Every finding on record at Grossmont Hospital Corporation

Observed in Record Review. In 1 of 3 patient records reviewed, the written plan of care was not based on the patient’s goals and the time frames, settings, and services required to meet those goals. In the chart for RRNHV#1, the wound care goal on the inpatient plan of care was not a goal and read ___has a DTI on coccyx. Apply mepilex, assess each shift, change q 7 days or prn for soiling dislodgement. This was discussed with the Hospice Director present for record review.

Observed in Tracer Activities. In 2 of 3 volunteer records reviewed, the organization had not provided ongoing education and training consistent with their roles and responsibilities in an emergency. Initial training had been provided during volunteer orientation for both volunteers. There was no documentation of additional emergency management training during a 6 year time period. This finding was discussed with the volunteer coordinator at the time of discovery.

Observed in Record Review. In 8 of 20 patient records reviewed., the hospice nurse surveyor observed that the initial comprehensive assessment did not include all required components. Agency policy for assessments states that a comprehensive assessment is completed in 5 days. On review of RRHV #1, it was noted that the spiritual counselor had not completed a spiritual assessment within the 5 days of admission and no other discipline completed a spiritual assessment that met agency policy for the spiritual assessment. On review of RRNHV #1, it was noted that the spiritual counselor had not completed a spiritual assessment within the 5 days of admission and no other discipline completed a spiritual assessment. On RRNHV #3, it was noted that a spiritual and emotional assessment were not completed within 5 days of admission. On RRNHV #4 it was noted that the spiritual assessment was not completed within 5 days of admission. On RRNHV #6, RRNHV #8 and RRNHV #10 the spiritual assessment was completed within 5 days of admission. This was reviewed with agency leadership. Observed in Record Review. Example #2: During the medical record review for RRNHV#11, it was noted that the initial comprehensive assessment did not include a spiritual assessment. This was reviewed with the agency leadership

Observed in Record Review. In 1 of 10 patient records reviewed, it was noted that the organization did not implement its policy related to pain management. For example, a review of the medical record for HosInptParkview#1, it was noted that the pain assessment completed on day 5 of services for benefit period #3, indicated the patient had a pain level of 10 and Morphine 20mg was administered. The clinical record did not include documentation of an evaluation and patient's response to the pain intervention. This was reviewed with agency leadership.

Observed in Record Review. In 2 out of 20 patient records reviewed, the initial bereavement assessment was not completed. Agency policy is that the MSW will completed the initial assessment. On RRNHV #4, it was noted that the MSW did not complete a bereavement risk assessment on admission. This was reviewed and validated with agency leadership who was present for the chart reviews. Observed in Record Review. Example #2: During the medical record review for RRNHV#11, it was noted that the initial comprehensive assessment did not include an initial bereavement risk assessment. This was reviewed with the agency leadership.

Observed in Record Review. In 13 of 17 patient records reviewed, goals were not measurable and specific to the care of the patient. On RRHV #1, it was noted that goals were not measurable and specific for the patient, examples include family will identify community resources and family will cope with grief. On RRHV #2, it was noted that the goals were not measurable, examples include establish pain goal with patient and verbalize understanding of how to decrease aspiration. On RRHV #3, it was noted that the goals were not specific to the patients' needs for example patient goals had not been updated since start of care a year ago. On review of RRNHV #1, RRNHV #2, RRNHV #3, RRNHV #4, RRNHV #5, RRNHV #6, RRNHV #7, RRNHV #8, RRNHV #9, and RRNHV #10 goals were also not measurable and specific to the patients. This was reviewed and confirmed with agency leadership who was present for chart reviews.

Observed in Record Review. In review of 5 of 10 patient records, it was noted that the organization did not ensure that plan of care goals include outcome measures for specific care activities. For example, during a review of the medical record for HosInptParkview#1, the following goal statement was noted, “Patient's pain/physical discomfort will be reduced to the level of patient's stated goal”. However, the goal statement did not include the patient’s stated pain relief goal. Example #2: During a review of the medical record for HosInptBonitaView#1, the following goal statement was noted, “Anxiety will be relieved to level acceptable to patient/caregiver throughout care.” The goal statement did not include a method to measure the effectiveness of problem interventions.Example #3: During a review of medical record for HosInptLakeview#1, the comprehensive assessment identified the presence of a stage 2 coccyx wound with surrounding excoriation requiring daily wound care; and a stage 2 wound at the right great toe and right inner base of toe. The plan of care did not include a goal statement to evaluate the response, to care, treatment, and services related to wound care interventions. Example #4: During a review of the medical record for RRHV#4, the following goal statement was noted, “During nursing visit, patient, caregiver, family establishes goal for pain control.” The goal statement did not include a method to measure the effectiveness of problem interventions. Example #5: During a review of the medical record for RRNHV#12, the following goal statement was noted, “Within 48 hours of complaint of dyspnea, patient verbalizes/exhibits dyspnea relieved to acceptable level.” The goal statement did not include a method to measure the effectiveness of problem interventions. This observation was reviewed with agency leadership.

