Every finding on record at High Care Hospice and Palliative

Observed in Record Review. In 1 of 12 patient records reviewed, During RRHV# 3's patient record review it was noted the organization had not ensured the registered nurse completed the initial assessment of the patient to determine the immediate needs of the patient. For example: review of RRHV# 3's patient record revealed a skilled nurse visit by the licensed vocation nurse (LVN) the same day as the election of benefit (EOB). Review of the LVN skilled nurse visit note revealed documentation of a pain assessment and vital signs. This was discussed with the Administrator that shared the registered nurse (RN) was not available on the day of the EOB and the LVN was sent to tuck in the patient by assessing for any immediate needs of RRHV# 3 until the RN could assess the patient the following day.

Observed in Record Review. In 12 of 12 patient records reviewed, During all the patient record review it was noted the organization had not ensured it assessed or reassessed the need for Volunteer services. For example: review of the patient records revealed no documentation the patient and family had been evaluated for or offered Volunteer services or a referral for Volunteer services had been implemented. This was reviewed, discussed, and validated with the Administrator.

Observed in Record Review. In 10 of 12 patient records reviewed, During RRHV# 1, RRHV# 2, RRHV# 3, RR# 1, RR# 2, RR# 3, RR# 5, RR# 7, D/C# 1, and D/C# 2's's patient records review it was noted the organization had not ensured the written plan of care was based on the patient's goals and the time frames, and services required to meet those goals. For example: during RRHV# 1's patient record review revealed a registered nurse (RN) start of care comprehensive assessment with documentation RRHV# 1 had a history of pain in two locations. The first location was the upper back with a pain history of 9/10 and the second location was in the right shoulder with a pain history of 5/10. In addition, the RN start of care comprehensive assessment revealed documentation RRHV# 1 was receiving oxygen continuously at 2 LPM via nasal cannula, and was a high fall risk. Review of the RRHV# 1's plan of care and subsequent updates to the plan of care revealed no goal for pain, Falls, or oxygen/respiratory. Further review of the plan of care revealed the disciplines Chaplain and Medical Social Worker (MSW) with the same frequency to include one time a month visits, and home health aide (HHA) with a frequency of twice weekly. However, the initial plan of care and subsequent updates to the plan of care revealed no goals for Chaplain, MSW, or HHA. Review of RRHV# 2's patient record revealed a RN start of care comprehensive assessment with documentation RRHV# 2 had three pressure ulcers, was receiving oxygen at 2 LPM as needed, was a high risk for fall. Review of RRHV# 2’s plan of care and subsequent updates to the plan of care and revealed a goal for integumentary that included the wound would decrease in size with no indication which wound(s) would decrease in size with no indication how to what a decrease in size would be. Further review of the plan of care and subsequent updates to the plan of care revealed the disciplines Chaplain and Medical Social Worker (MSW) with the same frequency to include one time a month visits, and home health aide (HHA) with a frequency of three visit a week. However, the initial plan of care and subsequent updates to the plan of care revealed no goals for Chaplain, MSW, or HHA. Review of RRHV# 2’s updated plan of care revealed RRHV# 2 had a foley placed for wound care and urine retention. Further review of the updated plans of care revealed the goal under Genitourinary that patient/caregiver would understand the medication for BPH [benign prostate hypertrophy] with no goals related to the indwelling foley catheter. In addition, RRHV# 2 had a diagnosis of Type 2 DM and receiving daily insulin. However, review of the plan of care revealed no goals for diabetes mellitus. Review of RRHV# 3's patient record revealed documentation of being a fall risk and oxygen as needed. Review of RRHV# 3's plan of care revealed Chaplain visit frequency of one time a month. Further review of RRHV# 3's plan of care revealed no documentation of a Chaplain goal or goal for fall risk. Review of RR# 5's patient record revealed RR# 5 was a fall risk. Review of the plan of care revealed Chaplain visit frequency of one time a month. Further review of RR# 5's plan of care revealed no goals for the Chaplain or fall risk. Review of RR# 7's record revealed documentation RR# 7 was a risk for falls. Review of RR# 7's plan of care revealed no goal for fall risk. Review of RR# 1, RR# 2, RR# 3, D/C# 1 and D/C# 2's patient records revealed documentation the patients were at risk for fall. Review of the plans of care revealed Chaplain visit frequency of one time a month. Further review of the plans of care revealed no goals for the Chaplain or fall risk. This was reviewed, discussed and validated with the Administrator.

