Every finding on record at Hamilton Medical Center - Hospice

Based on review of records, staff interview, review of policies and procedures, it was determined the hospice agency failed to ensure that the initial comprehensive assessment was completed within 48 hours after the election of hospice care for two patients (P) (P#3, P#17) of 19 sampled patients. --- The findings include: Review of the facility policy titled ";Hospice Admission Criteria and Process", effective date 12/2021, reveals the following: Procedure: 16. The hospice registered nurse will complete an initial assessment during this visit or within 48 hours after the election of hospice care (unless the physician, patient, or representative requests that the initial assessment be completed in less than 48 hours.) 1. Review of the record reveals P#3 was admitted on 3/16/2023. The initial skilled nurse assessment was completed on 3/21/23, six days after the election of hospice care. The clinical record failed to reveal documentation regarding the staff's delay in completing the assessments. 2. Review of the record reveals P#17 was admitted on 1/12/2024. The initial skilled nursing assessment was completed on 1/29/24, 17 days after the election of hospice care. The clinical record failed to reveal documentation regarding the staff's delay in completing the assessments. On 2/13/24 at 10:50 a.m., an interview was conducted with the Director of Hospice (DOH), who said the nurse that did the admissions had resigned from the agency, and she did not know why they were unable to complete the nursing admission assessment within forty-eight hours. The DOH said that the electronical charting system will show the staff signature that completes the initial nursing assessment narrative notes on the plan of care; DOH also said when they complete the assessment the nurse who completes the assessment signature will appear on plan of care and that was the assessment completion date. The DOH also confirmed that all surveyors were given all available documentation for the patients records.

Based on review of records, and staff interviews, it was determined the interdisciplinary group failed to ensure that the initial comprehensive assessment was completed within five days of admission for two patients (P) (P#2, P#9) of 19 sampled patients. --- The findings include: 1. Review of the records reveals P#2 was admitted on 4/6/2022. The initial spiritual assessment was completed on 7/4/22, three months after the patient's admission. The psychosocial assessment for P#2 was completed on 4/13/22, seven days after the patients admission. The clinical record failed to reveal documentation regarding the staff's delay in completing the assessments. 2. Review of the record reveals P#9 was admitted on 5/29/2021. The initial psychosocial assessment for P#9 was completed on 6/16/21, 18 days after the patient's admission. The clinical record failed to reveal documentation regarding the staff's delay in completing the assessments. On 2/13/24 at 10:39 a.m., an interview was conducted with the chaplain, who said that she was on medical leave and knew nothing about the late admission assessment. On 2/13/24 at 10:53 a.m., an interview was conducted with the Director of hospice, who said they have one chaplain, and she was on medical leave. The social worker resigned that is why they delayed the assessment. The Director of the hospice also confirmed that the surveyor has been provided with all available documentation for the patients records.