Every finding on record at Gundersen Lutheran Medical Center, Inc.

Observed in Record Review. In 1 of 18 patient records reviewed, the organization failed to assess bereavement needs according to time requirements. During record review for HOSRRNHV#10, the patient had been on hospice for a month and there was no documentation of a bereavement assessment. This was discussed and reviewed with the Hospice Leadership Team.

Observed in Record Review. In 1 of 18 patient records reviewed, the organization failed to maintain a complete and accurate patient record. During record review for HOSRRHV#3, the Hospice Nurse Surveyor observed the hospice diagnosis had been changed one certification period prior to survey but the CTI documentation from the provider was not updated. The CTI stated a diagnosis of Cerebral Vascular Disease but it had been changed and discussed with IDG that it was currently Alzheimer's. This was discussed and reviewed with the Hospice Leadership Team.

Observed in Record Review. In 1 of 18 patient records reviewed, the organization failed to plan the patient's care. During record review for HOSRRHV#2, the Hospice Nurse Surveyor observed the orders for port access were incomplete. They did not contain how often the port should be flushed. The care plan stated next to be flushed date but there was no documentation of how often this should happen. The policy also did not include how often the port should be flushed. This was discussed and reviewed with the Hospice Leadership Team.

Observed in Record Review. In 2 of 18 patient records reviewed, the organization failed to plan the patient's care. During record review for HOSRRNHV#4 and HOSRRNHV#8, the plan of care was not updated to reflect updates to the goals and outcomes. had For example in both patients the plan of care contained a goal to get a POLST signed and implemented with an active timeframe but both patients had a signed POLST. This was discussed and reviewed with the Hospice Leadership Team.

Observed in Record Review. In 5 of 6 patient records reviewed, where aide services were ordered, the organization failed to plan the patient's care. During record review for HOSRRHV#1, HOSRRHV#3, HOSRRHV#4, HOSRRNHV#1, and HOSRRNHV#6, the Hospice Nurse Surveyor observed the aide plan of care did not contain all needed elements. For example in HOSRRHV#1 and HOSRRHV#4, there were no precautions for fall or bleeding due to being on a blood thinner. In HOSRRHV#3 and HOSRRNHV#1, the patient's were a high risk for fall and had no precautions on the aide care plan for fall. In HOSRRNHV#6, the patient was a fall risk and it was not documented on the aide plan of care. This was discussed and reviewed with the Hospice Leadership Team.

Observed in Tracer Activities. During a review of the volunteer program and interview with the volunteer coordinator, the Hospice pharmacy surveyor noted that the volunteers had not met the requirement that they would provide day-to-day administrative and/or direct patient care services in an amount that at a minimum equals 5% of the total care hours of all paid hospice employees and contract staff.. However for Oct 2024 to Nov 2025 that number was only 4.6%. This percentage was valiidated with Hospice management at the time of the survey,

Observed in Record Review. In 1 of 3 patient records reviewed, the organization failed to follow the discharge process as required. During record review for HOSRRDC#1, the Hospice Nurse Surveyor observed there was no documentation that the discharge summary was sent to the provider taking over care. This was discussed and reviewed with the Hospice Leadership Team.

Observed in Record Review. In 5 of 13 patient records reviewed, The organization did not ensure the initial bereavement assessment was completed on patients who elected the hospice benefit. For example, the surveyor noted in clinical records for RR #4, RR #5, RR #7, RR #9 and RR #11, there was no documentation of an initial bereavement assessment. Standards require an initial bereavement assessment be completed at time of patient admission, as a part of the patient-specific comprehensive assessment. These findings were reviewed, discussed, and validated with the hospice quality coordinators and Director of Operations.

Observed in Record Review. In 11 of 13 patient records reviewed, The organization did not ensure patient care plan goals were individualized, measurable, realistic, and specific. For example, the surveyor noted on HV #1/RR #1, HV #2/RR #2, HV #3/RR #3, RR #4, RR #5, RR #6, and RR #7, RR #10, RR #11, RR #12, and RR #13 the patient’s care plan goals included statements such as: “Decrease and/or stabilization in amount of edema related to hospice care episode. On next visit chaplain will offer compassionate presence for ongoing listening and exploration of grief and loss. Patient/family grief heard and acknowledged throughout episodes of care. Maintain intact integument and reduce risk of injury/impairment t/o episode of care patient. Patient will demonstrate a return to baseline pulmonary function with resolution of infection t/o episode of care. Goal of shortness of breath is moderate or less. Caregiver will have adequate knowledge about skin integrity, prevention and monitoring of skin breakdown, and skin care t/o episode of care. wound will heal without complications in less than 2 weeks. Agreeable to care and will participate in the plan of are throughout hospice care. Elimination/management of edema, stabilization of 2+ edema throughout hospice episode of care. Patient demonstrates a return to baseline pulmonary function within episode of care. Absence of bowel complaints and skin breakdown through episode of care. Patient verbalize/exhibits ease-resting respiratory rate less than 28 t/o hospice certification period. Atrial fibrillation controlled with medication metoprolol and warfarin, if PPS falls below 30% or if increase in falling need to address if stopping warfarin t/o hospice episode of care. Control of drainage and prevention with early detection of infection for non-healing wounds. Patient verbalizes comfort and/or transitions to palliative care t/o the episode of care.” Many of these are interventions are interventions, not individually time framed and do not contain information that can be accurately measured to assist staff in determining whether the patient is progressing towards achieving their goals. These findings were reviewed, discussed, and validated with the hospice quality coordinators and Director of Operations.

Observed in Record Review. PC.02.01.05 EP 1 The organization failed to provide collaborative care at warranted times. For example, on RR #10, the social worker entered a communication note, requesting follow-up to a caregiver’s request for assessment of a patient who was potentially having swallowing difficulties. There was no documentation of a nurse visit or any type of indication of follow up. Standards require all disciplines that provide care to the patient coordinate their efforts for patient/caregiver support. These findings were reviewed, discussed, and validated with the quality coordinators and Director of Operations.

Observed in Record Review. In 9 of 13 patient records reviewed, The registered nurse did not ensure the written hospice aide care plan include specific directions for activities of daily living/personal care. For example, HV #1/RR #1, HV #3/RR #3, RR # 4, RR #7, and RR #9, the patients were on oxygen, either as needed or continuously. The nurse did not provided instructions as to whether the oxygen could be removed during care. RR #5, and RR #8 included directions for feeding or offering the patient fluids, but were not specific, providing the aide with multiple options. Likewise, RR #3 directed the aide to complete dressing changes on the patient but included complex options for the aide. RR #6 and RR #11 included general orders for the aide to inspect the patient’s skin. And RR #11 did provide specific directions for transferring the patient. Standards require a registered nurse who is a member of the interdisciplinary team prepare written instructions for aide care to the patient. These findings were reviewed, discussed, and validated by the quality coordinators and Director of Operations.