Observed in Record Review. In 2 of 12 patient records reviewed, During RRHV# 2, RRHV# 3, 's patient records review it was noted the organization had not ensured the Chaplain and/or the Medical Social Worker (MSW) followed the plan of care. For example: review of RRHV# 2's plan of care revealed the frequency of one time a month for the MSW. Review of RRHV# 2's patient record revealed no visit by the MSW for March. Review of RRHV# 3's plan of care revealed the frequency of once a month visits for the Chaplain. Review of RRHV# 3's patient record reveal no Chaplain visit for the month of April. This was reviewed, discussed, and validated with the Administrator.

Observed in Patient Home. In 1 of 3 home visits conducted, During RRHV# 2's home observation it was noted the organization had not ensured staff followed the organization policy Hand Hygiene that included performing hand hygiene after removing gloves and prior to putting gloves on. For example: during RRHV# 2's home observation the registered nurse (RN) was observed performing foley catheter care and cleaning the penis. The RN then removed the gloves and put new gloves on without performing hand hygiene and continued to assess the patient and reposition the patient. This was discussed and validated with the RN/Administrator.

Observed in Record Review. In 2 of 7 patient records reviewed with hospice aide, During RRHV# 2 and RR# 5's patient records review it was noted the organization had not ensured the registered nurse (RN) prepared complete written patient care instructions for the hospice aide. For example: review of RRHV# 2's patient record revealed RRHV# 2 had multiple pressure ulcers with dressings and had an indwelling foley catheter placed approximately five months prior to the surveyor review of the record. Review of RRHV# 2's hospice aide patient written instructions revealed no documentation of a wound or dressing or indwelling foley. During review of RR# 5's patient record revealed a pressure ulcer Stage III on the coccyx with a dressing. Review of the hospice aide patient written instructions revealed no documentation of a wound or dressing. This was discussed with the Administrator and Director of Patient Care Services and approved.

Observed in Patient Home. In 1 of 3 home visits conducted, During RRHV# 2's home observation it was noted the organization had not ensured it treated the patient in a dignified and respectful manner that supports the patient dignity. For example: during RRHV# 2's home observation the registered nurse (RN) was observed providing foley catheter care with the front of the house window curtain open and people observed walking by. This was discussed and validated with the RN/Administrator.

Observed in Patient Home. In 2 of 2 home visits conducted with medication reconciliation, During RRHV# 1 and RRHV# 2's home observation it was noted the organization had not ensured the patient record contained information that reflected the patient's care, treatment, or services. For example: during RRHV# 2's home observation the registered nurse (RN) was observed completing a medication reconciliation. Review of RRHV# 2's medication profile revealed Humulin R 4-10 units subcutaneous three times a day. However, review of the insulin in the home revealed Lantus 10 units every am. RRHV# 2's Son shared RRHV# 2 had been on Lantus for approximately six months prior to the home observation. During RRHV# 1's home observation the RN was observed completing a medication reconciliation. Review of RRHV# 1's medication profile revealed Furosemide tablet 20 mg daily. However, review of the medication revealed Furosemide 40 mg tablet daily. RRHV# 1's family representative shared the 40 mg tablet was cut in half with the pill cutter she/he purchased. Further review of the medication profile revealed Vitamin C 500 mg chewable tablet daily. However, review of RRHV# 1's medication revealed Vitamin C 500mg tablets. This was observed, reviewed, discussed, and validated with the RN/Administrator. Observed in Record Review. In 1 of 12 patient records reviewed, During RRHV# 3's patient record it was noted the organization had not ensured the patient record contained information that reflected the patient's care, treatment, or services. For example: review of RRHV# 3's patient record revealed an initial spiritual assessment with many assessment sections left blank or not assessed. This was reviewed, discussed, and validated with the RN/Administrator.