Every finding on record at Good Samaritan Hospice

Observed in Record Review. In 1 out of 10 Hospice records, the patient record was incomplete with documentation not promptly entered per policy. Example: In RRNHV#2, the nursing initial assessment done at the start of care was labeled in the medical record as not started and was therefore not available for review. The SOC was 6 days ago. The Nurse Manager confirmed that the visit was made by the admitting RN who is delayed in entering the assessment electronically into the medical record. The Nurse Manager identifies the policy as completed documentation being submitted within 72 hours of visit completion.

Observed in Record Review. In 4 out of 10 Hospice records, the plan of care did not include complete parameters to manage pain and symptoms. Examples: In RRHV#1, RRHV#3, RRNHV#5, RRNHV#6, 2-4 LPM range orders for oxygen did not have defined parameters and indications for adjusting and/or changing the settings. This was confirmed by the Nurse Manager.

Observed in Record Review. In 7 out of 10 Hospice record reviews, The nurse and or aide did not follow the visit frequency per the plan of care. Examples: In RRNHV#2, there were missed aide visits during weeks 1-6 of benefit period 1 without documentation related to the reasons for the missed visits. In RRNHV#3, there were missed nursing visits during weeks 1 and 4 of benefit period 1 without documentation related to the reasons for the missed visits. In RRHV#1, RRNHV#2, RRHHV#3, RRHHV#4, RRHHV#5, RRHHV#6, and RRHHV#7, the hospice plan of care was not followed with aide range frequency orders not starting at the top of the range. This was confirmed by the Nursing Manager. Observed in Record Review. In 7 out of 10 Hospice record reviews, the registered nurse did not accurately prepare the written patient care instructions for the hospice aide. Examples: In RRHV#1, RRNHV#2, RRNHV#3, RRNHV#7, the Aide visit frequency was 2 - 3 x's per week. The actual visit frequency per week varied without documentation from a skilled professional as to the reason for the changes. In RRNHV#4, RRNHV#5, and RRNHV#6, the Aide visit frequency was 1- 3 x's per week. The actual visit frequency per week varied without documentation from a skilled professional as to the reason for the changes. In discussing the observation with the Nurse Manager, she reports their use of daily huddles in the morning to determine which patients needed more or less visits for the week and aide availability. The Nurse Manager also confirmed their lack of documentation in the record related to reasons for the change.

Observed in Tracer Visit. In 1 out of 2 Hospice Home Visits, the registered nurse who is a member of the interdisciplinary group and is responsible for hospice aide supervision did not prepare complete written patient care instructions for the hospice aide. Example: During Hospice HV#2, the aide was observed applying Calmoseptine ointment to the reddened areas on the patient's buttocks. This intervention was not identified on the Aide's care plan. This was confirmed by the Nursing Manager.

Observed in Tracer Visit. In 1 out of 2 Hospice home visit record reviews, the registered nurse did not supervise the hospice aide during an on-site visit to the patient’s home every 14 days. Example: The Hospice Surveyor noted in RRHV#1 that no Aide Supervisory visits had been made since week 3 of benefit period 1. The patient is currently in week 6 of benefit period 1. This was confirmed by the Nursing Manager.

Observed in Tracer Visit. In 2 out of 2 record reviews with home visits, the medical record did not contain complete information related to the patient's list of medications used in the home. Example: DuringRRHV# 1 the patient reported to the Home Surveyor during their interview using an antidiarrhea medication seen on the living room table and the Gas-X tablets seen on the dining room table. Neither medication was listed on the medication profile in the medical record. During RRHV#2, the wife reported the patient being on Trazodone to assist with sleeping, which she has not administered yet. However, this medication was not present on the medication profile in the medical record. This was confirmed by the Nursing Manager.

Observed in Patient Home. In 1 of 3 hospice visits observed and confirmed by the nurse manager, care had not been provided as identified within the plan of care. Example: During observation of HOSv#2 the nurse had provided wound care with an antibiotic ointment. The plan of care had not identified the wound care to be provided.

Observed in Patient Home. In 1 of 3 hospice visits observed and confirmed by the Nurse Manager, the organization had not utilized personal protective equipment to reduce the risk of infection. Example: During observation of HOSv#2 the RN had failed to don gloves when providing wound care.

Observed in Patient Home. In 1 of 3 hospice visits observed, the home health aide had not provided care as identified in the plan of care. Example: During observation of HOSv#3 the HHA had stated she removed the oxygen when showering the patient. The plan of care had not instructed the aide to remove the oxygen when ordered for continuous use.

Observed in Record Review. In 1 of 2 Live Discharge records reviewed and confirmed by the Nurse Manager, a summary of care had not been completed to include care provided. Example: During review of HOS RR#1 a summary of care had not been completed to include the care provided at the time of discharge.