Every finding on record at Guadalupe Regional Medical Center

Observed in HR File Review. During review of the organization's HR files, the hospice pharmacy surveyor found no emergency management training or ongoing education for the employed medical director for 2023 or 2024 which was a requirement to be done every 2 years for all employees. This omission was validated with the HR team and director at the time of the survey.

Observed in Patient Home. In 2 of 4 home visits conducted, it was noted that the organization failed to conduct and document an environmental assessment. Based on staff interviews and patient record reviews, (RRHV#1, RRHV#2) no evidence of completed environmental assessments was found in the clinical records. This finding was discussed with and validated by the Clinical Coordinator and Administrator/DPCS.

Observed in Patient Home. In 2 of 4 home visits conducted, it was noted the organization did not ensure that a thorough and ongoing medication reconciliation process was conducted. It was observed during home visits (RRHV#1, RRHV#2, RRHV#3, RRHV#4) that the nurse provided an updated medication profile to the patient/family without verifying the medications currently in use by reviewing each medication bottle or prescription container during the visit. Based on staff interview, the clinical coordinator had confirmed that the medication reconciliation was limited to the time of admission and recertification. There was no evidence of ongoing verification during routine visits to ensure continued accuracy of the medication list. This finding was discussed and validated by the Administrator and Clinical Coordinator.

Observed in Record Review. In 3 of 14 active patient records reviewed, most plan of care goals were not measurable and were to be completed by death or discharge in records RRNHV#8, RRNHV#9, and RRNHV#10. Here are examples: Pain to be controlled; skin will stay intact; will understand home and equipment safety; will understand proper use, dosage and side effects of prescribed medications; will maintain safe use and storage of home oxygen; will be knowledgeable of disease process. This RFI was reviewed with the Executive Director Administrator and the Clinical Coordinator. Observed in Record Review. In 11 of 14 active patient records reviewed, it was noted the organization failed to ensure that the written plan of care was based on measurable patient-centered goals with defined time frames.For example, in the record for RRHV#1, RRHV#2, RRHV#3, RRHV#4, RRNHV#1, RRNHV#2, RRNHV#3, RRNHV#4, RRNHV#5, RRNHV#6, RRNHV#7, several goals documented in the plan of care, such as: Pain will be controlled; Skin will stay intact; Patient will understand home and equipment safety; Patient will understand proper use, dosage, and side effects of prescribed medications; Patient will maintain safe use and storage of home oxygen, were not measurable and did not include time frames for expected achievement. All time frames were to be achieved by the time of death. This finding was discussed and validated by the Administrator and Clinical Coordinator.

Observed in Record Review. In 3 of 14 active patient records reviewed, the organization did not ensure that the plan of care was revised to reflect changes identified through clinical re-assessment. In record RRNHV#8 the patient developed a DVT in the lower extremity and a pressure ulcer on the buttocks. In record RRNHV#9 Spironolactone was ordered for edema. And in record RRNHV#10 there was documentation of improvement in ambulation, pain, nutrition, and elimination. The plan of care in each record was not updated when these changes occurred. Rather, it was only revised at the time the patient was recertified for an additional benefit period. This RFI was reviewed with the Executive Director Administrator and the Clinical Coordinator.

Observed in Record Review. In 1 of 14 patient records reviewed, the plan of care did not indicate rationale for a prn order. In record RRNHV#9 a registered nurse documented that the patient had a foley catheter in place at the start of care. An order was written for it to be changed monthly and/or as needed. However, the order did not include criteria for changing the appliance as needed. This RFI was reviewed with the Executive Director Administrator and the Clinical Coordinator. Observed in Record Review. In 2 of 14 active patient records reviewed, the organization did not ensure that all PRN (as needed) orders included a clear indication or reason. For example, in RRNHV#2, an order was written for an indwelling Foley catheter (16 Fr/10 ml balloon) to be changed monthly and/or as needed; however, the order did not specify a clinical indication for the PRN change. Additionally, in RRHV#2, a registered nurse applied a barrier cream and a Mepilex dressing to the patient's sacral area, but there was no corresponding physician order found to support the intervention. Based on staff interview, the Clinical Coordinator confirmed that the nurse contacted the physician after the home visit to obtain an order, but still no order was found in the clinical record. This finding was discussed and validated by the Clinical Coordinator.

Observed in Record Review. In 3 of 14 active patient records reviewed, the organization did not ensure that the comprehensive assessment was updated no less than every 15 days. For example, in interdisciplinary group meeting notes written by core team members patient decline, progress towards desired outcomes and goals, and plans for the following two weeks were not addressed in records RRNHV#8, RRNHV#9, and RRNHV#10. This RFI was reviewed with the Executive Director Administrator and the Clinical Coordinator. Observed in Record Review. In 3 of 14 active patient records reviewed, the organization did not ensure that the comprehensive assessment was updated no less than every 15 days. For example, 16 days elapsed between interdisciplinary group meetings two times in records RRNHV#8, and RRNHV#9, and one time in record RRNHV#10. This RFI was reviewed with the Executive Director Administrator and the Clinical Coordinator. Observed in Record Review. In 1 of 14 active patient records reviewed, it was noted the organization did not ensure that the comprehensive assessment was updated at least every 15 days, as required. For example, in record RRNHV#6, 16 to 17 days elapsed between Interdisciplinary Group (IDG) meetings on two separate occasions. This finding was reviewed with the Administrator and Clinical Coordinator.

