Every finding on record at Golden Oaks Hospice, Inc

Observed in Record Review. In 1 of 10 records reviewed, the surveyor observed that the organization failed to provide care/treatment/services in accordance with orders as required by law and regulation. For example, in RRHV#1, surveyor noted documentation in an IDG note by the nurse that patient had a physical therapy evaluation with subsequent physical therapy visits for assistive device training due to weakness, however, there was no written order for the physical therapy evaluation and subsequent physical therapy visits in the electronic medical record. This was reviewed with the Director of Nursing and Administrator.

Observed in Record Review. In 1 of 10 records reviewed, surveyor observed that the visit frequency for MSW was not met per the order and plan of care. For example, the order stated MSW visits were to occur monthly, however, MSW visit was not made in November, 2024. This was reviewed with the Administrator and Director of Nursing.

Observed in Patient Home. In 1 of 3 visits, surveyor observed that the clinician failed to adhere to infection control and prevention protocol per the organization's policy. For example, in HV#3, the clinician did not disinfect the blood pressure monitor, oxygen saturation machine, nor the stethoscope after taking patient's vital signs and before returning the equipment to nursing bag, creating a risk for transmitting infectious material by using the same medical equipment to collect vital signs for subsequent patients. This was reviewed with the Director of Nursing/Administrator.

Observed in Patient Home. In 1 of 3 home visits, surveyor observed that the organization failed to maintain a medication record that reflects the patient's care treatment. In HV#1, during the review of medication reconciliation performed by the Nurse at the request of the surveyor, the medication profile was noted to be inaccurate and did not reflect updated changes to patient's medication regimen. For example, The order for Albuterol Sulfate HFA frequency stated every four hours as needed on the medication profile, however, the frequency on the medication box stated every six hours as needed. The order for Humalog Insulin dose and frequency stated 30 units twice daily before breakfast and before dinner, however, the dose and frequency on the medication box stated 4 units three times daily before meals. Additionally, the medication Amox-Clav was ordered and in patient's home to be taken for 14 days for upper respiratory infection, however, the medication was not listed on patient's medication profile. This was reviewed with the Director of Nursing.

Observed in Patient Home. During HV #1, the LPN cleansed the patient wounds with wound cleanser; however, the wound care order stated the wound to be cleansed with normal saline. This was validated with the Administrator and Nursing Director.

Observed in Patient Home. In 2 of 3 home visits conducted, the clinicians did not follow the organization's bag technique policy: Policy NO 9-014.1. During HV #1 the clinician was observed three times going into her equipment bag without disinfecting her hands. During HV #2, the clinicians bag did not have a designated dirty/clean area and remained open and exposed during the visit. The same clinician was also observed cleaning her equipment and placing the items immediately back into the open bag without an appropriate dwell time for bactericidal effects.  This was validated with the Administrator and the Nursing Director. Observed in Patient Home. in 2 of 3 home visits conducted, observation of the clinicians providing care revealed that hand hygiene had not been performed according to the agency's Policy NO 9-009.2 Hand Decontamination with Alcohol-Based Hand Rub. During HV #1, the clinician changed her gloves multiple times while providing care without disinfecting her hands between the changes. During HV #2, the clinician was observed cleaning her hands intermittently with used Clorox wipes, and not the approved alcohol based hand sanitizer. This was validated with the Administrator and the Nursing Director.

Observed in Patient Home. Pt record was inaccurate or contained errors (i.e. conflicted documentation between care provided and care performed). The LPN documented that skilled observation/ assessment of all body systems had been performed, including that there were no abnormal lung sounds; however, the lungs had not been assessed. The clinician also documented care provided to the right lower extremity, but was not observed to provide the care. This was validated with the Administrator and Nursing Director.