Every finding on record at Golden Gate Hospice Inc

Upon patient record review, 4 of 5 (Patient #1, 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. Patient 1: 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. The SN's initial assessment includes a Braden scale indicating that the patient is occasionally moist. 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) Patient 2: 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. The SN's initial assessment includes a Braden scale indicating that the patient is occasionally moist. It also indicates the patient is wheelchair bound and requires assistance with transfers. 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) Patient 3: The initial comprehensive assessment and physician's CTI indicate that the patient is incontinent of bladder and bowel. The IPOC indicates that the patient is supplied with diapers due to incontinence. The SN's initial assessment includes a Braden scale indicating that the patient is continuously moist. It also indicates the patient is quadriplegic, bedbound, and is fully dependent for repositioning. However, there has not been a care plan initiated or developed related to the patient's incontinence status or risk for skin breakdown. (corrected onsite) Patient 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. The SN's initial assessment includes a Braden scale indicating that the patient is occasionally moist. However, there has not been a care plan initiated or developed related to the patient's GU status or risk for skin breakdown.

Upon patient record review, 1 of 5 (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 initial plan of care includes treatment orders that state cleanse with soap & water, pat dry daily and as needed. Complete treatment orders require a location and specifier for the PRN instructions. (corrected onsite)