Every finding on record at Harbor Hospice of Missouri LP

Observed in Record Review. In 2 of 14 patient records, it was noted that the organization did not ensure a patient-specific comprehensive assessment that identified the patient's need for physical care included all required information. For example, during a review of the medical record for RRNHV#3, it was noted that the history and physical document [dated 2 days prior to the organization's start of care] identified the presence of wounds at the patient's bilateral heels, with the following prescribed treatment: Apply betadine to wound bed, skin prep to periwound to bilateral heels, cover with foam dressing 3 times per week and as needed for soiled/misplaced dressing. In addition, four days after the start of care assessment, the LPN member of the interdisciplinary team described the presence of wounds at the patient's bilateral heels. A review of the Registered Nurse start of care comprehensive assessment revealed that a description of the patient's non-intact skin at bilateral heels was not documented. Example #2: During a review of the medical record for RRNHV#5, it was noted that the comprehensive assessment did not include the initial bereavement risk assessment. This observation was reviewed with the Administrator and the Director of Nursing.

Observed in Record Review. In 2 of 14 patient records reviewed, it was noted that the organization did not ensure that the comprehensive assessment was updated at least every 15 days. For example, during a review of the medical record for RRHV#3, it was noted that the first update to the comprehensive assessment was completed 22 days after the start of care date. Example #2: During a review of the medical record for RRNHV#3, it was noted that the first update to the comprehensive assessment was completed 19 days after the start of care date. This observation was reviewed with the Administrator and the Director of Nursing.

Observed in Record Review. In 5 of 14 patient records, it was noted that the organization did not ensure goals were individualized to the patient’s needs and condition. For example, during a review of the medical record for RRHV#1, it was noted that the plan of care problem list included the following problem: Risk for falls/injury. The plan of care did not include a goal statement related to maintaining patient safety. In addition, the patient’s comprehensive assessment identified the patient had a cognitive impairment condition, and verbalization had no relationship to the questions being asked. The FLACC scale was used to assess the patient’s level of pain. However, the goal for pain management was “[Patient's name] will be pain free or verbalize an acceptable pain level with current pain management regimen through the next review. Example #2: A review of the medical record for RRHV#2, revealed that during week 5 of hospice services, the clinician documented the following: In the last two weeks patient has developed a sore area that is dime size on his scrotum, or using skin prep barrier on it daily in the nursing facility as well as barrier cream from hospice. The plan of care was not updated with a goal statement related to care, treatment, and services to be provided to non-intact skin. Example #3: A review of the medical record for RRHV#4, revealed that the patient's comprehensive assessment identified that the patient had a severe cognitive impairment condition. The FLACC scale was used to assess the patient’s level of pain. However, the goal for pain management was “[Patient's name] will be pain free or verbalize an acceptable pain level with current pain management regimen through next review. Example #4: A review of the medical record for RRNHV#4, revealed that during the first week of Hospice services a clinician identified the presence of non-intact skin at the patient’s bilateral heels. The plan of care did not include a goal statement related to the care, treatment, and services to be provided to non-intact skin. Example #5: A review of the medical record for RRNHV#8, revealed that the patient’s comprehensive assessment identified that the patient had non-intact skin at the left buttocks. The plan of care did not include a goal statement related to the care, treatment, and services to be provided to non-intact skin. This observation was reviewed with the Administrator and the Director of Nursing.

Observed in Record Review. In 4 of 14 patient records, it was noted that the plan of care did not include interventions based on the problems identified in the comprehensive assessment. For example, during a review of the medical record for RRHV#1, it was noted that the comprehensive assessment identified that the patient was at risk for falls. The plan of care did not include interventions to maintain safety, and strategies to prevent injury. Example #2: A review of the medical record for RRHV#2, revealed that during week 5 of hospice services, the clinician documented the following: In the last two weeks patient has developed a sore area that is dime size on his scrotum, or using skin prep barrier on it daily in the nursing facility as well as barrier cream from hospice. The plan of care was not updated with interventions to address the care, treatment, and services of the patient's non-intact skin. Example #3: A review of the medical record for RRNHV#4, revealed that during the first week of Hospice services a clinician identified the presence of non-intact skin at the patient’s bilateral heels. The plan of care did not include interventions to address the care, treatment, and services of the patient’s non-intact skin. Example #4: A review of the medical record for RRNHV#8, revealed that the patient’s comprehensive assessment identified that the patient had non-intact skin at the left buttocks. The plan of care did not include interventions to address the care, treatment, and services of the patient’s non-intact skin. This observation was reviewed with the Administrator and the Director of Nursing.

