Every finding on record at Frederick Health

Observed in Record Review. In 1 of 16 patient records reviewed, It was noted by the hospice surveyor that the bereavement, spiritual and social work assessments were not completed in 5 calendar days after the election of Hospice program by the patient. These assessment were completed 8 days after the Hospice Benefit. This was confirmed by the leadership accompanying the surveyor .

Observed in Infection Control System Tracer. In 1 of 18 patient records reviewed, It was noted that one physician order was not clarified The order stated wound care X 1/ day . There was no specificity of the what the wound required, if the wound needed a cleansing agent a cleansing agent or a specific dressing.

Observed in Tracer Activities. Upon interview, the Hospice Director confirmed that the Hospice QAPI bereavement and volunteer services had several data collection monitors and outcomes completed. However, information was reviewed by the Hospice Leadership but had not been sent to Senior Leadership at the Hospital - the Governing Board

Observed in Tracer Activities. Upon interview, the Hospice clinical manager confirmed that the multi-patient use INR monitor found at the Hospice House was disinfected with a different product (but effective against BBP) than what the manufacturer instructions specify for use for disinfection of the device.

Observed in Individual Tracer. In 2 of 20 patient records reviewed, It was also noted by the Hospice Surveyor that the dose of the Trazadone given to the patient was 25mg. However, the medication profile listed that 50 mg of Trazadone was ordered, and there was no explanation of why the dose was changed. Also this patient wound note was not complete, there were no measurements listed for the two wounds the patient had one on the sacrum and one on the gluteal fold. Also the note says the wound was cleansed but there is no documented cleanser agent. And the there is a notation that the wound was dressed but no indication of a specific dressing for this wound. Observed in Tracer Visit. In 2 of 20 patient records reviewed, It was noted by the hospice surveyor that the medication reconciliation was inaccurate. The medication profiles in the medical record in the LTC facility and the medication profile in the hospice's record did not match. Hyoscyamine was on the LTC medication profile but not included in the hospice's medication list. The frequencies for acetaminophen were different for the two medication profiles. These issues were confirmed by the RN and leadership accompanying the surveyor

Observed in Individual Tracer. In 1 of 16 patient records reviewed, It was noted by the hospice surveyor that there was no hospice plan of care provided to the contracted Skilled Nursing Facility for this patient. This was confirmed by the leadership accompanying the surveyor.