Every finding on record at Harbor Hospice 26, LP

Observed in Record Review. In 4 of 14 patient records reviewed, for active patients, it was noted by the nurse surveyor that the bereavement risk assessment was not completed as part of the comprehensive assessment for RRHV#2, RRHV#4, RRNHV#3, and RRNHV#4. Finding was verified by the Administrator and the Director of Nursing.

Observed in Record Review. In 14 of 14 patient records reviewed, for active patients, the nurse surveyor noted that the goals were not consistently measurable or individualized. For example, “Patient/Caregiver will maintain necessary measures to reduce risk and avoid skill infections,” and “Family/caregiver verbalize/demonstrate measure to achieve optimum comfort level”. Additionally, goals were mostly the same from patient to patient with minimal individualization. There were no short-term goals at start of care to address issues of immediate needs such as understanding medication management, symptom management, pain management, or safety, most time frames for completion were in six weeks or at end of certification period. Time frames for completion were mostly. Findings were discussed with the Administrator and the Director of Nursing.

Observed in Record Review. In 1 of 14 patient records reviewed, for active patients the nurse surveyor noted that the plan of care was not complete. For RRHV#2 the patient had oxygen in the home and was using it continuously, yet there was no order for the oxygen. Finding was verified by the Administrator and the Director of Nursing.

Observed in Record Review. In 2 of 14 patient records reviewed, for active patients, the nurse surveyor noted that plan of care revisions were not consistently documented. For RRHV#3 the patient had a wound to her toe that her husband was caring for, however the plan of care was not updated to document the healing process nor was the wound care order removed once it was healed. For RRHV#4, the patient had a wound from hip surgery and required a dressing upon admission. Several weeks later, the wound was documented in the nurses notes as healed, however the plan of care was not updated to remove the wound care orders. Findings were validated by the Administrator and the Director of Nursing.

Observed in Patient Home. In 1 of 4 home visits conducted, it was observed by the Nurse Surveyor that the organization did not implement the infection prevention and control activities it had planned per their “Hand Hygiene Policy No. 0-009.1”. For example, during RRHV#2 the Social Worker did not perform hand hygiene prior to entering the patient’s home or at any time during the visit even after touching the patient’s folder and several other items in the home. She did hand sanitize prior to entering her car. Findings were verified by the Director of Nursing who was present during the visit.

Observed in Record Review. In 1 of 14 patient records reviewed, for active patient records, it was noted by the nurse surveyor that Hospice Aide Supervisory visits were not documented the required every fourteen days. For RRHV#4, the most recent home health supervisory visits were completed sixteen days apart. Findings were verified with the Administrator and the Director of Nursing.