Observed in Record Review. In 4 of 14 patient records reviewed, it was noted that the organization did not ensure the plan of care was reviewed and revised every 15 days. For example, during a review of the medical record for RRHV#2, and RRHV#3, there was no documented evidence that the interdisciplinary group, in collaboration with the patient's attending physician reviewed and revised the plan of care during week 3 and week 5 of services. Example #2: During a review of the medical record for RRHV#4, there was no documented evidence that the interdisciplinary group, in collaboration with the patient’s attending physician reviewed and revised the plan of care every 15 days. The first documented review and revision of the plan of care was completed during week 8 of Hospice services. Example #3: During a review of the medical record for RRNHV#1, there was no documented evidence that the interdisciplinary group, in collaboration with the patient’s attending physician reviewed and revised the plan of care during week 9, week 11, and week 13 of the first benefit period, weeks one through thirteen of the second benefit period, and the first documented interdisciplinary meeting for the third benefit period was completed during week three of hospice services. This observation was reviewed with the Administrator and the Director of Nursing.

Observed in Competency Session. In 1 of 3 Human Resource files reviewed for Hospice Aides, it was noted that the organization did not fulfill the requirement to directly observe the Hospice Aide demonstrate needed tasks with a patient or pseudo- patient as part of a simulation. For example, a review of the competence evaluation for hospice aide #3 revealed that the following subject areas were not evaluated via direct observation: 1) Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other staff; 2) Reading and recording temperature, pulse, and respirations; 3) Appropriate and safe techniques in personal hygiene and grooming that include bed, sponge, tub, or shower bath; sink, tub, or bed shampoo; nail and skin care; oral hygiene; toileting and elimination. 4) Safe transfer techniques and ambulation; and 5) Normal range of motion and positioning. This observation was reviewed with the Administrator and the Director of Nursing.

Observed in Record Review. In 2 of 8 patient records reviewed, for patients receiving Hospice Aide services, it was noted that the organization did not ensure Hospice Aide supervision was effective. For example, during the review of the medical record for RRHV#3, it was noted that a Hospice Aide supervision visit was not documented by the Registered Nurse every 14 days during the first benefit period. Example #2: During a review of the medical record for RRNHV#4, it was noted that a Hospice Aide supervision visit was not documented by the Registered Nurse every 14 days. The first Hospice Aide supervision was documented 35 days after the start of Hospice Aide services. This observation was reviewed with the Administrator and the Director of Nursing.

Observed in Competency Session. In 1 of 6 Human Resource files reviewed, it was noted that the organization did not ensure that requirements for staff competence evaluation were completed. For example, during a review of the employee file for Social Worker #1, it was noted that competence was not initially assessed and documented as a part of orientation. This observation was reviewed with the Administrator and the Director of Nursing.

Observed in Record Review. In 1 of 14 patient records, it was noted that the organization did not ensure that required information was included in the patient record(s) within its defined time frames. For example, during the review of the medical record for RRHV#1, it was noted that the following forms were not present in the electronic medical record (EMR): Informed consent release, Hospice Election Statement, and Hospice Election Addendum. An interview with the Administrator revealed that these forms were not uploaded within five (5) days of completion. The above identified forms were uploaded on day two (2) of the survey, 13 days after the signature date on these forms. This observation was reviewed with the Administrator and the Director of Nursing.