Observed in Tracer Activities. documented volunteer hours equaled 4% of the total patient care hours for the previous year and had not been at the required 5% since the last survey. This RFI was reviewed with the Executive Director Administrator and the Clinical Coordinator.

Observed in Leadership Session. Leaders did not manage implementation of patient care policies and procedures governing the provision of care as evidenced by a condition level finding at §484.56. This RFI was reviewed with the Executive Director Administrator and the Clinical Coordinator.

Observed in HR File Review. The organization must assess all employed individuals including the employed medical director providing care and services annually as the organization required in such areas as infection control, blood born pathogens, etc.The medical director had no documentation of these competencies for 2023 and 2024. This omission was validated with the HR team andn director at the time of the survey.

Observed in Record Review. In 1 of 14 patient records reviewed, the surveyor observed that the organization did not conduct an initial bereavement assessment, psychosocial or spiritual assessment with in 5 days as required by agency policy for comprehensive assessment . Observed in record review #5, the comprehensive assessment for psychosocial, spiritual and Bereavement were not completed for 15 days after Election of Hospice Benefits. There was no documentation in the record by the MSW or chaplain as to why the assessment was delayed. This observation was discussed and verified with the Hospice Charge Nurse and the Administrator.

Observed in Record Review. In 1 of 14 patient records reviewed, the surveyor observed that the plan of care did not include al of the medications or treatments necessary to meet the patient's needs. Observed in record review #5, the nurse documented flushing the medi-port with normal saline and heparin. However, there was no documentation or orders for the flush in the Intradisciplinary Group plan of Care. This observation was discussed and verified with the Hospice Charge Nurse and Administrator. Observed in Record Review. In 7 of 14 patient records reviewed, the surveyor observed that PRN medication orders were not clear. Observed in record review for home visit #2, there were two medications ordered for constipation without clear indications for which medication to use first. The orders included MOM 30 ml po for constipation and Bisacodyl 10 mg suppository per rectum PRN constipation. Observed in record review for home visit #3, there were two medications for constipation without indication for which medications to use first Ducalox and Fleets enema. In record review for HV#4, there were orders for 2 PRN without an indication for which medication to use first Advil 200mg every 6 hours PARN pain and Tylenol 325 mg 2 tablets every 4 hours PRN pain. In record review #2, there were 2 PRN medications for constipation MOM 30 ml and Ducalox 5mg po. In record review #7, there were multiple PRN medications for constipation MOM, enema; Miralax and Bisacodyl Suppository. In Record review #8, there were 2 medications ordered for constipation Docusate 100 mg daily and MOM 30 ml without indication for which to use first. Additionally there were 2 medications ordered for pain without indication Tylenol 325 mg 2 tablets and Morphine sulfate 2 mg/ml, 0.25 ml every 2 hours for pain. In record review #10, there were 2 orders for pain medications without an indication for which to administer first, tramadol 50 mg every 6 hours and Morphine Sulfate 2mg/ml, 0.25 ml every 2 hours.These observations were discussed and verified with the Charge Nurse and Administrator.

Observed in Record Review. In 1 of 14 patient records reviewed, the surveyor observed that the plan of care did not include all services needed for the palliation and management of the terminal illness and related conditions, including the management of medical supplies and appliances necessary to meet the patient’s needs. Observed during record review #1, the surveyor observed that there was no order on the Plan of Care for management of the patient's Foley catheter to include catheter size , balloon size or frequency of change. This observation was discussed and verified with the Charge Nurse and Hospice Administrator.

Observed in Document Review. During review of the Infection Control plan, the surveyor observed that there was no written risk assessment for infection risks specific to Hospice. The hospital risk assessment did not include infections risks related to Hospice services This was verified with the Administrator.

Observed in Record Review. In 1 of 14 patient records reviewed, the surveyor observed that the organization had not documented reassessment of the patient's terminal illness. Observed in record review #9, the recertification statement was the same verbiage as what was written for the initial certification period. This observation discussed and verified Charge Nurse and Administrator.

Observed in Individual Tracer. In 1 of 4 home visits conducted, the surveyor observed that the patient record did not contain the following clinical information related to non prescription medication the patient was using. Observed in home visit #1, the following medications were next to the patient's recliner; TUMS, antacid tablets; cortisone-10 2 % cream; Ibuprofen and Tylenol. According to the patient and his caregiver, the patient takes the TUMS for reflux; the cortisone for itchy skin, and Ibuprofen or Tylenol when he has a headache. According to the clinician, she was not aware the patient was using these medications. This observation was observed and verified with the Charge Nurse.

Observed in Record Review. In 1 of 14 patient records reviewed, the surveyor observed that the patient record did not contain accurate information. During review of the record for home visit #4, the surveyor observed that the Certificates of Terminal Illness and Physician face 2 face assessments had 3 different ages for the patient. The patient's age was 91, however, the certificate dated 12/29/21 listed the patient's age as 95. The certificates dated 8/25/21 and 7/7/21 listed the patient's age as 93. This observation was discussed and verified with the Charge Nurse and the Administrator.

Observed in Patient Home. In 1 of 4 home visits conducted, the surveyor observed that the organization had not provided patient or caregiver education for safe storage of medical gases. During home visit #1, the surveyor observed 4 E cylinders standing unsecured in a corner of the room. The staff did not educate or reeducate the patient or caregiver during the visit, During review of the patient record, there was no documentation that the patient or caregiver had been educated on safe storage of the oxygen cylinders. This observation was discussed and verified with the Charge Nurse and Administrator.