit and remains unresolved without noted progress toward the goal currently nearly 8 weeks later. Similar lack of progress toward goals can be noted throughout the care plan for all records reviewed. These observations were reviewed with the Director and Assistant Director.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization failed to implement the infection prevention and control activities it had planned per policy. For example: during the home observation for HV#2 the RN was preforming wound care and failed to perform hand hygiene and change gloves after removing the soiled dressing and cleansing the wound, before replacing the new clean dressing as required by hand hygiene policy. This observation was reviewed with the Director and Assistant Director.

Observed in Record Review. In 4 of 11 patient records reviewed, where aide services were provided, the organization failed to ensure that the registered nurse provided written specific patient care instructions for the hospice aide. For example: upon review of HV#1, HV#2, and RR#8 the aide assignment instructed the aide to apply/remove simple dressings however the assignment did not specify what type or location of dressing, nor instructions on under what circumstances to apply or remove the dressing. Additionally HV#1, and HV#2 had wounds and there were no specific instructions for the aide as to how to handle the dressings during bathing. In HV#2 there was an assigned task of apply OTC topicals yet the assignment did not specify what type of OTC topicals and where to apply. In RR#10 the aide assignment noted both a shower and a bed bath yet there was no indication when to utilize what type of bath. These observations were reviewed with the Director and Assistant Director.

Observed in Record Review. In 1 of 13 patient records reviewed, the record did not include all information to reflect the patient's care, treatment, or services. For example: upon review of RR#12 there was an 18 day gap noted in RN visits to the patient. Upon further review and discussion with the Assistant Director it was documented that the patient visit was completed as scheduled however the documentation of the visit was unavailable for review in the electronic record.