Observed in Record Review. Example #2: A review of the medical record for RR#4, revealed that the comprehensive assessment did not include an initial bereavement risk assessment. In addition, survivor needs that may impact coping skills was not evaluated. This observation was reviewed with the Administrator/Director of Nursing. Observed in Record Review. In 2 of 13 patient records reviewed, it was noted that the organization did not ensure comprehensive assessments included an initial bereavement risk assessment. In addition, survivor needs that may impact coping skills was not evaluated. For example, during a review of HV #2 there was no documentation that the initial bereavement risk assessment was completed.

Observed in Record Review. Example #2: In RR #12 The clinician noted chronic pressure ulcers to sacrum/coccyx/vaginal area, L ischium pressure ulcer, skin tear to LL back area, L toe moisture skin integrity issues. The plan of care did not include a goal statement to evaluate the interventions for wound care and assessment. This observation was validated with the Regional Director. Observed in Record Review. In 2 of 13 patient records reviewed, it was noted that the organization did not ensure the plan of care included all required information. For example, a review of the medical record for RR#4, revealed that the start of care assessment indicated the patient scored high risk for falls. In addition, the patient had experienced a fall 2 days prior to the start of care date. The plan of care did not include a goal statement to evaluate response to care, treatment and services related to fall prevention interventions. This observation was reviewed with the Administrator/Director of Nursing.

Observed in Record Review. Example # 2: Observed during a review of RR #7 the following physicians order was noted: Change foley as ordered. The physician's order did not include the specific urinary catheter device, and frequency of device removal and replacement. Finding validated with Regional Director Observed in Record Review. In 3 of 13 patient records reviewed, it was noted that the organization did not ensure the plan of care included all required information. For example, a review of the medical record for RR#4, revealed that the start of care assessment indicated the patient scored high risk for falls. In addition, the patient had experienced a fall 2 days prior to the start of care date. The patient’s plan of care did not include interventions to maintain patient safety, and strategies to prevent injury. This observation was reviewed with the Administrator/Director of Nursing.

Observed in Record Review. Example #3: In RR #12, The clinician noted chronic pressure ulcers to sacrum/coccyx/vaginal area, L ischium pressure ulcer, skin tear to LL back area, L toe moisture skin integrity issues. The plan of care did not include interventions for the care, assessment and evaluation of identified wounds. In addition, a statement of the scope and frequency of the wound care services necessary to meet the patient's needs was not included. This observation was validated with the Regional Director.

Observed in Record Review. In 3 of 13 patient records reviewed, it was noted that care was not provided according to the plan of care. For example, a review of the medical record for HV #1 revealed, that the aide visit frequency order was 3 times per week. During week 3 the order for aide visits was changed to 2 times per week. During week 3 of Hospice services, the aide made 3 visits. This observation was validated with the Director of Nursing/Administrator. Example #2: During record review for RR #6, it was noted that the plan of care included orders for skilled nurse visits 1 time per week. There was no documented evidence that a skilled nurse visit was completed during week 5 of services. This observation was validated with the Regional Director. Observed in Record Review. Example #3: In RR #12 The start of care comprehensive assessment did not include an initial assessment of wounds. The clinician noted chronic pressure ulcers to sacrum/coccyx/vaginal area, L ischium pressure ulcer, skin tear to LL back area, L toe moisture skin integrity issues. The assessment of these wounds did not include condition of surrounding tissue, condition of wound beds and measurement of wounds. Finding validated with the Regional Director.

Observed in Patient Home. In 1 of 3 home visits, it was noted that the organization did not ensure that it's infection prevention and control activities were implemented. For example, a review of the policy titled Hand Hygiene revealed the following information: (3) Hand decontamination using an alcohol-based hand rub should be performed-(c) After contact with a patients' intact skin {when taking a pulse, blood pressure or lifting a patient} and (f) After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient.. For example, In HV #3, clinician did not perform hand hygiene after touching the patient for vital signs and physical assessment. The clinician also failed to perform hand hygiene after contact with stethoscope, blood pressure cuff, thermometer, and cell phone. Validated with Regional Director.