Every finding on record at Gentle Partners in Hospice LLC

Based on record review and interview, the Agency failed to revise and document the individualized plan as frequently as the patients condition required for 1 of 14 patients (Patient #1), whose records were reviewed. This failure can result in the patients of the agency not receiving the proper care by the agency staff due to lack of communication with the physician based on the patient's needs. --- Findings included: During a record review of Patient #1s plan of care, the plan of care revealed a start of care of 6/6/2023, with hospice services which included: skilled nursing twice weekly, home health aide three times weekly, chaplain services once monthly, and medical social worker services once monthly. Further review of the plan of care revealed the physician order of oxygen via a nasal cannula at 2-4 liters per minute continuously. During a review of Patient #1s nursing visit records, the agency began daily nursing visits on 6/26/2024 due to a change in Patients #1s condition. Further record review revealed a nursing visit on 6/27/2024 where RN B noted tat Patient #1s oxygen level was in the 70s and 80s (normal oxygen level is above 90). Further records reveal RN B repositioned Patient #1with pillows and increased Patient #1s oxygen to 5 liters per minute via nasal cannula to which the patient responded with increased blood oxygen into the 90s. Patient #1s condition was documented as stable the end of RN Bs visit. No documented evidence was noted that RN B called the physician to obtain orders for the increased oxygen to add to Patient #1 plan of care, or that RN B informed the physician of the what occurred during the visit. A joint interview was conducted with the Administrator and the Alternate Administrator on 10/9/024 at 1:30 p.m. and informed of the above findings. The Administrator stated she understood that RN B should have obtained a physicians order for the oxygen. The Alternate Administrator stated that she would begin to correct this issue with the staff. Record review of an Agency policy titled, "Administrative Policy Manual: ";Plan of Care Process," dated 9/1/2024, revealed in part, ";...VII. The Hospice .... will review revise, and document the individualized plan as frequently a the patients condition requires, but no less frequently then every 15 calendar days....1. the Hospice staff ill review the patient care at each visit to identify needs that may have changed to make adjustments to the plan of care. 2. All written changes to the plan of care will be incorporated to the patients medical record..."