Observed in Record Review. In 1 out of 17 patient records reviewed, the medication orders were not clear and accurate. On RRNHV #1, the hospice nurse surveyor noted that the physician's orders in the plan of care documented Senna as PRN. There was no indication for use documented in the physician's order. The organization's Medication Policy documented that all prn medications require an indication for use. This finding was reviewed with agency leadership who were present for chart review.Example #2: In 4 of 17 records reviewed, orders for care were not specific to the care provided. On review of RRHV #2, it was noted that there were range orders for SN, Aide, MSW and Chaplain, the aide did not follow the top of the frequency orders and there was no documentation to describe the rationale. On review of RRNHV #1, it was noted that there were range orders for the SN for 2-4 times per month with 5 PRN and the nurse went 6 times during the month and the extra visits did not note the reason for PRN visits. On review of RRNHV #2, it was noted that there were range orders for SN and MSW, it was noted that the MSW had orders for 1-3 visits per month and only made one visit in February and had only one missed visit note documented. On review of RRNHV #5 it was noted that there were range orders for the chaplain for 1-8 visits per month and chaplain saw the patient only 3 times. There was no documentation to describe why 8 visit contacts were not made. This finding was reviewed with agency leadership.Example #3: In 1 of 17 patient records reviewed, it was noted that medications with duplicate therapy was not addressed. On RRNHV #6, it was noted that the patient had duplicate therapy for constipation (lactulose and MiraLAX) that was for PRN use and there was no indication to address when to give each constipation medication. This finding was reviewed with agency leadership who were present for the chart reviews.

Observed in Individual Tracer. Example #2: During individual tracer activities for, RRHV#4, the clinician utilized a cleaning cloth that did not include a disinfecting agent. In addition, the cleaning cloth did not include the disinfecting agent alcohol. This observation was reviewed with agency leadership. Observed in Patient Home. In 1 of 6 home visits conducted , the hospice nurse surveyor noted that infection control practices were not followed. Agency Hand Hygiene and bag policy states that hands are to be washed before entering bag. On RRHV #2, it was noted during the visit that the nurse had performed patient care and equipment cleaning and entered nursing bag without removing gloves and performing hand hygiene. This finding was reviewed with agency leadership. Observed in Patient Home. In 2 of 6 hospice home visits conducted, the organization failed to follow manufacturer instructions for use of disinfectant. Agency policy states that equipment is cleaned with Alcohol wipes. On RRHV #2, it was noted that the RN cleaned her vital sign equipment using Sani-wipes and did not follow agency policy for cleaning or manufacture guidelines for Sani-wipes wet time of 2 minutes before placing the equipment back in her bag. This was discussed with agency leaders.

Observed in Individual Tracer. There was no evidence that the governing body and leadership had established requirements to support patient care treatment and services as evidenced by plan of care policies and procedures implementation and sustained compliance was not established – 418.56 Interdisciplinary group, care planning, and coordination of services.

Observed in Record Review. In 1 of 17 patient records reviewed, the patient record did not reflect all medications being used by the patient. During RRHV #1, the Hospice nurse surveyor noted that the patient record did not reflect all medications being used by the patient. During the home visit, the daughter stated she has been using constipation medications for her mother, when I asked what medications, she is using she pulled out Fiber Gummies and Dulcolax Oral Chewable and these medications were not reflected in the patient record. This was reviewed with agency leadership.

Observed in Individual Tracer. Example #2: During a review of patient education information in the home for RRHV#4, RRHV#5, and RRHV#6, an individualized disaster/emergency management plan was not identified. This observation was reviewed with agency leadership. Observed in Patient Home. In 6 of 6 home visits conducted, an individualized emergency management plan was not completed and left in the patient home. During RRHV#1, RRHV #2 and RRHV #3, it was noted there was no individualized emergency created and left in the home. This was discussed with the agency leadership.