Every finding on record at Garnet Hospice Care Inc

Upon patient record review, 3 of 5 (Patients #2, 3, 5) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patients 2, 3, 5: The initial comprehensive assessment and physician's CTI indicate that the patient is incontinent of urine. The IPOC indicates that the patient is supplied with diapers due to incontinence. However, there has not been a care plan initiated or developed related to the patient's GU status or risk for skin breakdown. (corrected onsite)

Upon patient client record review, 1 of 5 (Patient #1) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient 1: In the Sleep/Rest section of the comprehensive initial assessment, the SN indicates that the patient uses sleep aids nightly and sleeps only 4-6 hours per night. A review of the patient's medication list confirms that the patient does not utilize any sleep aids, nor does she use any nonpharmacologic methods to assist with sleep. (corrected onsite)

Upon patient record review, 5 of 5 records (Patient #1,#2,#3,#4,#5) did not have evidence that the patient received information about the scope of services that the hospice will provide and specific limitations on those services. Patients 1,2,3,4,5: The patients did not receive full information about the scope of services that the hospice will provide and specific limitations on those services. The medical record contains a Patient Notification of Non-covered items, services and drugs with no evidence of listing the medications not being covered by the hospice.

Upon patient record review, 5 of 5 records (Patient #1,#2,#3,#4,#5) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death. Patients 1,2,3,4,5: The comprehensive assessment does not show evidence of taking in to consideration the imminence of death.

Upon patient record review, 3 of 5 records (Patient #1,#3,#4) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. Patient 1: The medication profile contains Midodrine. In the drug class section it lists the medication is for hypothyroidism. The plan of care has the midodrine class for hypotension. Corrected on site. Patient 3: The medication profile contains lisinopril 20mg, 1 tablet twice daily with no evidence of route. Corrected on site. Patient 4: The medication profile contains loratadine 10mg 1 tab by mouth daily. The plan of care order is for loratadine 10mg by mouth daily prn.

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536

Upon patient record review, 1 of 5 (Patient #4) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient 4: The comprehensive assessment identifies wound care provided to bilateral lower legs for 4+pitting edema and blisters. The nursing care plan contains alteration in skin integrity related to edema and blisters on bilateral lower legs. There is no evidence of wound care or treatment interventions in the care plan. There were two follow up visits made by skilled nurse on 12-8-21 and 12-13-21 with no evidence of the nurse assessing the legs for edema. There was no documentation or education provided to patient/family at either visit for care for the patients legs. There was no evidence of the care plan being updated that goals were met for the patient's legs.

Upon patient record review, 3 of 5 (Patient #1, 4, 5) did not have evidence that each patient and family received education and training provided as appropriate to their responsibilities for the care and services identified in the plan of care. Patient 1: The nursing care plan contains alteration in nutrition related to loss of appetite. Goal is patient will maintain good nutrition and weight with no weight loss of more than 1-2 pounds per week. There is no evidence of an nursing intervention or teaching of patient or family to assess weight in the care plan. Patient 4: The plan of care contains an order to hold metoprolol if blood pressure less than 100/60. There is no evidence of educating patient or family to assess blood pressure in care plan. Patient 5: The plan of care contains orders for oxygen as needed for SOB 2 liters per minute for Ox sat less than 94%, 3 liters per minute for O2 sat less than 92%, 4 liters per minute for O2 sat less than 90%, 5 liters per minute for O2 sat less than 88%. There is no evidence in the nursing care plan to educate patient/family on assessing O2 saturation to determine Oxygen level needs.

Upon patient record review, 1 of 5 records (Patient #3) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 3: The plan of care contains lisinopril 20mg, 1 tablet twice daily with no evidence of route. Corrected on site.

Upon client record review, 1 of 5 records (Patient #4) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 4: The comprehensive assessment contains documentation by the RN that a soiled dressing was removed, cleansed both legs with soap and water, pat dry, applied bacitracin, covered with ABD, wrapped with kerlix gauze and wrapped with Ace wrap. There is no evidence of an order, standing order or policy that covers this wound care and medication to be provided.

Upon patient client record review, 4 of 5 records (Patient #1,#2,#4,#5) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient 1: The MSW evaluation, on page 1 of 2 is dated 3-14-22, page 2 of 2 is signed and dated 3-13-22. MSW said it was a typographical error. Corrected on site. MSW's bereavement assessment on page 1 of 2 is dated 2-26-22, page 2 of 2 is signed and dated 3-13-22. The MSW said it was a typographical error. Corrected on site. Patient 2: The MSW's bereavement assessment, page 1 of 2 is dated 3-1-22. Page 2 of 2 is signed and dated 3-15-22. The MSW stated it was a typographical error. Corrected on site. Patient 4: The medication profile contains Tylenol 325mg two tablets PO every 4 hours as needed for pain/fever, NTE 3000mg daily. No evidence that NTE is an approved abbreviation. Patient 5: The care plan contains an intervention of "Instruct patient/caregiver on medications as ordered and assess proper use and effectiveness of medication (fentanyl patch)". The plan of care does not contain an order for a fentanyl patch.